The Incremental Effects of Manual Therapy or Booster Sessions in Addition to Exercise Therapy for Knee Osteoarthritis: A Randomized Clinical Trial

Mitigating Persistent Symptoms Following Rehabilitation in Musculoskeletal Disorders: A Scoping Review on After-discharge Strategies

BACKGROUND

The majority of patients with musculoskeletal pain (62% to 64%) achieve their treatment goals upon completing rehabilitation. However, a high re-consultation rate after discharge is frequently reported. Numerous authors have recognized the necessity of secondary prevention programs (after-discharge strategy) to ensure that the gains are maintained or further pursued after the completion of a rehabilitation program. Little is known about the different strategies currently in use, and a detailed review of the existing strategies is needed for future integration into the healthcare systems.

OBJECTIVE

This review systematically scopes and synthesizes the after-discharge strategies reported in the literature following rehabilitation for individuals experiencing musculoskeletal pain.

METHODS

Four databases (OVID MEDLINE, EMBASE, Web of Sciences, and OVID PsycInfo) were screened from their inception until May 4, 2023. Literature search, screening, and extraction were performed according to the PRISMA extension for scoping review guidelines.

RESULTS

Different after-discharge strategies were identified and grouped into 2 main categories: (1) in-person and (2) remote strategies. In-person strategies included (1.1) in-person booster sessions and (1.2) the use of existing community programs after discharge. Remote strategies included remote strategies that (2.1) involve a health care professional service or (2.2) strategies that do not involve any health care professional service.

DISCUSSION

We identified various after-discharge strategies designed to sustain gains and improve patients' self-management skills following the completion of a rehabilitation program. The existence of numerous promising strategies suggests their potential suitability for various contexts.

Study protocol: effects of exercise booster sessions on preservation of exercise-induced adaptations in persons with multiple sclerosis, a multicentre randomised controlled trial-the MS BOOSTER trial

INTRODUCTION

Multiple sclerosis (MS) causes a broad range of symptoms, with physical function being one of the most disabling consequences according to patients themselves. Exercise effectively improves lower extremity physical function. Nonetheless, it is unknown which exercise modality is most effective and it remains challenging to keep persons with MS adhering to exercise over a longer period. Therefore, the present study aims to investigate how exercise booster sessions (EBS) influence the sustainability of exercise-induced effects on physical function, and furthermore, to investigate which exercise modality (aerobic training or resistance training) is most effective in terms of improving physical function.

MATERIALS AND METHODS

This study is a multi-arm, parallel-group, open-label multicentre randomised controlled trial investigating the effects of EBS. Participants (n=150) are initially randomised to 12 weeks of either resistance training+usual care, aerobic training+usual care or usual care. After 12 weeks of intervention, participants in the exercise groups will again be randomised to either EBS+usual care or usual care during a 40-week follow-up period. The primary outcome is physical function (composite score based on 6-min walk test and five-time sit to stand), and the secondary outcomes are fatigue, cognition, physical activity, symptoms of depression and quality of life.

ETHICS AND DISSEMINATION

The study is approved by the Central Denmark Region Committees on Health Research Ethics (1-10-72-237-21) and is registered at the Danish Data Protection Agency (2016-051-000001) and at Clinicaltrials.gov (NCT04913012). All study findings will be published in scientific peer-reviewed journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04913012.

Collaborative model of care between orthopaedics and allied healthcare professionals (CONNACT) in knee osteoarthritis: Effectiveness-implementation hybrid randomized controlled trial of a community-based, multidisciplinary, stratified intervention

OBJECTIVE

To compare the clinical and cost effectiveness of the Collaborative Model of Care between Orthopaedics and Allied Healthcare Professionals (CONNACT), a community-based, stratified, multidisciplinary intervention consisting of exercise, education, psychological and nutrition delivered through a chronic care model to usual hospital care in adults with knee osteoarthritis (OA).

METHODS

Pragmatic, parallel-arm, single-blinded superiority RCT trial. Community-dwelling, ambulant adults with knee OA (Kellgren-Lawrence grade > 1; Knee Injury and OA Outcome Score (KOOS4) ≤75) were enrolled. Primary outcome was KOOS4 at 12-months; secondary outcomes included: quality of life, physical performance measures, symptom satisfaction, psychological outcomes, dietary habits, and global perceived effect. Intention-to-treat analysis using generalized linear model (GLM) and regression modeling were conducted. Economic evaluation through a societal approach was embedded.

RESULTS

110 participants (55 control, 55 intervention) were randomized. No between-group difference found for the primary outcome (MD [95%CI]: -1.86 [-9.11. 5.38]), although both groups demonstrated within-group improvement over 12-months. Among the secondary outcomes, the CONNACT group demonstrated superior dietary change (12 months) and physical performance measures (3 months), and global perceived effect (6 months). While there was no between-group difference in total cost, significant productivity gains (reduced indirect cost) were seen in the CONNACT group.

CONCLUSION

CONNACT was not superior to usual care at 1 year. Further efforts are needed to understand the underlying contextual and implementation factors in order to further improve and refine such community-based, stratified care models moving forward.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT03809975. Registered January 18, 2019. https://clinicaltrials.gov/ct2/show/NCT03809975.

Booster visits in the management of the acute musculoskeletal injuries: Transforming care to improve outcomes-A perspective review

The current healthcare delivery system for patients with acute musculoskeletal injury is failing. Current rehabilitation management of acute musculoskeletal injury typically includes physical therapy, focused on management of impairments, with an eventual transition to functional activities and release to prior level of function. At that point, formal physical therapy is often discontinued, despite the knowledge that a high percentage of patients fail to maintain preinjury level of activity and often reduce participation in regular physical activity. Further, for those who attempt to return to prior levels of pivoting and cutting activities, there is a high second injury rate. The long-term human experience is compromised by the current model of care which terminates at the point of transition to activity. This model of care fails to meet the continued needs of these patients and may result in long term deficits and potential disability. Extended care models include intermittent follow up visits after discharge from an acute episode of care and have been efficacious and cost effective in some patient populations with musculoskeletal conditions. Specifically, a type of extended care model, labeled "booster sessions," represents an opportunity to provide structured, intermittent care to assist in a smooth transition back to function, following an acute episode of care and promote a healthier life outcome. This perspective review will discuss the opportunity to transform acute musculoskeletal care to booster visit care model in an attempt to develop a more efficacious and cost-effective system of care which could be generalizable to all musculoskeletal conditions.

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review

Objective: This review aimed to describe the quality and comprehensiveness of adverse event (AE) reporting in clinical trials incorporating manual therapy (MT) as an intervention for extremity conditions using the Consolidated Standards of Reporting Trials (CONSORT)-Harms extension as the benchmark. The secondary aim was to determine whether the quality of AE reporting improved after the availability of the CONSORT reporting checklist. Design: Systematic review. Methods: A literature search was conducted using multiple databases to identify trials where MT was used to treat extremity conditions. Studies that reported AEs were identified and evaluated using the CONSORT-Harms extension. The frequency of trials reporting study AEs before and after the publication of the updated 2010 CONSORT statement was calculated, along with the categorization of how study AEs were reported. Results: Of the 55,539 studies initially identified, 220 trials met all inclusion criteria. Eighty trials (36.4%) reported AE occurrence. None of the studies that reported AEs adhered to all 10 criteria proposed by the 2010 CONSORT-Harms extension. The most commonly reported criterion was number four, which clarified how AE-related information was collected (30% of trials). The least reported criterion was number six, which describes the participant withdrawals for each arm due to AEs and the experience with the allocated treatment (1.3% of trials). The nomenclature used to describe AEs varied substantially. Fifty-nine of 76 trials (33.3%) were published after the updated CONSORT Harms-checklist was available, compared to 21 of 44 trials (46.7%) published before it was available. Conclusion: Reporting of AEs in trials investigating MT for extremity conditions is poor. Every included trial lacked adherence to all 10 criteria proposed by the CONSORT-Harms Extension. The quality and comprehensiveness of AE reporting did not improve after the most recent CONSORT update recommending AE reporting. Clinicians must obtain informed consent before performing any intervention, including MT, which requires disclosing potential risks, which could be better known with improved tracking, analyzing, and reporting of AEs. The authors recommend improved adherence to best practices for adequately tracking and reporting AEs in future MT trials.

Pragmatism in manual therapy trials for knee osteoarthritis: a systematic review

Introduction

Manual therapy is an often-utilized intervention for the management of knee osteoarthritis (OA). The interpretation of results presented by these trials can be affected by how well the study designs align applicability to real-world clinical settings.

Aim

To examine the existing body of clinical trials investigating manual therapy for knee OA to determine where they fall on the efficacy-effectiveness spectrum.

Methods

This systematic review has been guided and informed by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Randomized controlled trials that investigated manual therapy treatments for adults with knee OA were retrieved via searches of multiple databases to identify trials published prior to April 2023. The Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool was used to objectively rate the efficacy-effectiveness nature of each trial design. The Cochrane Risk of Bias 2.0 assessment tool (RoB-2) was used to assess the risk of bias across five domains.

Results

Of the 36 trials, a higher percentage of trials had a greater emphasis on efficacy within all four domains: participant characteristics (75.0%), trial setting (77.8%), flexibility of intervention (58.3%), and clinical relevance of experimental and comparison intervention (47.2%). In addition, 13.9% of the trials had low risk of bias, 41.7% had high risk of bias, and 44.4% had some concerns regarding bias.

Conclusions

While many trials support manual therapy as effective for the management of knee OA, a greater focus on study designs with an emphasis on effectiveness would improve the applicability and generalizability of future trials.

Pain neuroscience education, blended exercises and booster sessions as an effective therapy for pain, functional and psychological factors in patients with knee osteoarthritis: a study protocol for a single-blind randomised controlled trial with 22 factorial design during 6-month follow-up

INTRODUCTION

This study aims to investigate whether a pain neuroscience education (PNE) combined with a blended exercises programme including aerobic, resistance, neuromuscular, breathing, stretching and balance exercises and diet education provides greater pain relief and improvement in functional and psychological factors than PNE and blended exercises alone and whether 'exercise booster sessions (EBS)' approach may improve outcomes and increase adherence in patients with knee osteoarthritis (KOA) (by telerehabilitation (TR)).

METHODS AND ANALYSIS

In this single-blind randomised controlled trial, 129 patients (both genders; age >40) diagnosed with KOA will be randomly assigned to one of the 22 treatment combinations as: (1) blended exercises alone (36 sessions over 12 weeks), (2) PNE alone (three sessions over 2 weeks), (3) combination of PNE with blended exercises (exercise three times a week for 12 weeks combined with three sessions of PNE) and (4) a control group. Outcome assessors will be blinded towards group allocation. The primary outcome variables are the visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis index in knee osteoarthritis (WOMAC) score. Secondary outcomes include Pain Self-Efficacy Questionnaire (PSEQ), Depression, Anxiety and Stress Scale (DASS), Tampa Scale for Kinesiophobia (TSK), Short Falls Efficacy Scale International (FES-I), Pain Catastrophising Scale (PCS), Short Form Health Survey (SF-12) and Exercise Adherence Rating Scale (EARS), 30 s sit-to-stand test (30CST), Timed Up and Go (TUG), lower limbs' muscle strength and lower limb joints' active range of motion (AROM) will be performed at baseline, 3 and 6 months' postinterventions. The primary and secondary outcomes will assess at baseline, 3 months and 6 months postinterventions.The findings will be useful in establishing an effective treatment strategy covering multiple aspects behind KOA. The study protocol is conducted in clinical settings, thereby enhancing the possibility of future implementation of the treatments in the healthcare systems and self-care management. Results in comparison between groups will help to clarify the most effective of mixed-method TR (blended exercise, PNE, EBS with diet education) on more improvement in pain, functional and psychological factors in patients with KOA. This study will combine some of the most critical interventions, to be able to introduce a 'gold standard therapy' in the treatment of KOA.

ETHICS AND DISSEMINATION

The trial has been approved by the ethics committee for research involving human subjects of the Sport Sciences Research Institute of Iran (IR.SSRC.REC.1401.021). The study findings will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

IRCTID: IRCT20220510054814N1.

Effect of an Integrated Physiotherapy Protocol on Knee Osteoarthritis Patients: A Preliminary Study

BACKGROUND

Exercise therapy can potentially relieve symptoms and improve functional status of the knee osteoarthritis population. Despite the proved practical benefits, there is no standard, comprehensive physiotherapeutic protocol available targeting the physical and physiological impairment cluster associated with disease. Osteoarthritis is a whole joint disease, affecting joint cartilage, ligaments, menisci and joint associated muscles, from variable pathophysiological processes. Hence, there is a need to develop a physiotherapy protocol to address the multi-structural physical, physiological and functional impairments associated with the disease.

OBJECTIVE

The objective of the present study is to evaluate the efficacy of designed, therapist supervised, patient education, progressive resistance exercises, passive stretching exercises, soft tissue manipulation, muscle energy technique, Maitland mobilization, aerobic exercise, and neuromuscular training physiotherapy protocol on pain, disability, balance, and physical functional performance in knee osteoarthritis patients.

METHODOLOGY

The preliminary study was conducted on a (n = 60) sample of convenience. The samples were randomly allocated into two study groups, intervention, and control group. The control group was advised on a basic home program. On the other hand, the treatment of the intervention group was designed with a therapist supervised Physiotherapy Protocol. The outcome variables studied were the Visual Analogue Scale, Modified WOMAC Scale, Timed Up and Go Test, Functional Reach Test, 40 m Fast Paced Walk Test, Stair Climb Test, 30 s Chair Stand Test.

RESULTS

The results of the study revealed a significant improvement among most of the studied outcome measures in the intervention group, hence the designed supervised physiotherapy protocol was found effective in relieving multiple physiological impairments associated with this whole joint disease.

Acute effects of an exercise based multimodal in-patient rehabilitation protocol in male knee osteoarthritis patients and the two years follow-up sustainability

BACKGROUND

Working with lifting and carrying heavy loads and kneeling postures with crawling, squats or heel seat position lead to progressive cartilage wear with premature degenerative changes.

OBJECTIVE

To investigate the effects of the exercise based multimodal 'knee college' and its sustainability in patients with knee osteoarthritis with data assessments before and after a starter course, before a 1-year and a 2-year follow-up refresher course in a retrospective observational study.

METHODS

A sample of 401 male patients (ICD10: M17 [arthrosis of knee]/ICF: s75011 [knee joint]) from the construction industries were assessed with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol (EQ-5D), Performance Assessment Capacity Testing (PACT), Isokinetic torque H/Q ratio and Physical Work Capacity Test (PWC). Retrospectively, after two years they were divided into three groups based on their intermediate sporting activity: gym (n = 194, age: 50.8±7.0, BMI: 28.8±4,3), home training (n = 110, age: 50.2±7.0, BMI: 28.4±4,2), no exercising (n = 97, age: 48.2±7.0, BMI: 29.2±4,6).

RESULTS

Patients did not differ significantly in their demographic and anthropometric data prior to the rehab program. Significant interaction effects indicated group-dependent differing sustainability effects for the 2-year follow-up (all outcomes: p < 0.001, except for H/Q ratio: p = 0.03). Group-wise analyses revealed significant acute improvements (after 3-week in-patient starter rehab program: p < 0.05) for all groups in almost all outcomes (except the 'no sport' group, H/Q ratio p = 0.08). These effects remained significant (p < 0.001) only for the 'gym' group during the 1-year and 2-year follow-up.

CONCLUSION

Our data indicate that 2-year sustainability of acute rehabilitation starter effects was demonstrated especially for patients with adherence and compliance to long-term gym based exercises.

Economic evaluation: a reader's guide to studies of cost-effectiveness

BACKGROUND

Understanding what an economic evaluation is, how to interpret it, and what it means for making choices in a health delivery context is necessary to contribute to decisions about healthcare resource allocation. The aim of this paper to demystify the working parts of a health economic evaluation, and explain to clinicians and clinical researchers how to read and interpret cost-effectiveness research.

MAIN BODY

This primer distils key content and constructs of economic evaluation studies, and explains health economic evaluation in plain language. We use the PICOT (participant, intervention, comparison, outcome, timeframe) clinical trial framework familiar to clinicians, clinical decision-makers, and clinical researchers, who may be unfamiliar with economics, as an aide to reading and interpreting cost-effectiveness research. We provide examples, primarily of physiotherapy interventions for osteoarthritis.

CONCLUSIONS

Economic evaluation studies are essential to improve decisions about allocating resources, whether those resources be your time, the capacity of your service, or the available funding across the entire healthcare system. The PICOT framework can be used to understand and interpret cost-effectiveness research.

Adjunctive therapies in addition to land-based exercise therapy for osteoarthritis of the hip or knee

BACKGROUND

Land-based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non-pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land-based exercise therapy is lacking.

OBJECTIVES

To evaluate the benefits and harms of adjunctive therapies used in addition to land-based exercise therapy compared with placebo adjunctive therapy added to land-based exercise therapy, or land-based exercise therapy only for people with hip or knee osteoarthritis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land-based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land-based exercise therapy, or land-based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant-reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short-term (6 months), medium-term (6 to 12 months) and long-term (12 months onwards) effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE.

MAIN RESULTS

We included 62 trials (60 RCTs and 2 quasi-RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 59 included people with knee osteoarthritis only. Thirty-six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty-one trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in eight (13%) trials. Comparing adjunctive therapies plus land-based exercise therapy against placebo therapies plus exercise up to six months (short-term), we found low-certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate-certainty evidence indicates that adjunctive therapies did not improve QOL (SF-36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low-certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant-reported global assessment was not measured in any studies. Compared with land-based exercise therapy, low-certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short-term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise-only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (45 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (45 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low-certainty evidence). Moderate-certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant-reported global assessment (short-term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI -0.32 to -0.18 mm); 12% relative improvement (6% better to 18% better). Low-certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27).

AUTHORS' CONCLUSIONS

Moderate- to low-certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant-reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short-term effects, with limited medium- or long-term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis.

The Benefits of Adding Manual Therapy to Exercise Therapy for Improving Pain and Function in Patients With Knee or Hip Osteoarthritis: A Systematic Review With Meta-analysis

OBJECTIVE: To evaluate if there was an additional benefit of combining manual therapy (MT) and exercise therapy over exercise therapy alone on pain and function in patients with hip or knee osteoarthritis. DESIGN: Intervention systematic review LITERATURE SEARCH: We (1) searched 4 databases from inception to June 20, 2021; (2) hand searched a reference list of included trials and relevant systematic reviews; and (3) contacted 2 researchers in the field. STUDY SELECTION CRITERIA: We included randomized controlled trials that compared MT and exercise therapy to similar exercise therapy programs alone in patients with hip or knee osteoarthritis. DATA SYNTHESIS: The data were combined using random-effects meta-analyses where appropriate. The certainty of evidence for each outcome was judged using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. RESULTS: We included 19 trials. There was very low to moderate certainty of evidence that MT added benefit in the short term for pain, and combined pain, function, and stiffness (WOMAC global scale), but not for performance-based function and self-reported function. In the medium term, there was low- to very-low-certainty evidence that MT added benefit for performance-based function and WOMAC global score, but not for pain. There was high-certainty evidence that MT provided no added benefit in the long term for pain and function. CONCLUSION: There was very low to moderate certainty of evidence supporting MT as an adjunct to exercise therapy for pain and WOMAC global scale, but not function in patients with knee or hip osteoarthritis in the short term. There was high certainty of evidence of no benefit for additional MT over exercise therapy alone in the long term. J Orthop Sports Phys Ther 2022;52(10):675-684. Epub: 27 July 2022. doi:10.2519/jospt.2022.11062.

Progressive resistance training compared to neuromuscular exercise in patients with hip osteoarthritis and the additive effect of exercise booster sessions: protocol for a multicentre cluster randomised controlled trial (The Hip Booster Trial)

INTRODUCTION

The primary aim of this randomised controlled trial is to investigate the effectiveness of 3 months of progressive resistance training (PRT) compared to neuromuscular exercise (NEMEX) on functional performance in patients with hip osteoarthritis (OA). Secondary aims are to investigate the effectiveness of exercise booster sessions (EBS) in prolonging the effects of the initial exercise interventions as well as to investigate the cost-effectiveness of PRT, NEMEX and EBS at 12-month follow-up.

METHODS AND ANALYSIS

This multicentre cluster randomised controlled trial will be conducted at hospitals and physiotherapy clinics across Denmark. A total of 160 participants with clinically diagnosed hip OA will be recruited. Participants will be cluster randomised to a 3-month intervention of either PRT or NEMEX and to receive EBS or not, resulting in four treatment arms.The primary outcome is change in functional performance, measured by the 30 s chair stand test at 3 months for the primary comparison and at 12 months for the EBS comparisons. Secondary outcomes include changes in 40 m fast-paced walk test, 9-step timed stair climb test, leg extensor muscle power and maximal strength, Hip disability and Osteoarthritis Outcome Score subscales, EuroQol Group 5-dimension, global perceived effect, physical activity and pain. Outcomes are measured at baseline, after the initial 3 months of intervention, and at 6-month, 9-month and 12-month follow-up. An intention-to-treat approach will be used for analysing changes in the primary and secondary outcome measures.

ETHICS AND DISSEMINATION

The trial has been approved by the Central Denmark Region Committee on Biomedical Research Ethics (Journal No 1-10-72-267-20) and registered at the Danish Data Protection Agency (Journal No 1-16-02-11-21). Results will be published in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04714047.

Effects of booster sessions on self-management interventions for chronic musculoskeletal pain: a systematic review and meta-analysis of randomised controlled trials

ABSTRACT

Our objective was to investigate the effectiveness of booster sessions after self-management interventions as a means of maintaining self-management behaviours in the treatment of chronic musculoskeletal pain. We searched MEDLINE, EMBASE, Science Citation Index, Cochrane Central Register of Controlled Trials, and PsychINFO. Two authors independently identified eligible trials and collected data. We calculated the odds ratio for the analyses of dichotomous data and standardised mean differences (SMDs) with 95% confidence interval (CI) for continuous variables. Our search identified 14 studies with a total of 1695 patients. All studies were at high risk of bias and provided very low quality evidence. For the primary outcomes, booster sessions had no evidence of an effect on improving patient-reported outcomes on physical function (SMD -0.13, 95% CI -0.32 to -0.06; P = 0.18), pain-related disability (SMD -0.16, 95% CI -0.36 to 0.03; P = 0.11), and pain self-efficacy (SMD 0.15, 95% CI -0.07 to 0.36; P = 0.18). For the secondary outcomes, booster sessions caused a significant reduction in patient-reported pain catastrophising (SMD -0.42, 95% CI -0.64 to -0.19; P = 0.0004) and no evidence of an effect on patient-reported pain intensity, depression, coping, or treatment adherence. There is currently little evidence that booster sessions are an effective way to prolong positive treatment effects or improve symptoms of long-term musculoskeletal conditions after self-management interventions. However, the studies were few with high heterogeneity, high risk of bias, and overall low quality of evidence. Our review argues against including booster sessions routinely to self-management interventions for the purpose of behaviour maintenance.

Are manual therapy or booster sessions worthwhile in addition to exercise therapy for knee osteoarthritis: Economic evaluation and 2-year follow-up of a randomized controlled trial

BACKGROUND

Exercise therapy is known to be an effective intervention for patients with osteoarthritis, however the evidence is limited as to whether adding manual therapy or booster sessions are cost-effective strategies to extend the duration of benefits.

OBJECTIVE

To investigate the cost-effectiveness, at 2-year follow-up, of adding manual therapy and/or booster sessions to exercise therapy.

DESIGN

2-by-2 factorial randomized controlled trial.

METHODS

Participants with knee osteoarthritis were randomly allocated (1:1:1:1) to: exercise therapy delivered in consecutive sessions within 9 weeks (control group), exercise therapy distributed over 1 year using booster sessions, exercise therapy plus manual therapy delivered within 9 weeks, and exercise therapy plus manual therapy with booster sessions. The primary outcome was incremental cost-effectiveness from health system and societal perspectives interpreted as incremental net monetary benefit (INMB).

RESULTS

Of 75 participants, 66 (88 %) were retained at 1-year and 40 (53 %) at 2-year follow-up. All three interventions were cost-effective from both the health system and societal perspectives (INMBs, at 0.5 × GDP/capita willingness to pay (WTP) threshold: $3278 (95%CI -3244 to 9800) and $3904 (95%CI -2823 to 10,632) respectively for booster sessions; $2941 (95%CI -3686 to 9568) and $2618 (95%CI -4005 to 9241) for manual therapy; $270 (95%CI -6139 to 6679) and $404 (95%CI -6097 to 6905) for manual therapy with booster sessions).

CONCLUSION

Manual therapy or booster sessions in addition to exercise therapy are cost-effective at 2-year follow-up. The evidence did not support combining both booster sessions and manual therapy in addition to exercise therapy.

The Efficacy of Manual Therapy in Patients with Knee Osteoarthritis: A Systematic Review

Background and objectives: Osteoarthritis (OA) is among the most common degenerative diseases that induce pain, stiffness and reduced functionality. Various physiotherapy techniques and methods have been used for the treatment of OA, including soft tissue techniques, therapeutic exercises, and manual techniques. The primary aim of this systemic review was to evaluate the short-and long-term efficacy of manual therapy (MT) in patients with knee OA in terms of decreasing pain and improving knee range of motion (ROM) and functionality. Materials and Methods: A computerised search on the PubMed, PEDro and CENTRAL databases was performed to identify controlled randomised clinical trials (RCTs) that focused on MT applications in patients with knee OA. The keywords used were 'knee OA', 'knee arthritis', 'MT', 'mobilisation', 'ROM' and 'WOMAC'. Results: Six RCTs and randomised crossover studies met the inclusion criteria and were included in the final analysis. The available studies indicated that MT can induce a short-term reduction in pain and an increase in knee ROM and functionality in patients with knee OA. Conclusions: MT techniques can contribute positively to the treatment of patients with knee OA by reducing pain and increasing functionality. Further research is needed to strengthen these findings by comparing the efficacy of MT with those of other therapeutic techniques and methods, both in the short and long terms.

Long-term effect of high-intensity laser therapy for persistent shoulder pain: A case report

BACKGROUND AND OBJECTIVE

This case report describes the long-term effect of the high-intensity laser therapy (HILT) in a patient with chronic shoulder pain refractory in comparison to other treatments.

CASE DESCRIPTION

Ten sessions of HILT were applied in a thirty-one-year-old woman diagnosed with subacromial syndrome. Assessment was carried out through different tests: Shoulder Pain and Disability Index (SPADI), Numeric Pain Rating Scale (NPRS) and pressure pain threshold (PPT). All measurements were taken at four different points: at the end of the 10 sessions, after one month, three months after the intervention and nine months after the initial intervention.

RESULTS

There was a clinically significant improvement in NPRS (decrease of 5 points), PPT (increase of 1.5 kg/cm2) and SPADI (decrease of 24 points) one month after the intervention. After three months, the increase of NPRS and SPADI required a 5-session intervention to support the clinical improvement. Six months after these booster sessions an increase in PPT and a decrease in NPRS and SPADI were observed.

CONCLUSION

Results indicate the suitability of developing new research lines which will optimize the use of HILT.

Predicting Recurrent Care Seeking of Physical Therapy for Musculoskeletal Pain Conditions

OBJECTIVE

Musculoskeletal pain conditions are a leading cause of pain and disability internationally and a common reason to seek health care. Accurate prediction of recurrence of health care seeking due to musculoskeletal conditions could allow for better tailoring of treatment. The aim of this project was to characterize patterns of recurrent physical therapy seeking for musculoskeletal pain conditions and to develop a preliminary prediction model to identify those at increased risk of recurrent care seeking.

DESIGN

Retrospective cohort.

SETTING

Ambulatory care.

SUBJECTS

Patients (n = 578,461) seeking outpatient physical therapy (United States).

METHODS

Potential predictor variables were extracted from the electronic medical record, and patients were placed into three different recurrent care categories. Logistic regression models were used to identify individual predictors of recurrent care seeking, and the least absolute shrinkage and selection operator (LASSO) was used to develop multivariate prediction models.

RESULTS

The accuracy of models for different definitions of recurrent care ranged from 0.59 to 0.64 (c-statistic), and individual predictors were identified from multivariate models. Predictors of increased risk of recurrent care included receiving workers' compensation and Medicare insurance, having comorbid arthritis, being postoperative at the time of the first episode, age range of 44-64 years, and reporting night sweats or night pain. Predictors of decreased risk of recurrent care included lumbar pain, chronic injury, neck pain, pregnancy, age range of 25-44 years, and smoking.

CONCLUSION

This analysis identified a preliminary predictive model for recurrence of care seeking of physical therapy, but model accuracy needs to improve to better guide clinical decision-making.

Outpatient Physical Therapy Use Following Tibial Fractures: A Retrospective Commercial Claims Analysis

OBJECTIVE

The purpose of this study was to characterize outpatient physical therapy (OPT) use following tibial fractures and examine the variability of OPT attendance, time of initiation, number of visits, and length of care by patient, injury, and treatment factors. In the absence of clinical guidelines, results will guide future efforts to optimize OPT following tibial fractures.

METHODS

This study used 2016 to 2017 claims from the IBM MarketScan Commercial Claims Research Database. The cohort included 9079 patients with International Classification of Diseases: Tenth Revision (ICD-10) diagnosis codes for tibial fractures. Use in the year following initial fracture management was determined using Current Procedural Terminology codes. Differences in use were examined using χ2 tests, t tests, and Kruskal-Wallace tests.

RESULTS

Sixty-seven percent of patients received OPT the year following fracture. OPT attendance was higher in female patients, in patients with 1 or no major comorbidity, and in the western United States. Attendance was higher in patients with upper tibial fractures, moderate-severity injuries, and treatment with external fixation and in patients discharged to an inpatient rehabilitation facility. Patients started OPT on average [SD] 50 [52.6] days after fracture and attended 18 [16.1] visits over the course of 101 [86.4] days. The timing of OPT, the number of visits attended, and the length of OPT care varied by patient, injury, and treatment-level factors.

CONCLUSIONS

One-third of insured patients do not receive OPT following tibial fracture. The timing of OPT initiation, the length of OPT care, and the number of visits attended by patients with tibial fractures were highly variable. Further research is needed to standardize referral and prescription practices for OPT following tibial fractures.

IMPACT

OPT use varies based on patient, injury, and treatment-level factors following tibial fractures. Results from this study can be used to inform future efforts to optimize rehabilitation care for patients with tibial fractures.

Efficacy of Specified Manual Therapies in Combination with a Supervised Exercise Protocol for Managing Pain Intensity and Functional Disability in Patients with Knee Osteoarthritis

PURPOSE

The current study aimed to determine the efficacy of specified manual therapies in combination with a supervised exercise protocol for managing pain intensity and functional disability in patients with knee osteoarthritis.

METHODS

The study was based on a two-arm parallel-group randomized controlled trial design, including a total of 32 participants with knee osteoarthritis randomly divided into groups A and B. Group A received a supervised exercise protocol; however, group B received specified manual therapies in combination with a supervised exercise protocol. Pain and functional disability were measured with the numeric pain rating scale (NPRS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), respectively. Data were collected at baseline (pre-intervention), 2 weeks, and 4 weeks post-intervention. To evaluate the efficacy of specific manual therapies with supervised exercise compared to supervised exercise alone, an unpaired t-test and repeated measures ANOVA were used to analyze the data, keeping the level of significance at p<0.05.

RESULTS

A significant (p<0.05) mean difference (∆MD) was found within group A and group B for both outcomes when we compared their baseline scores with 2-week (group A, NPRS: ∆MD=-1.56 and WOMAC: ∆MD=14.94; group B, NPRS: ∆MD=2.06 and WOMAC: ∆MD=22.19) and 4-week post-intervention scores (group A, NPRS: ∆MD=0.62 and WOMAC: ∆MD=6.75; group B, NPRS: ∆MD=0.75 and WOMAC: ∆MD=11.12). In addition, significant mean differences (p<0.05) reported for both outcomes when we compared their scores between groups A and B at 2 weeks (∆MD: NPRS=0.69; WOMAC=10.87) and 4 weeks post-intervention (∆MD: NPRS=0.31; WOMAC=8.00). Furthermore, a post hoc Scheffe analysis for the outcomes NPRS and WOMAC revealed the superiority of group B over group A.

CONCLUSION

The specified manual therapies, in combination with a supervised exercise protocol, were found to be more effective than a supervised exercise protocol alone for improving pain and functional disability in patients with knee osteoarthritis.

The Combination of Exercise and Manual Therapy Versus Exercise Alone in Total Knee Arthroplasty Rehabilitation: A Randomized Controlled Clinical Trial

BACKGROUND

Total knee arthroplasty (TKA) is one of the most commonly performed orthopedic surgeries in the lower extremity. However, patient dissatisfaction and functional disability are mostly experienced because of pain and limited range of motion (ROM). Although manual therapy is commonly implemented to improve ROM and modulate pain in the management of musculoskeletal disorders, there is a lack of evidence about its clinical effectiveness on postoperative TKA rehabilitation.

OBJECTIVE

To investigate the effectiveness of an exercise program combined with manual therapy compared with an exercise program only for pain, ROM, function, quality of life, and patient satisfaction outcomes.

DESIGN

A randomized controlled clinical trial.

SETTING

Rehabilitation unit of a university hospital.

PARTICIPANTS

Forty-two patients (68.45 ± 6.3 years) scheduled for unilateral TKA as a treatment of severe osteoarthritis.

INTERVENTIONS

Joint and soft tissue mobilizations in addition to exercise therapy were provided to the mobilization group (n = 21) while the control group received exercise therapy only (n = 21).

MAIN OUTCOME MEASURES

The outcome measures were numeric pain-rating scale, knee ROMs, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, 10-meter walk test (10MWT), 5-times sit to stand test (5SST), and Short Form-12 (SF-12).

RESULTS

Improvements in pain outcomes were significantly higher in the mobilization group than in the control group (P = .001, F [3, 33] = 7.06) and the between-group difference in change score was 1.3 points (P = .001). Although the between-group difference in change score was 12.8° for knee flexion at 2 months (P = .001), the overall group-by-time interactions were not significant for flexion and extension ROMs (P = .175, F [3, 33] = 1.75 and P = .57, F [2, 34] = 0.56, respectively). Additionally, there were statistically meaningful group-by-time interactions on total WOMAC score (P = .006, F [2, 34] = 5.29), 10MWT (P = .002, F [3, 33] = 5.98), and SF-12 mental component summary (P = .01, F [2, 34] = 4.92) favoring the mobilization group. Also, patient satisfaction was higher in the mobilization group (P = .02).

CONCLUSIONS

A structured exercise program combined with manual therapy can be more beneficial in improving pain, function, and patient satisfaction compared to exercise program alone for postoperative TKA patients.

The effect of an integrated multidisciplinary rehabilitation programme for patients with chronic low back pain: Long-term follow up of a randomised controlled trial

Objective:

To compare the long-term effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme, in terms of back-specific disability, in patients with chronic low back pain.

Design:

A single-centre, pragmatic, two-arm parallel, randomised controlled trial.

Setting:

A rheumatology rehabilitation centre in Denmark.

Subjects:

A total of 165 adults (aged ⩾ 18 years) with chronic low back pain.

Interventions:

An integrated programme (a pre-admission day, two weeks at home, two weeks inpatient followed by home-based activities, plus two 2-day inpatient booster sessions, and six-month follow-up visit) was compared with an existing programme (four-week inpatient, and six-month follow-up visit).

Main measure:

The primary outcome was disability measured using the Oswestry Disability Index after one year. Secondary outcomes included pain intensity (Numerical Rating Scale), pain self-efficacy (Pain Self-Efficacy Questionnaire), health-related quality of life (EuroQol-5 Domain 5-level (EQ-5D)), and depression (Major Depression Inventory). Analysis was by intention-to-treat, using linear mixed models.

Results:

303 patients were assessed for eligibility of whom 165 patients (mean age 50 years (SD 13) with a mean Oswestry Disability Index score of 42 (SD 11)) were randomly allocated (1:1 ratio) to the integrated programme (n = 82) or the existing programme (n = 83). The mean difference (integrated programme minus existing programme) in disability was –0.53 (95% CI –4.08 to 3.02); p = 0.770). No statistically significant differences were found in the secondary outcomes.

Conclusion:

The integrated programme was not more effective in reducing long-term disability in patients with chronic low back pain than the existing programme.

Dry Needling Combined With Guideline-Based Physical Therapy Provides No Added Benefit in the Management of Chronic Neck Pain: A Randomized Controlled Trial

OBJECTIVE

To determine the added benefit of combining dry needling with a guideline-based physical therapy treatment program consisting of exercise and manual therapy on pain and disability in people with chronic neck pain.

DESIGN

Randomized controlled trial.

METHODS

Participants were randomized to receive either guideline-based physical therapy or guideline-based physical therapy plus dry needling. The primary outcomes, measured at 1 month post randomization, were average pain intensity in the previous 24 hours and previous week, measured with a numeric pain-rating scale (0-10), and disability, measured with the Neck Disability Index (0-100). The secondary outcomes were pain and disability measured at 3 and 6 months post randomization and global perceived effect, quality of sleep, pain catastrophizing, and self-efficacy measured at 1, 3, and 6 months post randomization.

RESULTS

One hundred sixteen participants were recruited. At 1 month post randomization, people who received guideline-based physical therapy plus dry needling had a small reduction in average pain intensity in the previous 24 hours (mean difference, 1.56 points; 95% confidence interval [CI]: 1.11, 2.36) and in the previous week (mean difference, 1.20 points; 95% CI: 1.02, 2.21). There was no effect of adding dry needling to guideline-based physical therapy on disability at 1 month post randomization (mean difference, -2.08 points; 95% CI: -3.01, 5.07). There was no effect for any of the secondary outcomes.

CONCLUSION

When combined with guideline-based physical therapy for neck pain, dry needling resulted in small improvements in pain only at 1 month post randomization. There was no effect on disability. J Orthop Sports Phys Ther 2020;50(8):447-454. Epub 9 Apr 2020. doi:10.2519/jospt.2020.9389.

Long term efficacy of mobilisation with movement on pain and functional status in patients with knee osteoarthritis: a randomised clinical trial

OBJECTIVES

To evaluate the long term effect of mobilisation with movement on disability, pain and function in subjects with symptomatic knee osteoarthritis.

DESIGN

A randomised controlled trial.

SETTING

A general hospital.

SUBJECTS

Forty adults with knee osteoarthritis (grade 1-3 Kellgren-Lawrence scale).

INTERVENTIONS

The experimental group received mobilisation with movement and usual care (exercise and moist heat) while the control group received usual care alone in six sessions over two weeks.

MAIN MEASURES

The primary outcome was the Western Ontario McMaster University Osteoarthritis index, higher scores indicating greater disability. Pain intensity over 24 hours and during sit to stand were measured on a 10 centimetre visual analogue scale. Functional outcomes were the timed up and go test, the 12 step stair test, and knee range of motion. Patient satisfaction was measured on an 11 point numerical rating scale. Variables were evaluated blind pre- and post intervention, and at three and six months follow-up.

RESULTS

Thirty five participants completed the study. At each follow-up including six-months, significant differences were found between groups favouring those receiving mobilisation with movement for all variables except knee mobility. The primary outcome disability showed a mean difference of 7.4 points (95% confidence interval, 4.5 to 10.3) at six-months and a mean difference of 13.6 points (95% confidence interval, 9.3 to 17.9) at three-months follow-up.

CONCLUSION

In patients with symptomatic knee osteoarthritis, the addition of mobilisation with movement provided clinically significant improvements in disability, pain, functional activities and patient satisfaction six months later.

Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee

BACKGROUND

Both physical therapy and intraarticular injections of glucocorticoids have been shown to confer clinical benefit with respect to osteoarthritis of the knee. Whether the short-term and long-term effectiveness for relieving pain and improving physical function differ between these two therapies is uncertain.

METHODS

We conducted a randomized trial to compare physical therapy with glucocorticoid injection in the primary care setting in the U.S. Military Health System. Patients with osteoarthritis in one or both knees were randomly assigned in a 1:1 ratio to receive a glucocorticoid injection or to undergo physical therapy. The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year (scores range from 0 to 240, with higher scores indicating worse pain, function, and stiffness). The secondary outcomes were the time needed to complete the Alternate Step Test, the time needed to complete the Timed Up and Go test, and the score on the Global Rating of Change scale, all assessed at 1 year.

RESULTS

We enrolled 156 patients with a mean age of 56 years; 78 patients were assigned to each group. Baseline characteristics, including severity of pain and level of disability, were similar in the two groups. The mean (±SD) baseline WOMAC scores were 108.8±47.1 in the glucocorticoid injection group and 107.1±42.4 in the physical therapy group. At 1 year, the mean scores were 55.8±53.8 and 37.0±30.7, respectively (mean between-group difference, 18.8 points; 95% confidence interval, 5.0 to 32.6), a finding favoring physical therapy. Changes in secondary outcomes were in the same direction as those of the primary outcome. One patient fainted while receiving a glucocorticoid injection.

CONCLUSIONS

Patients with osteoarthritis of the knee who underwent physical therapy had less pain and functional disability at 1 year than patients who received an intraarticular glucocorticoid injection. (ClinicalTrials.gov number, NCT01427153.).

Effects of manual therapies on stability in people with musculoskeletal pain: a systematic review

Introduction

Chronic musculoskeletal pain is associated with reduced balance performance and falls risk. Manual therapies are commonly used interventions for musculoskeletal pain. There is emerging evidence that manual therapies may improve balance. The aim of this systematic review was to examine the effectiveness of manual therapies for musculoskeletal pain on measures of static and dynamic stability.

Methods

Six electronic databases were searched using pre-defined eligibility criteria and two independent reviewers assessed all identified records. Risk of bias was assessed using the 12-item Cochrane Risk of Bias assessment by two authors independently and any discrepancies resolved through consensus. Meta-analysis was conducted when three or more studies used the same outcome measures including gait speed, timed up and go test, step test and sit-to-stand test.

Results

Twenty-six studies were included in the analysis. Both spinal and extremity musculoskeletal pain conditions were represented. Manual therapies included manipulation, mobilisation and massage. The most common intervention compared to manual therapy was exercise. Outcome measures included both clinical and objective measures of stability. Overall the risk of bias was reported as generally low or unclear.

Conclusion

Improvement in stability measures were reported in studies comparing manual therapy in the short term, but not long-term follow-up. There was no clear association between significant pain reduction and measures of stability. Further prospective studies are recommended to investigate whether manual therapies should be part of an integrative healthcare plan for risk of falls management and when a transition from manual therapy to more active interventions should occur for long term management.

Protective effects of Erdosteine on interleukin-1β-stimulated inflammation via inhibiting the activation of MAPK, NF-κB, and Wnt/β-catenin signaling pathways in rat osteoarthritis

Osteoarthritis (OA), a degenerative arthropathy, is featured with progressive degradation of cartilage and a chondrocyte inflammatory response. Erdosteine (ER) showed the anti-oxidant properties and various anti-inflammatory effects in various diseases. However, whether it protects against OA remains unknown. In this study, we explore the potential therapeutic properties of ER on IL-1β-stimulated rat chondrocytes and its underlying mechanism in vitro and vivo. Cell viability, pro-inflammatory cytokines and the degradation of ECM biomarkers were tested to determine the effects of ER at 10, 20, and 40 μM doses on IL-1β-induced rat chondrocytes for 24 h in virto. In vivo, intra-articular injections of 50 μl of 100 mg/ml ER twice a week for 8 weeks. The results showed ER significantly suppressed the expressions of IL-1β-induced the production of inflammatory factors in a dose-dependent pattern (4.30-fold decrease in COX-2, p < 0.05; 4.77-fold decrease in iNOS, p < 0.05 at 40 μM in protein levels). Moreover, ER could attenuate the degradation of ECM in IL-1β-induced rat chondrocytes by repressing the expression of OA-related factors (2.40-fold decrease in ADAMTS-5, p < 0.05; 3.12-fold decrease in MMP1, p < 0.05; 3.97-fold decrease in MMP3, p < 0.05; and 2.62-fold decrease in MMP-13, p < 0.05 at 40 μM in protein levels). Furthermore, our study revealed that ER could inhibit the activations of IL-1β-induced MAPK and Wnt/β-catenin. Besides, ER could suppress the process of IL-1β-induced P65 from the cytoplasm into the nucleus. In vivo, ER delaied the osteoarthritis progression in rat OA models. Collectively, ER might become a new therapeutic agent for OA.

The effect of an integrated multidisciplinary rehabilitation programme alternating inpatient interventions with home-based activities for patients with chronic low back pain: a randomized controlled trial

Objective:

To compare the effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme in patients with chronic low back pain.

Design:

A single-centre, pragmatic, two-arm parallel, randomized controlled trial (1:1 ratio).

Setting:

A rheumatology inpatient rehabilitation centre in Denmark.

Subjects:

A total of 165 adults (aged ⩾ 18 years) with chronic low back pain.

Interventions:

An integrated rehabilitation programme comprising an alternation of three weeks of inpatient stay and 12 weeks of home-based activities was compared with an existing rehabilitation programme of four weeks of inpatient stay.

Main measures:

Patient-reported outcomes were collected at baseline and at the 26-week follow-up. The primary outcome was back-specific disability (Oswestry Disability Index). Secondary outcomes included pain intensity (Numerical Rating Scale), pain self-efficacy (Pain Self-Efficacy Questionnaire), health-related quality of life (EuroQol-5 Domain 5-level (EQ-5D)), and depression (Major Depression Inventory). A complete case analysis was performed.

Results:

A total of 303 patients were assessed for eligibility of whom 165 (mean age: 50 years (SD 13) and mean Oswestry Disability Index score 42 (SD 11)) were randomized (83 to existing rehabilitation programme and 82 to integrated rehabilitation programme). Overall, 139 patients provided the 26-week follow-up data. Baseline demographic and clinical characteristics were comparable between programmes. The between-group difference in the Oswestry Disability Index score when adjusting for the corresponding baseline score was −0.28 (95% confidence interval (CI): −4.02, 3.45) which was neither statistically nor clinically significant. No significant differences were found in the secondary outcomes.

Conclusion:

An integrated rehabilitation programme was no more effective than an existing rehabilitation programme at the 26-week follow-up.

[Effects and sustainability of knee school : 2-year results of a secondary prevention program for gonarthrosis]

BACKGROUND

Craftsmen and workers in the construction industry are at an increased risk of developing gonarthrosis due to their work-related burdens. In order to maintain the ability to work, occupational co-operative measures for secondary prevention can be carried out (BG Bau/Kniekolleg). The aim was to evaluate the efficacy after 2 years, depending on the degree of exercise adherence.

MATERIAL AND METHODS

In a repeated measurement design (T1 before, T2 after knee school, T3 after 1 year, T4 after 2 years), 140 construction patients were assessed for their dynamic muscular strength (knee extension, 60°/s,); their quality of life (SF-36) and characteristics for gonarthrosis (WOMAC) were evaluated using analyses of variances, whereby one group trained after the knee training in the gym with instruction (Gr. 1 n = 63), one group completed a home-training program (Gr. 2 n = 38), and one group completed exercises outside of knee school (Gr.3 n = 39).

RESULTS

For all parameters, significant acute efficacy and 2‑year sustainability effects were observed (p ≤ 0.05, d: 0.2-0.8). There was no interaction with adherence during training after knee school (p > 0.05).

CONCLUSION

Knee school has proved to be effective in the long term, leading to a critical questioning of future research, why there are no differences between guided, reduced or even missing long-term maintenance training.

A consensus-based process identifying physical therapy and exercise treatments for patients with degenerative meniscal tears and knee OA: the TeMPO physical therapy interventions and home exercise program

Background

Knee osteoarthritis (OA) is prevalent and often associated with meniscal tear. Physical therapy (PT) and exercise regimens are often used to treat OA or meniscal tear, but, to date, few programs have been designed specifically for conservative treatment of meniscal tear with concomitant knee OA. Clinical care and research would be enhanced by a standardized, evidence–based, conservative treatment program and the ability to study the effects of the contextual factors associated with interventions for patients with painful, degenerative meniscal tears in the setting of OA. This paper describes the process of developing both a PT intervention and a home exercise program for a randomized controlled clinical trial that will compare the effectiveness of these interventions for patients with knee pain, meniscal tear and concomitant OA.

Methods

This paper describes the process utilized by an interdisciplinary team of physical therapists, physicians, and researchers to develop and refine a standardized in-clinic PT intervention, and a standardized home exercise program to be carried out without PT supervision. The process was guided in part by Medical Research Council guidance on intervention development.

Results

The investigators achieved agreement on an in-clinic PT intervention that included manual therapy, stretching, strengthening, and neuromuscular functional training addressing major impairments in range of motion, musculotendinous length, muscle strength and neuromotor control in the major muscle groups associated with improving knee function. The investigators additionally achieved agreement on a progressive, protocol-based home exercise program (HEP) that addressed the same major muscle groups. The HEP was designed to allow patients to perform and progress the exercises without PT supervision, utilizing minimal equipment and a variety of methods for instruction.

Discussion

This multi-faceted in-clinic PT program and standardized HEP provide templates for in-clinic and home-based care for patients with symptomatic degenerative meniscal tear and concomitant OA. These interventions will be tested as part of the Treatment of Meniscal Tear in Osteoarthritis (TeMPO) Trial.

Trial registration

The TeMPO Trial was first registered at clinicaltrials.gov with registration No. NCT03059004 on February 14, 2017. TeMPO was also approved by the Institutional Review Board at Partners HealthCare/Brigham and Women’s Hospital.

Effectiveness of behaviour change techniques in physiotherapy interventions to promote physical activity adherence in lower limb osteoarthritis patients: A systematic review

Background

Lower limb osteoarthritis (OA) causes high levels of individual pain and disability and is an increasing socio-economic burden to global healthcare systems. Physical Activity interventions are commonly provided by physiotherapists to help patients with lower limb OA manage their clinical symptoms.

Objective

To identify and evaluate the effectiveness of behavioural change techniques (BCTs) within physiotherapy interventions to increase physical activity (PA) adherence in patients with lower limb OA.

Design

A systematic review was conducted, following Cochrane guidelines according to a published and registered protocol (CRD42016039932). Two independent researchers conducted searches, determined eligibility, assessed risk of bias (Cochrane tool), intervention fidelity (NIHBCC checklist), and coded randomised controlled trials (RCTs) for BCTs (V1 taxonomy). BCT effectiveness ratios were calculated and RCT risk of bias and intervention fidelity were summarised narratively.

Data sources

A highly sensitive search strategy was conducted on Medline, Embase, PsycINFO, CENTRAL, CINAHL and PEDro and grey literature databases from inception to January 2^nd, 2018. Reference lists of included RCTs and relevant articles were reviewed, and a citation search was conducted using Web of Science.

Eligibility criteria for selecting studies

RCTs that evaluated the effectiveness of a physiotherapy intervention that incorporated ≥1 BCT that promoted home or community-based PA adherence in patients with lower limb osteoarthritis.

Results

Twenty-four RCTs (n = 2366 participants) of variable risk of bias (RoB) (5 low; 7 moderate; 12 high) and poor intervention reporting from 10 countries were included. Heterogeneity of intervention BCTs and PA adherence outcome measures precluded meta-analysis. Thirty-one distinct BCTs were identified in 31 interventions across RCTs. In general, BCTs demonstrated higher effectiveness ratios for short-term and long-term PA adherence compared with medium-term outcomes. The BCTs ‘behavioural contract’, ‘non-specific reward’, ‘patient-led goal setting’ (behaviour), ‘self-monitoring of behaviour’, and ‘social support (unspecified) demonstrated the highest effectiveness ratios across time points to promote PA adherence.

Conclusions

BCTs demonstrate higher short and long-term than medium-term effectiveness ratios. Further research involving low RoB RCTs incorporating transparently reported interventions with pre-specified BCTs aimed at optimising lower limb OA patient PA adherence is required.

Incremental clinical effectiveness and cost effectiveness of providing supervised physiotherapy in addition to usual medical care in patients with osteoarthritis of the hip or knee: 2-year results of the MOA randomised controlled trial

OBJECTIVE

To investigate the clinical- and cost-effectiveness at 2-year follow-up of providing individual, supervised exercise physiotherapy and/or manual physiotherapy in addition to usual medical care.

METHOD

People with hip or knee osteoarthritis meeting the American College of Rheumatology clinical diagnostic criteria were randomised (1:1, concealed, assessor-blinded) to four groups: usual medical care; supervised exercise physiotherapy; manual physiotherapy; or combined exercise and manual physiotherapy. Physiotherapy group participants were provided 10 50-min treatment sessions including booster sessions at 4 and 13 months, in addition to usual care. The primary outcome at 2-year follow-up was incremental cost-utility ratio (ICUR) of each physiotherapy intervention in addition to usual care, compared with usual care alone, from the health system and societal perspectives. To allow interpretation of negative ICURs, we report incremental net benefit (INB). The primary clinical outcome was the Western Ontario and McMaster Osteoarthritis Index (WOMAC).

RESULTS

Of 206 patients, 186 (90·3%) were retained at 2-year follow-up. Exercise physiotherapy and manual physiotherapy dominated usual care, demonstrating cost savings; combined therapy did not. Exercise therapy had the highest incremental net benefits (INBs), statistically significant at all willingness-to-pay (base-case: societal New Zealand (NZ)$6,312, 95%CI 334 to 12,279; health system NZ$8,065, 95%CI 136 to 15,994). Clinical improvements were superior to usual care only in the exercise physiotherapy group (-28.2 WOMAC points, 95%CI -49.2 to -7.1). No serious adverse events were recorded.

CONCLUSION

Individually supervised exercise therapy is cost-effective and clinically effective in addition to usual medical care at 2-year follow-up, and leads to cost savings for the health system and society.

TRIAL REGISTRATION

Prospectively registered with the Australian NZ Clinical Trials Registry, reference ACTRN12608000130369.

Individuals with lumbar spinal stenosis seek education and care focused on self-management-results of focus groups among participants enrolled in a randomized controlled trial

BACKGROUND CONTEXT

The effectiveness of treatments for chronic, degenerative conditions of the lumbar spine can be influenced by patient perceptions and expectations regarding treatment.

PURPOSE

The primary purpose of this study was to understand the factors that are important to individuals with lumbar spinal stenosis (LSS) regarding different nonsurgical treatments. These factors were considered within the context of each treatment received as a part of the parent randomized controlled trial (RCT).

STUDY DESIGN

Focus group study of RCT participants.

PATIENT SAMPLE

Convenience sample of 50 individuals with LSS (28 female, average age 73±7.7 years) from an RCT participated in one of six focus groups. Focus groups consisted of patients previously randomized to one of three nonsurgical treatments: (1) medical care; (2) community-based group exercise; and (3) clinic-based manual therapy and individualized exercise.

OUTCOME MEASURES

Experiences, opinions, and preferences of individuals with LSS who participated in an RCT. Inter-coder agreement for qualitative analysis was conducted with kappa statistics.

METHODS

Participants discussed their experiences and perceptions regarding study treatment and their general experience with LSS using open-ended questions provided by a facilitator. Transcripts were coded according to modified grounded theory in an open approach, using codes that addressed the primary focus group discussion topics (primary coding) and codes for emerging topics (secondary coding). Secondary coding sought to identify themes concerning living with LSS and seeking treatment that were emergent from the focus groups. This study was funded by the Patient-Centered Research Outcomes Institute. The authors report no conflicts of interest.

RESULTS

Three themes related to medical treatment and symptom management arose from analyses: (1) an emotional response to LSS; (2) a desire for education about LSS and motivation to pursue education from any available source; and (3) a desire for individualized care based on self-management techniques and lifestyle changes. Emotional responses were more evident in individuals receiving medical care, whereas the other two themes were consistent across all three treatment groups.

CONCLUSIONS

The chronic pain associated with LSS may result in negative emotional responses. Individuals with LSS may believe misinformation and information from nonmedical sources, especially when medical providers do not spend sufficient time explaining the disease process and the reasoning behind treatment strategies. Receiving individualized care focused on self-management led to fewer negative emotions toward care and the disease process. Clinicians should be prepared to address all three of these aspects when providing care to individuals with LSS.

Effects of orthopaedic manual therapy in knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

This systematic review to aimed to evaluate the effects of orthopaedic manual therapy (OMT) on pain, improving function, and physical performance in patients with knee osteoarthritis (OA).

DATA SOURCES

Four databases (PubMed, Web of Science, CENTRAL, and CINAHL) were searched.

STUDY SELECTION

Trials were required to compare OMT alone or OMT in combination with exercise therapy, with exercise therapy alone or control.

DATA EXTRACTION

Data extraction and risk assessment were done by two independent reviewers. Outcome measures were visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, WOMAC function score, WOMAC global score, and stairs ascending-descending time.

RESULTS

Eleven randomized controlled trials were included (494 subjects), four of which had a PEDro score of 6 or higher, indicating adequate quality. The results of the meta-analysis indicated that reduction of VAS score in OMT compared with the control group was statistically insignificant (SDM: -0.59; 95% CI: -1.54 to -0.36; P=0.224). The reduction of VAS score in OMT compared with exercise therapy group was statistically significant (SDM: -0.78; 95% CI: -1.42 to -0.17; P=0.013). The reduction of WOMAC pain score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.79; 95% CI: -1.14 to -0.43; P=0.001). Similarly, the reduction of WOMAC function score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.85; 95% CI: -1.20 to -0.50; P=0.001). However, the reduction of WOMAC global score in OMT compared with the exercise therapy group was statistically insignificant (SDM: -0.23; 95% CI: -0.54 to -0.09; P=0.164). The reduction of stairs ascending-descending time in OMT compared with the exercise therapy group was statistically significant (SDM: -0.88; 95% CI: -1.48 to -0.29; P=0.004).

CONCLUSIONS

This review indicated OMT compared with exercise therapy alone provides short-term benefits in reducing pain, improving function, and physical performance in patients with knee OA.

REVIEW REGISTRATION

PROSPERO 2016:CRD42016032799.

Physical Activity and Exercise Therapy Benefit More Than Just Symptoms and Impairments in People With Hip and Knee Osteoarthritis

Synopsis Osteoarthritis (OA) of the hip and knee is among the leading causes of global disability, highlighting the need for early, targeted, and effective treatment. The benefits of exercise therapy in people with hip and knee OA are substantial and supported by high-quality evidence, underlining that it should be part of first-line treatment in clinical practice. Furthermore, unlike other treatments for OA, such as analgesia and surgery, exercise therapy is not associated with risk of serious harm. Helping people with OA become more physically active, along with structured exercise therapy targeting symptoms and impairments, is crucial, considering that the majority of people with hip and knee OA do not meet physical activity recommendations. Osteoarthritis is associated with a range of chronic comorbidities, including type 2 diabetes, cardiovascular disease, and dementia, all of which are associated with chronic low-grade inflammation. Physical activity and exercise therapy not only improve symptoms and impairments of OA, but are also effective in preventing at least 35 chronic conditions and treating at least 26 chronic conditions, with one of the potential working mechanisms being exercise-induced anti-inflammatory effects. Patient education may be crucial to ensure long-term adherence and sustained positive effects on symptoms, impairments, physical activity levels, and comorbidities. J Orthop Sports Phys Ther 2018;48(6):439-447. Epub 18 Apr 2018. doi:10.2519/jospt.2018.7877.

Effects of dry needling in an exercise program for older adults with knee osteoarthritis: A pilot clinical trial

BACKGROUND

Few studies have investigated the dry needling (DN) approach on knee osteoarthritis (KO) patients. The study's aim was to evaluate the short-term efficacy of adding DN to a therapeutic exercise protocol in the treatment of KO in older adults.

METHODS

A double-blind, pilot clinical trial with parallel groups [NCT02698072] was carried out for 12 weeks of treatment and follow-up. Twenty patients aged 65 years and older with myofascial trigger points (MTrPs) in the muscles of the thigh were recruited from older-adult care centers and randomly assigned to a DN + Exercise group or a Sham-DN + Exercise group. The Numeric Rating Scale (NRS; primary outcome) and Western Ontario and McMaster Universities Osteoarthritis Index questionnaire (WOMAC) were assessed before and after the intervention.

RESULTS

The NRS (analysis of variance, ANOVA) showed statistically significant differences in the time factor (F = 53.038; P < .0001; ηp = 0.747). However, it did not show a significant change in the group-time interaction (F = 0.082; P = .777; ηp = 0.005). The WOMAC scores (ANOVA) showed statistically significant differences in the time factor for total score WOMAC questionnaire (F = 84.826; P < .0001; ηp = 0.825), WOMAC pain (F = 90.478; P < .0001; ηp = 0.834), WOMAC stiffness (F = 14.556; P < .001; ηp = 0.447), and WOMAC function (F = 70.872; P < .0001; ηp = 0.797). However, it did not show a statistically significant change in the group-time interaction.

CONCLUSION

Despite the pain intensity and disability clinically relevant improvement for both DN and Sham-DN combined with exercise, 6 sessions of DN added to a therapeutic exercise program for older adults with KO did not seem to improve pain intensity and functionality.

The Influence of Exercise Dosing on Outcomes in Patients With Knee Disorders: A Systematic Review

Study Design Systematic review. Background Therapeutic exercise is commonly used to treat individuals with knee disorders, but dosing parameters for optimal outcomes are unclear. Large variations exist in exercise prescription, and research related to specific dosing variables for knee osteoarthritis, patellar tendinopathy, and patellofemoral pain is sparse. Objectives To identify specific doses of exercise related to improved outcomes of pain and function in individuals with common knee disorders, categorized by effect size. Methods Five electronic databases were searched for studies related to exercise and the 3 diagnoses. Means and standard deviations were used to calculate effect sizes for the exercise groups. The overall quality of evidence was assessed using the Physiotherapy Evidence Database scale. Results Five hundred eighty-three studies were found after the initial search, and 45 were included for analysis after screening. Physiotherapy Evidence Database scale scores were "fair" quality and ranged from 3 to 8. For knee osteoarthritis, 24 total therapeutic exercise sessions and 8- and 12-week durations of exercise were parameters most often associated with large effects. An exercise frequency of once per week was associated with no effect. No trends were seen with exercise dosing for patellar tendinopathy and patellofemoral pain. Conclusion This review suggests that there are clinically relevant exercise dosing variables that result in improved pain and function for patients with knee osteoarthritis, but optimal dosing is still unclear for patellar tendinopathy and patellofemoral pain. Prospective studies investigating dosing parameters are needed to confirm the results from this systematic review. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2018;48(3):146-161. Epub 10 Jan 2018. doi:10.2519/jospt.2018.7637.

Exercise, Manual Therapy, and Booster Sessions in Knee Osteoarthritis: Cost-Effectiveness Analysis From a Multicenter Randomized Controlled Trial

BACKGROUND

Limited information exists regarding the cost-effectiveness of rehabilitation strategies for individuals with knee osteoarthritis (OA).

OBJECTIVE

The study objective was to compare the cost-effectiveness of 4 different combinations of exercise, manual therapy, and booster sessions for individuals with knee OA.

DESIGN

This economic evaluation involved a cost-effectiveness analysis performed alongside a multicenter randomized controlled trial.

SETTING

The study took place in Pittsburgh, Pennsylvania; Salt Lake City, Utah; and San Antonio, Texas.

PARTICIPANTS

The study participants were 300 individuals taking part in a randomized controlled trial investigating various physical therapy strategies for knee OA.

INTERVENTION

Participants were randomized into 4 treatment groups: exercise only (EX), exercise plus booster sessions (EX+B), exercise plus manual therapy (EX+MT), and exercise plus manual therapy and booster sessions (EX+MT+B).

MEASUREMENTS

For the 2-year base case scenario, a Markov model was constructed using the United States societal perspective and a 3% discount rate for costs and quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios were calculated to compare differences in cost per QALY gained among the 4 treatment strategies.

RESULTS

In the 2-year analysis, booster strategies (EX+MT+B and EX+B) dominated no-booster strategies, with both lower health care costs and greater effectiveness. EX+MT+B had the lowest total health care costs. EX+B cost[Formula: see text]1061 more and gained 0.082 more QALYs than EX+MT+B, for an incremental cost-effectiveness ratio of[Formula: see text]12,900/QALY gained.

LIMITATIONS

The small number of total knee arthroplasty surgeries received by individuals in this study made the assessment of whether any particular strategy was more successful at delaying or preventing surgery in individuals with knee OA difficult.

CONCLUSIONS

Spacing exercise-based physical therapy sessions over 12 months using periodic booster sessions was less costly and more effective over 2 years than strategies not containing booster sessions for individuals with knee OA.

Immediate effects of Maitland mobilization versus Mulligan Mobilization with Movement in Osteoarthritis knee- A Randomized Crossover trial

BACKGROUND

Maitland Mobilization or Mulligan Mobilization with Movement (MWM) approaches have been widely used clinically for pain relief and improving mobility in Osteoarthritis knee. However the experimental evidence supporting the usage of these mobilization techniques as sole interventions in management of Osteoarthritis knee is insufficient.

OBJECTIVE

To determine from Maitland Mobilization and Mulligan MWM, which mobilization technique will be more effective in reducing pain and improving mobility and function in OA knee immediately after the intervention.

STUDY DESIGN

Randomized Crossover trial.

MATERIALS AND METHODS

30 subjects with osteoarthritis knee were recruited and 15 each were randomly allocated to two intervention sequences-one sequence was where Maitland was given first followed by Mulligan and the other was where Mulligan was given first followed by Maitland with a washout period of 48 h in between the two interventions. Numeric Pain Rating Scale (NPRS), Timed Up and Go (TUG) test and Pain free Squat Angle were the outcome measures measured before and immediately after both interventions.

RESULTS

Using Repeated Measures ANOVA for analysis of outcomes between and within interventions, no significant differences were seen between Maitland Mobilization and Mulligan MWM, for NPRS, TUG and Pain free Squat Angle (p = 0.18, p = 0.27,p = 0.17) respectively whereas within the interventions both Maitland and Mulligan all outcome measures showed significant changes (p < 0.001).

CONCLUSION

Thus it can be seen that Maitland mobilization and Mulligan MWM, both are equally effective in osteoarthritis knee in reducing pain and improving functional mobility and pain free squat angle immediately post treatment.

August 2017 Letters to the Editor-in-Chief

Letter to the Editor-in-Chief of JOSPT as follows: "Manual Therapy: More Than Elaborate Swordplay" with Authors' Response "Comparing Dry Needling to Corticosteroid Injection for Greater Trochanteric Pain Syndrome" with Authors' Response J Orthop Sports Phys Ther 2017;47(8):580-585. doi:10.2519/jospt.2017.0204.

2016 JOSPT Awards: Additive Effects and Biological Mechanisms of Interventions Offer Important Insights

During the American Physical Therapy Association's Combined Sections Meeting in San Antonio, TX in February 2017, JOSPT recognized the authors of the most outstanding research and clinical practice manuscripts published in JOSPT during 2016. The 2016 JOSPT Excellence in Research Award was presented to Carol A. Courtney, Alana D. Steffen, César Fernández-de-las-Peñas, John Kim, and Samuel J. Chmell, MD, for their March 2016 article "Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee." The 2016 George J. Davies-James A. Gould Excellence in Clinical Inquiry Award was presented to Seyda Toprak Celenay, Turkan Akbayrak, and Derya Ozer Kaya for their February 2016 article "A Comparison of the Effects of Stabilization Exercises Plus Manual Therapy to Those of Stabilization Exercises Alone in Patients With Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial." J Orthop Sports Phys Ther 2017;47(4):225-227. doi:10.2519/jospt.2017.0104.

Dry Needling Combined With Physical Therapy in Patients With Chronic Postsurgical Pain Following Total Knee Arthroplasty: A Case Series

Study Design Case series. Background This case series describes a combined program of dry needling and therapeutic exercise in a small group of patients with persistent pain following total knee arthroplasty (TKA). Case Description Fourteen patients who underwent TKA had persistent postsurgical pain and myofascial trigger points that were nonresponsive to treatment with conventional physical therapy and/or medication. The patients received a weekly dry needling treatment in combination with therapeutic exercises for 4 weeks. Pain perception was assessed preintervention and postintervention with a visual analog scale and function was assessed with the Western Ontario and McMaster Universities Osteoarthritis Index, 6-minute walk test, timed up-and-go test, 30-second chair-stand test, and knee joint range of motion. Outcomes After TKA, the patients had a mean ± SD symptom duration of 6.3 ± 3.1 months. Subsequent to dry needling, patients reported a significant mean ± SD decrease in pain intensity from 55.6 ± 6.6 to 19.3 ± 5.6 (P<.001) and improvements in Western Ontario and McMaster Universities Osteoarthritis Index scores from 10.1 ± 0.8 to 4.9 ± 1.0 for pain (P<.001), from 5.3 ± 0.4 to 2.4 ± 1.2 for stiffness (P<.001), and from 36.7 ± 2.0 to 20.1 ± 3.2 for function (P<.001). Knee flexion increased from a mean ± SD of 82.7° ± 5.2° to 93.3° ± 4.3° (P<.001), and joint extension improved from 15.8° ± 2.9° to 5.3° ± 2.4° (P<.05). The 6-minute walk test also showed improvement in postintervention values from a mean ± SD of 391.4 ± 23.7 to 424.7 ± 28.4 m (P<.05). Discussion After dry needling combined with therapeutic exercises, patients who had chronic pain following TKA showed clinically significant improvements in pain, range of motion, function, and myofascial trigger points. Future randomized clinical trials should further investigate the effectiveness of this protocol under similar conditions. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther 2017;47(3):209-216. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7089.

Discord Between Approaches to Spinal and Extremity Disorders: Is It Logical?

Rapid advances in the basic, clinical, and behavioral sciences are molding developments in conservative management of musculoskeletal disorders. Curiously, there seems to be discord developing between approaches to the assessment and management of patients, depending on whether they present with an extremity or spinal disorder. This viewpoint will comment on examples of differences emerging in some current practices. The aim is not to present a scientific treatise about underpinning sciences and evidence-based practice or to comment on what is correct or incorrect. Rather, the aim is to stimulate thought on the seeming discord in clinical practice, with respect to both the clinical evaluation of, as well as management approaches to, extremity and spinal disorders. J Orthop Sports Phys Ther 2016;46(11):938-941. doi:10.2519/jospt.2016.0610.