Effects of impairment-based exercise on performance of specific self-reported functional tasks in individuals with knee osteoarthritis

Exploring Race Differences in Satisfaction with Rehabilitation Following Total Knee Arthroplasty: a Qualitative Study

BACKGROUND

The purpose of this qualitative focus group study was to explore race differences in the rehabilitation experience and satisfaction with rehabilitation following total knee arthroplasty (TKA).

METHODS

We conducted a series of qualitative focus group discussions with groups of Non-Hispanic White and Non-Hispanic Black older adults who recently underwent TKA. We used grounded theory approach, which asks the researcher to develop theory from the data that are collected. Participants discussed barriers and facilitators to accessing rehabilitation after surgery, opinions regarding their physical therapists, the amount of post-operative physical therapy received, and overall satisfaction with the post-operative rehabilitation process.

RESULTS

Thirty-six individuals participated in focus groups. Three major themes emerged: (1) Participants reported overall positive views of their post-TKA rehabilitation experience. They particularly enjoyed one-on-one care, the ability to participate in "prehabilitation", and often mentioned specific interventions they felt were most helpful in their recovery. (2) Despite this, substantial barriers to accessing physical therapy exist. These include suboptimal pain management, copayments and other out-of-pocket costs, and transportation to visits. (3) There were minor differences in the rehabilitation experiences between Black and White participants. Black participants reported longer paths toward surgery and occasional difficulty interacting with rehabilitation providers.

CONCLUSIONS

Individuals undergoing TKA can largely expect positive rehabilitation experiences post-operatively. However, some barriers to post-operative physical therapy exist and may differ between Black and White patients. Physical therapists should increase their awareness of these barriers and work to minimize them whenever possible.

Relative Efficacy of Different Exercises for Pain, Function, Performance and Quality of Life in Knee and Hip Osteoarthritis: Systematic Review and Network Meta-Analysis

Background

Guidelines recommend exercise as a core treatment for osteoarthritis (OA). However, it is unclear which type of exercise is most effective, leading to inconsistency between different recommendations.

Objectives

The aim of this systematic review and network meta-analysis was to investigate the relative efficacy of different exercises (aerobic, mind–body, strengthening, flexibility/skill, or mixed) for improving pain, function, performance and quality of life (QoL) for knee and hip OA at, or nearest to, 8 weeks.

Methods

We searched nine electronic databases up until December 2017 for randomised controlled trials that compared exercise with usual care or with another exercise type. Bayesian network meta-analysis was used to estimate the relative effect size (ES) and corresponding 95% credibility interval (CrI) (PROSPERO registration: CRD42016033865).

Findings

We identified and analysed 103 trials (9134 participants). Aerobic exercise was most beneficial for pain (ES 1.11; 95% CrI 0.69, 1.54) and performance (1.05; 0.63, 1.48). Mind–body exercise, which had pain benefit equivalent to that of aerobic exercise (1.11; 0.63, 1.59), was the best for function (0.81; 0.27, 1.36). Strengthening and flexibility/skill exercises improved multiple outcomes at a moderate level. Mixed exercise was the least effective for all outcomes and had significantly less pain relief than aerobic and mind–body exercises. The trend was significant for pain (p = 0.01), but not for function (p = 0.07), performance (p = 0.06) or QoL (p = 0.65).

Conclusion

The effect of exercise varies according to the type of exercise and target outcome. Aerobic or mind–body exercise may be the best for pain and function improvements. Strengthening and flexibility/skill exercises may be used for multiple outcomes. Mixed exercise is the least effective and the reason for this merits further investigation.

Electronic supplementary material

The online version of this article (10.1007/s40279-019-01082-0) contains supplementary material, which is available to authorized users.

Self-reported Instability in Knee Osteoarthritis: A Scoping Review of Literature

BACKGROUND

Knee Osteoarthritis (OA) is a disabling musculoskeletal condition among the elderly. Self-reported instability is one of the impairments associated with osteoarthritis. A complete understanding of the self-reported instability in knee OA is essential, to identify the best strategies for overcoming this impairment. The focus of this scoping review is to provide an overview of evidence supported information about the prevalence and other associated features of selfreported instability in Knee OA. A broad search of the database PubMed with keywords such as knee osteoarthritis and instability resulted in 1075 articles. After title abstract and full-text screening, 19 relevant articles are described in the review. Overall, there is less amount of published literature on this topic. Studies reported prevalence rates of more than 60% for self-reported instability in knee osteoarthritis, which causes functional deterioration and high fear of falls. The most probable causative factors for self-reported instability in knee OA were altered sensory mechanisms and decreased muscle strength.

CONCLUSION

To conclude, self-reported knee instability in knee OA requires thorough evaluation and directed treatment with further studies providing rationalistic evidence-based management strategies. The current literature regarding self-reported knee instability is summarized, highlighting the research gaps.

Task-Specific Training for Adults With Chronic Knee Pain: A Case Series

Study Design Case series. Background Recent evidence suggests that traditional impairment-based rehabilitation approaches for patients with knee pain may not result in improved function or reduced disability. This case series describes a novel task-specific training approach to exercise therapy for patients with chronic knee pain and reports changes in measures of clinical outcome (pain and physical function) following participation in the training program. Case Description Seven patients with chronic knee pain aged 40 years or older were included. Each reported at least "moderate" difficulty with sit-to-stand transfers, floor transfers, and/or stair negotiation at baseline. Experienced physical therapists provided between 8 and 16 treatment sessions focusing on improving performance of difficult or painful tasks. Outcomes A majority of patients demonstrated clinically important improvements in both patient-rated outcomes (Knee injury and Osteoarthritis Outcome Score, numeric pain-rating scale, modified Arthritis Self-Efficacy Scale) and performance-based outcomes (30-second chair-rise test, timed stair-climb test, floor transfer test, Performance Assessment of Self-Care Skills). Discussion A task-specific training approach for patients with chronic knee pain was described and yielded considerable improvement in pain and function for most of the individuals in this case series. Larger studies are needed to determine how task-specific training compares with more traditional impairment-based exercise approaches for chronic knee pain. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2017;47(8):548-556. doi:10.2519/jospt.2017.7349.

High-intensity versus low-intensity physical activity or exercise in people with hip or knee osteoarthritis

BACKGROUND

Exercise or physical activity is recommended for improving pain and functional status in people with knee or hip osteoarthritis. These are complex interventions whose effectiveness depends on one or more components that are often poorly identified. It has been suggested that health benefits may be greater with high-intensity rather than low-intensity exercise or physical activity.

OBJECTIVES

To determine the benefits and harms of high- versus low-intensity physical activity or exercise programs in people with hip or knee osteoarthritis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; issue 06, 2014), MEDLINE (194 8 to June 2014) , EMBASE (198 0 to June 2014), CINAHL (1982 to June 2014), PEDro (1929 to June 2014), SCOPUS (to June 2014) and the World Health Organization (WHO) International Clinical Registry Platform (to June 2014) for articles, without a language restriction. We also handsearched relevant conference proceedings, trials, and reference lists and contacted researchers and experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomized controlled trials of people with knee or hip osteoarthritis that compared high- versus low-intensity physical activity or exercise programs between the experimental and control group.High-intensity physical activity or exercise programs training had to refer to an increase in the overall amount of training time (frequency, duration, number of sessions) or the amount of work (strength, number of repetitions) or effort/energy expenditure (exertion, heart rate, effort).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and extracted data on trial details. We contacted authors for additional information if necessary. We assessed the quality of the body of evidence for these outcomes using the GRADE approach.

MAIN RESULTS

We included reports for six studies of 656 participants that compared high- and low-intensity exercise programs; five studies exclusively recruited people with symptomatic knee osteoarthritis (620 participants), and one study exclusively recruited people with hip or knee osteoarthritis (36 participants). The majority of the participants were females (70%). No studies evaluated physical activity programs. We found the overall quality of evidence to be low to very low due to concerns about study limitations and imprecision (small number of studies, large confidence intervals) for the major outcomes using the GRADE approach. Most of the studies had an unclear or high risk of bias for several domains, and we judged five of the six studies to be at high risk for performance, detection, and attrition bias.Low-quality evidence indicated reduced pain on a 20-point Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scale (mean difference (MD) -0.84, 95% confidence interval (CI) -1.63 to -0.04; 4% absolute reduction, 95% CI -8% to 0%; number needed to treat for an additional beneficial outcome (NNTB) 11, 95% CI 14 to 22) and improved physical function on the 68-point WOMAC disability subscale (MD -2.65, 95% CI -5.29 to -0.01; 4% absolute reduction; NNTB 10, 95% CI 8 to 13) immediately at the end of the exercise programs (from 8 to 24 weeks). However, these results are unlikely to be of clinical importance. These small improvements did not continue at longer-term follow-up (up to 40 weeks after the end of the intervention). We are uncertain of the effect on quality of life, as only one study reported this outcome (0 to 200 scale; MD 4.3, 95% CI -6.5 to 15.2; 2% absolute reduction; very low level of evidence).Our subgroup analyses provided uncertain evidence as to whether increased exercise time (duration, number of sessions) and level of resistance (strength or effort) have an impact on the exercise program effects.Three studies reported withdrawals due to adverse events. The number of dropouts was small. Only one study systematically monitored adverse effects, but four studies reported some adverse effects related to knee pain associated with an exercise program. We are uncertain as to whether high intensity increases the number of adverse effects (Peto odds ratio 1.72, 95% CI 0.51 to 5.81; - 2% absolute risk reduction; very low level of evidence). None of the included studies reported serious adverse events.

AUTHORS' CONCLUSIONS

We found very low-quality to low-quality evidence for no important clinical benefit of high-intensity compared to low-intensity exercise programs in improving pain and physical function in the short term. There was insufficient evidence to determine the effect of different types of intensity of exercise programs.We are uncertain as to whether higher-intensity exercise programs may induce more harmful effects than those of lower intensity; this must be evaluated by further studies. Withdrawals due to adverse events were poorly monitored and not reported systematically in each group. We downgraded the evidence to low or very low because of the risk of bias, inconsistency, and imprecision.The small number of studies comparing high- and low-intensity exercise programs in osteoarthritis underscores the need for more studies investigating the dose-response relationship in exercise programs. In particular, further studies are needed to establish the minimal intensity of exercise programs needed for clinical effect and the highest intensity patients can tolerate. Larger studies should comply with the Consolidated Standards of Reporting Trials (CONSORT) checklist and systematically report harms data to evaluate the potential impact of highest intensities of exercise programs in people with joint damage.

Intensive Gait Training for Older Adults with Symptomatic Knee Osteoarthritis

OBJECTIVE

The objective of this study was to determine whether individualized gait training is more effective than usual care for reducing mobility disability and pain in individuals with symptomatic knee osteoarthritis.

DESIGN

Adults aged 60 yrs or older with symptomatic knee osteoarthritis and mobility limitations were randomized to physical therapist-directed gait training on an instrumented treadmill, with biofeedback individualized to optimize knee movements, biweekly for 3 mos or usual care (control). Mobility disability was defined using Late Life Function and Disability Index Basic Lower Limb Function score (primary); mobility limitations, using timed 400-m walk, chair-stand, and stair-climb tests; and symptoms, using the Knee Injury/Osteoarthritis Outcome Score at baseline, as well as at 3, 6, and 12 mos. The analyses used longitudinal mixed models.

RESULTS

There were no significant intergroup differences between the 35 gait-training (74.3% women; age, 69.7 ± 8.2 yrs) and 21 control (57.1% women; age, 68.9 ± 6.5 yrs) participants at baseline. At 3 mos, the gait-training participants had greater improvement in mobility disability (4.3 ± 1.7; P = 0.0162) and symptoms (8.6 ± 4.1; P = 0.0420). However, there were no intergroup differences detected for pain, 400-m walk, chair-stand, or stair-climb times at 3 mos or for any outcomes at 6 or 12 mos.

CONCLUSIONS

Compared with usual care, individualized gait training resulted in immediate improvements in mobility disability knee symptoms in adults with symptomatic knee osteoarthritis, but these effects were not sustained.

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.

Physical therapies for improving balance and reducing falls risk in osteoarthritis of the knee: a systematic review

INTRODUCTION

osteoarthritis (OA) of knee has been reported as a risk factor for falls and reduced balance in the elderly. This systematic review evaluated the effectiveness of physical therapies in improving balance and reducing falls risk among patients with knee OA.

METHODS

a computerised search was performed to identify relevant studies up to November 2013. Two investigators identified eligible studies and extracted data independently. The quality of the included studies was assessed by the PeDro score.

RESULTS

a total of 15 randomised controlled trials involving 1482 patients were identified. The mean PeDro score was 7. The pooled standardised mean difference in balance outcome for strength training = 0.3346 (95% CI: 0.3207-0.60, P = 0.01 < 0.00001, P for heterogeneity = 0.85, I(2) = 0%). Tai Chi = 0.7597 (95% CI: 0.5130-1.2043, P<=0.0014, P for heterogeneity = 0.26, I(2) = 0%) and aerobic exercises = 0.6880 (95% CI: 0.5704-1.302, P < 0.00001, P for heterogeneity = 0.71, I(2) = 0%). While pooled results for falls risk outcomes in, strength training, Tai chi and aerobics also showed a significant reduction in reduced risk of falls significantly with pooled result 0.55 (95% CI: 0.41-0.68, P < 0.00001, P for heterogeneity = 0.39, I(2) = 6%).

CONCLUSION

strength training, Tai Chi and aerobics exercises improved balance and falls risk in older individuals with knee OA, while water-based exercises and light treatment did not significantly improve balance outcomes. Strength training, Tai Chi and aerobics exercises can therefore be recommended as falls prevention strategies for individuals with OA. However, a large randomised controlled study using actual falls outcomes is recommended to determine the appropriate dosage and to measure the potential benefits in falls reduction.

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.

A biomechanical perspective on physical therapy management of knee osteoarthritis

SYNOPSIS

Altered knee joint biomechanics and excessive joint loading have long been considered as important contributors to the development and progression of knee osteoarthritis. Therefore, a better understanding of how various treatment options influence the loading environment of the knee joint could have practical implications for devising more effective physical therapy management strategies. The aim of this clinical commentary was to review the pertinent biomechanical evidence supporting the use of treatment options intended to provide protection against excessive joint loading while offering symptomatic relief and functional improvements for better long-term management of patients with knee osteoarthritis. The biomechanical and clinical evidence regarding the effectiveness of knee joint offloading strategies, including contralateral cane use, laterally wedged shoe insoles, variable-stiffness shoes, valgus knee bracing, and gait-modification strategies, within the context of effective disease management is discussed. In addition, the potential role of therapeutic exercise and neuromuscular training to improve the mechanical environment of the knee joint is considered. Management strategies for treatment of joint instability and patellofemoral compartment disease are also mentioned. Based on the evidence presented as part of this clinical commentary, it is argued that special considerations for the role of knee joint biomechanics and excessive joint loading are necessary in designing effective short- and long-term management strategies for treatment of patients with knee osteoarthritis.

LEVEL OF EVIDENCE

Therapy, level 5.