Patients With Higher Treatment Outcome Expectations Are More Satisfied With the Results of Nonoperative Treatment for Thumb Base Osteoarthritis: A Cohort Study

ObjectiveTo investigate how satisfaction with treatment outcome is associated with patient mindset and Michigan Hand Outcome Questionnaire (MHQ) scores at baseline and 3 months in patients receiving nonoperative treatment for first carpometacarpal joint (CMC-1) osteoarthritis (OA).DesignCohort studySettingA total of 20 outpatient locations of a clinic for hand surgery and hand therapy in the Netherlands.ParticipantsPatients (N=308) receiving nonoperative treatment for CMC-1 OA, including exercise therapy, an orthosis, or both, between September 2017 and February 2019.InterventionsNonoperative treatment (ie, exercise therapy, an orthosis, or both)Main Outcome MeasuresSatisfaction with treatment outcomes was measured after 3 months of treatment. We measured total MHQ score at baseline and at 3 months. As baseline mindset factors, patients completed questionnaires on treatment outcome expectations, illness perceptions, pain catastrophizing, and psychological distress. We used multivariable logistic regression analysis and mediation analysis to identify factors associated with satisfaction with treatment outcomes.ResultsMore positive pretreatment outcome expectations were associated with a higher probability of being satisfied with treatment outcomes at 3 months (odds ratio, 1.15; 95% confidence interval, 1.07-1.25). Only a relatively small part (33%) of this association was because of a higher total MHQ score at 3 months. None of the other mindset and hand function variables at baseline were associated with satisfaction with treatment outcomes.ConclusionsThis study demonstrates that patients with higher pretreatment outcome expectations are more likely to be satisfied with treatment outcomes after 3 months of nonoperative treatment for CMC-1 OA. This association could only partially be explained by a better functional outcome at 3 months for patients who were satisfied. Health care providers treating patients nonoperatively for CMC-1 OA should be aware of the importance of expectations and may take this into account in pretreatment counseling.     

Photobiomodulation does not provide incremental benefits to patients with knee osteoarthritis who receive a strengthening exercises program: a randomized controlled trial

BackgroundThere is lack of agreement in the literature about the effectiveness of photobiomodulation (PBM) for reducing pain-related symptoms in patients with knee osteoarthritis (OA).ObjectiveTo evaluate whether PBM, when combined to exercises, provides incremental therapeutic benefits for pain, physical function, and quality of life (QoL) in patients with knee OA.MethodsA six-month double-blind placebo-controlled randomized trial was conducted. Patients with knee OA were randomly assigned to one of three treatment groups: Exercise, Exercise plus Active PBM, or Exercise plus Placebo PBM. Treatment was provided over an eight-week period, three times per week. The primary outcomes were pain at rest and upon movement, assessed by a visual analogue scale (VAS). WOMAC global score, QoL, and a core-set of performance-based tests were measured as secondary outcomes. All outcomes were collected at baseline, immediately after treatment, and after three- and six-month post-treatment.Results127 participants were allocated as follows: Exercise, N = 41; Exercise plus Active PBM, N = 44; and Exercise plus Placebo PBM, N = 42. There was no between-groups difference in improvement in pain, physical function, and QoL for all follow-up times. However, all groups presented significant, clinically relevant improvements in pain, physical function, and QoL immediately and three months after treatment compared with baseline measures.ConclusionPatients with knee OA who received a strengthening exercises program did not experience incremental benefits regarding pain, physical function, or QoL when adding PBM to their therapeutic exercises.     

Efficacy of strengthening exercises for osteoarthritis (Part I): A meta-analysis

Abstract

Objective: Osteoarthritis (OA) is highly prevalent among older adults and is associated with increased pain, loss of strength and joint range of motion (ROM), as well as to an overall decrease in functional status. Therapeutic strength exercises are recommended as part of the standard intervention programme for the patient with OA in an effort to control pain and improve functional and health status. The purpose of this meta-analysis is to review the strength and quality of evidence supporting the effectiveness of therapeutic strengthening exercises for improving a variety of measured outcomes relevant for OA.

Methods: A systematic review was conducted, following a protocol of methods recommended by the Cochrane Collaboration. Trials were identified by a literature search of Medline, EMBASE, and the Cochrane Controlled Trials Register. Only randomised controlled trials using strengthening exercises as an intervention and treating clients with OA were eligible. Twenty-two trials were included with 2325 patients undergoing various forms strengthening exercises (e.g. isometric, isotonic, isokinetic, concentric, concentric/eccentric, dynamic). The exercises were implemented either in stand-alone format or in combination with other exercises, such as stretching and ROM. Interventions were either facility-based, home-based or a combination of the two.

Results: Evidence is provided for the inclusion of strengthening exercises in the rehabilitation programme for the patient with OA. Improvements were found for strength, pain, function and quality of life (QOL). Important components of the exercise programme that influence outcome include: (i) the combination of joint-specific strengthening with general strength, flexibility and functional exercises; (ii) progression of the exercise programme; and (iii) level of client self-reliance to sustain the programme. There is no evidence that the type of strengthening (i.e. isometric, isotonic or isokinetic) has an important impact on programme outcome. However, evidence is provided that the control of pain may be a dominant mechanism by which strengthening exercise produces beneficial effects for the patient with OA.

Conclusion: Strengthening exercises alone have some effects on improving pain and functional outcomes in clients with OA. However, in order to maximise the effectiveness of strengthening exercise for these clients, it is necessary to combine strengthening exercises with a more complete exercise programme including ROM, stretching, functional balance and aerobic exercises.     

Transcutaneous Electrical Nerve Stimulation and Interferential Current Combined with Exercise for the Treatment of Knee Osteoarthritis: A Randomised Controlled Trial

Interferential current (IFC) and transcutaneous electrical nerve stimulation (TENS) are forms of electrical stimulation frequently used to treat knee osteoarthritis (OA). The relative effectiveness of these two modalities is currently unknown. The purpose of this study was to evaluate the effects of IFC and TENS, when used in conjunction with exercise, on pain and function in patients with knee OA. Forty-six subjects with radiographically confirmed OA were randomly assigned to one of three groups: TENS and standardised exercises, IFC and exercises or exercises alone. An electrical stimulator was used to apply IFC or TENS at 80 Hz for 20 minutes. All groups had a standardised exercise programme. Treatment was applied twice per week for 4 weeks. Outcomes included a 10-point pain rating scale for pain intensity and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC). A two-way repeated measures ANOVA performed on the pain assessment score showed a statistically significant effect of time (p < 0.001), but not of experimental group (p = 0.813) or interaction (p = 0.067). A similar result was obtained for WOMAC score (p < 0.001, p = 0.241 and p = 0.130 for time, group and interaction effects, respectively). All treatment protocols led to significant improvements in pain and function over time. Neither IFC nor TENS displayed significant additional effects over exercise alone.     

Crenobalneotherapy (spa therapy) in patients with knee and generalized osteoarthritis: A post-hoc subgroup analysis of a large multicentre randomized trial

ObjectiveTo determine whether the addition of spa therapy to home exercises provides any benefit over exercises and the usual treatment alone in the management of generalised osteoarthritis associated with knee osteoarthritis.MethodsThis study was a post-hoc subgroup analysis of our randomised multicentre trial (www.clinicaltrial.gov: NCT00348777). Participants who met the inclusion criteria of generalized osteoarthritis (Kellgren, American College of Rheumatology, or Dougados criteria) were extracted from the original randomised controlled trial. They had been randomised using Zelen randomisation. The treatment group received 18 days of spa treatment in addition to a home exercise programme. Main outcome was number of patients achieving minimal clinically important improvement at six months (MCII) (≥ −19.9 mm on the VAS pain scale and/or ≥ −9.1 points in a WOMAC function subscale), and no knee surgery. Secondary outcomes included the “patient acceptable symptom state” (PASS) defined as VAS pain ≤ 32.3 mm and/or WOMAC function subscale ≤ 31 points.ResultsFrom the original 462 participants, 214 patients could be categorized as having generalised osteoarthritis. At sixth month, 182 (88 in control and 94 in SA group) patients, were analysed for the main criteria. MCII was observed more often in the spa group (n = 52/94 vs. 38/88, P = 0.010). There was no difference for the PASS (n = 19/88 vs. 26/94, P = 0.343).ConclusionsThis study indicates that spa therapy with home exercises may be superior to home exercise alone in the management of patients with GOA associated with knee OA.     

Exercises for hand osteoarthritis: a systematic review of clinical practice guidelines and consensus recommendations

Background: Individuals with hand osteoarthritis (OA) often experience hand pain, joint stiffness and reduced grip strength, which affect performance of everyday functional tasks. There is a need to evaluate evidence-based rehabilitation strategies that aim to lessen the burden and improve the quality of life of people living with hand OA.

Objectives: Our objectives were to (1) identify guidelines and consensus recommendations on hand OA management to ascertain whether hand exercises are recommended as part of best practice; (2) identify the type and dosage of exercises recommended regarding frequency, intensity and duration and (3) provide a summary of exercise recommendations for the management of hand OA.

Methods: This systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and was registered on Prospero (CRD42018086440). Seven published databases and 20 grey literature sources were searched (January 1997–January2019). Quality assessment was conducted with the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument and, using a narrative approach, evidence was synthesized based on the levels of evidence and strength of recommendations.

Results: Eight guidelines and consensus recommendations were identified and included. Evidence from seven guidelines was rated between fair to high quality. Five out of seven guidelines recommended exercises for the management of hand OA. Limited information on exercise dosage (frequency, intensity and duration) was reported. Three strong and two weak recommendations for using different hand exercises were proposed in this systematic review.

Conclusion: Available guidelines and consensus recommendations on hand OA recommend exercises as part of current best practice for hand OA management. There is strong evidence to support the recommendation of strengthening, stretching and joint mobility exercises for the management of the hand OA. These recommended exercises, however, lacked specific details regarding the type and dosage (frequency, intensity and time) for optimal uptake, which therefore need to be established through research.     

Joint Mobilization of the Hands of Patients With Rheumatoid Arthritis: Results From an Assessor-Blinded,Randomized Crossover Trial

ObjectiveThe purpose of this study was to assess the clinical feasibility and effectiveness of manual mobilization of the hands of patients with rheumatoid arthritis (RA).MethodsA total of 320 individual hand joints were evaluated after recruiting an experimental research group of 12 participants with RA and, for clinical comparability, 8 participants with hand osteoarthritis (OA). One hand per participant was randomized to receive weekly low-grade (I-II) Kaltenborn manual mobilization, using passive sustained stretch of the metacarpophalangeal (MCP) joints II to V by licensed manual therapists. After 2 weeks, the randomized treated hand was crossed over to control (untreated) during weeks 3 to 4 and vice versa. Final assessment was at 2 months, which was 1 month after the last treatment at week 4. Primary hand outcomes included pain by visual analog scale, tender or swollen joint count, and presence of Doppler signal or synovial fluid and radiographic joint space by musculoskeletal ultrasound.ResultsIn the RA group, both the initially randomized treated hand and the contralateral hand improved significantly from baseline to crossover to follow-up at 2 months (pain outcomes and Doppler signal, P < .050; synovial fluid and MCP joint space, P ≤ .001). Hand pain and MCP joint space also improved significantly in OA. There were no dropouts or reported adverse events in either the RA or OA group.ConclusionIn this study, manual mobilization of the hands of patients with RA was shown to be feasible, safe, and effective to integrate into specialized healthcare.     

Hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee: a randomized clinical trial

BACKGROUND AND PURPOSE: This study was designed to evaluate the effectiveness of hydrotherapy in subjects with osteoarthritis (OA) of the knee compared with subjects with OA of the knee who performed land-based exercises. SUBJECTS AND METHODS: Sixty-four subjects with OA of the knee were randomly assigned to 1 of 2 groups that performed exercises for 18 weeks: a water-based exercise group and a land-based exercise group. The outcome measures included a visual analog scale (VAS) for pain in the previous week, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), pain during gait assessed by a VAS at rest and immediately following a 50-foot (15.24-m) walk test (50FWT), walking time measured at fast and comfortable paces during the 50FWT, and the Lequesne Index. Measurements were recorded by a blinded investigator at baseline and at 9 and 18 weeks after initiating the intervention. RESULTS: The 2 groups were homogenous regarding all parameters at baseline. Reductions in pain and improvements in WOMAC and Lequesne index scores were similar between groups. Pain before and after the 50FWT decreased significantly over time in both groups. However, the water-based exercise group experienced a significantly greater decrease in pain than the land-based exercise group before and after the 50FWT at the week-18 follow-up. DISCUSSION AND CONCLUSION: Both water-based and land-based exercises reduced knee pain and increased knee function in participants with OA of the knee. Hydrotherapy was superior to land-based exercise in relieving pain before and after walking during the last follow-up. Water-based exercises are a suitable and effective alternative for the management of OA of the knee.     

Phonophoresis of Phyllanthus amarus nanoparticle gel improves functional capacity in individuals with knee osteoarthritis: A randomized controlled trial

ObjectiveThis study examined the effects of treatment with Phyllanthus amarus nanoparticle gel applied by phonophoresis (PP) and ultrasound therapy (UT) in patients with symptomatic knee osteoarthritis (OA) using a randomized, double-blind, controlled trial.MethodsPatients with knee OA (n = 40; mean age ± SD, 64.30 ± 9.71 years), who had visual analogue scale (VAS) scores for knee pain intensity of 68.00 ± 9.58 (UT group) and 71.00 ± 8.74 (PP group, respectively) before treatment, were randomly allocated into two groups. Both groups were treated with an ultrasound program in continuous mode, 1.0 W/cm², 10 min per session, for 10 sessions. Nanoparticles of P. amarus were used in the PP group, whereas a nondrug coupling gel was used in the UT group. The 6-min walk test (6-MWT) was performed to evaluate functional capacity. The VAS and the 6-MWT were evaluated before and after 10 treatment sessions in both groups using a double-blind procedure.ResultsVAS and 6-MWT showed significant improvement after treatment in both groups (p < 0.05). The PP group showed more significant effects than the UT group, in terms of both reducing the VAS pain score (p < 0.05) and improving 6-MWT (p < 0.05).ConclusionsPP is suggested as an effective method for the treatment of symptomatic knee OA for reducing pain and improving functional capacity.     

Osteopathic manipulative treatment combined with exercise improves pain and disability in individuals with non-specific chronic neck pain: A pragmatic randomized controlled trial

PurposeTo determine effectiveness of osteopathic manipulative treatment combined with stretching and strengthening exercises in the cervical region on pain and disability in individuals with non-specific chronic neck pain.Methods90 adults with non-specific chronic neck pain were randomized to either exercises group (EG, n = 45) or osteopathic manipulative treatment associated with exercises group (OMT/EG, n = 45). The primary outcomes were obtained by the use of Numeric Pain-Rating Scale (NPRS), Pressure Pain Threshold (PPT) and Neck Disability Index (NDI). Secondary outcomes included range of motion (ROM) for cervical spine rotation, Fear-Avoidance Beliefs Questionnaire Work/Physical Activity (FABQ-W/PA) and Pain-self efficacy at two different moments: baseline and 4 weeks after the first treatment. Techniques and dosages of OMT were selected pragmatically by a registered osteopath. Generalized Estimating Equations model (GEE), complemented by the Least Significant Difference (LSD) and the intention-to-treat analysis, was used to assess the clinical outcomes.ResultsAnalysis with GEE indicated that OMT/EG reduced pain and disability more than the EG alone after 4 weeks of treatment with statistically significant difference (p < 0,05), as well as cervical active rotation was significantly improved (p = 0.03). There were no between-group differences observed in Pressure Pain Threshold (PPT) measure, Fear-Avoidance Beliefs Questionnaire and Pain-self efficacy.ConclusionThe association between OMT and exercises reduces pain and improves functional disability more than only exercise for individuals with non-specific chronic neck pain.     

Efficacy of core exercises in patients with osteoarthritis of the knee: A randomized controlled clinical trial

Trial designRandomized, evaluator blinded, controlled, parallel group.MethodsThis trial was conducted between July 2011 and January 2015 at a public hospital in Argentina. Patients older than 40 years with a medical diagnosis of osteoarthritis (OA) were randomly assigned to the experimental group (EG) or control group (CG). Both groups performed conventional exercises 3 times a week for 12 weeks and core exercises were added to the EG intervention.The objective was to compare the efficacy of conventional treatment combined with core muscle strengthening exercises, with conventional treatment alone in terms of short- and medium-term pain reduction and physical function in patients with knee OA.The primary outcome was knee pain assessed using a visual analog scale and the secondary outcome was physical function assessed at baseline, week 8 and 12, and 2 follow-up visits held 1 month and 3 months after the end of treatment.Results113 patients were randomized to a CG (n = 60) or EG (n = 53). 66 patients were eliminated and 25 patients in the EG and 22 in the CG were analyzed.Both pain reduction and improved physical function were observed throughout the intervention in both groups. At the end of the treatment, a statistically and clinically significant pain reduction was observed in the EG. No adverse effects were reported.ConclusionThe combination of core muscle activation exercises and conventional treatment was more effective in short-term pain reduction in patients with knee OA.     

Functional performance and inflammatory cytokines after squat exercises and whole-body vibration in elderly individuals with knee osteoarthritis

Simão AP, Avelar NC, Tossige-Gomes R, Neves CD, Mendonça VA, Miranda AS, Teixeira MM, Teixeira AL, Andrade AP, Coimbra CC, Lacerda AC. Functional performance and inflammatory cytokines after squat exercises and whole-body vibration in elderly individuals with knee osteoarthritis.ObjectiveTo investigate the effects of squat exercises combined with whole-body vibration on the plasma concentration of inflammatory markers and the functional performance of elderly individuals with knee osteoarthritis (OA).DesignClinical, prospective, randomized, single-blinded study.SettingExercise physiology laboratory.ParticipantsElderly subjects with knee OA (N=32) were divided into 3 groups: (1) squat exercises on a vibratory platform (platform group, n=11); (2) squat exercises without vibration (squat group, n=10); and (3) the control group (n=11).InterventionsThe structured program of squat exercises in the platform and squat groups was conducted 3 times per week, on alternate days, for 12 weeks.Main Outcome MeasuresPlasma soluble tumor necrosis factor-α receptors 1 (sTNFR1) and 2 (sTNFR2) were measured using immunoassays (the enzyme-linked immunosorbent assay method). The Western Ontario and McMaster Universities Osteoarthritis Index questionnaire was used to evaluate self-reported physical function, pain, and stiffness. The 6-minute walk test, the Berg Balance Scale, and gait speed were used to evaluate physical function.ResultsIn the platform group, there were significant reductions in the plasma concentrations of the inflammatory markers sTNFR1 and sTNFR2 (P<.001 and P<.05, respectively) and self-reported pain (P<.05) compared with the control group, and there was an increase in balance (P<.05) and speed and distance walked (P<.05 and P<.001, respectively). In addition, the platform group walked faster than the squat group (P<.01).ConclusionsThe results suggest that whole-body vibration training improves self-perception of pain, balance, gait quality, and inflammatory markers in elderly subjects with knee OA.     

Short-Term Effect of Peer Volunteers in Providing Inpatient Rehabilitative Exercises for Patients After Total Knee Arthroplasty

ObjectiveTo investigate the short-term outcomes at discharge of patients who receive additional postoperative rehabilitative exercises by peer volunteers after total knee arthroplasty (TKA).DesignRetrospective cohort study.SettingTertiary teaching hospital.ParticipantsA total of 476 adult patients who had undergone a primary elective unilateral TKA (N=467).InterventionsAn intervention group received a standardized postoperative rehabilitative exercise protocol taught and supervised by peer volunteers in additional to standard physiotherapy (n=309) compared with a control group receiving standard physiotherapy alone (n=167).Main Outcome MeasuresDischarge outcomes were the pain score using the Numeric Rating Scale pain score, passive knee flexion and extension range of motion (ROM), length of hospitalization, ability to perform an unassisted straight leg raise of the operated leg, ambulation distance, ability in independent walking, walking aids required, discharge destination, and adverse events.ResultsOn multivariate analysis, patients in the intervention group had an increased discharge passive knee flexion ROM of 7.89 degrees (95% confidence interval, 5.47-10.33; P<.001). There were no significant differences for the other outcome measures between the intervention and control group.ConclusionsA rehabilitative exercise program by peer volunteers is feasible and safe after TKA in addition to standard physiotherapy and is associated with improved knee flexion ROM on discharge.     

Effects of myofascial trigger point dry cupping on pain and function in patients with plantar heel pain: A randomized controlled trial

ObjectiveTo investigate the effects of dry cupping on calf muscle myofascial trigger points (MTrPs) on pain and function in patients with plantar heel pain.MethodsSeventy-one patients were randomly divided into an intervention group or control group. Both groups performed stretching exercises for the calf muscle and plantar fascia and ankle dorsiflexion exercises. The intervention group also received dry cupping. The primary outcome measures were visual analogue scale (VAS), pressure pain threshold (PPT), and patient-specific functional scale (PSFS). The secondary outcomes were ankle dorsiflexion range of motion (ROM) and ankle plantar flexor strength. These measurements were performed at baseline, immediately after intervention, and after 2 days.ResultsCurrent VAS significantly decreased immediately in the intervention group (p = 0.002), but not in the control group (p ≥ 0.220). Morning VAS decreased significantly in both groups (p < 0.001) after 2 days, but decreased more in the intervention group (p = 0.006). Trigger point PPT significantly improved immediately in the intervention group (p = 0.003), but not in the control group (p = 0.112). Both groups improved significantly in PSFS (p < 0.001) and ankle dorsiflexion ROM (p < 0.001). Plantar flexor strength significantly increased immediately in the intervention group (p < 0.001), but not in the control group (p = 0.556).ConclusionAdding dry cupping on calf MTrPs to self-stretching and ankle dorsiflexion exercises for patients with plantar heel pain was superior to only self-stretching and active ankle dorsiflexion exercises in pain, ankle dorsiflexion ROM, and plantar flexor strength.     

Posterolateral Hip Muscle Strengthening Versus Quadriceps Strengthening for Patellofemoral Pain: A Comparative Control Trial

Objective

To compare the efficacy of posterolateral hip muscle strengthening versus quadriceps strengthening in reducing pain and improving health status in persons with patellofemoral pain (PFP).

Design

Comparative control trial.

Setting

Rehabilitation facility.

Participants

Persons with a diagnosis of PFP (N=36; 18 men, 18 women).

Interventions

Patients were alternately assigned to a posterolateral hip muscle strengthening group (9 men and 9 women) or a quadriceps strengthening group (9 men and 9 women). The posterolateral hip muscle strengthening group performed hip abductor and external rotator strengthening exercises, whereas the quadriceps strengthening group performed quadriceps strengthening exercises (3 times a week for 8wk).

Main Outcome Measures

Pain (visual analog scale [VAS]) and health status (Western Ontario McMaster Universities Osteoarthritis Index [WOMAC]) were assessed at baseline, postintervention, and 6-month follow-up.

Results

Significant improvements in VAS and WOMAC scores were observed in both groups from baseline to postintervention and baseline to 6-month follow-up (P<.001). Improvements in VAS and WOMAC scores in the posterolateral hip exercise group were superior to those in the quadriceps exercise group postintervention and at 6-month follow-up (P<.05).

Conclusions

Although both intervention programs resulted in decreased pain and improved function in persons with PFP, outcomes in the posterolateral hip exercise group were superior to the quadriceps exercise group. The superior outcomes obtained in the posterolateral hip exercise group were maintained 6 months postintervention.     

No evidence for stratified exercise therapy being cost-effective compared to usual exercise therapy in patients with knee osteoarthritis: Economic evaluation alongside cluster randomized controlled trial

BackgroundA stratified approach to exercise therapy may yield superior clinical and economic outcomes, given the large heterogeneity of individuals with knee osteoarthritis (OA).ObjectiveTo evaluate the cost-effectiveness during a 12-month follow-up of a model of stratified exercise therapy compared to usual exercise therapy in patients with knee OA, from a societal and healthcare perspective.MethodsAn economic evaluation was conducted alongside a cluster-randomized controlled trial in patients with knee OA (n = 335), comparing subgroup-specific exercise therapy for a ‘high muscle strength subgroup’, ‘low muscle strength subgroup’, and ‘obesity subgroup’ supplemented by a dietary intervention for the ‘obesity subgroup’ (experimental group), with usual (‘non-stratified’) exercise therapy (control group). Clinical outcomes included quality-adjusted life years – QALYs (EuroQol-5D-5 L), knee pain (Numerical Rating Scale) and physical functioning (Knee Injury and Osteoarthritis Outcome Score in daily living). Costs were measured by self-reported questionnaires at 3, 6, 9 and 12-month follow-up. Missing data were imputed using multiple imputation. Data were analyzed through linear regression. Bootstrapping techniques were applied to estimate statistical uncertainty.ResultsDuring 12-month follow-up, there were no significant between-group differences in clinical outcomes. The total societal costs of the experimental group were on average lower compared to the control group (mean [95% confidence interval]: € 405 [-1728, 918]), albeit with a high level of uncertainty. We found a negligible difference in QALYs between groups (mean [95% confidence interval]: 0.006 [-0.011, 0.023]). The probability of stratified exercise therapy being cost-effective compared to usual exercise therapy from the societal perspective was around 73%, regardless of the willingness-to-pay threshold. However, this probability decreased substantially to 50% (willingness-to-pay threshold of €20.000/QALY) when using the healthcare perspective. Similar results were found for knee pain and physical functioning.ConclusionsWe found no clear evidence that stratified exercise therapy is likely to be cost-effective compared to usual exercise therapy in patients with knee OA. However, results should be interpreted with caution as the study power was lower than intended, due to the Coronavirus disease (COVID-19) pandemic.     

Adding high-frequency transcutaneous electrical nerve stimulation to the first phase of post anterior cruciate ligament reconstruction rehabilitation does not improve pain and function in young male athletes more than exercise alone: a randomized single-blind clinical trial

Abstract

Purpose: Knee ligamentous trauma and the following pain is one of the most prevalent athletic injuries. Transcutaneous electrical nerve stimulation is one of the conservative approaches in controlling pain which is low cost, noninvasive, and safe with low complications. Our purpose was to study whether transcutaneous electrical nerve stimulation (TENS) could help athletes perform better during the first phase of rehabilitation (0–4?weeks) after anterior cruciate ligament (ACL) reconstruction surgery and until the follow-up.

Methods: This randomized single blind (exercise instructor and assessor) clinical trial was performed on 70 male athletes, undergone ACL surgery. After the surgery, patients were randomly divided into two groups: the first group received semi-supervised exercise plus high-frequency TENSTENS for 35?min a day and the second group only performed exercises. Treatment duration continued for 20 sessions, 4?weeks. The visual analog scale (VAS) score (100?mm), International Knee Documentation Committee (IKDC) questionnaire and knee flexion Range of motion (ROM) were evaluated for all patients after the surgery (before commencing the rehabilitation program), after 4?weeks and 14?weeks from the surgery.

Results: Mixed ANOVA was used to explore the interaction effects of time and group on outcome measures and post hoc additional tests were performed on the data. The VAS, IKDC questionnaire score and knee flexion ROM increased in both groups over time, but the amount of improvement did not differ between the two groups, implying no additional improvement in the group receiving TENS along with exercises.

Conclusion: The findings of the present trial shows that adding TENS to a specific protocol of semi-supervised exercise in the first phase of rehabilitation after ACL reconstruction is not efficient on improving knee function and pain more than exercise alone.

• Implications for Rehabilitation

• Injury to the anterior cruciate ligament of the knee is a common injury specifically in athletes.

• Incorporating effective pain relieving strategies during the post anterior cruciate ligament reconstruction surgery rehabilitation could lead to improvement in regaining the range of motion and function of the knee which is of crucial importance after the surgery.

• Applying transcutaneous electrical nerve stimulation alongside a specific protocol of semi-supervised exercise in the first phase of rehabilitation after anterior cruciate ligament reconstruction did not have any additional effect to exercise alone.