Effect of a walking program on gait characteristics in patients with osteoarthritis

Effect of Land-Based Generic Physical Activity Interventions on Pain, Physical Function, and Physical Performance in Hip and Knee Osteoarthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this study was to evaluate the effects of land-based generic physical activity interventions on pain, physical function, and physical performance in individuals with hip/knee osteoarthritis, when compared with a control group that received no intervention, minimal intervention, or usual care.

METHODS

A systematic search for randomized controlled trials on 11 electronic databases (from their inception up until April 30, 2016) identified 27 relevant articles. According to the compendium of physical activities, interventions were categorized into: recreational activities (tai chi/Baduajin-6 articles), walking (9 articles), and conditioning exercise (12 articles).

RESULTS

Meta-analysis for recreational activity (n = 3) demonstrated significant mean difference (MD) of -9.56 (95% confidence interval [CI], -13.95 to -5.17) for physical function (Western Ontario and McMaster Universities Arthritis Index) at 3 mos from randomization. Pooled estimate for walking intervention was not significant for pain intensity and physical performance but was significant for physical function (n = 2) with a MD of -10.38 (95% CI, -12.27 to -8.48) at 6 mos. Meta-analysis for conditioning exercise was significant for physical function (n = 3) with a MD of -3.74 (95% CI, -5.70 to -1.78) and physical performance (6-minute walk test) with a MD of 42.72 m (95% CI, 27.78, 57.66) at 6 mos. The timed stair-climbing test (n = 2) demonstrated a significant effect at 18 mos with a MD of -0.49 secs (95% CI, -0.75 to -0.23).

CONCLUSION

Very limited evidence to support recreational activity and walking intervention was found for knee osteoarthritis, in the short-term on pain and physical function, respectively.

Efficacy of Hip Strengthening Exercises Compared With Leg Strengthening Exercises on Knee Pain, Function, and Quality of Life in Patients With Knee Osteoarthritis

OBJECTIVE

The purpose of this study was to compare the efficacy of hip and leg strengthening exercise programs on knee pain, function, and quality of life (QOL) of patients with knee osteoarthritis (KOA).

DESIGN

Single-Blinded Randomized Clinical Trial.

SETTING

Patients with KOA.

PARTICIPANTS

Male and female subjects were recruited from patients referred to the University of Calgary Sport Medicine Center and from newspaper advertisements.

INTERVENTIONS

Thirty-seven and 35 patients with KOA were randomly assigned to either a 12-week hip or leg strengthening exercise program, respectively. Both exercise programs consisted of strengthening and flexibility exercises, which were completed 3 to 5 days a week. The first 3 weeks of exercise were supervised and the remaining 9 weeks consisted of at-home exercise.

MAIN OUTCOME MEASURES

Knee Injury and Osteoarthritis Score (KOOS) and Western Ontario McMaster Arthritis Index (WOMAC) questionnaires, 6-minute walk test, hip and knee range of motion (ROM), and hip and leg muscle strength.

RESULTS

Statistically and clinically significant improvements in the KOOS and WOMAC pain subscale scores were observed in both the hip and leg strengthening programs. There was no statistical difference in the change in scores observed between the 2 groups. Equal improvements in the KOOS and WOMAC function and QOL subscales were observed for both programs. There was no change in hip and knee ROM or hip and leg strength in either group.

CONCLUSIONS

Isolated hip and leg strengthening exercise programs seem to similarly improve knee pain, function, and QOL in patients with KOA.

CLINICAL RELEVANCE

The results of this study show that both hip and leg strengthening exercises improve pain and QOL in patients with KOA and should be incorporated into the exercise prescription of patients with KOA.

Exercise for osteoarthritis of the knee

BACKGROUND

Knee osteoarthritis (OA) is a major public health issue because it causes chronic pain, reduces physical function and diminishes quality of life. Ageing of the population and increased global prevalence of obesity are anticipated to dramatically increase the prevalence of knee OA and its associated impairments. No cure for knee OA is known, but exercise therapy is among the dominant non-pharmacological interventions recommended by international guidelines.

OBJECTIVES

To determine whether land-based therapeutic exercise is beneficial for people with knee OA in terms of reduced joint pain or improved physical function and quality of life.

SEARCH METHODS

Five electronic databases were searched, up until May 2013.

SELECTION CRITERIA

All randomised controlled trials (RCTs) randomly assigning individuals and comparing groups treated with some form of land-based therapeutic exercise (as opposed to exercise conducted in the water) with a non-exercise group or a non-treatment control group.

DATA COLLECTION AND ANALYSIS

Three teams of two review authors independently extracted data, assessed risk of bias for each study and assessed the quality of the body of evidence for each outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. We conducted analyses on continuous outcomes (pain, physical function and quality of life) immediately after treatment and on dichotomous outcomes (proportion of study withdrawals) at the end of the study; we also conducted analyses on the sustained effects of exercise on pain and function (two to six months, and longer than six months).

MAIN RESULTS

In total, we extracted data from 54 studies. Overall, 19 (20%) studies reported adequate random sequence generation and allocation concealment and adequately accounted for incomplete outcome data; we considered these studies to have an overall low risk of bias. Studies were largely free from selection bias, but research results may be vulnerable to performance and detection bias, as only four of the RCTs reported blinding of participants to treatment allocation, and, although most RCTs reported blinded outcome assessment, pain, physical function and quality of life were participant self-reported.High-quality evidence from 44 trials (3537 participants) indicates that exercise reduced pain (standardised mean difference (SMD) -0.49, 95% confidence interval (CI) -0.39 to -0.59) immediately after treatment. Pain was estimated at 44 points on a 0 to 100-point scale (0 indicated no pain) in the control group; exercise reduced pain by an equivalent of 12 points (95% CI 10 to 15 points). Moderate-quality evidence from 44 trials (3913 participants) showed that exercise improved physical function (SMD -0.52, 95% CI -0.39 to -0.64) immediately after treatment. Physical function was estimated at 38 points on a 0 to 100-point scale (0 indicated no loss of physical function) in the control group; exercise improved physical function by an equivalent of 10 points (95% CI 8 to 13 points). High-quality evidence from 13 studies (1073 participants) revealed that exercise improved quality of life (SMD 0.28, 95% CI 0.15 to 0.40) immediately after treatment. Quality of life was estimated at 43 points on a 0 to 100-point scale (100 indicated best quality of life) in the control group; exercise improved quality of life by an equivalent of 4 points (95% CI 2 to 5 points).High-quality evidence from 45 studies (4607 participants) showed a comparable likelihood of withdrawal from exercise allocation (event rate 14%) compared with the control group (event rate 15%), and this difference was not significant: odds ratio (OR) 0.93 (95% CI 0.75 to 1.15). Eight studies reported adverse events, all of which were related to increased knee or low back pain attributed to the exercise intervention provided. No study reported a serious adverse event.In addition, 12 included studies provided two to six-month post-treatment sustainability data on 1468 participants for knee pain and on 1279 (10 studies) participants for physical function. These studies indicated sustainability of treatment effect for pain (SMD -0.24, 95% CI -0.35 to -0.14), with an equivalent reduction of 6 (3 to 9) points on 0 to 100-point scale, and of physical function (SMD -0.15 95% CI -0.26 to -0.04), with an equivalent improvement of 3 (1 to 5) points on 0 to 100-point scale.Marked variability was noted across included studies among participants recruited, symptom duration, exercise interventions assessed and important aspects of study methodology. Individually delivered programmes tended to result in greater reductions in pain and improvements in physical function, compared to class-based exercise programmes or home-based programmes; however between-study heterogeneity was marked within the individually provided treatment delivery subgroup.

AUTHORS' CONCLUSIONS

High-quality evidence indicates that land-based therapeutic exercise provides short-term benefit that is sustained for at least two to six months after cessation of formal treatment in terms of reduced knee pain, and moderate-quality evidence shows improvement in physical function among people with knee OA. The magnitude of the treatment effect would be considered moderate (immediate) to small (two to six months) but comparable with estimates reported for non-steroidal anti-inflammatory drugs. Confidence intervals around demonstrated pooled results for pain reduction and improvement in physical function do not exclude a minimal clinically important treatment effect. Since the participants in most trials were aware of their treatment, this may have contributed to their improvement. Despite the lack of blinding we did not downgrade the quality of evidence for risk of performance or detection bias. This reflects our belief that further research in this area is unlikely to change the findings of our review.

Exercise and osteoarthritis: cause and effects

Osteoarthritis (OA) is a common chronic joint condition predominantly affecting the knee, hip, and hand joints. Exercise plays a role in the development and treatment of OA but most of the literature in this area relates to knee OA. While studies indicate that exercise and physical activity have a generally positive effect on healthy cartilage metrics, depending upon the type of the activity and its intensity, the risk of OA development does appear to be moderately increased with sporting participation. In particular, joint injury associated with sports participation may be largely responsible for this increased risk of OA with sport. Various repetitive occupational tasks are also linked to greater likelihood of OA development. There are a number of physical impairments associated with OA including pain, muscle weakness and altered muscle function, reduced proprioception and postural control, joint instability, restricted range of motion, and lower aerobic fitness. These can result directly from the OA pathological process and/or indirectly as a result of factors such as pain, effusion, and reduced activity levels. These impairments and their underlying physiology are often targeted by exercise interventions and evidence generally shows that many of these can be modified by specific exercise. There is currently little clinical trial evidence to show that exercise can alter mechanical load and structural disease progression in those with established OA, although a number of impairments, that are amenable to change with exercise, appears to be associated with increased mechanical load and/or disease progression in longitudinal studies.

The effect of walking on cardiorespiratory fitness in adults with knee osteoarthritis

Walking programs alone or in combination with behavioral interventions have proven effective at improving quality of life among older adults with osteoarthritis (OA). It is unclear, however, whether the combination of both of these treatments is more effective at improving cardiorespiratory fitness in older adults with knee OA than a walking program alone or than unsupervised self-directed walking. In this study, we assessed cardiorespiratory fitness with 3 programs: a structured supervised community-based aerobic walking program with a behavioral intervention (WB; n = 41); a supervised program of walking only (W; n = 42); and an unsupervised self-directed walking program (n = 32). We measured maximal oxygen uptake (V̇O2peak), exercise test duration, and workload, heart rate, and ventilation at maximum aerobic capacity in older adults with knee OA after 6 months of WB, W, or self-directed walking. Overall, V̇O2peak improved by 4% in female walkers (+0.9 ± 2.5 mL O2·kg−1·min−1; p < 0.001) and 5% in male walkers (+1.3 ± 2.7 mL O2·kg−1·min−1; p < 0.001), and the change in fitness was similar with all 3 walking interventions. In conclusion, low- to moderate-intensity walking may improve and (or) prevent decrements in cardiorespiratory fitness in older adults with OA. This response was comparable in supervised walkers with and without a behavioral intervention and in unsupervised self-directed walkers.

EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis

The objective was to develop evidence -based recommendations and a research and educational agenda for the non-pharmacological management of hip and knee osteoarthritis (OA). The multidisciplinary task force comprised 21 experts: nurses, occupational therapists, physiotherapists, rheumatologists, orthopaedic surgeons, general practitioner, psychologist, dietician, clinical epidemiologist and patient representatives. After a preliminary literature review, a first task force meeting and five Delphi rounds, provisional recommendations were formulated in order to perform a systematic review. A literature search of Medline and eight other databases was performed up to February 2012. Evidence was graded in categories I-IV and agreement with the recommendations was determined through scores from 0 (total disagreement) to 10 (total agreement). Eleven evidence-based recommendations for the non-pharmacological core management of hip and knee OA were developed, concerning the following nine topics: assessment, general approach, patient information and education, lifestyle changes, exercise, weight loss, assistive technology and adaptations, footwear and work. The average level of agreement ranged between 8.0 and 9.1. The proposed research agenda included an overall need for more research into non-pharmacological interventions for hip OA, moderators to optimise individualised treatment, healthy lifestyle with economic evaluation and long-term follow-up, and the prevention and reduction of work disability. Proposed educational activities included the required skills to teach, initiate and establish lifestyle changes. The 11 recommendations provide guidance on the delivery of non-pharmacological interventions to people with hip or knee OA. More research and educational activities are needed, particularly in the area of lifestyle changes.

Osteoarthritis of the knee: why does exercise work? A qualitative study of the literature

The effectiveness of exercise to reduce pain and improve functioning in osteoarthritis of the knee (OAk) is well substantiated. Underlying mechanisms are still under debate and better understanding of the pathways involved may contribute to more targeted treatment strategies. The present qualitative analysis of the literature aims to provide an overview of theoretical models that are put forward to explain the beneficial treatment effects of exercise in OAk. An inductive qualitative approach, based on the 'grounded theory' of Glaser and Straus, was used. Twenty-two studies emphasizing on exercise therapy for OAk, collected from three Cochrane reviews and nine guidelines of the Physiotherapy Evidence Database (PEDRO) published between 2000 and 2012, were included. The introduction and discussion parts of these papers were screened for explanations of exercise-induced benefits in OAk patients. Seventy-three key points were identified which were subdivided into 16 core theoretical concepts. Finally, 5 categories were formed: neuromuscular, peri-articular, intra-articular, psychosocial components, and general fitness and health. We referred to scientific evidence that was used in the included studies to describe and categorize the concepts. Future research on exercise in OAk should allow distinguishing the contribution of different potential pathways to the treatment effects.

The implementation of a community-based aerobic walking program for mild to moderate knee osteoarthritis: a knowledge translation randomized controlled trial: part II: clinical outcomes

BACKGROUND

Osteoarthritis (OA) is the most common joint disorder in the world, as it is appears to be prevalent among 80% of individuals over the age of 75. Although physical activities such as walking have been scientifically proven to improve physical function and arthritic symptoms, individuals with OA tend to adopt a sedentary lifestyle. There is therefore a need to improve knowledge translation in order to influence individuals to adopt effective self-management interventions, such as an adapted walking program.

METHODS

A single-blind, randomized control trial was conducted. Subjects (n = 222) were randomized to one of three knowledge translation groups: 1) Walking and Behavioural intervention (WB) (18 males, 57 females) which included the supervised community-based aerobic walking program combined with a behavioural intervention and an educational pamphlet on the benefits of walking; 2) Walking intervention (W) (24 males, 57 females) wherein participants only received the supervised community-based aerobic walking program intervention and the educational pamphlet; 3) Self-directed control (C) (32 males, 52 females) wherein participants only received the educational pamphlet. One-way analyses of variance were used to test for differences in quality of life, adherence, confidence, and clinical outcomes among the study groups at each 3 month assessment during the 12-month intervention period and 6-month follow-up period.

RESULTS

The clinical and quality of life outcomes improved among participants in each of the three comparative groups. However, there were few statistically significant differences observed for quality of life and clinical outcomes at long-term measurements at 12-months end of intervention and at 6- months post intervention (18-month follow-up). Outcome results varied among the three groups.

CONCLUSION

The three groups were equivalent when determining the effectiveness of knowledge uptake and improvements in quality of life and other clinical outcomes. OA can be managed through the implementation of a proven effective walking program in existing community-based walking clubs.

TRIAL REGISTRATION

Current Controlled Trials IRSCTNO9193542.

Two-dimensional radial laser scanning for circular marker detection and external mobile robot tracking

This paper presents the use of an external fixed two-dimensional laser scanner to detect cylindrical targets attached to moving devices, such as a mobile robot. This proposal is based on the detection of circular markers in the raw data provided by the laser scanner by applying an algorithm for outlier avoidance and a least-squares circular fitting. Some experiments have been developed to empirically validate the proposal with different cylindrical targets in order to estimate the location and tracking errors achieved, which are generally less than 20 mm in the area covered by the laser sensor. As a result of the validation experiments, several error maps have been obtained in order to give an estimate of the uncertainty of any location computed. This proposal has been validated with a medium-sized mobile robot with an attached cylindrical target (diameter 200 mm). The trajectory of the mobile robot was estimated with an average location error of less than 15 mm, and the real location error in each individual circular fitting was similar to the error estimated with the obtained error maps. The radial area covered in this validation experiment was up to 10 m, a value that depends on the radius of the cylindrical target and the radial density of the distance range points provided by the laser scanner but this area can be increased by combining the information of additional external laser scanners.

A comprehensive review of the effectiveness of different exercise programs for patients with osteoarthritis

Exercise is recommended as a first-line conservative intervention approach for osteoarthritis (OA). A wide range of exercise programs are available and scientific evidence is necessary for choosing the optimal strategy of treatment for each patient. The purpose of this review is to discuss the effectiveness of different types of exercise programs for OA based on trials, systematic reviews, and meta-analyses in the literature. Publications from January 1997 to July 2012 were searched in 4 electronic databases using the terms osteoarthritis, exercise, exercise program, effectiveness, and treatment outcome. Strong evidence supports that aerobic and strengthening exercise programs, both land- and water-based, are beneficial for improving pain and physical function in adults with mild-to-moderate knee and hip OA. Areas that require further research include examination of the long-term effects of exercise programs for OA, balance training for OA, exercise programs for severe OA, the effect of exercise programs on progression of OA, the effectiveness of exercise for joint sites other than the knee or hip, and the effectiveness of exercise for OA by such factors as age, sex, and obesity. Efforts to improve adherence to evidence-based exercise programs for OA and to promote the dissemination and implementation of these programs are crucial.

The implementation of a community-based aerobic walking program for mild to moderate knee osteoarthritis (OA): a knowledge translation (KT) randomized controlled trial (RCT): Part I: The Uptake of the Ottawa Panel clinical practice guidelines (CPGs)

Background

The implementation of evidence based clinical practice guidelines on self-management interventions to patients with chronic diseases is a complex process. A multifaceted strategy may offer an effective knowledge translation (KT) intervention to promote knowledge uptake and improve adherence in an effective walking program based on the Ottawa Panel Evidence Based Clinical Practice Guidelines among individuals with moderate osteoarthritis (OA).

Methods

A single-blind, randomized control trial was conducted. Patients with mild to moderate (OA) of the knee (n=222) were randomized to one of three KT groups: 1) Walking and Behavioural intervention (WB) (18 males, 57 females) which included the supervised community-based aerobic walking program combined with a behavioural intervention and an educational pamphlet on the benefits of walking for OA; 2) Walking intervention (W) (24 males, 57 females) wherein participants only received the supervised community-based aerobic walking program intervention and the educational pamphlet; 3) Self-directed control (C) (32 males, 52 females) wherein participants only received the educational pamphlet. One-way analyses of variance were used to test for differences in quality of life, adherence, confidence, and clinical outcomes among the study groups at each 3 month assessment during the 12-month intervention period and 6-month follow-up period.

Results

Short-term program adherence was greater in WB compared to C (p<0.012) after 3 months. No statistical significance (p> 0.05) was observed for long-term adherence (6 to 12 months), and total adherence between the three groups. The three knowledge translation strategies demonstrated equivalent long-term results for the implementation of a walking program for older individuals with moderate OA. Lower dropout rates as well as higher retention rates were observed for WB at 12 and 18 months.

Conclusion

The additional knowledge translation behavioural component facilitated the implementation of clinical practice guidelines on walking over a short-term period. More studies are needed to improve the long-term walking adherence or longer guidelines uptake on walking among participants with OA. Particular attention should be taken into account related to patient’s characteristic and preference. OA can be managed through the implementation of a walking program based on clinical practice guidelines in existing community-based walking clubs as well as at home with the minimal support of an exercise therapist or a trained volunteer.

Trial Registration

Current Controlled Trials IRSCTNO9193542

Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight

BACKGROUND AND PURPOSE

The objective of this review was to construct an updated evidence-based clinical practice guideline on the use of physical activity and diet for the management of osteoarthritis (OA) in adults (>18 years of age) who are obese or overweight (body mass index ≥25 kg/m(2)).

DATA SOURCES

Articles were extracted from the following databases: MEDLINE, EMBASE (Current Contents), SPORTDiscus, SUM, Scopus, CINAHL, AMED, BIOMED, PubMed, ERIC, the Cochrane Controlled Trials, and PEDro.

STUDY SELECTION

The Ottawa Panel and research assistance team strictly applied the inclusion and exclusion criteria from previous Ottawa Panel publications.

DATA EXTRACTION

An a priori literature search was conducted for articles related to obesity and OA of the lower extremities that were published from January 1, 1966, to November 30, 2010. Inclusion criteria and the methods to grade the recommendations were created by the Ottawa Panel.

RECOMMENDATIONS

were graded based on the strength of evidence (A, B, C, C+, D, D+, or D-) as well as experimental design (I for randomized controlled trials and II for nonrandomized studies). In agreement with previous Ottawa Panel methods, Cochrane Collaboration methods were utilized for statistical analysis. Clinical significance was established by an improvement of ≥15% in the experimental group compared with the control group. There were a total of 79 recommendations from 9 articles. From these recommendations, there were 36 positive recommendations: 21 grade A and 15 grade C+. There were no grade B recommendations, and all recommendations were of clinical benefit.

LIMITATIONS

Further research is needed, as more than half of the trials were of low methodological quality.

CONCLUSIONS

This review suggests that physical activity and diet programs are beneficial, specifically for pain relief (9 grade A recommendations) and improved functional status (6 grade A and 7 grade C+ recommendations), for adults with OA who are obese or overweight. The Ottawa Panel was able to demonstrate that when comparing physical activity alone, diet alone, physical activity combined with diet, and control groups, the intervention including physical activity and diet produced the most beneficial results.

Measuring oscillating walking paths with a LIDAR

This work describes the analysis of different walking paths registered using a Light Detection And Ranging (LIDAR) laser range sensor in order to measure oscillating trajectories during unsupervised walking. The estimate of the gait and trajectory parameters were obtained with a terrestrial LIDAR placed 100 mm above the ground with the scanning plane parallel to the floor to measure the trajectory of the legs without attaching any markers or modifying the floor. Three different large walking experiments were performed to test the proposed measurement system with straight and oscillating trajectories. The main advantages of the proposed system are the possibility to measure several steps and obtain average gait parameters and the minimum infrastructure required. This measurement system enables the development of new ambulatory applications based on the analysis of the gait and the trajectory during a walk.

Effects of exercise on functional aerobic capacity in lower limb osteoarthritis: a systematic review

Osteoarthritis (OA) is a degenerative joint disease. The reduced aerobic capacity of patients with lower limb osteoarthritis affects their independence in performing everyday activities. The purpose of this systematic review was to summarize evidence for the effectiveness and structure of exercise programs on functional aerobic capacity (ability to perform activities of daily living that require sustained aerobic metabolism) in patients with hip and knee osteoarthritis. A computerized search was made of seven databases. Effect sizes (ES) and 95% confidence intervals (CI) were calculated, and the heterogeneity of the studies was assessed using Cochran's Q statistic applied to the ES means. The 20 studies that satisfied the inclusion criteria were selected for analysis. These studies were grouped into five categories according to the characteristics of the exercise program: land-based interventions (strength programs, tai chi, aerobic programs, mixed exercise programs) and aquatic intervention (hydrotherapy). The functional aerobic capacity improved in tai chi programs (ES=0.66; 95% CI, 0.23-1.09), aerobic programs (ES=0.90; 95% CI, 0.70-1.10), and mixed programs (ES=0.47; 95% CI, -0.38-0.39). The conclusions were: (i) despite recommendations for the use of exercise programs for aerobic fitness in patients with hip and knee osteoarthritis, few randomized clinical trials have been conducted; (ii) the structure of the exercise programs (program content and duration, and session frequency and duration) is very heterogeneous; (iii) overall, exercise programs based on tai chi, aerobic, and mixed exercise seem to give better results than hydrotherapy programs, but without the differences being altogether clear.

Strength and Speed Training for Elders with Mobility Disability

The purpose of this study was to pilot test a function-focused exercise intervention consisting of strength and gait-speed training in elders with reduced walking speed, decreased walking endurance, and functional impairment. Twelve participants, 77.2 years old (± 7.34), whose usual gait speed was <0.85 m/s, with walking endurance of <305 m in 5 min, and who were functionally impaired participated in a moderate-intensity exercise intervention. The training occurred 3 times per week, 75 min per session, for 3 months and combined 4 weeks of gait-speed training, walking exercise, and functional strengthening. The participants demonstrated mean usual gait speeds (≥1.0 m/s), endurance (≥350 m), and functional ability (≥10 score on performance battery) that were within normal limits after 12 weeks of training. Fastest gait speed (≥1.5 m/s) and muscle strength also improved significantly. Improvements were maintained during follow-up testing after 3–6 months. In summary, a 12-week intervention for frail, mobility-disabled participants led to improvements in walking, function, and strength.

Exercise for osteoarthritis of the knee

BACKGROUND

Biomechanical factors, such as reduced muscle strength and joint malalignment, have an important role in the initiation and progression of knee osteoarthritis (OA). Currently, there is no known cure for OA; however, disease-related factors, such as impaired muscle function and reduced fitness, are potentially amenable to therapeutic exercise.

OBJECTIVES

To determine whether land-based therapeutic exercise is beneficial for people with knee OA in terms of reduced joint pain or improved physical function.

SEARCH STRATEGY

Five electronic databases were searched, up until December 2007.

SELECTION CRITERIA

All randomized controlled trials randomising individuals and comparing some form of land-based therapeutic exercise (as opposed to exercises conducted in the water) with a non-exercise group.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed methodological quality. All analyses were conducted on continuous outcomes.

MAIN RESULTS

The 32 included studies provided data on 3616 participants for knee pain and 3719 participants for self-reported physical function. Meta-analysis revealed a beneficial treatment effect with a standardized mean difference (SMD) of 0.40 (95% confidence interval (CI) 0.30 to 0.50) for pain; and SMD 0.37 (95% CI 0.25 to 0.49) for physical function. There was marked variability across the included studies in participants recruited, symptom duration, exercise interventions assessed and important aspects of study methodology. The results were sensitive to the number of direct supervision occasions provided and various aspects of study methodology. While the pooled beneficial effects of exercise programs providing less than 12 direct supervision occasions or studies utilising more rigorous methodologies remained significant and clinically relevant, between study heterogeneity remained marked and the magnitude of the treatment effect of these studies would be considered small.

AUTHORS' CONCLUSIONS

There is platinum level evidence that land-based therapeutic exercise has at least short term benefit in terms of reduced knee pain and improved physical function for people with knee OA. The magnitude of the treatment effect would be considered small, but comparable to estimates reported for non-steroidal anti-inflammatory drugs.

Small increase of actual physical activity 6 months after total hip or knee arthroplasty

Limitation in daily physical activity is one of the reasons for total hip arthroplasty (THA) or total knee arthroplasty (TKA). However, studies of the effects of THA or TKA generally do not determine actual daily activity as part of physical functioning. We determined the effect of THA or TKA on patients' actual physical activity and body function (pain, stiffness), capacity to perform tasks, and self-reported physical functioning. We also assessed whether there are differences in the effect of the surgery between patients undergoing THA or TKA and whether the improvements vary between these different outcome measures. We recruited patients with long-standing end-stage osteoarthritis of the hip or knee awaiting THA or TKA. Measurements were performed before surgery and 3 and 6 months after surgery. Actual physical activity improved by 0.7%. Patients' body function, capacity, and self-reported physical functioning also improved. The effects of the surgery on these aspects of physical functioning were similar for THA and TKA. The effect on actual physical activity (8%) was smaller than on body function (80%-167%), capacity (19%-36%), and self-reported physical functioning (87%-112%). Therefore, in contrast to the large effect on pain and stiffness, patients' capacity, and their self-reported physical functioning, the improvement in actual physical activity of our patients was less than expected 6 months after surgery.

LEVEL OF EVIDENCE

Level I, prospective study. See the Guidelines for Authors for a complete description of levels of evidence.

The value of individual or collective group exercise programs for knee or hip osteoarthritis. Clinical practice recommendations

OBJECTIVE

To develop clinical practice guidelines concerning individual and group exercise therapy for knee and/or hip osteoarthritis (OA).

METHOD

We used the SOFMER (French Physical Medicine and Rehabilitation Society) methodology, combining systematic literature review, collection of everyday clinical practice, and external review by a multidisciplinary expert panel, to develop the guidelines.

RESULTS

Physical exercises are proposed for knee and hip OA. The benefit of individual exercises is low to moderate for pain, strength and ability to walk. The effectiveness is not maintained over time if the individual exercise program is not continued. The benefit of group exercise is also low to moderate for pain, strength, balance and ability to walk. There is no evidence of the superiority of one modality over the other (individual or group).

CONCLUSION

More randomised controlled trials with good methodology are needed to compare the effectiveness of individual versus group exercise therapy for knee and hip OA.

Evidence for prescribing exercise as therapy in chronic disease

Considerable knowledge has accumulated in recent decades concerning the significance of physical activity in the treatment of a number of diseases, including diseases that do not primarily manifest as disorders of the locomotive apparatus. In this review we present the evidence for prescribing exercise therapy in the treatment of metabolic syndrome-related disorders (insulin resistance, type 2 diabetes, dyslipidemia, hypertension, obesity), heart and pulmonary diseases (chronic obstructive pulmonary disease, coronary heart disease, chronic heart failure, intermittent claudication), muscle, bone and joint diseases (osteoarthritis, rheumatoid arthritis, osteoporosis, fibromyalgia, chronic fatigue syndrome) and cancer, depression, asthma and type 1 diabetes. For each disease, we review the effect of exercise therapy on disease pathogenesis, on symptoms specific to the diagnosis, on physical fitness or strength and on quality of life. The possible mechanisms of action are briefly examined and the principles for prescribing exercise therapy are discussed, focusing on the type and amount of exercise and possible contraindications.

Osteoarthritis of the knee and hip and activity: a systematic international review and synthesis (OASIS)

The goal of this study was to determine which activities in four domains, daily life, exercises, sports and occupational activities, should be recommended, in favor or against, for the patient suffering from knee or hip OA.

METHODS

Scientific literature was searched in Medline, Embase and Cochrane databases for articles in French or English, reporting original data. The articles were evaluated with standardized epidemiological criteria. Seventy-two articles were retained. Recommendations were graded according to the level of scientific evidence (A high, B moderate, C clinical consensus) and were formulated for primary care.

CONCLUSIONS AND RECOMMENDATIONS

For activity of daily life (ADL), the OASIS group states with a moderate level of scientific evidence, that ADL are a risk factor for knee OA and that risk increases with intensity and duration of activity. The group concludes that healthy subjects as well as OA patients in general can pursue a high level of physical activity, provided the activity is not painful and does not predispose to trauma (grade B). Radiographic or clinical OA is not a contraindication to promoting activity in patients who have a sedentary lifestyle (grade C). For exercises and other structured activities pursued with a goal of health improvement, the group states with a high level of scientific evidence that they have a favourable effect on pain and function in the sedentary knee OA patient. The OASIS group recommends the practice of exercises and other structured activities for the sedentary patient with knee OA (grade A). Static exercises are not favored over dynamic exercises, availability, preference and tolerance being the criteria for the choice of an exercise (grade A). As results deteriorate when exercises are stopped, they should be performed at a frequency of between one and three times per week (grade B). Professional assistance can be useful in improving initial compliance and perseverance (grade B). There is no scientific argument to support halting exercise in case of an OA flare-up (grade C). For sports and recreational activity, the group states with a high degree of scientific evidence, that these activities are a risk factor for knee and hip OA and that the risk correlates with intensity and duration of exposure. The group also states, with a high degree of scientific evidence, that the risk of OA associated with sport is lesser than that associated with a history of trauma and overweight. No firm conclusion could be drawn about the possible protective role of sports such as cycling, swimming or golf. The OASIS group recommends that athletes should be informed that joint trauma is a greater risk factor than the practice of sport (Grade A). The high level athlete should be informed that the risk of OA is associated with the duration and intensity of exposure (Grade B). The OA patient can continue to engage regularly in recreational sports as long as the activity does not cause pain (Grade C). The OA patient who practices a sport at risk for joint trauma should be encouraged to change sport (Grade C). For occupational activity, the OASIS group states with a high level of scientific evidence that there is a relationship between occupational activity and OA of the knee and hip. The precise nature of biomechanical stresses leading to OA remains unclear but factors such as high loads on the joint, unnatural body position, heavy lifting, climbing and jumping may contribute to knee and hip OA. The group recommends that taking an occupational history should always be part of managing the OA patient (Grade B). In the knee or hip OA patient, work-related activity that produces or maintains pain should be avoided (Grade B). Physicians should be alerted by the early knee and hip signs and symptoms in workers exposed to stresses that are known or supposed to favour knee or hip OA (Grade C).

Auditory hallucinations as primary disorders of syntax: an evolutionary theory of the origins of language

A theory of the evolutionary origins of language is built around: (1) the notion that language is a sapiens-specific capacity that arose in the speciation event that separated modern Homo sapiens from a prior hominid species, and (2) Broca's concept of asymmetry (subsequently recognised as a "torque" from right frontal to left occipital cortices) as the defining characteristic of the human brain. The four chambers of human association cortex thus created allow the separation of "thought" from the speech output and "meaning" from the speech input, these abstractions representing the associations in the nondominant hemisphere of the motor and sensory phonological representations in the dominant hemisphere. The nuclear symptoms of schizophrenia are conceived as manifestations of the breakdown of the boundaries between these four compartments, and as indicating the necessity of the separation of motor and sensory speech engrams as the basis for the speaker-hearer distinction. They further illustrate a requirement for a "deictic core" to the cerebral organisation of language as Mueller and Buehler proposed. In this sense the nuclear symptoms are disorders of the syntax of universal grammar.

[Physical therapy of osteoarthritis]

Physical therapy is part of guidelines and recommendations in the treatment of osteoarthritis. Different methods of physical therapy are used in osteoarthritis. There is evidence that manual physical therapy and exercise improve function and reduce pain in osteoarthritic joints. Thermal modalities are employed for short-term pain relief and change the intraarticular temperature. Electrotherapy, therapeutic ultrasound and balneotherapy show positive therapeutic effects. Based on studies and clinical experience, physical therapy must be recommended in the therapy of osteoarthritis.

Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review

OBJECTIVE

To compare the efficacy of aerobic walking and home based quadriceps strengthening exercises in patients with knee osteoarthritis.

METHODS

The Medline, Pubmed, EMBASE, CINAHL, and PEDro databases and the Cochrane controlled trials register were searched for randomised controlled trials (RCTs) of subjects with knee osteoarthritis comparing aerobic walking or home based quadriceps strengthening exercise with a non-exercise control group. Methodological quality of retrieved RCTs was assessed. Outcome data were abstracted for pain and self reported disability and the effect size calculated for each outcome. RCTs were grouped according to exercise mode and the data pooled using both fixed and random effects models.

RESULTS

35 RCTs were identified, 13 of which met inclusion criteria and provided data suitable for further analysis. Pooled effect sizes for pain were 0.52 for aerobic walking and 0.39 for quadriceps strengthening. For self reported disability, pooled effect sizes were 0.46 for aerobic walking and 0.32 for quadriceps strengthening.

CONCLUSIONS

Both aerobic walking and home based quadriceps strengthening exercise reduce pain and disability from knee osteoarthritis but no difference between them was found on indirect comparison.

Rehabilitation of the Osteoarthritic Patient: Focus on the Knee

This article reviews the factors involved in the rehabilitation process of the knee. Use of patient education, pain management, restoration of range of motion, and strengthening within the foundation of an aerobic fitness program are discussed.

Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: a single-blind randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of a new intensive functional rehabilitation (IFR) program on functional ability and quality of life (QOL) in persons who underwent a first total knee arthroplasty (TKA).

DESIGN

Randomized controlled trial.

SETTING

Ambulatory care.

PARTICIPANTS

Seventy-seven people with knee osteoarthritis.

INTERVENTION

Two months after TKA, subjects were randomly assigned to either a group with IFR (n=38), who received 12 supervised rehabilitation sessions combined with exercises at home between months 2 and 4 after TKA, or to a control group (n=39), who received standard care. All participants were evaluated by a blind evaluator at baseline (2mo after TKA), immediately after IFR (2mo later; POST1), and 2 and 8 months later (POST2 and POST3). Main outcome measures The primary outcome measure with respect to effectiveness was the 6-minute walk test (6MWT) at POST2. Secondary outcome measures were the 6MWT at the other evaluations and the Western Ontario and McMaster Universities Osteoarthritis Index and Medical Outcomes Study 36-Item Short-Form Health Survey.

RESULTS

Subjects in the IFR group walked longer distances (range, 23-26m) in 6 minutes at the 3 POST evaluations than subjects in the control group. At POST1 and POST2, they also had less pain, stiffness, and difficulty in performing daily activities. Positive changes in QOL in favor of the IFR were found only at POST2.

CONCLUSIONS

The IFR was effective in improving the short-term and mid-term functional ability after uncomplicated primary TKA. The magnitude of the IFR effect on the primary outcome was modest but consistent. More intensive rehabilitation should be promoted in the subacute recovery period after TKA, to optimize functional outcomes in the first year after surgery.

The Arthritis, Diet and Activity Promotion Trial (ADAPT): design, rationale, and baseline results

Osteoarthritis (OA) of the knee leads to restrictions of physical activity and ability to perform activities of daily living. Obesity is a risk factor for knee OA and it appears to exacerbate knee pain and disability. The Arthritis, Diet, and Activity Promotion Trial (ADAPT) was developed to test the efficacy of lifestyle behavioral changes on physical function, pain, and disability in obese, sedentary older adults with knee OA. This controlled trial randomized 316 sedentary overweight and obese older adults in a two-by-two factorial design into one of four 18-month duration intervention groups: Healthy Lifestyle Control; Dietary Weight Loss; Structured Exercise; or Combined Exercise and Dietary Weight Loss. The weight-loss goal for the diet groups was a 5% loss at 18 months. The intervention was modeled from principles derived from the group dynamics literature and social cognitive theory. Exercise training consisted of aerobic and strength training for 60 minutes, three times per week in a group and home-based setting. The primary outcome measure was self-report of physical function using the Western Ontario and McMaster University Osteoarthritis Index. Other measurements included timed stair climb, distance walked in 6 minutes, strength, gait, knee pain, health-related quality of life, knee radiographs, body weight, dietary intake, and cost-effectiveness of the interventions. We report baseline data stratified by level of overweight and obesity focusing on self-reported physical function and physical performance tasks. The results from ADAPT will provide approaches clinicians should recommend for behavioral therapies that effectively reduce the incidence of disability associated with knee OA.

Preoperative predictors of locomotor ability two months after total knee arthroplasty for severe osteoarthritis

OBJECTIVE

To identify preoperative predictors of locomotor ability 2 months after total knee arthroplasty (TKA).

METHODS

Sixty-five participants scheduled for a first TKA were recruited. The dependent variable was the distance covered during the 6-minute gait test 2 months after TKA. The independent variables, measured before surgery, were grouped into 3 categories: 1). personal; 2). organic system, and 3). capability variables. Multiple regression analyses were conducted to determine the best predictors of the dependent variable. Modified cross-validation of the model combining predictors from the three categories was obtained with 10 random samples derived from the original cohort by resampling with replacement.

RESULTS

Predictors were identified in the 3 categories: 1). gender, number of comorbidities, body mass index, 2). knee pain, flexion and strength, lower limb mechanical power, and 3). preoperative 6-minute gait distance. When these variables were modeled together only the preoperative 6-minute gait distance and knee pain and flexion remained significant (adjusted R(2) = 0.66).

CONCLUSION

Using variables easily measured before surgery, it is possible to predict with good accuracy locomotor ability 2 months after TKA.

Screening for Falls in Community-Dwelling Elderly

Fifty community-dwelling elders were screened and followed for 14 months. Sixteen experienced falls and 34 did not. The screening variables consisted of age, the Clinical Test of Sensory Interaction in Balance, the Performance-Oriented Mobility Assessment for Balance, functional reach, the Physical Performance Test, and the following timed tests: floor transfer; 5-step test; 5 chair stands; tandem, semitandem, and side-by-side stance; penny pick-up; 360° turn; 50-ft walk; and 5-min walk. Data analysis and chi-squared orttests were performed for each variable to determine significant differences between groups. Correlations, sensitivity, and specificity were calculated, and a stepwise discriminant analysis was conducted to determine which significant variables best predicted falls. Discriminant analysis determined that the floor transfer and then the 50-ft walk predicted falls in community-dwelling elders, correctly classifying 95.5% of participants. Prediction for falls was 81.8%, and for no falls, 100%. The timed floor transfer and 50-ft walk were the most discriminating measures to identify potential fallers.

Locomotor deficits before and two months after knee arthroplasty

OBJECTIVES

To quantify the locomotor deficits before and 2 months after a total knee arthroplasty (TKA) in patients with osteoarthritis of the knee, and to compare pre- and postoperative performance.

METHODS

Locomotor capacity of patients was evaluated using laboratory gait and stair-ascent evaluations (kinematic and kinetic variables, electromyographic activity of 4 muscles of both lower limbs, and spatiotemporal parameters), the timed Up & Go (TUG), and the 6-minute walk (6MW) test.

RESULTS

Large locomotor deficits (increased hip flexion, decreased excursions of the knee and ankle, smaller extensor and flexor moments of force at the 3 joints, and muscle activation levels lower in all muscles tested) are still present in patients, particularly in the single-limb support subphase before and 2 months after TKA. These deficits explain the slower walk and stair-ascent speeds and a reduced performance at the TUG and 6MW tests.

CONCLUSIONS

These results emphasize the need for more careful followup and intensive rehabilitation programs in the first months following TKA.

Exercise for preventing and treating osteoporosis in postmenopausal women

BACKGROUND

Osteoporosis is a condition resulting in an increased risk of skeletal fractures due to a reduction in the density of bone tissue. Prevention of osteoporotic-related fractures is dependent on the ability to detect individuals with low bone mass, including those women who are asymptomatic. Treatment of osteoporosis involves the use of either anti-resorptive (e.g. estrogen and bisphosphonate) or bone formation agents (e.g. fluoride and PTH). The value of exercise as an intervention for the prevention of postmenopausal bone loss is a controversial subject.

OBJECTIVES

To examine the effectiveness of exercise therapy at preventing bone loss and fractures in postmenopausal women.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group's specialised register, MEDLINE, EMBASE, Current Contents and the Cochrane Controlled Trials Registry up to January 2000 according to the methods suggested by Dickersin et al and Haynes et al and the Cochrane Handbook. We hand searched reference lists and consulted content experts.

SELECTION CRITERIA

This review was proceeded by a peer reviewed protocol published in the Cochrane Library. Two reviewers independently selected all randomized controlled trials (RCTs) which met our predetermined inclusion criteria.

DATA COLLECTION AND ANALYSIS

The same two reviewers abstracted the data using predetermined forms and assessed trial quality using a validated assessment tool. For dichotomous outcomes (fractures), relative risks were calculated using fixed effects models. For continuous data, weighted mean differences (WMD) of the percentage change from baseline were calculated. Where heterogeneity existed (determined by a chi square test), a random effects model was used.

MAIN RESULTS

Eighteen randomized controlled trials (RCTs) met the inclusion criteria. The trials had a mean methodological quality score of 2.53. Aerobics, weight bearing and resistance exercises were all effective on the BMD of the spine. The WMD for the combined aerobics and weight bearing program on the spine was 1.79 [95%CI (0.58, 3.01)]. The analyzed results showed walking to be effective on both BMD of the spine 1.31[95%CI (-0.03, 2.65) and the hip 0.92[95%CI (0.21, 1.64). Aerobic exercise was effective in increasing BMD of the wrist 1.22[95%CI (0.71, 1.74)].

REVIEWER'S CONCLUSIONS

Aerobics, weight bearing and resistance exercises are all effective in increasing the BMD of the spine in postmenopausal women. Walking is also effective on the hip. The quality of the reporting of the trials in the meta-analysis was low, in particular, in the areas of allocation concealement and blinding.

Comparative responsiveness of locomotor tests and questionnaires used to follow early recovery after total knee arthroplasty

OBJECTIVES

To compare the responsiveness of 3 locomotor tests and 2 questionnaires in the early stage after a total knee arthroplasty (TKA) and to determine if the 4 responsiveness statistics ranked the measures similarly.

DESIGN

Longitudinal study.

SETTING

Rehabilitation institute.

PARTICIPANTS

Twenty-five men and 40 women with knee osteoarthritis scheduled for a first TKA.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Six-minute gait distance, in-laboratory gait speed and stair ascent duration, Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index difficulty subscale, and Medical Outcomes Study Short-Form 36-Item Health Survey role-physical and physical functioning subscale scores. Effect size, standardized response mean, paired t test, and relative efficiency statistics were computed for 3 time intervals: (1) before TKA to 2 months after TKA, (2) 2 to 4 months after TKA, and (3) before TKA to 4 months after TKA.

RESULTS

Responsiveness varied according to tests and intervals considered. For all intervals, the WOMAC difficulty subscale was the most responsive questionnaire and the 6-minute gait test was the most responsive locomotor test. Stair ascent duration was the least responsive measure. Of the responsiveness indices used, only effect size ranked the tests differently.

CONCLUSIONS

The 6-minute gait test and the WOMAC difficulty subscale are recommended for outcome assessment during the early recovery period after TKA. Because interpretation guidelines are available and confidence intervals can be calculated for it, the standardized response mean is the most useful statistic.

How to use education as an intervention in osteoarthritis

Definitions of health education and patient education form the starting point for an overview of patient education interventions for people with osteoarthritis (OA). Recipients, tutors and the key messages that education can deliver are considered, followed by a review of the methods used and the typical content of current educational provision for OA. The theoretical and empirical basis for interventions is illustrated using examples from the somewhat limited field. The outcomes used to evaluate education and the evidence for effectiveness is presented. The issues of which patients benefit most, adherence, length of interventions, optimal timing and frequency are raised. The chapter concludes with a brief discussion of the best health care system is needed to underpin educational provision and suggestions for a research agenda that will go some way towards addressing the many questions that remain unanswered.

Exercise and weight loss in obese older adults with knee osteoarthritis: a preliminary study

OBJECTIVE

The purposes of this pilot study were to determine if a combined dietary and exercise intervention would result in significant weight loss in older obese adults with knee osteoarthritis, and to compare the effects of exercise plus dietary therapy with exercise alone on gait, strength, knee pain, biomarkers of cartilage degradation, and physical function.

DESIGN

Single-blind, two-arm, randomized clinical trial conducted for 24 weeks.

SETTING

A university health and exercise science center.

PARTICIPANTS

Twenty-four community-dwelling obese older adults aged > or = 60 years, body mass index > or = 28, knee pain, radiographic evidence of knee osteoarthritis, and self-reported physical disability.

INTERVENTION

Randomization into two groups: exercise and diet (E&D) and exercise alone (E). Exercise consisted of a combined weight training and walking program for 1 hour three times per week. The dietary intervention included weekly sessions with a nutritionist utilizing cognitive-behavior modification to change dietary habits to reach a group goal of an average weight loss of 15 lb (6.8 kg) over 6 months.

MEASUREMENTS

All measurements were conducted at baseline and 3 and 6 months, except for synovial fluid analysis, which was obtained only at baseline and 6 months. In addition, weight was measured weekly in the E&D group. Physical disability and knee pain were measured by self-report and physical performance was measured using the 6-minute walk and stair climb tasks. Biomechanical testing included kinetic and kinematic analysis of gait and isokinetic strength testing. Synovial fluid was analyzed for levels of total proteoglycan, keratan sulfate, and interleukin-1 beta.

RESULTS

Twenty-one of the 24 participants completed the study, with one dropout in the E&D group and two in the E group. The E&D group lost a mean of 18.8 lb (8.5 kg) at 6 months compared with 4.0 lb (1.8 kg) in the E group (P = .01). Significant improvements were noted in both groups in self-reported disability and knee pain intensity and frequency as well as in physical performance measures. However, no statistical differences were found between the two groups at 6 months in knee pain scores or self-reported performance measures of physical function. There was no difference in knee strength between the groups, with both groups showing modest improvements from baseline to 6 months. At 6 months, the E&D group had a significantly greater loading rate (P = .03) and maximum braking force (P = .01) during gait. There were no significant between-group differences in the other biomechanical measures. Synovial fluid samples were obtainable at both baseline and 6 months in eight participants (four per group). The level of keratan sulfate decreased similarly in both groups from an average baseline of 96.8 +/- 37.1 to 71.5 +/- 23 ng/microg total proteoglycan. The level of IL-1 decreased from 25.3 +/- 9.8 at baseline to 8.3 +/- 6.1 pg/mL. The decrease in IL-1 correlated with the change in pain frequency (r = -0.77, P = .043).

CONCLUSIONS

Weight loss can be achieved and sustained over a 6-month period in a cohort of older obese persons with osteoarthritis of the knee through a dietary and exercise intervention. Both exercise and combined weight loss and exercise regimens lead to improvements in pain, disability, and performance. Moreover, the trends in the biomechanical data suggest that exercise combined with diet may have an additional benefit in improved gait compared with exercise alone. A larger study is indicated to determine if weight loss provides additional benefits to exercise alone in this patient population.

The relationship between ankle plantar flexor muscle moments and knee compressive forces in subjects with and without pain

OBJECTIVE

The purpose of this study was to compare the compressive knee joint reaction force and ankle plantar flexor muscle moment during the terminal stance phase in symptomatic osteoarthritic and non-symptomatic subjects.DESIGN. The study design was a comparative investigation of walking patterns.BACKGROUND. Patients with knee osteoarthritic symptoms may employ altered gait patterns to reduce the loading of painful joints. Speculation is that decreased ankle plantar flexor moments in the terminal stance phase may be an attempt to minimize compressive knee joint reaction forces.METHODS. Twenty community-dwelling men (52-83 years old), ten with knee osteoarthritis and ten non-symptomatic, were studied while walking across a walkway containing two force plates at a comfortable speed. Retroreflective markers were placed in accordance with the Helen Hayes marker system and recorded with six 120 Hz cameras. Three-dimensional kinematics and kinetics were computed.RESULTS. Group means for gait velocity, peak ankle plantar flexor moment and compressive knee joint reaction force were significantly less for the osteoarthritic group relative to the non-symptomatic group. When accounting for the decreased velocity in the osteoarthritic group, however, no group differences were observed. There were significant correlations between all three gait parameters (r>0.75), but peak ankle plantar flexor moment was the greatest predictor of compressive knee joint reaction force.CONCLUSIONS. While no group differences were found for compressive knee joint reaction forces when accounting for gait velocity, it appears that subjects with osteoarthritis utilize gait velocity as a mechanism to reduce compressive knee joint reaction forces. RelevanceAn understanding of compressive knee joint reaction forces is important to the understanding of the disabling effects of knee osteoarthritis on physical function and to the understanding of appropriate and safe interventions to improve not only global parameters (e.g., pain, gait velocity), but also to "re-program" the locomotor pattern to develop "normal" muscle moments without increasing compressive knee joint reaction forces to painful levels.

Feasibility of an eight-week dance-based exercise program and its effects on locomotor ability of persons with functional class III rheumatoid arthritis

OBJECTIVES

The main objectives of this experimental case series were to evaluate the feasibility of a modified dance-based exercise program with low ground impacts in persons with rheumatoid arthritis (RA) functional class III and to describe its effects on locomotor ability. The relationship between 3 locomotor tests and their responsiveness also were addressed.

METHODS

Ten female subjects participated in an 8-week exercise program. Locomotor ability was measured before and after the program using the 50-foot test of walking time, the 6-minute test of walking distance, and the locomotion biomechanical analysis.

RESULTS

All subjects showed a high compliance (92.5% presence at sessions) over the 8 weeks of exercise without any aggravation in disease status. They were able to train efficiently at moderate intensity up to 25 minutes. Significant improvements were found in locomotor ability, with a higher responsiveness measured by the locomotion biomechanical analysis, followed by the 6-minute gait test and the 50-foot gait test. Inconsistent relationships between tests suggested that different locomotor abilities are required during tests.

CONCLUSION

These results support the feasibility of a modified dance-based exercise program for persons with severe RA. With high levels of responsiveness, the detailed biomechanical analysis and the 6-minute gait test are recommended for the assessment of locomotor ability.

Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials

OBJECTIVE

To review the effectiveness of exercise therapy in patients with osteoarthritis (OA) of the hip or knee.

METHODS

A computerized literature search of Medline, Embase, and Cinahl was carried out. Randomized clinical trials on exercise therapy for OA of the hip or knee were selected if treatment had been randomly allocated and if pain, self-reported disability, observed disability, or patient's global assessment of effect had been used as outcome measures. The validity of trials was systematically assessed by independent reviewers. Effect sizes and power estimates were calculated. A best evidence synthesis was conducted, weighting the studies with respect to their validity and power.

RESULTS

Six of the 11 assessed trials satisfied at least 50% of the validity criteria. Two trials had sufficient power to detect medium-sized effects. Effect sizes indicated small-to-moderate beneficial effects of exercise therapy on pain, small beneficial effects on both disability outcome measures, and moderate-to-great beneficial effects according to patient's global assessment of effect.

CONCLUSION

There is evidence of beneficial effects of exercise therapy in patients with OA of the hip or knee. However, the small number of good studies restricts drawing firm conclusions.

The pathobiology of osteoarthritis and the rationale for the use of pentosan polysulfate for its treatment

OBJECTIVES

Structure-modifying osteoarthritis (OA) drugs (SMOADs) may be defined as agents that reverse, retard, or stabilize the underlying pathology of OA, thereby providing symptomatic relief in the long-term. The objective of this review was to evaluate the literature on sodium pentosan polysulfate (NaPPS) and calcium pentosan polysulfate (CaPPS), with respect to the pathobiology of OA to ascertain whether these agents should be classified as SMOADs.

METHODS

Published studies on NaPPS and CaPPS were selected on the basis of their relevance to the known pathobiology of OA, which also was reviewed.

RESULTS

Both NaPPS and CaPPS exhibit a wide range of pharmacological activities. Of significance was the ability of these agents to support chondrocyte anabolic activities and attenuate catabolic events responsible for loss of components of the cartilage extracellular matrix in OA joints. Although some of the anti-catabolic activities may be mediated through direct enzyme inhibition, NaPPS and CaPPS also have been shown to enter chondrocytes and bind to promoter proteins and alter gene expression of matrix metalloproteinases and possibly other mediators. In rat models of arthritis, NaPPS and CaPPS reduced joint swelling and inflammatory mediator levels in pouch fluids. Moreover, synoviocyte biosynthesis of high-molecular-weight hyaluronan, which is diminished in OA, was normalized when these cells were incubated with NaPPS and CaPPS or after intraarticular injection of NaPPS into arthritic joints. In rabbit, canine, and ovine models of OA, NaPPS and CaPPS preserved cartilage integrity, proteoglycan synthesis, and reduced matrix metalloproteinase activity. NaPPS and CaPPS stimulated the release of tissue plasminogen activator (t-PA), superoxide dismutase, and lipases from vascular endothelium while concomitantly decreasing plasma levels of the endogenous plasminogen activator inhibitor PAI-1. The net thrombolytic and lipolytic effects exhibited by NaPPS and CaPPS may serve to improve blood flow through subchondral capillaries of OA joints and improve bone cell nutrition. In geriatric OA dogs, NaPPS and CaPPS reduced symptoms, as well as normalized their thrombolytic status, threshold for platelet activation, and plasma triglyceride levels. These hematologic parameters were shown to be abnormal in OA animals before drug treatment. Similar outcomes were observed in OA patients when CaPPS or NaPPS were given orally or parenterally in both open and double-blind trials.

CONCLUSIONS

The data presented in this review support the contention that NaPPS and CaPPS should be classified as SMOADs. However, additional long-term clinical studies employing methods of assessing joint structural changes will be needed to confirm this view.

Functional capacity and early radiographic osteoarthritis in middle-aged people with chronic knee pain

BACKGROUND AND PURPOSE

In order to improve the physiotherapeutic treatment of patients with long-standing knee pain, it is important to identify osteoarthritis (OA) of the knee at an early stage. The aim of the present study was to test the value of single functional measurement variables with the focus on the lower extremities for the association to early radiographic signs of OA of the knee. The classification by Ahlbäck grade I (joint space narrowing) was used in a cohort of 204 individuals aged 35-54 years with long-standing knee pain.

METHODS

The following five selected tests were employed: three tests of static and dynamic balance (Balance I-III); one test of muscle strength (one-leg-rising-test, OLR); and one test of walking ability (time for walking 300 m indoors). Odds ratios (ORs) were calculated with a 95% confidence interval.

RESULTS AND CONCLUSIONS

Results revealed that the selected tests of functional capacity due to rather low sensitivity (0.15-0.81), specificity (0.21-0.86) and inconclusive odds ratios (0.78-1.62) are probably of limited value as assessment tools to find radiographic knee OA in a younger population with mild OA. However, it is also possible to conclude that in middle-aged individuals with chronic knee pain, the diagnosis of radiographic OA is not related to the functional capacity as measured in the present study.

One-year followup of patients with osteoarthritis of the knee who participated in a program of supervised fitness walking and supportive patient education

OBJECTIVE

To determine whether gains in functioning observed immediately following participation in an 8-week program of supervised fitness walking for patients with knee osteoarthritis were sustained at 1-year followup.

METHODS

Twenty-nine (61.1%) of 47 original intervention program patients and 23 (51.1%) of 45 original control patients were interviewed by telephone at 1-year followup. Patients completed the Arthritis Impact Measurement Scales physical activity, arthritis impact, pain, medication use, and general health perceptions subscales, as well as a separate visual analog pain scale and measures of perceived self-efficacy to cope with arthritis pain and other symptoms.

RESULTS

Adherence to walking was low, and there were no statistically significant differences between intervention and control patients at one year.

CONCLUSIONS

The failure of intervention patients to maintain regular walking resulted in loss of functional benefits that were observed at 8 weeks in the original study. Long-term adherence to walking is critical to maintenance of initial gains in functional outcomes.

Non-pharmacological therapies in osteoarthritis

Non-pharmacological therapies are very important in osteoarthritis. Each form of this treatment should be individually devised, taking into account the anatomical distribution, the phase and the progression rate of the disease. Indications, contraindications, dosage and precautions are as important in non-pharmacological therapy as they are in drug treatment. Therapeutic exercises decrease pain, increase muscle strength and range of joint motion as well as improve endurance and aerobic capacity. Exercise programmes should be designed, conducted and regularly supervised by professionally trained physiotherapists. Weight reduction is of proven benefit in obese patients with osteoarthritis of the knee. Walking aids, crutches, shoe insoles, braces and patellar taping are useful tools in some form of osteoarthritis. Patient education and the management of the psychosocial consequences are priority tasks. Therapeutic heat and cold, electrotherapy, ultrasound, acupuncture, hydrotherapy and spa treatment are widely used, although the effects and benefits have not been fully established. Non-pharmacological therapies should undergo rigorous randomized controlled trials in a similar manner to pharmacological studies.

A revised group exercise program for osteoarthritis of the knee

The purpose of this study was to determine the effectiveness of a group exercise program for subjects with osteoarthritis of the knee referred for physiotherapy in terms of pain, physical function and gait. This study was initiated after an initial group exercise program at this centre failed to demonstrate significant changes in pain, physical function or gait. The study was based on repeated measures with a two month follow up, carried out in the outpatients department of a large public hospital. Pain levels in various functional situations were assessed on visual analogue scales, physical function with the Stanford Health Assessment Questionnaire, and quantitative gait variables at a normal and a fast self-selected speed with an electric foot switch walkway. On completion of the program (n = 40) more than 90% of the pain and physical function scores demonstrated significant improvements without increases in medication, use of walking aids or fatigue. The gait variables of velocity, cadence and stride length at both self-selected speeds demonstrated significant increases at this assessment without deterioration of gait symmetry. All improvements were maintained at the two month follow up assessments. This study suggests that a clinically realistic group exercise program supplemented with a home program can reduce pain, increase physical function and objective gait measures in subjects with osteoarthritis of the knee.