Efficacy of a target-matching foot-stepping exercise on proprioception and function in patients with knee osteoarthritis

Effectiveness of balance training on pain and functional outcomes in knee osteoarthritis: A systematic review and meta-analysis

Background: Knee osteoarthritis (OA) is a musculoskeletal disorder that causes pain and increasing loss of function, resulting in reduced proprioceptive accuracy and balance. Therefore, the goal of this systematic review and meta-analysis is to evaluate the effectiveness of balance training on pain and functional outcomes in knee OA. Methods: "PubMed", "Scopus", "Web of Science", "Cochrane", and "Physiotherapy Evidence Database" were searched for studies conducted between January 2000 and December 2021. Randomized controlled trials (RCTs) that investigated the effectiveness of balance training in knee OA, as well as its effects on pain and functional outcome measures, were included. Conference abstracts, case reports, observational studies, and clinical commentaries were not included. Meta-analysis was conducted for the common outcomes, i.e., Visual Analog Scale (VAS), The Timed Up and Go (TUG), Western Ontario and McMaster Universities Arthritis Index (WOMAC). The PEDro scale was used to determine the quality of the included studies. Results: This review includes 22 RCTs of which 17 articles were included for meta-analysis. The included articles had 1456 participants. The meta-analysis showed improvement in the VAS scores in the experimental group compared to the control group [ I 2= 92%; mean difference= -0.79; 95% CI= -1.59 to 0.01; p<0.05] and for the WOMAC scores the heterogeneity ( I 2) was 81% with a mean difference of -0.02 [95% CI= -0.44 to 0.40; p<0.0001]. The TUG score was analyzed, the I 2 was 95% with a mean difference of -1.71 [95% CI= -3.09 to -0.33; p<0.0001] for the intervention against the control group. Conclusions: Balance training significantly reduced knee pain and improved functional outcomes measured with TUG. However, there was no difference observed in WOMAC. Although due to the heterogeneity of the included articles the treatment impact may be overestimated. Registration: The current systematic review was registered in PROSPERO on 7th October 2021 (registration number CRD42021276674).

The effectiveness of exercise with behavior change techniques in people with knee osteoarthritis: A systematic review with meta-analysis

OBJECTIVE

The purpose of this systematic review with meta-analysis was to examine the effectiveness of exercise with behavior change techniques (BCTs) on core outcome sets in people with knee osteoarthritis.

LITERATURE SURVEY

We searched randomized controlled trials (RCTs) in eight databases (MEDLINE, Embase, CENTRAL, CINAHL, PsycINFO, PEDro, ICTRP, and ClinicalTrials.gov) up to November 4, 2021.

METHODOLOGY

Eligible participants were people with knee osteoarthritis. The intervention was exercise with BCTs. Primary outcomes included physical function, quality of life (QOL) 6 to 12 months after intervention, and adverse events. Secondary outcomes were knee pain, exercise adherence, mobility, and self-efficacy 3 months or more after intervention. The bias risk was assessed using the Risk of Bias 2 tool. The random-effects model was used for the meta-analysis.

SYNTHESIS

We found 16 individual BCTs, and 37.7% of trials used a single BCT. For meta-analysis, we included 21 RCTs (n = 1623). Most outcomes had a very low certainty of evidence, and the risk of bias was the consistent reason for downgrading evidence levels. The standardized mean difference (SMD) with 95% confidence interval (95% CI) was 0.00 (-0.24, 0.24) in physical function, 0.33 (-0.51, 1.17) in exercise adherence, and 0.04 (-0.39, 0.47) in self-efficacy. The risk ratio (95% CI) of adverse events was 3.6 (0.79, 16.45). QOL was not pooled due to insufficient data (very low certainty of evidence). In contrast, the SMD (95% CI) for knee pain reduction and mobility improvement was -0.33 (-0.53, -0.13) and 0.21 (-0.05, 0.47) with moderate and low certainty of evidence, respectively.

CONCLUSION

The evidence is inconclusive regarding the effectiveness of BCTs with exercises on core outcome sets. Further research should explore the effectiveness of BCTs with valid design.

PROTOCOL REGISTRATION

PROSPERO (CRD42020212904).

The effects of exercise training on knee repositioning sense in people with knee osteoarthritis: a systematic review and meta-analysis of clinical trials

OBJECTIVE

Osteoarthritis (OA) of the knee is one of the most common global joint disorders, especially in aging population, and is among leading health-related concerns of societies. Therefore, this systematic review and meta-analysis was done to investigate the results related to the effects of exercise interventions on knee repositioning sense in patients with knee OA.

METHODS

An extensive search was independently performed in electronic databases including PubMed, MEDLINE, Web of Science, SCOPUS, and Google Scholar, to identify randomized clinical trials (RCTs) conducted on knee OA and to evaluate knee repositioning sense before and after different exercise interventions. After extracting relevant data from eligible studies, results of the studies were pooled using a random-effects model of meta-analysis. The Physiotherapy Evidence Database (PEDro) of clinical trials was used for quality assessment of eligible studies.

RESULTS

Among 2702 studies identified in the initial search, 17 studies were eligible for final systematic review and meta-analysis. The results showed that the patients who participated in different exercise interventions had significantly less knee repositioning error (mean differences: -1.141 degrees (95%CI: -1.510, -0.772, P < .001) compared to those who did not undergo exercise interventions. The eligible studies exhibited publication bias (Intercept: -6.69, P = .002), and the data showed significant heterogeneity (I2 = 85.633%, Q = 153.125, P < .001). Moreover, meta regression showed more prolonged exercise duration might have more effects on knee repositioning error (Coefficient=-0.860, 95% CI=-1.705, -0.016, Z=-2.00, P = .045).

CONCLUSION

There is strong evidence that exercise interventions may effectively reduce knee repositioning error. Moreover, it seems that more prolonged exercise duration may be associated with the greater effect size.

Investigating Therapies for Freezing of Gait Targeting the Cognitive, Limbic, and Sensorimotor Domains

Background

Freezing of gait (FOG) is arguably the most disabling motor symptom experienced with Parkinson’s disease (PD), but treatments are extremely limited due to our poor understanding of the underlying mechanisms. Three cortical domains are postulated in recent research (ie, the cognitive, limbic, and sensorimotor domains), thus, treatments targeting these mechanisms of FOG may potentially be effective. Cognitive training, cognitive behavioral therapy (CBT, a well-known anxiety intervention), and proprioceptive training may address the cognitive, limbic, and sensorimotor domains, respectively.

Objective

To investigate whether these 3 treatments could improve functional outcomes of FOG.

Methods

In a single-blind, randomized crossover design, 15 individuals with PD and FOG were randomized into different, counterbalanced orders of receiving the interventions. Each consisted of eight 1-hour sessions, twice weekly for 4 weeks. FOG severity was assessed as the primary outcome using a novel gait paradigm that was aimed at evoking FOG when the cognitive, limbic, or sensorimotor domains were independently challenged.

Results

FOG severity significantly improved after the cognitive intervention, with strong trends toward improvement specifically in the baseline and cognitive-challenge assessment conditions. CBT, as the anxiety intervention, resulted in significantly worse FOG severity. In contrast, proprioceptive training significantly improved FOG severity, with consistent trends across all conditions.

Conclusions

The cognitive and proprioceptive treatments appeared to improve different aspects of FOG. Thus, either of these interventions could potentially be a viable treatment for FOG. However, although the results were statistically significant, they could be sensitive to the relatively small number of participants in the study. Considering the significant results together with nonsignificant trends in both FOG and gait measures, and given equal time for each intervention, proprioceptive training produced the most consistent indications of benefits in this study. (clinicaltrials.gov NCT03065127).

mHealth technologies for osteoarthritis self-management and treatment: A systematic review

Osteoarthritis is a common chronic disease that can be better treated with the help of self-management interventions. Mobile health (mHealth) technologies are becoming a popular means to deliver such interventions. We reviewed the current state of research and development of mHealth technologies for osteoarthritis self-management to determine gaps future research could address. We conducted a systematic review of English articles and a survey of apps available in the marketplace as of 2016. Among 117 unique articles identified, 25 articles that met our inclusion criteria were reviewed in-depth. The app search identified 23 relevant apps for osteoarthritis self-management. Through the synthesis of three research themes (osteoarthritis assessment tools, osteoarthritis measurement tools, and osteoarthritis motion monitoring tools) that emerged from the current knowledge base, we provide a design framework to guide the development of more comprehensive osteoarthritis mHealth apps that facilitate self-management, decision support, and shared decision-making.

Effect of 6-week retro or forward walking program on pain, functional disability, quadriceps muscle strength, and performance in individuals with knee osteoarthritis: a randomized controlled trial (retro-walking trial)

BACKGROUND

Previous studies reported the beneficial effects of walking in individual with mild to moderate knee osteoarthritis (OA). The current study aimed to compare the effect of 6-week retro versus forward walking program versus control group on pain, functional disability, quadriceps muscle strength and physical performance in individuals with knee OA.

METHODS

A three-arm single-blinded, randomized, controlled trial and intention-to-treat analysis was conducted in outpatient physiotherapy department, King Saud University, Saudi Arabia. Sixty-eight individuals (mean age, 55.6 years; 38 female) with knee OA participated. The participants in the retro or forward walking group completed 10 min of supervised retro or forward walking training in addition to usual care, 3 days/week for 6 weeks. The control group received a routine physiotherapy program. This program comprises a combination of closed and open kinematic chain exercises, including straight leg raising, isometric quadriceps, isometric hip adduction, terminal knee extension, semi-squat, and leg press. The primary outcomes were mean pain and knee function score measured by the numerical rating scale and the Western Ontario and McMaster Universities Osteoarthritis Index, respectively. The secondary outcomes were mean score of quadriceps muscle strength and timed up and go test scores. All the outcomes were analyzed at baseline and week 6.

RESULTS

In total, 68 subjects participated in this 6-week randomized, controlled trial. The completion rates of the primary and secondary outcome measures at week 6 were 91, 87, and 82% in the retro walking, forward walking, and control groups, respectively. In the intention-to-treat analysis, the retro walking group had a greater reduction in pain intensity (mean changes, 1.8 versus 1; p = 0.01) and functional disability (mean changes, 4.8 versus 2.2; p = 0.008) than the control group. Similarly, the retro walking group had a greater improvement in the quadriceps muscle strength (mean changes, 1.7 kg versus 0.7 kg; p = 0.008) and the timed up and go test (mean changes, 0.6 s versus 0.1 s; p = 0.003) than the control group.

CONCLUSIONS

The 6-week retro walking program compared with forward walking or control groups resulted in greater reduction in pain and functional disability and improved quadriceps muscle strength and performance in individuals with knee OA.

TRIAL REGISTRATION

Controlled Trials ISRCTN12850845 , Registered 26 January 2015.

Poor replicability of recommended exercise interventions for knee osteoarthritis: a descriptive analysis of evidence informing current guidelines and recommendations

OBJECTIVE

To examine the reporting completeness of exercise-based interventions for knee osteoarthritis (OA) in studies that form the basis of current clinical guidelines, and examine if the clinical benefit (pain and disability) from exercise is associated with the intervention reporting completeness.

DESIGN

Review of clinical OA guidelines METHODS: We searched MEDLINE and EMBASE for guidelines published between 2006 and 2016 including recommendations about exercise for knee OA. The studies used to inform a recommendation were reviewed for exercise reporting completeness. Reporting completeness was evaluated using a 12-item checklist; a combination of the Template for Intervention Description and Replication (TIDieR) and Consensus on Exercise Reporting Template (CERT). Each item was scored 'YES' or 'NO' and summarized as a proportion of interventions with complete descriptions and each intervention's completeness was summarized as the percentage of completely described items. The association between intervention description completeness score and clinical benefits was analyzed with a multilevel meta-regression.

RESULTS

From 10 clinical guidelines, we identified 103 original studies of which 100 were retrievable (including 133 interventions with 6,926 patients). No interventions were completely described on all 12 items (median 33% of items complete; range 17-75%). The meta-regression analysis indicated that poorer reporting was associated with greater effects on pain and no association with effects on disability.

CONCLUSION

The inadequate description of recommended interventions for knee OA is a serious problem that precludes replication of effective interventions in clinical practice. By consequence, the relevance and usability of clinical guideline documents and original study reports are diminished.

PROSPERO

CRD42016039742.

Inter-limb effects of isometric quadriceps strengthening on untrained contra-lateral homologous muscle of patients with knee osteoarthritis

PURPOSE

The primary objective of this study was to establish if there would be inter-limb crossing of strength from trained quadriceps muscles of unaffected limb to the untrained homologous group of muscles in subjects with knee osteoarthritis.

METHODS

Twenty-one patients with knee osteoarthritis were recruited for the study. The affected knee was not trained while the unaffected quadriceps group of muscles was trained for 6 weeks using isometric contraction exercises. The patients sat on a quadricep bench with knee flexed to 90° as starting position. An ankle strap was used to fasten the required weight for isometric training at the lower one-third of the unaffected limb. Each patient extended the unaffected knee until the leg was fully straightened, maintaining quadriceps isometric contraction for 3 to 5 seconds; and then slowly returned to the starting position; 12 repetitions and 3 sets were performed thrice a week for 6 weeks. The peak isometric quadricep strengths of both limbs were quantified with spring balance at baseline and after 6 weeks. During quantification, all the patients were verbally motivated to achieve maximum voluntary contraction at extension. The data were analyzed using descriptive statistics of mean, standard deviation and percentages. Parametric inferential statistics of dependent t-test (paired) was used to compare the pre and post values obtained.

RESULTS

The peak isometric quadriceps strength of the affected limb with knee osteoarthritis without training at baseline was 132.67 ± 42.26 N while at the 6th week it was 159.30 ± 49.33 N showing a significant increase of 20% (p = 0.001). For the trained unaffected knee, at onset and at 6th week, the peak isometric quadricep strengths were 158.83 ± 43.28 N and 192.00 ± 47.31 N respectively. There was significant increase of 21% in the quadriceps muscle strength of the unaffected knee after training (p = 0.001). However, there was no significant difference in the increments observed between the peak isometric quadriceps strengths of both limbs (p = 0.06).

CONCLUSION

We concluded that there was cross training effect on the contralateral quadriceps muscle when only the ipsilateral (unaffected) homologous muscle was strengthened.

Effect of proprioception cross training on repositioning accuracy and balance among healthy individuals

[Purpose] To investigate possible cross effects of proprioception training on proprioception repositioning accuracy of the knee joint and on balance in healthy subjects. [Subjects and Methods] Sixty healthy college students and faculty members from faculty of physical therapy, Cairo University were recruited to participate. Participants were randomly assigned to training group (n=30) and control group (n=30). The training group received proprioceptive training program only for the dominant leg while the control group did not receive any kind of training. Outcome measures were twofold: (1) proprioception repositioning accuracy quantified through the active repositioning test for the non-dominant knee; and (2) balance stability indices determined through using Biodex balance system. Measurements were recorded before and after 8 weeks of proprioception training. [Results] There were significant decrease in the error of repositioning accuracy and the stability indices including anterposterior stability index, mediolateral stability index, and overall stability index of training group, measured post training, compared with control group. [Conclusion] Proprioception training has significant cross training effects on proprioception repositioning accuracy of the knee joint and on balance among healthy subjects.

Factors Affecting Length of Stay in Adult Outpatient Physical Rehabilitation: A Scoping Review of the Literature

PURPOSE

To identify factors affecting length of stay (LOS) for adults participating in outpatient physical or occupational therapy programmes.

METHOD

A scoping review of the literature was conducted using the Ovid MEDLINE, EMBASE, CINAHL, AMED, and Cochrane Library databases.

RESULTS

A total of 19 articles were retained from the search, and 2 additional articles were retrieved from grey literature (i.e., non-published sources). Personal factors affecting LOS are age and sex, both of which had inconsistent effects on LOS, and communication, language, physical, and cognitive difficulties, for which higher levels of function were generally associated with shorter LOS. Institutional factors affecting LOS were location, interdisciplinary communication, number of disciplines involved, and type of rehabilitation setting. Finally, two clinician-related factors-fewer treatment goals and a selection of evidence-informed treatment techniques-were associated with shorter LOS.

CONCLUSIONS

Research on factors affecting adult outpatient rehabilitation LOS is limited and inconsistent. A preliminary list of LOS factors was produced, but this topic should be further explored with the collaboration of researchers and clinical institutions.

Effect of proprioceptive training on foot posture, lower limb alignment, and knee adduction moment in patients with degenerative knee osteoarthritis: a randomized controlled trial

[Purpose] The purpose of this study was to determine the effect of proprioceptive training on foot progression angle, weight-bearing ratio, and knee adduction moment in patients with degenerative osteoarthritis of the knee. [Subjects] The subjects were 37 patients diagnosed with Kellgren-Lawrence grade 2 or 3 degenerative knee osteoarthritis. They were randomly allocated to three groups: a proprioceptive training group (PT group), quadriceps strengthening group (QS group), and control group. [Methods] The study parameters of the three groups were compared before and after a 12-week training period. Therapeutic exercises were performed twice per week for 12 weeks. Outcomes included the foot progression angle, weight-bearing ratio, and knee adduction moment. [Results] First, a significant difference in the foot progression angle was observed among the groups, significantly increasing in the PTG compared with the CG. Second, a significant difference in the weight-bearing ratio was observed among the groups, significantly increasing in the PTG compared with the CG. Third, a significant difference in the first peak knee adduction moment was observed among the groups, significantly decreasing in the PTG compared with the CG. [Conclusion] The results of the present study indicate that proprioceptive training increased the foot progression angle and weight-bearing ratio and decreased the first peak knee adduction moment. Moreover, incorporating proprioceptive training into a physical therapy exercise program could improve functional ability and delay the progression of degenerative osteoarthritis.

Effects of exercise therapy on walking ability in individuals with knee osteoarthritis: a systematic review and meta-analysis of randomised controlled trials

Objective:

To examine the effect of exercise therapy on the walking ability of individuals with knee osteoarthritis.

Data sources:

Randomised clinical trials (RCTs) were identified by searching through PubMed, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Cumulative Index to Nursing and Allied Health Literature. All literature published to October 2014 were included in the search.

Review methods:

Data were collected from RCTs that compared the effects of exercise therapy on walking ability with the effects of no intervention or psychoeducational intervention in participants with knee osteoarthritis. The outcome data on the total distance walked (6-minute walk test); the amount of time spent walking (the time to walk arbitrary distances); and gait velocity were obtained and analysed. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated.

Results:

Twenty-eight RCTs were identified. Meta-analysis provided very-low-quality evidence that exercise therapy increased the total distance walked in the 6-minute walk test, in comparison with the effects of the control interventions (SMD = 0.44, 95% CI 0.27 to 0.60). Meta-analysis also provided low- or moderate-quality evidence that the amount of time spent walking and gait velocity were improved more by exercise therapy than by the control interventions (the amount of time spent walking: SMD = −0.50, 95% CI −0.70 to −0.30; gait velocity: SMD = 1.78, 95% CI 0.98 to 2.58).

Conclusion:

In individuals with knee osteoarthritis, exercise therapy can improve the amount of time spent walking, gait velocity, and maybe the total distance walked.

The effectiveness of proprioceptive training for improving motor function: a systematic review

OBJECTIVE

Numerous reports advocate that training of the proprioceptive sense is a viable behavioral therapy for improving impaired motor function. However, there is little agreement of what constitutes proprioceptive training and how effective it is. We therefore conducted a comprehensive, systematic review of the available literature in order to provide clarity to the notion of training the proprioceptive system.

METHODS

Four major scientific databases were searched. The following criteria were subsequently applied: (1) A quantified pre- and post-treatment measure of proprioceptive function. (2) An intervention or training program believed to influence or enhance proprioceptive function. (3) Contained at least one form of treatment or outcome measure that is indicative of somatosensory function. From a total of 1284 articles, 51 studies fulfilled all criteria and were selected for further review.

RESULTS

Overall, proprioceptive training resulted in an average improvement of 52% across all outcome measures. Applying muscle vibration above 30 Hz for longer durations (i.e., min vs. s) induced outcome improvements of up to 60%. Joint position and target reaching training consistently enhanced joint position sense (up to 109%) showing an average improvement of 48%. Cortical stroke was the most studied disease entity but no clear evidence indicated that proprioceptive training is differentially beneficial across the reported diseases.

CONCLUSIONS

There is converging evidence that proprioceptive training can yield meaningful improvements in somatosensory and sensorimotor function. However, there is a clear need for further work. Those forms of training utilizing both passive and active movements with and without visual feedback tended to be most beneficial. There is also initial evidence suggesting that proprioceptive training induces cortical reorganization, reinforcing the notion that proprioceptive training is a viable method for improving sensorimotor function.

Exercise for osteoarthritis of the knee

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

Five electronic databases were searched, up until May 2013.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Exercise and osteoarthritis: cause and effects

Osteoarthritis (OA) is a common chronic joint condition predominantly affecting the knee, hip, and hand joints. Exercise plays a role in the development and treatment of OA but most of the literature in this area relates to knee OA. While studies indicate that exercise and physical activity have a generally positive effect on healthy cartilage metrics, depending upon the type of the activity and its intensity, the risk of OA development does appear to be moderately increased with sporting participation. In particular, joint injury associated with sports participation may be largely responsible for this increased risk of OA with sport. Various repetitive occupational tasks are also linked to greater likelihood of OA development. There are a number of physical impairments associated with OA including pain, muscle weakness and altered muscle function, reduced proprioception and postural control, joint instability, restricted range of motion, and lower aerobic fitness. These can result directly from the OA pathological process and/or indirectly as a result of factors such as pain, effusion, and reduced activity levels. These impairments and their underlying physiology are often targeted by exercise interventions and evidence generally shows that many of these can be modified by specific exercise. There is currently little clinical trial evidence to show that exercise can alter mechanical load and structural disease progression in those with established OA, although a number of impairments, that are amenable to change with exercise, appears to be associated with increased mechanical load and/or disease progression in longitudinal studies.

Impaired varus-valgus proprioception and neuromuscular stabilization in medial knee osteoarthritis

Impaired proprioception and poor muscular stabilization in the frontal plane may lead to knee instability during functional activities, a common complaint in persons with knee osteoarthritis (KOA). Understanding these frontal plane neuromechanical properties in KOA will help elucidate the factors contributing to knee instability and aid in the development of targeted intervention strategies. The objectives of the study were to compare knee varus-valgus proprioception, isometric muscle strength, and active muscular contribution to stability between persons with medial KOA and healthy controls. We evaluated knee frontal plane neuromechanical parameters in 14 participants with medial KOA and 14 age- and gender-matched controls, using a joint driving device (JDD) with a customized motor and a 6-axis force sensor. Analysis of covariance with BMI as a covariate was used to test the differences in varus-valgus neuromechanical parameters between these two groups. The KOA group had impaired varus proprioception acuity (1.08±0.59° vs. 0.69±0.49°, p<0.05), decreased normalized varus muscle strength (1.31±0.75% vs. 1.79±0.84% body weight, p<0.05), a trend toward decreased valgus strength (1.29±0.67% vs. 1.88±0.99%, p=0.054), and impaired ability to actively stabilize the knee in the frontal plane during external perturbation (4.67±2.86 vs. 8.26±5.95 Nm/degree, p<0.05). The knee frontal plane sensorimotor control system is compromised in persons with medial KOA. Our findings suggest varus-valgus control deficits in both the afferent input (proprioceptive acuity) and muscular effectors (muscle strength and capacity to stabilize the joint).

Manual physical therapy and perturbation exercises in knee osteoarthritis

Objectives:

Knee osteoarthritis (OA) causes disability among the elderly and is often associated with impaired balance and proprioception. Perturbation exercises may help improve these impairments. Although manual physical therapy is generally a well-tolerated treatment for knee OA, perturbation exercises have not been evaluated when used with a manual physical therapy approach. The purpose of this study was to observe tolerance to perturbation exercises and the effect of a manual physical therapy approach with perturbation exercises on patients with knee OA.

Methods:

This was a prospective observational cohort study of 15 patients with knee OA. The Western Ontario and McMaster Universities Arthritis Index (WOMAC), global rating of change (GROC), and 72-hour post-treatment tolerance were primary outcome measures. Patients received perturbation balance exercises along with a manual physical therapy approach, twice weekly for 4 weeks. Follow-up evaluation was done at 1, 3, and 6 months after beginning the program.

Results:

Mean total WOMAC score significantly improved (P = 0.001) after the 4-week program (total WOMAC: initial, 105; 4 weeks, 56; 3 months, 54; 6 months, 57). Mean improvements were similar to previously published trials of manual physical therapy without perturbation exercises. The GROC score showed a minimal clinically important difference (MCID)≥+3 in 13 patients (87%) at 4 weeks, 12 patients (80%) at 3 months, and 9 patients (60%) at 6 months. No patients reported exacerbation of symptoms within 72 hours following each treatment session.

Discussion:

A manual physical therapy approach that also included perturbation exercises was well tolerated and resulted in improved outcome scores in patients with knee OA.

Clinical effectiveness of knee rehabilitation techniques and implications for a self-care treatment model

BACKGROUND

Physiotherapy is a complex intervention frequently recommended for knee conditions. The International Classification of Functioning and Disability (ICF) can be used as a framework to evaluate evidence to develop care models and clinical guidelines.

OBJECTIVE

To evaluate the clinical effectiveness of knee rehabilitation modalities categorised according to the ICF domains.

DATA SOURCES

A keyword search of Medline, Cinahl, Amed, Embase and Cochrane databases from 1996 to 2010 using terms related to the knee joint and physiotherapeutic interventions.

STUDY SELECTION

Reviewer assessment using inclusion/exclusion criteria and a quality assessment tool compiled from the Critical Appraisal Skills Programme Tool, Consort and Cochrane Bone Joint and Muscle Trauma Groups.

DATA EXTRACTION

Information about the research design, intervention and subjects was extracted. Outcome measures and findings were categorised according to ICF domains.

DATA SYNTHESIS

The majority of studies evaluated exercise. Findings were supportive but specific recommendations were limited due to variations in content and application. There was limited quality research to support the theory that manual therapy, electrotherapy or taping in isolation contributes to recovery. Multimodality physiotherapy programmes were found to be beneficial and to reflect clinical practice, but the effectiveness of each component is unknown. Outcome measures from the participation domain of the ICF were used least frequently and were not generally true measures of participation.

CONCLUSION

Development of participation outcome measures is required to evaluate the long-term benefits of interventions. Rehabilitation should be based around delivery of effective exercise programmes incorporating participation outcomes to provide feedback and complement self-care for knee conditions.

Treatment options for osteoarthritis: considerations for older adults

Osteoarthritis (OA) is the most common form of arthritis and the leading cause of disability among older adults in the United States. Treatment options such as acetaminophen and nonsteroidal anti-inflammatory drugs are the most widely used agents to manage mild-to-moderate pain. Treatment with tramadol or opioids is usually reserved for severe pain associated with OA. These agents do not come without risk, especially for older adults. Patient-specific parameters and comorbid conditions must be considered when evaluating treatment options for older adults. This article reviews pharmacological and nonpharmacological approaches to the management of OA in older adults.

Proprioception in knee osteoarthritis: a narrative review

OBJECTIVE

To give an overview of the literature on knee proprioception in knee osteoarthritis (OA) patients.

METHOD

A literature search was performed and reviewed using the narrative approach.

RESULTS

(1) Three presumed functions of knee proprioception have been described in the literature: protection against excessive movements, stabilization during static postures, and coordination of movements. (2) Proprioceptive accuracy can be measured in different ways; correlations between these methods are low. (3) Proprioceptive accuracy in knee OA patients seems to be impaired when compared to age-matched healthy controls. Unilateral knee OA patients may have impaired proprioceptive accuracy in both knees. (4) Causes of impaired proprioceptive accuracy in knee OA remain unknown. (5) There is currently no evidence for a role of impaired proprioceptive accuracy in the onset or progression of radiographic osteoarthritis (ROA). (6) Impaired proprioceptive accuracy could be a risk factor for progression (but not for onset) of both knee pain and activity limitations in knee OA patients. (7) Exercise therapy seems to be effective in improving proprioceptive accuracy in knee OA patients.

CONCLUSIONS

Recent literature has shown that proprioceptive accuracy may play an important role in knee OA. However, this role needs to be further clarified. A new measurement protocol for knee proprioception needs to be developed. Systematic reviews focusing on the relationship between impaired proprioceptive accuracy, knee pain and activity limitations and on the effect of interventions (in particular exercise therapy) on proprioceptive accuracy in knee OA are required. Future studies focusing on causes of impaired proprioceptive accuracy in knee OA patients are also needed, taking into account that also the non-symptomatic knee may have proprioceptive impairments. Such future studies may also provide knowledge of mechanism underlying the impact of impaired proprioceptive accuracy on knee pain and activity limitations.

A review of the clinical evidence for exercise in osteoarthritis of the hip and knee

Osteoarthritis (OA) is a chronic joint disease with the hip and knee being commonly affected lower limb sites. Osteoarthritis causes pain, stiffness, swelling, joint instability and muscle weakness, all of which can lead to impaired physical function and reduced quality of life. This review of evidence provides recommendations for exercise prescription in those with hip or knee OA. A narrative review was performed. Conservative non-pharmacological strategies, particularly exercise, are recommended by all clinical guidelines for the management of OA and meta-analyses support these exercise recommendations. Aerobic, strengthening, aquatic and Tai chi exercise are beneficial for improving pain and function in people with OA with benefits seen across the range of disease severities. The optimal exercise dosage is yet to be determined and an individualized approach to exercise prescription is required based on an assessment of impairments, patient preference, co-morbidities and accessibility. Maximising adherence is a key element dictating success of exercise therapy. This can be enhanced by the use of supervised exercise sessions (possibly in class format) in the initial exercise period followed by home exercises. Bringing patients back for intermittent consultations with the exercise practitioner, or attendance at "refresher" group exercise classes may also assist long-term adherence and improved patient outcomes. Few studies have evaluated the effects of exercise on structural disease progression and there is currently no evidence to show that exercise can be disease modifying. Exercise plays an important role in managing symptoms in those with hip and knee OA.

Efficacy of 2 non-weight-bearing interventions, proprioception training versus strength training, for patients with knee osteoarthritis: a randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVE

To investigate the clinical and functional efficacy of 2 different non-weight-bearing exercise regimens, proprioceptive training (PrT) versus strength training (ST), for patients with knee osteoarthritis (OA).

BACKGROUND

Both strength and proprioceptive training are important interventions for individuals with knee OA. The benefits of weight-bearing exercises are generally recognized in the clinical setting. However, exercising in a standing or weight-bearing position may aggravate symptoms in patients with knee OA.

METHODS AND MEASURES

One hundred eight patients were randomly assigned to the PrT, ST, or no exercise (control) group for an 8-week intervention. Both the PrT and ST interventions consisted of non-weight-bearing exercises. Western Ontario and McMaster Universities Osteoarthritis Index-pain (WOMAC-pain) and -function scores, walking time on 3 different terrains, knee strength, and absolute knee reposition error were assessed before and after intervention. Data were analyzed using mixed-model ANOVAs.

RESULTS

Both PrT and ST significantly improved WOMAC-pain and -function score after intervention (P<.008). The improvement secondary to ST in the WOMAC-function scores (17.2 points) and for knee extension strength (10.3-14.9 Nm) was greater than the minimally clinically important difference for these measurements. The PrT group demonstrated greater improvement in walking time on a spongy surface and knee reposition error than the other 2 groups. No improvements were apparent in the control group.

CONCLUSION

Both types of non-weight-bearing exercises (PrT and ST) significantly improved outcomes in this study. PrT led to greater improvements in proprioceptive function, while ST resulted in a greater increase in knee extensor muscle strength.