Neuromuscular electrical stimulation (NMES) for patellofemoral pain syndrome

Nonpharmacological Therapies for Musculoskeletal Injury in Military Personnel: A Systematic Review/Meta-Analysis

INTRODUCTION

Musculoskeletal (MSK) injury is an inherent risk for military personnel that can potentially impact job performance, productivity, and military readiness. Evidence is needed to show the efficacy of nonpharmacological, self-managed therapies to reduce MSK symptoms at common injury sites that are feasible for use during expeditionary operations and home stations. This systematic review and meta-analysis identified, summarized, and synthesized available evidence from randomized and non-randomized trials on the effectiveness of self-managed, home-use therapies to improve pain, muscle strength, and physical performance in military personnel with MSK injuries, when compared to controls.

METHODS

The electronic databases of MEDLINE ALL Ovid, Embase.com, Cochrane Library, Scopus, Clinicaltrial.gov, and CINAHL Complete via EBSCO were systematically searched for relevant reports published in English. Utilizing the Covidence platform and consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, multiple reviewers, using pre-determined data fields, screened for eligibility, assessed risk of bias (RoB), and performed data extraction. Evaluation of treatment effectiveness was determined using multilevel mixed-effects meta-analysis.

RESULTS

The database and register search yielded 1,643 reports that were screened for eligibility. After screening of titles/abstracts and full texts, 21 reports were identified for evidence synthesis. Of these, two reports were excluded and two described the same study, resulting in a final list of 18 studies (19 reports). For quality assessment, the overall RoB for the 18 studies was categorized as 33.3% low risk, 55.6% with some concerns, and 11.1% high risk. Across the five domains of bias, 70% of the reports were classified as low risk. This systematic review found that the differences in interventions, outcome measures, and design between the studies were associated with a substantial degree of heterogeneity (I2 = 60.74%), with a small overall improvement in outcomes of the interventions relative to their specific control (standard mean difference 0.28; 95% CI, 0.12 to 0.45). There were varying degrees of heterogeneity for individual body regions. This was due, in part, to a small number of studies per bodily location and differences in the study designs. For the neck/shoulder, heterogeneity was moderate, with the clearest positive effect being for physical performance outcomes via other medical devices. For the back, there was substantial heterogeneity between studies, with modest evidence that pain was favorably improved by other medical devices and exercise interventions. For the leg, one study showed a clear large effect for other medical devices (shockwave treatment) on pain with substantial heterogeneity. The best evidence for positive effects was for the knee, with mainly negligible heterogeneity and some benefits from bracing, electrotherapy, and exercise.

CONCLUSION

Evidence showed small beneficial effects in pain, strength, and physical performance by individual body regions for some interventions, compared to controls. The best evidence for a positive effect was for the knee. The findings suggest that some benefit may be obtained by including several treatments during deployment in austere environments and prolonged casualty care scenarios of military personnel with MSK injuries. Further research is warranted to better assess the potential benefits of using these treatments during deployments in austere environments as part of an individualized, multimodal approach for MSK injuries.

Effectiveness of Kinesio tape in the treatment of patients with patellofemoral pain syndrome: A systematic review and meta-analysis

OBJECTIVE

To evaluate the clinical effectiveness of the Kinesio tape in the treatment of patellofemoral pain syndrome (PFPS) by meta-analysis.

METHODS

Two investigators independently conducted an electronic literature search to assess the outcomes of intramuscular patches for PFPS. Electronic databases included PubMed, Embase, Web of Science, Cochrane Library, Wanfang Database, Chinese Journal Full Text Database (CNKI), and Wipo Database from November 2023. Extracted inclusion indicators included pain score VAS or NRS, knee function assessment knee pain syndrome (Kujala) score, and knee symptom score Lysholm knee score scale. Data were extracted and then meta-analyzed using Review Manager 5.3 software and Stata 17.0 software.

RESULT

Fourteen studies were included, all of which were randomized controlled studies. The results showed that short-term pain relief was superior in the Kinesio tape (KT) group compared with the control group, with a statistically significant difference in the results (MD = -1.54, 95% CI [-2.32, -0.76], P = .0001); medium-term pain relief was superior in the KT group compared with the control group, with a statistically significant difference in the results (MD = -0.84, 95% CI [-1.50, -0.18], P = .01); long-term pain relief in the KT group was better than the control group, with statistically different results (MD = -0.56, 95% CI [-0.98, -0.13], P < .00001). In contrast, there was no significant difference between the KT group and the control group in the assessment of knee function (MD = -0.98, 95% CI [-4.03, 2.06], P = .03), and there was no significant difference between the KT group and the control group in the Lysholm knee score scale score of knee symptoms (MD = 4.18, 95% CI [-6.70, 15.05], P = .45).

CONCLUSION

Kinesio taping can effectively relieve the pain of PFPS, but has no significant effect on the improvement of knee joint function and symptoms.

Do Electrical Stimulation Devices Reduce Pain and Improve Function?-A Comparative Review

BACKGROUND

Multiple forms of electrical stimulation (ES) potentially offer widely varying clinical benefits. Diminished function commonly associated with acute and chronic pain lessens productivity and increases medical costs. This review aims to compare the relative effects of various forms of ES on functional and pain outcomes.

METHODS

A comprehensive literature search focused on studies of commonly marketed forms of ES used for treatment of pain and improvement of function. Peer-reviewed manuscripts were categorized as "Important" (systematic review or meta-analysis, randomized controlled trial, observational cohort study) and "Minor" (retrospective case series, case report, opinion review) for each identified form of ES.

RESULTS AND DISCUSSION

Varying forms of ES have markedly different technical parameters, applications, and indications, based on clinically meaningful impact on pain perception, function improvement, and medication reduction. Despite being around for decades, there is limited quality evidence for most forms of ES, although there are several notable exceptions for treatment of specific indications. Neuromuscular electrical stimulation (NMES) has well-demonstrated beneficial effects for rehabilitation of selective spinal cord injured (SCI), post-stroke, and debilitated inpatients. Functional electrical stimulation (FES) has similarly shown effectiveness in rehabilitation of some stroke, SCI, and foot drop outpatients. H-Wave® device stimulation (HWDS) has moderate supportive evidence for treatment of acute and refractory chronic pain, consistently demonstrating improvements in function and pain measures across diverse populations. Interestingly, transcutaneous electrical nerve stimulation (TENS), the most widely used form of ES, demonstrated insignificant or very low levels of pain and functional improvement.

CONCLUSION

Ten of 13 reviewed forms of ES have only limited quality evidence for clinically significant reduction of pain or improvement of function across different patient populations. NMES and FES have reasonably demonstrated effectiveness, albeit for specific clinical rehabilitation indications. HWDS was associated with the most clinically significant outcomes, in terms of functional improvement combined with reduction of pain and medication use. More rigorous long-term clinical trials are needed to further validate appropriate use and specific indications for most forms of ES.

LEVEL OF EVIDENCE

II.

What is the landscape of evidence about the safety of physical agents used in physical medicine and rehabilitation? A scoping review

BACKGROUND

Several systematic reviews (SRs) assessing the effectiveness of superficial physical agents have been published, but the evidence about their safety remains controversial.

OBJECTIVE

To identify areas where there is evidence of the safety of physical agents by a scoping review.

DESIGN

Four databases were systematically searched for including English SRs that explored and reported safety in terms of adverse events (AEs) related to the application of physical agents in outpatient and inpatient physical medicine and rehabilitation settings managed by healthcare professionals, published in January 2011-29 September 2021. The severity of AEs was classified according to the Common Terminology Criteria. Then, AE findings were summarised according to the SR syntheses. Finally, the reporting of the certainty of the evidence was mapped.

RESULTS

Overall, 117 SRs were retrieved. Most of the SRs included randomised controlled trials (77%) and patients with musculoskeletal disorders (67%). The most investigated physical agents were extracorporeal shock wave therapy (ESWT) (15%), transcutaneous electrical nerve stimulation (13%) and electrical stimulation (12%). No AE (35%) was reported in one-third of the included primary studies in SRs, whereas few severe AEs occurred in less than 1% of the sample. Among physical agents, ESWT showed an increased risk of experiencing mild AEs compared with the control. Most SRs reported a qualitative AE synthesis (65.8%), and few reported the certainty of the evidence (17.9%), which was mainly low.

CONCLUSION

We found evidence of safety on several physical agents coming mostly from qualitative synthesis. No significant harms of these interventions were found except for ESWT reporting mild AEs. More attention to the AEs reporting and their classification should be pursued to analyse them and assess the certainty of evidence quantitatively.

REVIEW REGISTRATION

https://osf.io/6vx5a/.

Arthralgia: a map of Cochrane evidence relevant to rehabilitation for people with post COVID-19 condition

INTRODUCTION

Rehabilitation focuses on impairments, activity limitations and participation restrictions being informed by the underlying health condition. In the current absence of direct "evidence on" rehabilitation interventions for people with post COVID-19 condition (PCC), we can search and synthesize the indirect "evidence relevant to" coming from interventions effective on the symptoms of PCC in other health conditions. The World Health Organization (WHO) required this information to inform expert teams and provide specific recommendations in its Guidelines. With this overview of reviews with mapping we aimed to synthesize the Cochrane evidence relevant to rehabilitation for arthralgia due to PCC in a map.

EVIDENCE ACQUISITION

We searched the last five years' Cochrane Systematic Review (CSRs) using the terms "arthralgia," "joint pain," and "rehabilitation" and their synonyms in the Cochrane Library. We extracted and summarized all the available evidence using a map. We grouped the included CSRs for health conditions and interventions, indicating the effect and the quality of evidence.

EVIDENCE SYNTHESIS

We found 200 CSRs published between 2016 and 2021, and included 11 in this overview. They provided data from 7 health conditions, with osteoarthritis (5 studies) being the most studied. Effective rehabilitation interventions included exercise training, transcranial magnetic stimulation, different types of electrical stimulation and Tai chi. The overall quality of evidence was mainly low to very low, and moderate in a few cases.

CONCLUSIONS

These results provided the requested information to the WHO and served as the basis for one recommendation on treatments for arthralgia due to PCC in the current Guidelines for clinical practice. These results should be interpreted as a first step of indirect evidence able to generate helpful hypotheses for future research.

Comparison between the effects of Maitland's mobilization versus its combination with vastus medialis oblique neuromuscular stimulation on two scales (NPRS & WOMAC) in knee osteoarthritis patients

Background & objectives

Osteoarthritis (OA) is the most common form of arthritis that increases with age affecting the population from the middle age to the elderly. The present study was undertaken to find whether neuromuscular stimulation of vastus medialis oblique (VMO) in combination with Maitland's mobilization and exercises was more effective as compared to Maitland's mobilization with exercises alone in patients with knee OA.

Methods

Sixty patients with knee OA were purposively selected and randomly distributed to two groups that received an intervention for eight weeks. Group A patients received Maitland's mobilization in combination with exercises and group B patients received the same intervention as group A in combination with neuromuscular stimulation of VMO muscle. After eight weeks, outcome measures, i.e. Numeric Pain Rating Scale (NPRS) and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) index, were reassessed.

Results

Both groups showed significant (P<0.05) within-group improvement in the knee pain levels and stiffness as reflected by NPRS and WOMAC index.

Interpretation & conclusions

Patients of both the groups (A and B) were found to be improving significantly in pain and disability, group A patients receiving Maitland's mobilization in combination with exercises were found to get more relief in pain and disability.

Effect of plyometric training and neuromuscular electrical stimulation assisted strength training on muscular, sprint, and functional performances in collegiate male football players

Background

The study's objective was to analyze the influence of an 8-week neuromuscular electrical stimulation (NMES) with a plyometric (PT) and strength training (ST) program on muscular, sprint, and functional performances in collegiate male football players.

Methods

Sixty collegiate male football players participated in this randomized controlled trial single-blind study. All the participants were randomly divided into two groups: (1) NMES group (Experimental, n = 30) who received NMES assisted ST and (2) sham NMES group (Control, n = 30) who received sham NMES assisted ST. In addition, participants from both groups received a PT program; both groups received intervention on three days a week for 8-weeks. The study's outcomes, such as muscular, sprint, and functional performances, were assessed using a strength test (STN) for quadriceps muscle, sprint test (ST), and single-leg triple hop test (SLTHT), respectively, at baseline pre-intervention and 8-week post-intervention. The interaction between group and time was identified using a mixed design (2 × 2) ANOVA.

Results

Significant difference found across the two time points for the scores of STN: F (1.58) = 5,479.70, p < 0.05; SLTHT: F (1.58) = 118.17, p < 0.05; and ST: F (1.58) = 201.63, p < 0.05. Similarly, the significant differences were found between groups averaged across time for the scores of STN: F (1.58) = 759.62, p < 0.05 and ST: F (1.58) = 10.08, p < 0.05. In addition, after 8-week of training, Cohen's d observed between two groups a large to medium treatment's effect size for the outcome STN (d = 10.84) and ST (d = 1.31). However, a small effect size was observed only for the SLTHT (d = 0.613).

Conclusions

Findings suggest that the effect of PT and ST with either NMES or sham NMES are equally capable of enhancing muscular, sprint, and functional performances in collegiate male football players. However, PT and ST with NMES have shown an advantage over PT and ST with sham NMES in improving muscular performance and sprint performance among the same participants.

Efficacy and safety of electrical stimulation for stress urinary incontinence in women: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

This systematic review and meta-analysis was aimed at investigating the safety and short- and long-term efficacy of electrical stimulation (ES) in women with stress urinary incontinence (SUI).

METHODS

PubMed, Embase, and the Cochrane database were searched for randomized controlled trials (RCTs) conducted up to 2020. Studies comparing ES with sham ES or no intervention were included. Standardized mean differences (SMDs), weighted mean differences (WMDs), relative risks (RR), and 95% confidence intervals (CIs) were calculated.

RESULTS

This study included 9 RCTs, involving a total of 982 patients, of whom 520 received ES. Our results showed that in the short term (< 3 months), compared with sham ES or no intervention, ES significantly improved incontinence-specific quality of life (IQOL) (p = 0.003; SMD = 0.90 [95% CI, 0.30 to 1.50]; I2 = 88%) and reduced urine leakage (p < 0.00001; WMD = -6.15 [95% CI, -8.29 to -4.01]; I2 = 0%) but did not significantly reduce the frequency of incontinence episodes (p = 0.34; WMD = -0.98 [95% CI, -2.99 to 1.04]; I2 = 85%). In the long term (3-7.5 months), ES significantly improved IQOL (p = 0.0009; SMD = 1.14 [95% CI, 0.47 to 1.81]; I2 = 91%) and reduced the frequency of incontinence episodes (p = 0.0009; WMD = -2.45 [95% CI, -3.90 to -1.01]; I2 = 79%) but did not significantly reduce urine leakage (p = 0.27; WMD = -9.21 [95% CI, -25.57 to 7.14]; I2 = 71%). There was no significant difference in adverse events between ES and sham ES or no intervention (p = 0.36; RR = 1.34 [95% CI, 0.72 to 2.50]; I2 = 0%). A test for subgroup differences showed that electroacupuncture (EA) improved long-term IQOL to a greater extent than vaginal ES (VES), whereas there was no significant difference in efficacy between EA and VES in short- or long-term reduction of urine leakage, frequency of incontinence episodes, or short-term IQOL improvement.

CONCLUSIONS

ES may improve short- and long-term IQOL for women with SUI, but it appears to provide only short-term reduction in urine leakage and long-term reduction in frequency of incontinence episodes. However, we cannot draw any conclusion on the safety between ES and sham ES or no intervention because of the rarity of adverse events. It is still uncertain whether EA is comparable or superior to VES owing to an insufficient number of studies and patients. The conclusions should be considered carefully because of the limited quality and quantity of the RCTs included. Further rigorous RCTs with adequate sample sizes and long follow-up are necessary to fully validate our findings.

Effects of neuromuscular electrical stimulation on energy expenditure and postprandial metabolism in healthy men

It is unclear whether neuromuscular electrical stimulation (NMES) has meaningful metabolic effects when users have the opportunity to self-select the intensity to one that can be comfortably tolerated. Nine healthy men aged 28 ± 9 y (mean ± SD) with a body mass index 22.3 ± 2.3 kg/m2 completed 3 trials involving a 2-h oral glucose tolerance test whilst, in a randomised counterbalanced order, (1) sitting motionless (SIT), (2) standing motionless (STAND); and (3) sitting motionless with NMES of quadriceps and calves at a self-selected tolerable intensity. The mean (95% confidence interval [CI]) total energy expenditure was greater in the NMES trial (221 [180-262] kcal/2 h) and STAND trial (178 [164-191] kcal/2 h) than during SIT (159 [150-167] kcal/2 h) (both, p < 0.05). This was primarily driven by an increase in carbohydrate oxidation in the NMES and STAND trials compared with the SIT trial (p < 0.05). Postprandial insulin iAUC was lower in both NMES and STAND compared with SIT (16.4 [7.7-25.1], 17 [7-27] and 22.6 [10.8-34.4] nmol·120 min/L, respectively; both, p < 0.05). Compared with sitting, both NMES and STAND increased energy expenditure and whole-body carbohydrate oxidation and reduced postprandial insulin concentrations in healthy men, with more pronounced effects seen with NMES. Self-selected NMES is a potential strategy for improving metabolic health. This trial is registered at ClinicalTrials.gov (ID: NCT04389736). Novelty: NMES at a comfortable intensity enhances energy expenditure and carbohydrate oxidation, and reduces postprandial insulinemia. Thus, self-selected NMES represents a potential strategy to improve metabolic health.

The effectiveness of superimposed neuromuscular electrical stimulation combined with strengthening exercises on patellofemoral pain: A randomized controlled pilot trial

BACKGROUND

Patellofemoral pain (PFP) is one of the most common disorders of the knee. Neuromuscular electrical stimulation (NMES) is often assumed by clinicians to be an effective adjunctive therapy to quadriceps strengthening.

OBJECTIVE

The aim of this study was to assess the efficacy of superimposed NMES combined with strengthening exercises to improve the recovery of quadriceps strength and function in patients with PFP.

METHODS

This study was planned as a single blind randomized controlled pilot study. A total of twenty-seven patients diagnosed with PFP were randomly assigned into 2 groups. Patients received superimposed NMES in addition to the standardized program (Group I) or only the standardized program (Group II). The patients in both groups were treated 3 times a week for 6 weeks and followed at 12 weeks. Primary outcome measure was quadriceps isokinetic muscle strength. The changes in dependent variables before treatment, 6th, and 12th weeks were analyzed using a 2 × 3 mixed-model analysis of variance.

RESULTS

There were significant improvements in the within groups statistics of all parameters for both groups (p< 0.05). No differences in quadriceps strength, Kujala and Lysholm scores between groups were found at the different time points [F (2, 21) = 0.86; p= 0.12, F (2, 21) = 0.001; p= 0.97, F (2, 21) = 0.12; p= 0.73, respectively].

CONCLUSIONS

The results indicate that superimposed NMES combined with the standardized rehabilitation program has no clinically significant superiority to standardized rehabilitation program alone.

Physical Therapist Management of Anterior Knee Pain

PURPOSE OF REVIEW

Anterior knee pain is a common musculoskeletal complaint among people of all ages and activity levels. Non-operative approaches with an emphasis on physical therapy management are the recommended initial course of care. The purpose of this review is to describe the current evidence for physical therapist management of anterior knee pain with consideration of biomechanical and psychosocial factors.

RECENT FINDINGS

The latest research suggests anterior knee pain is a combination of biomechanical, neuromuscular, behavioral, and psychological factors. Education strategies to improve the patient's understanding of the condition and manage pain are supported by research. Strong evidence continues to support the primary role of exercise therapy and load progression to achieve long-term improvements in pain and function. Preliminary studies suggest blood flow restriction therapy and movement retraining may be useful adjunct techniques but require further well-designed studies. Anterior knee pain includes multiple conditions with patellofemoral pain being the most common. An insidious onset is typical and often attributed to changes in activity and underlying neuromuscular impairments. A thorough clinical history and physical examination aim to identify the patient's pain beliefs and behaviors, movement faults, and muscle performance that will guide treatment recommendations. Successful physical therapist management involves a combination of individualized patient education, pain management, and load control and progression, with an emphasis on exercise therapy.

The addition of blood flow restriction to resistance exercise in individuals with knee pain: a systematic review and meta-analysis

BACKGROUND

Blood flow restriction (BFR) is an effective clinical intervention used to increase strength in healthy individuals. However, its effects on pain and function in individuals with knee pain are unknown.

OBJECTIVE

To determine the effectiveness of adding BFR to resistance exercise for pain relief and improvement of function in patients with knee pain.

METHODS

Systematic review with meta-analysis of randomized clinical trials. Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases were searched from inception to May 2019. Randomized clinical trials that compared resistance exercise with or without BFR to treat knee pain and function in individuals older than 18 years of age with knee pain were included.

RESULTS

Eight randomized clinical trials met the eligibility criteria and for the quantitative synthesis, five studies were included. The pooled standardized mean difference (SMD) estimate showed that resistance exercises with BFR was not more effective than resistance exercises for reducing pain (SMD: -0.37cm, 95% CI=-0.93, 0.19) and improving knee function (SMD=-0.23 points, 95% CI=-0.71, 0.26) in patients with knee pain.

CONCLUSION

In the short term, there is low quality of evidence that resistance exercise with BFR does not provide significant differences in pain relief and knee function compared to resistance exercises in patients with knee pain. PROSPERO registration number: CRD42018102839.

Targeted Treatment Protocol in Patellofemoral Pain: Does Treatment Designed According to Subgroups Improve Clinical Outcomes in Patients Unresponsive to Multimodal Treatment?

BACKGROUND

Targeted intervention for subgroups is a promising approach for the management of patellofemoral pain.

HYPOTHESIS

Treatment designed according to subgroups will improve clinical outcomes in patients unresponsive to multimodal treatment.

STUDY DESIGN

Prospective crossover intervention.

LEVEL OF EVIDENCE

Level 3.

METHODS

Patients with patellofemoral pain (PFP; n = 61; mean age, 27 ± 9 years) were enrolled. Patients with PFP received standard multimodal treatment 3 times a week for 6 weeks. Patients not responding to multimodal treatment were then classified into 1 of 3 subgroups (strong, weak and tight, and weak and pronated foot) using 6 simple clinical tests. They were subsequently administered 6 further weeks of targeted intervention, designed according to subgroup characteristics. Visual analog scale (VAS), perception of recovery scale (PRS), 5-Level European Quality 5 Dimensions (EQ-5D-5L), and self-reported version of the Leeds Assessment of Neuropathic Symptoms and Signs scale (S-LANSS) were used to assess pain, knee function, and quality of life before and after the interventions.

RESULTS

In total, 34% (n = 21) of patients demonstrated recovery after multimodal treatment. However, over 70% (n = 29/40) of nonresponders demonstrated recovery after targeted treatment. The VAS, PRS, S-LANSS, and EQ-5D-5L scores improved significantly after targeted intervention compared with after multimodal treatment (P < 0.001). The VAS score at rest was significantly lower in the "weak and pronated foot" and the "weak and tight" subgroups (P = 0.011 and P = 0.008, respectively). Posttreatment pain intensity on activity was significantly lower in the "strong" subgroup (P = 0.006).

CONCLUSION

Targeted treatment designed according to subgroup characteristics improves clinical outcomes in patients unresponsive to multimodal treatment.

CLINICAL RELEVANCE

Targeted intervention could be easily implemented after 6 simple clinical assessment tests to subgroup patients into 1 of 3 subgroups (strong, weak and tight, and weak and pronated foot). Targeted interventions applied according to the characteristics of these subgroups have more beneficial treatment effects than a current multimodal treatment program.

Utilization and outcomes of neuromuscular electric stimulation in patients with knee osteoarthritis: a retrospective analysis

Background

Knee osteoarthritis (OA) is a chronic debilitating condition that is estimated to affect approximately 12% of the current adult population in the United States, and is associated with severe pain and disability. Among these patients, quadriceps muscle atrophy and concomitant weakness are frequent findings that contribute significantly to the burden of this disease. One emerging method of quadriceps muscle strengthening and rehabilitation in knee OA patients is the use of neuromuscular electrical stimulation therapy (NMES). Among the currently available systems for NMES therapy are the mobile health (mHealth) platforms allowing clinicians to monitor patient compliance and utilization trends in addition to capturing certain clinical outcome points. The aim of this study was to analyze data collected by a commercially available mobile-app controlled NMES platform and to examine: (I) utilization trends, (II) range-of-motion (ROM) changes, (III) pain scores, and (IV) patient reported outcome scores in patients who used this device as part of management of their knee OA.

Methods

We retrospectively reviewed patients who received mobile-app controlled NMES therapy for knee OA who were enrolled in this multi-center study between April 2017 and July 2018 in a cloud-based provider online portal system. A total of 41 patients met all our inclusion and exclusion criteria and were included in our final analysis. For each patient, the total number of NMES sessions, the duration of NMES therapy, visual analogue pain scores, ROM, and the Knee injury Osteoarthritis Outcome Score (KOOS, JR) were collected and analyzed. Patient's utilization trends were reported through analyzing NMES sessions and therapy durations. Descriptive statistics were utilized to analyze all relevant values.

Results

Across all patients, NMES therapy was utilized for an average of 3.5 months (range, 2 weeks to 10 months). On average, 90 sessions (range, 6 to 487) of therapy were received by patients for an average of 1,819 minutes (range, 120 to 9,740 minutes). Overall, patients achieved a mean ROM of 99˚±4.3˚ at final follow-up. Pain scores reduced from a mean of 5 points prior to device use (range, 1 to 8 points) to 2.5 points after use (range, 0 to 6 points) (P<0.001). Evaluation of KOOS questionnaires available for 17 patients showed incremental improvement from 52.46 points when therapy was started, to 63 points at 6 months following NMES therapy. No complications or adverse events were reported from any of the participants.

Conclusions

Although NMES therapy has been reported on by multiple authors, including in knee OA, there are limited have been no studies that have reported on the compliance, feasibility, and patient outcomes of using a mobile-app controlled NMES therapy devices in the setting of knee OA. Furthermore, the incorporation of cloud-based provider online platform may offer an additional advantage by allowing clinicians to monitor the progress and compliance of their patients in real-time. Therefore, patients who are making sub-optimal progress may benefit from an early intervention to modify their therapy protocol to achieve the best outcome.

The current management of patients with patellofemoral pain from the physical therapist's perspective

Patellofemoral pain (PFP) is a common diagnosis that includes an amalgam of conditions that are typically non-traumatic in origin and result in peripatellar and/or retropatellar knee pain. The purpose of this review is to provide an overview of the physical therapist's management, including the evaluation and treatment, of the patient with PFP. A thorough history is critical for appropriately diagnosing and optimally managing PFP; the history should include the date of symptom onset, mechanism of injury and/or antecedent events, location and quality of pain, exacerbating and alleviating symptoms, relevant past medical history, occupational demands, recreational activities, footwear, and patient goals. Physical examination should identify the patient's specific impairments, assessing range of motion (ROM), muscle length, effusion, resisted isometrics, strength, balance and postural control, special tests, movement quality, palpation, function, and patient reported outcome measures. Objective assessments should guide treatment, progression, and clinical decision-making. The rehabilitation program should be individually tailored, addressing the patient's specific impairments and functional limitations and achieving the patient's goals. Exercise therapy, including hip, knee, and core strengthening as well as stretching and aerobic exercise, are central to the successful management of PFP. Other complimentary treatments may include patellofemoral and tibiofemoral joint mobilizations, patellofemoral taping, neuromuscular training, and gait retraining. Appropriate progression of interventions should consider objective evaluations (e.g., effusion, soreness rules), systematic increases in loading, and the chronicity of symptoms. Although short-term changes or reductions in movement often are necessary in a protective capacity, the persistence of altered movement is a key characteristic of chronic pain, which may be managed in part through emphasis on function over symptoms, graded exposure, patient education, and perhaps referral. PFP etiology is largely movement related and a comprehensive conservative treatment using movement can be successful.

Neuromuscular electrical stimulation (NMES) for patellofemoral pain syndrome

BACKGROUND

Patellofemoral pain syndrome, now generally referred to as patellofemoral pain (PFP), is one of the most common orthopaedic disorders, characterised by pain in the anterior or retropatellar knee region. Neuromuscular electrical stimulation (NMES) has been proposed generally as a complementary treatment, associated with other interventions such as exercise, or as a single treatment to increase muscle force, reduce knee pain, and improve function.

OBJECTIVES

To assess the effects (benefits and harms) of neuromuscular electrical stimulation for people with patellofemoral pain.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PEDro, CINAHL, SPORTDiscus, AMED, LILACS, trial registers, conference abstracts, and reference lists. We carried out the search in May 2017.

SELECTION CRITERIA

We included randomised controlled clinical trials that evaluated the use of NMES for people with PFP.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the process of study selection, data extraction, and 'Risk of bias' assessment in duplicate. The primary outcomes were knee pain, knee function, and adverse events. The timing of outcome measurements was up to three months (short term), three to 12 months (medium term), and 12 months and above from trial entry (long term). We calculated risk ratios for dichotomous data and mean differences or standardised mean differences for continuous data. Where appropriate, we pooled data using the fixed-effect model.

MAIN RESULTS

We included eight randomised clinical trials, reporting results for 345 participants with PFP. The mean ages of trial populations ranged from 25 to 43 years, and the majority (53% to 100%) of participants were female. There was a wide duration of symptoms, with the minimum duration of symptoms for trial inclusion ranging from one to six months. In addition to the study inclusion criteria, studies varied widely in the characteristics of the NMES and its application, and associated co-interventions. We assessed all trials as at high risk of bias in at least one domain, particularly blinding and incomplete outcome data. The results of a laboratory-based trial reporting knee pain immediately after a single 15-minute session of NMES are not reported here as these are of questionable clinical relevance. The seven remaining trials provided evidence for three comparisons. We assessed the overall quality of the evidence, using GRADE, for all primary outcomes for all comparisons as very low, thus we are very unsure of the findings.Four studies compared NMES plus exercise versus exercise alone. Patellar taping was applied as well as exercise to all participants of one study, and patellar taping and ice were also applied in another study. Each trial tested a different multiple-session NMES programme. Pooled data from three studies (118 participants) provided very low-quality evidence that NMES is associated with reduced pain at the end of treatment (ranging from 3 to 12 weeks): mean difference -1.63, 95% confidence interval (CI) -2.23 to -1.02; visual analogue scale (VAS) 0 to 10; higher scores = worse pain. However, this result may not be clinically relevant since the minimal clinically important difference for VAS during activities (1.5 to 2.0, out of 10 points) lies within the 95% CI. We found very low-quality evidence from pooled data from two trials of little effect of NMES on knee function, as measured by two knee function rating systems. We found inconclusive and very low-quality evidence from one trial (29 participants) of little effect of NMES on pain and function at one-year follow-up. None of the four trials reported on adverse effects of treatment.One study (94 participants) compared NMES, applied four hours per day on a daily basis for four weeks, with two types of exercises (isometric and isokinetic). The study did not report on knee pain or adverse events. The study provided very low-quality evidence of no important difference between the two groups in knee function at the end of the four-week treatment. Of note is the potentially onerous NMES schedule in this study, which does not correspond to that typically used in clinical practice.Two studies compared different types of NMES. Simultaneously delivered high-low frequencies NMES was compared with sequentially delivered high-low frequencies NMES in one trial (14 participants) and with fixed frequency NMES in the second trial (64 participants). The studies provided very low-quality evidence of no important differences at the end of the six-week treatment programme between the simultaneous frequencies NMES and the two other NMES programmes in overall knee pain, knee function, or in quadriceps fatigue (an adverse event).

AUTHORS' CONCLUSIONS

This review found insufficient and inconclusive evidence from randomised controlled trials to inform on the role of NMES for treating people with PFP in current clinical practice. The very low-quality evidence available means that we are uncertain whether or not a multiple-session programme of NMES combined with exercise over several weeks versus exercise alone results in clinically important differences in knee pain and function at the end of the treatment period or at one year. There were no data on adverse effects such as muscle fatigue and discomfort. High-quality randomised clinical trials are needed to inform on the use of NMES for people with PFP. However, professional and stakeholder consensus is required on prioritisation of the research questions for interventions for treating people with PFP, including on the NMES treatment protocol for trials testing NMES.