Effects of mind-body exercise on knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To evaluate the effect of mind-body exercise on improving knee osteoarthritis (KOA) and thereby informing osteoarthritis exercise rehabilitation. METHODS: The China National Knowledge Infrastructure (CNKI), Wanfang, PubMed/Medline, Cochrane Library, Web of Science, EBSCO, Embase, Scopus, and ProQuest databases were searched to identify randomized controlled trials (RCTs) that involved tai chi, yoga, and baduanjin interventions for KOA. The search period ranged from inception to October 25, 2022. The methodological quality of the included studies was evaluated by the Cochrane risk of bias assessment tool, and the included data were statistically analyzed and plotted using Review Manager 5.3 and Stata 14.0 software. RESULTS: We included 17 articles with a total of 1122 patients. Compared with the control group, mind-body exercise significantly improved patient pain (standardized mean difference (SMD) = -0.65, 95% confidence interval (CI) [-0.87, -0.42], p < 0.00001), stiffness (SMD = -0.75, 95% CI [-1.05, -0.45], p < 0.00001), physical function (SMD = -0.82, 95% CI [-1.03, -0.62], p < 0.00001), mental health (SMD = 0.31, 95% CI [0.11, 0.51], p = 0.002), and depression (SMD = -0.32, 95% CI [-0.50, -0.15], p = 0.0003). In terms of motor ability, mind-body exercise significantly increased the 6-min walking distance (SMD = 18.45, 95% CI [5.80, 31.10], p = 0.004) and decreased timed up and go test time (SMD = -1.15, 95% CI [-1.71, -0.59], p < 0.0001). CONCLUSIONS: The current study showed that mind-body exercise is safe and effective for KOA patients. However, given the methodological limitations of the included studies, additional high-quality evidence is needed to support the conclusions of this study.

Effectiveness of neuromuscular electrical stimulation training combined with exercise on patient-reported outcomes measures in people with knee osteoarthritis: A systematic review and meta-analysis.

OBJECTIVE: This study examined the effectiveness of neuromuscular electrical stimulation (NMES) added to the exercise or superimposed on voluntary contractions on patient-reported outcomes measures (PROMs) in people with knee osteoarthritis (OA). METHODS: This systematic review was described according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs) were obtained from a systematic literature search in five electronic databases (PubMed, PEDro, LILACS, EMBASE, and SPORTDiscus) in April 2022. We described the effects of intervention according to each PROMs (scores for Pain; Self-reported functional ability; Symptoms (hear clicking, swelling, catching, restricted range of motion, and stiffness); Daily living function; Sports function; and Quality of life) and used a random-effect model to examine the impact of NMES plus exercise on pain compared with exercise in people with knee OA. RESULTS: Six RCTs (n = 367) were included. In the qualitative synthesis, the systematic literature analysis showed improvement in pain after NMES plus exercise compared with exercise alone in three studies. The other three studies revealed no difference between groups in pain, although similar improvement after treatments. In the meta-analysis, NMES at a specific joint angle combined with exercise was not superior to exercise alone in pain management (standardized mean difference = -0.33, 95% CI = -1.05 to 0.39, p = 0.37). There was no additional effect of NMES on exercise on self-reported functional ability, stiffness, and physical function compared with exercise alone. In only one study, symptoms, activities of daily living, sports function, and quality of life improved after whole-body electrostimulation combined with exercise. CONCLUSION: This review found insufficient evidence for the effectiveness of NMES combined with exercise in treating knee OA considering PROMs. While pain relief was observed in some studies, more high-quality clinical trials are needed to support the use of NMES added to the exercise in clinical practice. Electrical stimulation in a whole-body configuration combined with exercise shows promise as an alternative treatment option.

OARSI year in review 2023: Rehabilitation and outcomes.

OBJECTIVE: We systematically reviewed the literature to identify comparative studies of core treatments (exercise, education, or weight management), adjunct treatments (e.g. electrotherapeutical modalities, bracing), or multimodal treatments (core plus other treatments), for treating osteoarthritis (OA) complaints, published between 1 March 2022 and 1 March 2023. DESIGN: We searched three electronic databases for peer-reviewed comparative studies evaluating core treatments, adjunct treatments, or multimodal treatments for OA affecting any joint, in comparison to other OA treatments. Two authors independently screened records. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. A narrative synthesis focusing on pain and function outcomes was performed in studies with a mean sample size of at least 46 participants per treatment arm. RESULTS: 33 publications (28 studies), 82% with PEDro ratings of good or excellent, were eligible for narrative synthesis: 23 studies evaluated knee OA; one knee OA or chronic low back pain; two knee or hip OA; one hip OA only; and one thumb OA. No studies identified a dose, duration or type of exercise that resulted in better pain or function outcomes. Core treatments generally showed modest benefits compared to no or minimal intervention controls. CONCLUSIONS: Rehabilitation research continues to be focused on the knee. Most studies are not adequately powered to assess pain efficacy. Further work is needed to better account for contextual effects, identify treatment responder characteristics, understand treatment mechanisms, and implement guideline care.

Effectiveness of home-based exercise interventions on pain, physical function and quality of life in individuals with knee osteoarthritis: a systematic review and meta-analysis.

OBJECTIVE: The objective of the study was to evaluate the effectiveness of home-based exercise interventions on pain, physical function and quality of life in individuals with knee osteoarthritis (KOA). METHODS: Five databases (PubMed, Embase, Cochrane Library, CINAHL, Web of Science Core Collection) were searched for relevant randomized controlled trials (RCTs) published from database inception to 2 August 2022. The Cochrane Collaboration's standards were followed for study selection, eligibility criteria, data extraction and statistics, using the Cochrane Collaboration Risk of Bias Tool and PEDro for quality assessment. A meta-analysis and subgroup analyses, stratified by control condition and intervention duration, were conducted using RevMan 5.4. The study was reported in compliance with the PRISMA statement. RESULTS: A total of 12 independent RCTs with 1442 participants were included. The meta-analysis showed that the home-based exercise interventions significantly reduced pain in individuals with KOA (SMD = - 0.32, 95% CI [- 0.41, - 0.22], p < .01) and improved physical function (SMD = - 0.25, 95% CI [- 0.47, - 0.02], p = .03) and quality of life (SMD = 0.63, 95% CI [0.41, 0.85], p < .001). Subgroup analysis revealed that home-based exercise interventions were superior to health education and no treatment, in terms of pain and physical function, and similar to clinic-based exercise and pharmacologic treatment. CONCLUSIONS: The effect of home-based exercise intervention is significantly better than health education and no treatment for reducing knee pain and improving physical function, and was able to achieve the effects of clinic-based exercise treatment and pharmacologic treatment. With regard to quality of life, the unsupervised home strength exercise intervention showed a significant effect compared with the health education control and combined with cognitive behavioural therapies may produce better results. Although home-based intervention provides effective treatment options for individuals with clinical treatment limitations, individual disease complications and the dosimetry of exercise need to be considered in practice. Furthermore, growing evidence supports the effectiveness of Tai Chi in the rehabilitation of KOA.

High-intensity versus low-intensity resistance training in patients with knee osteoarthritis: A randomized controlled trial.

OBJECTIVES: To assess whether (i) high-intensity resistance training (RT) leads to increased muscle strength compared to low-intensity RT in patients with knee osteoarthritis (OA); and (ii) RT with vitamin D supplementation leads to increased muscle strength compared to placebo in a subgroup with vitamin D deficiency. DESIGN: Randomized controlled trial. SETTING: Outpatient rehabilitation centre. SUBJECTS: Patients with knee OA. INTERVENTIONS: 12 weeks of RT at high-intensity RT (70-80% of 1-repetition maximum (1-RM)) or low-intensity RT (40-50% of 1-RM) and 24 weeks of vitamin D (1200 International units vitamin D3 per day) or placebo supplementation. MAIN MEASURES: Primary outcome measure was isokinetic muscle strength. Other outcome measure for muscle strength was the estimated 1-RM. Secondary outcome measures were knee pain and physical functioning. RESULTS: 177 participants with a mean age of 67.6 ± 5.8 years were included, of whom 50 had vitamin D deficiency. Isokinetic muscle strength (in Newton metre per kilogram bodyweight) at start, end and 24 weeks after the RT was 0.98 ± 0.40, 1.11 ± 0.40, 1.09 ± 0.42 in the high-intensity group and 1.02 ± 0.41, 1.15 ± 0.42, 1.12 ± 0.40 in the low-intensity group, respectively. No differences were found between the groups, except for the estimated 1-RM in favour of the high-intensity group. In the subgroup with vitamin D deficiency, no difference on isokinetic muscle strength was found between the vitamin D and placebo group. CONCLUSIONS: High-intensity RT did not result in greater improvements in isokinetic muscle strength, pain and physical functioning compared to low-intensity RT in knee OA, but was well tolerated. Therefore these results suggest that either intensity of resistance training could be utilised in exercise programmes for patients with knee osteoarthritis. No synergistic effect of vitamin D supplementation and RT was found, but this finding was based on underpowered data.

Relaxation exercise therapy improves pain, muscle strength, and kinesiophobia following total knee arthroplasty in the short term: a randomized controlled trial.

PURPOSE: This study aimed to compare progressive muscle relaxation (PMR) + standard physiotherapy (PT) to standard PT during inpatient rehabilitation of total knee arthroplasty (TKA) patients in terms of post-operative outcomes. The hypothesis was that PMR + standard PT would lead to better pain, function, and neuromuscular outcomes than standard PT. METHODS: A total of 106 patients were randomly allocated into PMR or standard rehabilitation (SR) groups. Both groups received standard PT during their hospital stay. PMR group additionally performed PMR exercise on post-operative days 1, 2, and 3. Patients were evaluated regarding pain intensity, functional outcomes, muscle strength, active range of motion, knee edema, anxiety, depression, and kinesiophobia. RESULTS: There were no differences between groups at baseline (n.s.). During the inpatient period and at discharge, the PMR group had better results in terms of pain relief (p < 0.05), quadriceps strength (p = 0.001), kinesiophobia level (p = 0.011) compared to the SR group. No difference was detected between groups regarding other evaluation parameters during the inpatient period, at discharge, and third post-operative month (n.s.). The within-group analysis showed statistically significant differences over time in both groups in each variable (p < 0.05). CONCLUSION: Our findings support that PMR therapy offers beneficial results in subjective and objective measures of TKA patients during the inpatient period. Therefore, PMR therapy could be implemented into the rehabilitation program of TKA patients to enhance their early recovery from various symptoms following TKA. LEVEL OF EVIDENCE: II.

A Retrospective Study on the Efficacy of Two Different Rehabilitation Interventions on KOA: Shock Wave Therapy vs. Electroacupuncture Therapy.

OBJECTIVE: In this paper, we retrospectively reviewed the difference in clinical effectiveness of shock wave therapy and electroacupuncture therapy on knee osteoarthritis. METHODS: A total of 128 treatment cases of knee osteoarthritis patients were extracted from the medical record system of Shenzhen Longhua District Central Hospital during the period from January 1, 2018, to January 30, 2020. The cases were divided into three groups for different treatments: shock wave group (n = 54), electroacupuncture group (n = 41), and control group (n = 33). The shock wave group was given shock wave therapy combined basis clinical treatment; meanwhile, the electroacupuncture group was given electroacupuncture on the basis of actual clinical treatment. The control group was given conventional topical nonsteroidal anti-inflammatory drugs (Voltaren). Osteoarthritis index scale, NRS scale, and WHOQOL-BREF were observed before treatment, after 2 weeks, and 4 weeks after treatment. RESULTS: This study found that the osteoarthritis index scale and NRS scale of the shock wave group and the electroacupuncture group were lower than those before treatment; it had significant difference (P < 0.001). In WHOQOL-BREF, the shock wave group and the electroacupuncture group improved significantly four weeks after treatment (P < 0.001), which was statistically different from the conventional group (P = 0.04). CONCLUSION: Physical and rehabilitation medicine treatment (shock wave therapy) and traditional medical treatment (electroacupuncture) have better clinical effects on knee osteoarthritis, compared with conventional treatment. Shock wave and electric acupuncture have no apparent adverse reaction, suggesting that the treatment is safe and effective.

Joint Angles and Joint Moments of the Lower Limbs in Four Typical Tai Chi Movements: Consideration for Management of Knee Osteoarthritis.

This study examined the biomechanics of the lower limbs during four typical Tai Chi (TC) movements: wave hand in cloud, leaning fly side, repulse monkey, and brush knee and twist step, in order to provide biomechanical evidence-based recommendations for patients with knee osteoarthritis (OA) practicing TC. Joint angles and joint moments of the hip, knee, and ankle in frontal and sagittal plane as well as ground reaction forces were examined while performing TC and regular walking in an experienced 38 years old TC master. The results showed that relative to walking, the four TC movements are characterized by a wide motion range of lower limbs, slow increase in joint loading, and strong muscle activity during performance. Therefore, these TC movements could be suitable for patients with knee OA to practice for improving the muscle strength of their lower limbs and functional ability.

Effects of Tai Chi exercise on improving walking function and posture control in elderly patients with knee osteoarthritis: A systematic review and meta-analysis.

OBJECTIVE: It remains unclear whether Tai Chi is effective for walking function and posture control improvements in aged populations with knee osteoarthritis. The aim of this study was to systematically evaluate the effects of Tai Chi on improving walking function and posture control in elderly patients with knee osteoarthritis by updating the latest trial evidence. METHODS: Web of Science, PubMed/Medline, Embase, Scopus, PEDro, and Cochrane library were searched up to October 1, 2020 to identify RCTs evaluating Tai Chi for improving walking function and posture control in older adults with knee osteoarthritis. The primary outcomes were walking function and posture control. Meta-analysis was performed with RevMan Version 5.3 software. RESULTS: A total of 603 participants with knee osteoarthritis in the 11 trials were included. The results of meta-analysis showed that: The Tai Chi group was associated with better performance in 6-minute walk test (6 MWT), time up and go test (TUG) and "Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index" Physical Function Score than the control group ([MD: 46.67, 95% CI 36.91-56.43, P < .001]), ([MD: -0.89, 95% CI -1.16 to -0.61, P < .001]), ([MD: -11.28, 95% CI -13.33 to -9.24, P < .001]). CONCLUSION: This meta-analysis provided evidence from 11 RCTs that Tai Chi could be an excellent physical training strategy for improving walking function and posture control in older adults with knee osteoarthritis. Assuming that Tai Chi is at least effective and safe in most areas, it can be used as an adjuvant and reliable physical training strategy for walking function upgrading and balance control improvements for older patients with knee osteoarthritis.

The effectiveness of traditional Chinese medicine fumigation and washing nursing care after arthroscopic debridement of Knee Osteoarthritis: A protocol for systematic review and meta-analysis.

BACKGROUND: Knee Osteoarthritis (KOA) is a degenerative osteoarthrosis with knee joint pain as the main symptom. In recent years, arthroscopic removal of loose body and repair of meniscus have become common methods for the treatment of KOA. However, postoperative pain, swelling and limited joint movement affect the functional recovery of knee joint and the effect of surgical treatment. Early postoperative control of pain and swelling is of great significance to improve the curative effect of arthroscopic debridement and promote the recovery of knee joint function. In recent years, many clinical studies have reported that the nursing method of fumigation and washing with Chinese medicine after arthroscopic debridement of KOA can relieve pain, promote the recovery of joint function and improve the clinical curative effect, but there is a lack of evidence-based medicine. The purpose of this study is to evaluate the efficacy and safety of fumigation and washing with traditional Chinese medicine after KOA arthroscopy. METHODS: Computer retrieval English database (PubMed, Embase, Web of Science, the Cochrane Library) and Chinese database (China National Knowledge Infrastructure, Wanfang, VIP Database for Chinese Technical Periodicals, China Biology Medicine disc), moreover manual retrieval academic, Google and baidu from building to since December 2020, traditional Chinese medicine fumigation applied to KOA arthroscopy postoperative nursing of randomized controlled clinical research, by two researchers independently evaluated the quality of the included study and extracted the data. Meta-analysis of the included literatures was performed using RevMan5.3 software. RESULTS: The main observation index of this study was the effective rate, and the secondary indexes included Visual Analogue Scale Score, the Western Ontario and McMaster university orthopedic index, Lysholms score and adverse reactions, so as to evaluate the efficacy and safety of traditional Chinese medicine fumigation nursing after KOA arthroscopy. CONCLUSION: This study will provide reliable evidence for the clinical application of Fumigation and washing nursing of traditional Chinese medicine after KOA arthroscopy. ETHICS AND DISSEMINATION: Private information from individuals will not be published. This systematic review also does not involve endangering participant rights. Ethical approval will not be required. The results may be published in a peer-reviewed journal or disseminated at relevant conferences. OSF REGISTRATION NUMBER: DOI 10.17605/OSF.IO/THZP4.

"It's the single best thing I've done in the last 10 years": a qualitative study exploring patient and dietitian experiences with, and perceptions of, a multi-component dietary weight loss program for knee osteoarthritis.

OBJECTIVE: Explore patient and dietitian experiences with a multi-component dietary weight loss program for knee osteoarthritis to understand enablers and challenges to success at 6-months. DESIGN: Qualitative study embedded within a randomised controlled trial. Semi-structured individual interviews with 24 patients with knee osteoarthritis who undertook, and five dietitians who supervised, a weight management program (involving a ketogenic very low calorie diet (VLCD), video consultations, educational resources) over 6 months. Data were thematically analysed. RESULTS: Five themes were developed: (1) ease and convenience of program facilitated adherence (structure and simplicity of the meal replacements; not feeling hungry on diet; convenience of consulting via video) (2) social and professional support crucial for success (encouragement from partner, family, and friends; guidance from, and accountability to, dietitian; anxiety around going at it alone) (3) program was engaging and motivating (determination to stick to program; rapid weight loss helped motivation) (4) holistic nature of program was important (suite of high-quality educational resources; exercise important to compliment weight loss) (5) rewarding experience and lifelong impact (improved knee pain and function; positive lifestyle change). CONCLUSIONS: Patients and dietitians described positive experiences with the weight management program, valuing its simplicity, effectiveness, and convenience. Support from dietitians and a comprehensive suite of educational resources, incorporated with an exercise program, were considered crucial for success. Findings suggest this multi-component dietary program is an acceptable weight loss method in people with knee osteoarthritis that may benefit symptoms. Strategies for supporting long-term independent weight management should be a focus of future research.

Tai Chi exercise can ameliorate physical and mental health of patients with knee osteoarthritis: systematic review and meta-analysis.

OBJECTIVE: To systematically review the effects of Tai Chi exercise as a nonpharmacological therapeutic strategy on the physical and mental health in individuals with knee osteoarthritis. DATA SOURCES: A systematic literature retrieval has been conducted in PubMed, Web of Science, EMbase, CENTRAL, OVID, CINAHL, Physiotherapy Evidence Database, Chinese Biomedical Database and China National Knowledge Infrastructure up to June 2020 to identify the relevant randomised controlled trials (RCTs). METHODS: Two authors assessed independently the risk of bias using the Cochrane Collaboration's tool. Standardised mean difference (SMD) and 95% CI were calculated and data were combined using the fixed or random-effect model. The strength of evidence was rated with Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS: A total of 16 RCTs involving 986 patients with knee osteoarthritis met the established inclusion criteria. The strength of evidence for the main outcomes was low or moderate. The systematic review illustrated the efficacy of Tai Chi exercise in treating and managing knee osteoarthritis. Patients' outcomes practising Tai Chi exercise were improved significantly, including pain (SMD = ‒0.69, 95%CI: ‒0.95 to ‒0.44, P < 0.001), stiffness (SMD = ‒0.59, 95%CI: ‒0.91 to ‒0.27, P < 0.001), physical function (SMD = ‒0.92, 95%CI: -1.16 to ‒0.69, P < 0.001), dynamic balance (SMD = 0.69, 95%CI: 0.38 to 0.99, P < 0.001), physiological and psychological health (SF-36 PCS: SMD = 0.48, 95%CI: 0.28 to 0.68, P < 0.001; SF-36 MCS: SMD = 0.26, 95%CI: 0.06 to 0.45, P = 0.01). No adverse events associated with Tai Chi exercise were reported. CONCLUSION: Tai Chi exercise was beneficial for ameliorating physical and mental health of patients with knee osteoarthritis and should be available as an alternative non-pharmacological therapy in rehabilitation programmes.

Using TENS to Enhance Therapeutic Exercise in Individuals with Knee Osteoarthritis.

Transcutaneous electrical nerve stimulation (TENS) facilitates quadriceps voluntary activation in experimental settings. Augmenting therapeutic exercise (TE) with TENS may enhance the benefits of TE in individuals with knee osteoarthritis (KOA) and quadriceps voluntary activation failure (QVAF). PURPOSE: This study aimed to determine the effect of TENS + TE on patient-reported function, quadriceps strength, and voluntary activation, as well as physical performance compared with sham TENS + TE (Sham) and TE alone in individuals with symptomatic KOA and QVAF. METHODS: Ninety individuals participated in a double-blinded randomized controlled trial. Everyone received 10 standardized TE sessions of physical therapy. TENS + TE and Sham groups applied the respective devices during all TE sessions and throughout activities of daily living over 4 wk. The Western Ontario and McMaster University Osteoarthritis Index (WOMAC), quadriceps strength, and voluntary activation, as well as a 20-m walk test, chair-stand test, and stair-climb test were performed at baseline, after the 4-wk intervention (post 1) and at 8 wk after the start of the intervention (post 2). Mixed-effects models were used to determine between-group differences between baseline and post 1, as well as baseline and post 2. RESULTS: Improvements in WOMAC subscales, quadriceps strength, and voluntary activation, 20-m walk times, chair-stand repetitions, and stair-climb time were found at post 1 and post 2 compared with baseline for all groups (P < 0.05). WOMAC Pain and Stiffness improved in the TENS + TE group compared with TE alone at post 1 (P < 0.05); yet, no other between-group differences were found. CONCLUSIONS: TE effectively improved patient-reported function, quadriceps strength, and voluntary activation, as well as physical performance in individuals with symptomatic KOA and QVAF, but augmenting TE with TENS did not improve the benefits of TE.

Effect of Tai Chi Training on Plantar Loads during Walking in Individuals with Knee Osteoarthritis.

Tai Chi is an available method for the treatment of knee osteoarthritis (KOA). The impacts of Tai Chi on plantar loads of individuals with KOA are not fully understood. 46 participants with knee osteoarthritis were randomly assigned into the Tai Chi group (n = 23) or the control group (n = 23). The Tai Chi group attended a 6-month Tai Chi program, and the control group participated in a wellness education program. Novel Pedar-X system was used to collect the peak pressure (PP) and maximum force (MF) during walking before and 6 months after the intervention. Significant higher peak pressure and maximum force were observed in the 4th and 5th metatarsophalangeal joints in the Tai Chi group. However, there were significant declines in the peak pressure of the whole foot and the 2nd and 3rd metatarsophalangeal joints and maximum force of the heel in the control group. These results suggested that individuals with KOA might change the pattern of plantar loads during walking through Tai Chi, and plantar loads would be useful as a parameter to assess the effect of Tai Chi on knee osteoarthritis. This trial is registered with Clinical Trials: CHiCTR-TRC-13003264.

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

OBJECTIVE: The goal of this systematic review was to provide guidelines for treatment parameters regarding electrical stimulation by investigating its efficacy in improving muscle strength and decreasing pain in patients with knee osteoarthritis. DESIGN: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standard, three electronic databases (CINAHL, PubMed, and PEDro) and gray literature were used. Randomized control trials comparing electrical stimulation and conservative physical therapy were critically appraised using the 2005 University of Oxford standard. RESULTS: Nine randomized control trials were included in our review. First, our review confirmed that neuromuscular electrical stimulation is the most effective electrical stimulation treatment in the management of knee OA, and its efficiency is higher when combined with a strengthening program. Second, frequency of at least 50 Hz and no more than 75 Hz with a pulse duration between 200 and 400 µs and a treatment duration of 20 mins is necessary for successful treatment. CONCLUSIONS: For the first time, our review provides standardized clinical treatment parameters for neuromuscular electrical stimulation to be included in a strengthening program for the adult patient with knee OA. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Recall the impact of quadriceps femoris weakness on joint stability; (2) Summarize the mechanism of action of neuromuscular electrical stimulation (NMES) on reducing pain and increasing muscle strength; and (3) Plan the clinical treatment parameters of NMES to be included in a strengthening program for an adult patient with knee osteoarthritis. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Limited effect of a self-management exercise program added to spa therapy for increasing physical activity in patients with knee osteoarthritis: A quasi-randomized controlled trial.

BACKGROUND: The efficacy of spa therapy in osteoarthritis (OA) has ever been demonstrated, with a good level of evidence for pain and disability. The effect of a self-management program with spa therapy on physical activity (PA) level has never been demonstrated. OBJECTIVE: This study aimed to assess, at 3 months, the effectiveness of 5 sessions of a self-management exercise program in patients with knee OA (KOA) who benefit from 18 days of spa therapy and received an information booklet (on proposed physical exercises) on improvement in at least one PA level. METHODS: This was an interventional, multicentre, quasi-randomized controlled trial with a cluster randomized design (1-month period). People 50 to 75 years old with symptomatic knee OA were included in 3 spa therapy centres in France (Bourbon Lancy, Le Mont Dore, Royat). Both groups received conventional spa therapy sessions during 18 days and an information booklet on the benefits of PA practice for KOA. The intervention group additionally received 5 self-management exercise sessions. The main outcome was improvement in at least one PA level according to the International Physical Activity Questionnaire (IPAQ) short-form categorical score (low to moderate or high, or moderate to high) at 3 months. Secondary outcomes were the evolution of PA (MET-min/week), disability, pain, anxiety, depression, self-efficacy, fears and beliefs concerning KOA, barriers to and facilitators of regular PA practice, consumption of painkillers and adherence to physical exercise program at 3 months. Assessors but not participants or caregivers were blinded. RESULTS: In total, 123 patients were randomized, 54 to the intervention group and 69 to the control group. Considering the main outcome, at 3 months, 37% of patients in the intervention group showed improvement in at least one PA level according to the IPAQ categorical score versus 30.4% in the control group (P=0.44). In the intervention group, 13 (24.1%) patients showed improvement from low to moderate PA level (vs. 8 [11.6%] in the control group), 2 (3.7%) from low to high (vs. 2 [2.9%]) and 5 (9.3%) from moderate to highvs. 11 [15.9%]). Both intervention and control groups showed increased IPAQ continuous scores (MET-min/week) at 3 months, although not significantly. HAD anxiety and depression scores were significantly reduced in the intervention group (P=0.001 and P=0.049, respectively) and the perception of PA was better in the intervention than control group for motivation and barriers scores (P=0.019 and P=0.002, respectively). CONCLUSIONS: This study showed the lack of impact of a short self-management program on PA level in addition to 18-day spa therapy for KOA, but both intervention and control groups showed improved PA level.

Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty: VERITAS, a Randomized Controlled Trial.

BACKGROUND: Financial burden for patients, providers, and payers can reduce access to physical therapy (PT) after total knee arthroplasty (TKA). The purpose of the present study was to examine the effect of a virtual PT program on health-care costs and clinical outcomes as compared with traditional care after TKA. METHODS: At least 10 days before unilateral TKA, patients from 4 clinical sites were enrolled and randomized 1:1 to the virtual PT program (involving an avatar [digitally simulated] coach, in-home 3-dimensional biometrics, and telerehabilitation with remote clinician oversight by a physical therapist) or to traditional PT care in the home or outpatient clinic. The primary outcome was total health-care costs for the 12-week post-hospital period. Secondary (noninferiority) outcomes included 6 and 12-week Knee injury and Osteoarthritis Outcome Score (KOOS); 6-week knee extension, knee flexion, and gait speed; and 12-week safety measures (patient-reported falls, pain, and hospital readmissions). All outcomes were analyzed on a modified intent-to-treat basis. RESULTS: Of 306 patients (mean age, 65 years; 62.5% women) who were randomized from November 2016 to November 2017, 290 had TKA and 287 (including 143 in the virtual PT group and 144 in the usual care group) completed the trial. Virtual PT had lower costs at 12 weeks after discharge than usual care (median, $1,050 compared with $2,805; p < 0.001). Mean costs were $2,745 lower for virtual PT patients. Virtual PT patients had fewer rehospitalizations than the usual care group (12 compared with 30; p = 0.007). Virtual PT was noninferior to usual PT in terms of the KOOS at 6 weeks (difference, 0.77; 90% confidence interval [CI], -1.68 to 3.23) and 12 weeks (difference, -2.33; 90% CI, -4.98 to 0.31). Virtual PT was also noninferior to usual care at 6 weeks in terms of knee extension, knee flexion, and gait speed and at 12 weeks in terms of pain and hospital readmissions. Falls were reported by 19.4% of virtual PT patients and 14.6% of usual care patients (difference, 4.83%; 90% CI, -2.60 to 12.25). CONCLUSIONS: Relative to traditional home or clinic PT, virtual PT with telerehabilitation for skilled clinical oversight significantly lowered 3-month health-care costs after TKA while providing similar effectiveness. These findings have important implications for patients, health systems, and payers. Virtual PT with clinical oversight should be considered for patients managed with TKA. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Effects of Taichi exercise on knee and ankle proprioception among individuals with knee osteoarthritis.

The study aimed to investigate the effects of 24 weeks Taichi intervention on knee and ankle proprioception amongst individuals with knee osteoarthritis (KOA). Ninety-two patients with KOA were included in the current study, involving 52 participants in the intervention group and 40 participants in the control group. The intervention group performed Taichi exercise for 24 weeks, the control group accepted the health education lectures. The main outcome of this study was the proprioception of the knee and ankle which was measured by an electric-driven movable frame. Between- and within-group differences were evaluated through the repeated-measurement ANOVA. For the Taichi group, the differences in the changes in ankle proprioception were significant on ankle plantarflexion (p = 0.03), ankle dorsiflexion (p = 0.043), ankle varus (p = 0.019) and knee flexion (p = 0.01) between the baseline and post-test measures. Twenty-four weeks Taichi exercise may improve the ankle and knee proprioception of patients with KOA.

Real-Time Three-Dimensional Knee Moment Estimation in Knee Osteoarthritis: Toward Biodynamic Knee Osteoarthritis Evaluation and Training.

We investigated differences in knee kinetic variables (external knee adduction, flexion, internal rotation moments, and impulses) between patients with knee osteoarthritis (KOA) and healthy controls during stepping on a custom elliptical trainer; and searched knee kinetic variable candidates for real-time biofeedback and for complementing diagnosis/evaluation on the elliptical trainer based on the knee kinetic variables' associations with the knee injury and osteoarthritis outcome score (KOOS). Furthermore, we explored potential gait re-training strategies on the elliptical trainer by investigating the knee kinetic variables' associations with 3-D ankle angles. The knee kinetic variables and ankle angles were determined in real-time in a patient group of 10 patients with KOA and an age-and sex-matched control group of 10 healthy subjects. The mean peak external knee adduction moment of the patient group was 47% higher than that of the control group. The KOOS-Sports and Recreational Activities and KOOS-Pain scores were found to be significantly associated with the knee kinetic variables. All the ankle angles were associated with the knee kinetic variables. The findings support the use of the knee kinetic variables on the elliptical trainer to complement KOA diagnosis quantitatively and provide potential real-time KOA gait re-training strategies/guides.

Does adding transcutaneous electrical nerve stimulation to therapeutic ultrasound affect pain or function in people with osteoarthritis of the knee? A randomized controlled trial.

OBJECTIVE: To compare the efficacy of therapeutic ultrasound combined with transcutaneous electrical nerve stimulation versus therapeutic ultrasound alone for pain relief and functional improvement in patients with symptomatic knee osteoarthritis. DESIGN: Randomized controlled trial (blinded assessor). SETTING: Outpatient. PARTICIPANTS: A total of 148 ambulatory knee osteoarthritis patients (pain score ⩾ 5/10) were recruited as study participants. INTERVENTIONS: Ultrasound combined with transcutaneous electrical nerve stimulation (study group) or ultrasound (control group). Both groups received treatment in the supine position for 10 minutes per session, for 10 sessions within two weeks. MAIN OUTCOMES: Pain score and gait speed were measured after random allocation and on day 10. Adverse events, global assessment, and patient satisfaction were recorded after treatment. RESULTS: All baseline data were comparable between groups. The mean (SD) pain score at baseline and day 10 was 5.9 (1.3) and 2.7 (1.7) in the control group, and 5.8 (1.3) and 2.9 (1.7) in the study group, respectively. Gait speed at baseline and day 10 was 1.11 (0.30) and 1.23 (0.38) m/s in the control group, and 1.10 (0.36) and 1.17 (0.39) m/s in the study group, respectively. No difference was observed between groups for total pain score (0.28; 95% confidence interval (CI): -0.28, 0.84) or gait speed (-0.03; 95% CI: -0.13, 0.07). The results from intention-to-treat analysis were similar to those from per-protocol analysis. No difference was observed between groups for adverse events. Most participants reported satisfaction and improvement for the global assessment. CONCLUSION: Adding transcutaneous electrical nerve stimulation to ultrasound demonstrated no additional beneficial effect over ultrasound alone in patients with symptomatic knee osteoarthritis.