Pain trajectory and exercise-induced pain flares during 8 weeks of neuromuscular exercise in individuals with knee and hip pain

The influence of education on pain during and following acute exercise in people with knee osteoarthritis: A randomised controlled trial

BACKGROUND

Explicit education about exercise-induced hypoalgesia (EIH) reduces experimental pain after a single exercise session in pain-free individuals. However, the effect in people with chronic pain is unclear. This study aimed to determine the effect of EIH education on pain during and following exercise in people with knee osteoarthritis (OA).

METHODS

All procedures were administered online. Participants were randomised to receive 15-min of explicit EIH education or 15-min of general education about knee OA. Participants then completed a questionnaire on their beliefs about exercise and pain, followed by a bout of home-based lower limb resistance exercise. Pain intensity (0-10) was assessed before, during and immediately after exercise.

RESULTS

40 participants completed the study (67.3 ± 10.8 years old, 73 % female). Participants only somewhat agreed pain could be reduced following a single session of exercise and that the education changed what they thought about exercise and pain, but these beliefs were not significantly different between groups (p = 0.053 and p = 0.104, respectively). Pain was similar between groups (adjusted mean difference [95 % CI]) during exercise (0.51 [-0.72 to 1.74], p = 0.410) and following exercise (-0.75 [-1.62 to 1.11], p = 0.087. Compared to baseline, pain (mean difference [95 % CI]) was lower during exercise (-1.01 [-1.66 to -0.36], p = 0.003) and following exercise (-0.96 [-1.5 to -0.42], p < 0.001).

CONCLUSION

A single exercise session reduces pain in people with knee OA, but this was not influenced by pre-exercise education about EIH. Further research is needed to understand if and how EIH can be modulated in people with knee OA.

Exercise for osteoarthritis of the knee

BACKGROUND

Knee osteoarthritis (OA) is a major public health issue causing chronic pain, impaired physical function, and reduced quality of life. As there is no cure, self-management of symptoms via exercise is recommended by all current international clinical guidelines. This review updates one published in 2015.

OBJECTIVES

We aimed to assess the effects of land-based exercise for people with knee osteoarthritis (OA) by comparing: 1) exercise versus attention control or placebo; 2) exercise versus no treatment, usual care, or limited education; 3) exercise added to another co-intervention versus the co-intervention alone.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and two trial registries (ClinicalTrials.gov and World Health Organisation International Clinical Trials Registry Platform), together with reference lists, from the date of the last search (1st May 2013) until 4 January 2024, unrestricted by language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated exercise for knee OA versus a comparator listed above. Our outcomes of interest were pain severity, physical function, quality of life, participant-reported treatment success, adverse events, and study withdrawals.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane for systematic reviews of interventions.

MAIN RESULTS

We included 139 trials (12,468 participants): 30 (3065 participants) compared exercise to attention control or placebo; 60 (4834 participants) compared exercise with usual care, no intervention or limited education; and 49 (4569 participants) evaluated exercise added to another intervention (e.g. weight loss diet, physical therapy, detailed education) versus that intervention alone. Interventions varied substantially in duration, ranging from 2 to 104 weeks. Most of the trials were at unclear or high risk of bias, in particular, performance bias (94% of trials), detection bias (94%), selective reporting bias (68%), selection bias (57%), and attrition bias (48%). Exercise versus attention control/placebo Compared with attention control/placebo, low-certainty evidence indicates exercise may result in a slight improvement in pain immediately post-intervention (mean 8.70 points better (on a scale of 0 to 100), 95% confidence interval (CI) 5.70 to 11.70; 28 studies, 2873 participants). Moderate-certainty evidence indicates exercise likely results in an improvement in physical function (mean 11.27 points better (on a scale of 0 to 100), 95% CI 7.64 to 15.09; 24 studies, 2536 participants), but little to no improvement in quality of life (mean 6.06 points better (on a scale of 0 to 100), 95% CI -0.13 to 12.26; 6 studies, 454 participants). There was moderate-certainty evidence that exercise likely increases participant-reported treatment success (risk ratio (RR) 1.46, 95% CI 1.11 to 1.92; 2 studies 364 participants), and likely does not increase study withdrawals (RR 1.08, 95% CI 0.92 to 1.26; 29 studies, 2907 participants). There was low-certainty evidence that exercise may not increase adverse events (RR 2.02, 95% CI 0.62 to 6.58; 11 studies, 1684 participants). Exercise versus no treatment/usual care/limited education Compared with no treatment/usual care/limited education, low-certainty evidence indicates exercise may result in an improvement in pain immediately post-intervention (mean 13.14 points better (on a scale of 0 to 100), 95% CI 10.36 to 15.91; 56 studies, 4184 participants). Moderate-certainty evidence indicates exercise likely results in an improvement in physical function (mean 12.53 points better (on a scale of 0 to 100), 95% CI 9.74 to 15.31; 54 studies, 4352 participants) and a slight improvement in quality of life (mean 5.37 points better (on a scale of to 100), 95% CI 3.19 to 7.54; 28 studies, 2328 participants). There was low-certainty evidence that exercise may result in no difference in participant-reported treatment success (RR 1.33, 95% CI 0.71 to 2.49; 3 studies, 405 participants). There was moderate-certainty evidence that exercise likely results in no difference in study withdrawals (RR 1.03, 95% CI 0.88 to 1.20; 53 studies, 4408 participants). There was low-certainty evidence that exercise may increase adverse events (RR 3.17, 95% CI 1.17 to 8.57; 18 studies, 1557 participants). Exercise added to another co-intervention versus the co-intervention alone Moderate-certainty evidence indicates that exercise when added to a co-intervention likely results in improvements in pain immediately post-intervention compared to the co-intervention alone (mean 10.43 points better (on a scale of 0 to 100), 95% CI 8.06 to 12.79; 47 studies, 4441 participants). It also likely results in a slight improvement in physical function (mean 9.66 points better, 95% CI 7.48 to 11.97 (on a 0 to 100 scale); 44 studies, 4381 participants) and quality of life (mean 4.22 points better (on a 0 to 100 scale), 95% CI 1.36 to 7.07; 12 studies, 1660 participants) immediately post-intervention. There was moderate-certainty evidence that exercise likely increases participant-reported treatment success (RR 1.63, 95% CI 1.18 to 2.24; 6 studies, 1139 participants), slightly reduces study withdrawals (RR 0.82, 95% CI 0.70 to 0.97; 41 studies, 3502 participants), and slightly increases adverse events (RR 1.72, 95% CI 1.07 to 2.76; 19 studies, 2187 participants). Subgroup analysis and meta-regression We did not find any differences in effects between different types of exercise, and we found no relationship between changes in pain or physical function and the total number of exercise sessions prescribed or the ratio (between exercise group and comparator) of real-time consultations with a healthcare provider. Clinical significance of the findings To determine whether the results found would make a clinically meaningful difference to someone with knee OA, we compared our results to established 'minimal important difference' (MID) scores for pain (12 points on a 0 to 100 scale), physical function (13 points), and quality of life (15 points). We found that the confidence intervals of mean differences either did not reach these thresholds or included both a clinically important and clinically unimportant improvement.

AUTHORS' CONCLUSIONS

We found low- to moderate-certainty evidence that exercise probably results in an improvement in pain, physical function, and quality of life in the short-term. However, based on the thresholds for minimal important differences that we used, these benefits were of uncertain clinical importance. Participants in most trials were not blinded and were therefore aware of their treatment, and this may have contributed to reported improvements.

Pre-exercise and acute movement-evoked pain trajectories during a 24-week outdoor walking program for knee osteoarthritis (WALK)

Objectives

Exploring (1) pre-exercise and acute movement-evoked pain (AMEP) during an outdoor walking program in individuals with knee osteoarthritis (OA); and (2) comparing baseline physical performance and AMEP flares initiated by walking between participants with either a higher or lower attendance rate.

Methods

Individuals with knee OA were prescribed a 24-week walking program, including one unsupervised walk and two supervised walk classes per week. Participants self-reported knee pain on a numerical rating scale (NRS; 0-10) before and after each supervised class. Mixed-effects models were used to investigate trajectories over time for pre-exercise pain and AMEP change (post-minus pre-exercise pain; positive value indicates flare-up). Baseline physical performance (6 tests) and AMEP flares were compared between participants with higher (attending ≥70% of supervised classes) and lower attendance rates.

Results

Of 24 participants commencing the program, 7 (29%) withdrew. Over 24 weeks, pre-exercise pain improved by 1.20 NRS (95% CI -1.41 to -0.99), with estimated largest per class improvements during the first 8 weeks (-0.05 (-0.06 to -0.03) and plateauing around 20-weeks. The AMEP was estimated to improve by 0.19 NRS (95% CI -0.38 to -0.004) over 24-weeks, with improvements plateauing around 12-weeks. Participants with lower attendance (n ​= ​11) scored poorer on all physical performance tests and experienced a slight increase in AMEP during the first two weeks of the program.

Conclusions

Participants improved in pre-exercise pain and AMEP in the first 20 and 12 weeks, respectively. Despite supervision, physical performance and AMEP flares may have contributed to lower attendance.

Trial registration number

12618001097235.

The effects of upper- vs. lower-body aerobic exercise on perceived pain in individuals with chronic knee pain: a randomised crossover trial

Background and objectives

Some patients with chronic knee pain experience an increase in knee pain following a single bout of exercise involving their knee joint, which can negatively affect exercise adherence and thus result in reduced overall health and lack of disease management. We want to determine whether a single bout of upper-body (UB) aerobic arm-ergometry exercise is effective in reducing the experience of pain in those with chronic knee pain compared with lower-body (LB) aerobic leg ergometry exercise.

Methods

A total of 19 individuals (women = 11, men = 8; age = 63 ± 8 years; body mass index = 24 ± 3 kg/m2) who suffered from chronic knee pain for ≥3 months took part in this study. Arm-ergometry and cycle-ergometry exercises were performed for 30 min at a moderate intensity, separated by 7 days. Pain intensity was assessed by means of a visual analogue scale (VAS) pre- and post-exercise and for 7 days post-exercise. Pressure pain threshold (PPT) and mechanical detection threshold (MDT) were measured pre- and post-exercise at both local and distal anatomical sites. Data are presented as mean ± SD.

Results

VAS pain was significantly reduced (p = 0.035) at 1 day post-exercise following the UB exercise trial (-1.4 ± 0.8) when compared with the LB exercise trial (+0.1 ± 2.1). Both UB and LB exercises were effective in reducing local and distal PPT. MDT responses were heterogeneous, and no differences between the UB and LB exercise conditions were noted.

Conclusion

An acute bout of upper-body aerobic arm-ergometry exercise evoked a significant decrease in the affected knee joint pain in individuals with chronic knee pain of up to 24 h/1 day post-exercise compared with lower-body aerobic exercise. While the exact mechanisms remain unclear, upper-body exercise may offer a viable, novel therapeutic treatment for patients with chronic knee pain.

Fundamentals of osteoarthritis. Rehabilitation: Exercise, diet, biomechanics, and physical therapist-delivered interventions

Insights related to the pathogenesis of osteoarthritis (OA) have informed rehabilitative treatments that aim to mitigate the influence of several known impairments and risk factors for OA, with the goal to improve pain, function, and quality of life. The purpose of this invited narrative review is to provide fundamental knowledge to non-specialists about exercise and education, diet, biomechanical interventions, and other physical therapist-delivered treatments. In addition to summarizing the rationale for common rehabilitative therapies, we provide a synthesis of current core recommendations. Robust evidence based on randomized clinical trials supports exercise with education and diet as core treatments for OA. Structured, supervised exercise therapy is advised. The mode of exercise may vary but should be individualized. The dose should be based on an initial assessment, the desired physiological changes, and progressed when appropriate. Diet combined with exercise is strongly recommended and studies demonstrate a dose-response relationship between the magnitude of weight loss and symptom improvement. Recent evidence suggests the use of technology to remotely deliver exercise, diet and education interventions is cost-effective. Although several studies support the mechanisms for biomechanical interventions (e.g., bracing, shoe inserts) and physical therapist-delivered (passive) treatments (e.g., manual therapy, electrotherapeutic modalities) fewer rigorous randomized trials support their clinical use; these therapies are sometimes recommended as adjuncts to core treatments. The mechanisms of action for all rehabilitative interventions include contextual factors such as attention and placebo effects. These effects can challenge our interpretation of treatment efficacy from clinical trials, yet also provide opportunities to maximize patient outcomes in clinical practice. When evaluating rehabilitative interventions, the field may benefit from increased emphasis on research that considers contextual factors while evaluating mechanistic, longer-term, clinically-important and policy-relevant outcome measures.

Ambulatory support moment contribution patterns and MRI-detected tibiofemoral and patellofemoral disease worsening in adults with knee osteoarthritis: A preliminary study

We investigated whether baseline sagittal-plane ankle, knee, and hip contribution to the total support moment (TSM) are each associated with baseline-to-2-year tibiofemoral and patellofemoral tissue damage worsening in adults with knee osteoarthritis. Ambulatory lower-limb kinetics were captured and computed. TSM is the sum of ankle, knee, and hip extensor moments at each instant during gait. Ankle, knee, and hip contributions to TSM were computed as joint moments divided by TSM, expressed as percentages. Participants underwent MRI of both knees at baseline and 2 years later. Logistic regression models assessed associations of baseline ankle contribution to TSM with baseline-to-2-year cartilage damage and bone marrow lesion worsening, adjusted for age, sex, BMI, gait speed, disease severity, and pain. We used similar analytic approaches for knee and hip contributions to TSM. Sample included 391 knees from 204 persons (age[SD]: 64[10] years; 76.5% women). Greater ankle contribution may be associated with increased odds of tibiofemoral cartilage damage worsening (OR = 2.38; 95% CI: 1.02-5.57) and decreased odds of patellofemoral bone marrow lesion worsening (OR = 0.14; 95% CI: 0.03-0.73). The ORs for greater knee contribution were in the protective range for tibiofemoral compartment and in the deleterious range for patellofemoral. Greater hip contribution may be associated with increased odds of tibiofemoral worsening (OR = 2.71; 95% CI: 1.17-6.30). Greater ankle contribution to TSM may be associated with baseline-to-2-year tibiofemoral worsening, but patellofemoral tissue preservation. Conversely, greater knee contribution may be associated with patellofemoral worsening, but tibiofemoral preservation. Preliminary findings illustrate potential challenges in developing biomechanical interventions beneficial to both tibiofemoral and patellofemoral compartments.

A pilot randomized controlled trial evaluating outdoor community walking for knee osteoarthritis: walk

OBJECTIVES

To determine the feasibility of a randomized controlled trial (RCT) examining outdoor walking on knee osteoarthritis (KOA) clinical outcomes and magnetic resonance imaging (MRI) structural changes.

METHOD

This was a 24-week parallel two-arm pilot RCT in Tasmania, Australia. KOA participants were randomized to either a walking plus usual care group or a usual care control group. The walking group trained 3 days/week. The primary outcome was feasibility assessed by changes being required to the study design, recruitment, randomization, program adherence, safety, and retention. Exploratory outcomes were changes in symptoms, physical performance/activity, and MRI measures.

RESULTS

Forty participants (mean age 66 years (SD 1.4) and 60% female) were randomized to walking (n = 24) or usual care (n = 16). Simple randomization resulted in a difference in numbers randomized to the two groups. During the study, class sizes were reduced from 10 to 8 participants to improve supervision, and exclusion criteria were added to facilitate program adherence. In the walking group, total program adherence was 70.0% and retention 70.8% at 24 weeks. The walking group had a higher number of mild adverse events and experienced clinically important improvements in symptoms (e.g., visual analogue scale (VAS) knee pain change in the walking group: - 38.7 mm [95% CI - 47.1 to - 30.3] versus usual care group: 4.3 mm [- 4.9 to 13.4]).

CONCLUSIONS

This study supports the feasibility of a full-scale RCT given acceptable adherence, retention, randomization, and safety, and recruitment challenges have been identified. Large symptomatic benefits support the clinical usefulness of a subsequent trial.

TRIAL REGISTRATION NUMBER

12618001097235. Key Points • This pilot study is the first to investigate the effects of an outdoor walking program on knee osteoarthritis clinical outcomes and MRI joint structure, and it indicates that a full-scale RCT is feasible. • The outdoor walking program (plus usual care) resulted in large improvements in self-reported knee osteoarthritis symptoms compared to usual care alone. • The study identified recruitment challenges, and the manuscript explores these in more details and provides recommendations for future studies.

The effects of a mobile app-delivered intervention in people with symptomatic hand osteoarthritis: a pragmatic randomized controlled trial

BACKGROUND

Exercise therapy, self-management and education are recommended interventions for hand osteoarthritis (OA), but new delivery systems are needed to solve lack of adherence.

AIM

To determine the effects on hand function and pain related measures of a mobile app-delivered intervention, compared with usual care, in patients with symptomatic hand OA.

DESIGN

A pragmatic, multicenter, two-group parallel randomized controlled trial.

SETTING

Community health centers in rural southern Spain.

POPULATION

Eighty-three participants with unilateral or bilateral symptomatic hand OA were proposed to participate, and finally 74 were included and randomized.

METHODS

Participants received a home multimodal treatment (exercise, education, and self-management recommendations) with the CareHand mobile app or usual care (written exercises) over 12 weeks. Monthly telephone calls were performed to monitor adherence. The primary outcome was hand physical function (Australian/Canadian Hand Osteoarthritis Index, AUSCAN) at 3- and 6-months. Secondary measures included hand pain intensity and morning stiffness, upper limb function, hand dexterity, and grip and pinch strength.

RESULTS

The CareHand group showed significant within-group changes in hand function at 6-months (-3.0, 95% CI -5.1 to -0.9 vs. usual care: -0.9, 95% CI -3.3 to 1.5). Neither group showed improvements in hand function at 3-months (CareHand: -1.5, 95% CI -3.1 to 0.1; usual care: -0.5, 95% CI -2.7 to 1.7). For the secondary outcomes, the CareHand group showed better results on upper limb function both at 3- and 6-months, and on pain both at 1- and 3-months compared to usual care group. Linear regression models indicated that baseline scores of pain intensity, hand status, and upper limb function were associated with a greater improvement in hand pain and physical function.

CONCLUSIONS

A mobile app-delivered intervention is effective for improving hand function, and better than usual care for upper limb function and pain. Further research is warranted to understand the impact of mobile health (mHealth) in people with hand OA.

CLINICAL REHABILITATION IMPACT

mHealth interventions are a feasible and secure multimodal delivery approach in older adults with hand OA in rural primary care setting. Baseline pain and upper limb function might predict functional hand outcomes.

Exercise & Sports Science Australia (ESSA) updated Position Statement on exercise and physical activity for people with hip/knee osteoarthritis

This Position Statement is an update to the existing statement. It is intended for all health practitioners who manage people with hip/knee osteoarthritis. It synthesises the most recent evidence (with a focus on clinical guidelines and systematic reviews) for exercise in people with hip/knee osteoarthritis, and provides guidance to practitioners about how best to implement exercise in clinical practice. Clinical practice guidelines for hip/knee osteoarthritis advocate physical activity and exercise as fundamental core components of evidence-based management. Research evidence indicates that exercise can reduce joint pain, increase physical function, and improve quality of life in hip/knee osteoarthritis, and that a range of exercise types (both supervised and unsupervised) may be beneficial. Exercise dosage should be guided by the principles of the American College of Sports Medicine. As people with osteoarthritis experience many barriers to exercise, practitioners should take an active role in monitoring and promoting adherence to exercise in order to optimise therapeutic benefits.

Exercised-Induced Hypoalgesia following An Elbow Flexion Low-Load Resistance Exercise with Blood Flow Restriction: A Sham-Controlled Randomized Trial in Healthy Adults

We aimed to evaluate the hypoalgesic effect of an elbow flexion low-load resistance exercise with blood flow restriction (LLRE-BFR) when compared to high-load resistance exercise (HLRE) with sham-BFR in healthy individuals. Forty healthy young adults (17 women), with a mean age ± SD: 26.6 ± 6.8 years, and mean body mass index ± SD: 23.6 ± 2.7 were randomly assigned to either an LLRE-BFR (30% 1 repetition maximum, RM) or an HLRE with sham-BFR group (70% of 1 RM). Blood pressure and pressure pain thresholds (PPTs) were measured pre- and post-exercise intervention. The rating of perceived exertion (RPE) was recorded after each set. There were non-significant between-group changes in PPT at the dominant biceps (-0.61, 95%CI: -1.92 to 0.68) with statistically significant reductions between pre- and post-exercise in LLRE-BFR (effect size, d = 0.88) and HLRE-BFR (effect size, d = 0.52). No within- or between-group differences were recorded in PPT at non-exercising sites of measurement. No mediating effects of changes in blood pressure or RPE on the changes in pressure pain threshold were observed. LLRE-BFR produced a similar hypoalgesic effect locally compared to HLRE and can be used as an alternative intervention to decrease pain sensitivity when HLRE is contraindicated or should be avoided.

Is low intensity exercise sufficient to induce exercise-induced pain threshold modulation in people with persistent pain?

OBJECTIVES

We investigated whether a 12-min walk test (12MWT) yielded exercise-induced pain threshold modulation (EIPM) within people with persistent pain and whether baseline self-report and pain sensitivity measures differed according to these responses.

DESIGN

Cross-sectional study.

METHODS

Two cohorts (tertiary/community) (n = 88) with persistent pain underwent pressure pain threshold (PPT) testing before and after a 12MWT to determine exercise-induced pain threshold modulation responses. Baseline self-report (pain severity, pain distribution, psychological distress, sleep) and baseline widespread pain sensitivity (WPS) (high/low) were recorded. Within and between-group differences were analysed using paired t-tests and repeated measure analyses of covariance. Individual EIPM responses were categorised as hyperalgesic, no change and hypoalgesic responses. Differences in baseline self-report and pain sensitivity measures between EIPM categories were investigated.

RESULTS

No significant within- or between-group differences in PPT following the 12MWT were detected (p > 0.05). Individual responses showed that up to 30% of the community and 44% of the tertiary cohort demonstrated >20% change in PPT (in either direction). Significant differences were shown in pain distribution (p = 0.002) and baseline WPS (p = 0.001) between people with hyperalgesic, no change, hypoalgesic responses. People with 4-5 pain regions were more likely hyperalgesic (χ2 = 9.0, p = 0.003); people with low baseline WPS were more likely to demonstrate no change (p = 0.002).

CONCLUSION

Low or self-selected intensity exercise was insufficient to induce exercise-induced pain modulation at group level. Individual responses were variable with pain distribution and baseline WPS differing between responses. Future research could evaluate responses and associated factors in larger samples with high baseline pain sensitivity specifically.

Tensile strain and altered synovial tissue metabolism in human knee osteoarthritis

Synovium is critical for maintaining joint homeostasis and may contribute to mechanobiological responses during joint movement. We investigated mechanobiological responses of whole synovium from patients with late-stage knee osteoarthritis (OA). Synovium samples were collected during total knee arthroplasty and assigned to histopathology or cyclic 10% tensile strain loading, including (1) static (control); (2) low-frequency (0.3 Hz); and iii) high-frequency (1.0 Hz) for 30-min. After 6-h incubation, tissues were bisected for RNA isolation and immunostaining (3-nitrotyrosine; 3-NT). RNA sequencing was analyzed for differentially expressed genes and pathway enrichment. Cytokines and lactate were measured in conditioned media. Compared to controls, low-frequency strain induced enrichment of pathways related to interferon response, Fc-receptor signaling, and cell metabolism. High-frequency strain induced enrichment of pathways related to NOD-like receptor signaling, high metabolic demand, and redox signaling/stress. Metabolic and redox cell stress was confirmed by increased release of lactate into conditioned media and increased 3-NT formation in the synovial lining. Late-stage OA synovial tissue responses to tensile strain include frequency-dependent increases in inflammatory signaling, metabolism, and redox biology. Based on these findings, we speculate that some synovial mechanobiological responses to strain may be beneficial, but OA likely disturbs synovial homeostasis leading to aberrant responses to mechanical stimuli, which requires further validation.

Are progressive shoulder exercises feasible in patients with glenohumeral osteoarthritis or rotator cuff tear arthropathy?

BACKGROUND

Little is known about the feasibility of progressive shoulder exercises (PSE) for patients with glenohumeral osteoarthritis (OA) or rotator cuff tear arthropathy (CTA). The aim of this study was to investigate whether 12 weeks of PSE is feasible in patients with glenohumeral OA or CTA eligible for shoulder arthroplasty. Moreover, to report changes in shoulder function and range of motion (ROM) following the exercise program.

METHODS

Twenty patients were included. Eighteen patients (11 women, 15 with OA), mean age 70 years (range 57-80), performed 12 weeks of PSE with one weekly physiotherapist-supervised and two weekly home-based sessions. Feasibility was measured by dropout rate, adverse events, pain, and adherence to PSE. At baseline and end of intervention, patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) score and Disabilities of the Arm, Shoulder and Hand (DASH). Data to assess feasibility were analyzed using descriptive statistics.

RESULTS

Two patients dropped out and no adverse events were observed. Sixteen of the eighteen patients (89%) had a high adherence (≥ 70%) to the physiotherapist-supervised sessions. Acceptable pain levels were reported; in 76% of all exercise sessions with no numeric rating scale (NRS) score over five for any exercise. WOOS improved with a mean of 23 points (95% CI 13;33), and DASH improved with a mean of 13 points (95% CI 6;19).

CONCLUSION

Adherence to PSE was high and dropout rates were low. PSE is feasible, safe and may relieve shoulder pain, improve function and ROM in patients with glenohumeral OA or CTA. The patient-experienced gains after PSE seem clinically relevant and should be compared to arthroplasty surgery in a RCT setting.

TRIAL REGISTRATION

According to Danish law, this study did not need an approval by the Central Denmark Region Committee on Health Research Ethics. Approval from The Danish Data Protection Agency (journal number 1-16-02-15-20) was obtained.

Feasibility of 'parkrun' for people with knee osteoarthritis: A mixed methods pilot study

Objective

To investigate the feasibility of 'parkrun' for people with knee osteoarthritis (OA) and examine its potential to improve symptoms and increase physical activity.

Design

This uncontrolled mixed methods pilot study enrolled people with knee OA not meeting physical activity guidelines. Participants were asked to walk in four consecutive parkrun events supervised by an exercise physiologist/physiotherapist. Feasibility was assessed by recruitment data (numbers screened and time to enrol 15 participants), adherence to the protocol, acceptability (measured by confidence, enjoyment, difficulty ratings and qualitative interviews), and safety (adverse events). Secondary measures were changes in knee pain, function, stiffness, and physical activity levels.

Results

Participants (n ​= ​17) were enrolled over 11 months and recruitment was slower than anticipated. Fourteen participants attended all four parkruns and three of these participants shortened the 5 ​km course to ∼3 ​km. Across all four parkruns, 75% of participants reported high confidence that they could complete the upcoming parkrun and the majority (87%) enjoyed participating. Most participants rated parkrun either "slightly difficult" (38.5%) or "moderately difficult" (35%) and two mild adverse events were reported. Participants showed improvements in knee pain, function, stiffness, and physical activity levels.

Conclusions

This pilot study demonstrates parkrun's feasibility, acceptability, safety and, its potential to improve knee OA symptoms and physical activity levels. Participating in parkrun was acceptable and enjoyable for some, but not all participants. The scalability, accessibility and wide appeal of parkrun supports the development of larger programs of research to evaluate the use of parkrun for people with knee OA.

Osteoarthritis Flares

The phenomenon of flares is a common feature in the daily life of people with osteoarthritis (OA). Characterized by episodes of sudden-onset increases in signs and symptoms, their impact can often be distressing and disabling. Despite their potential to have both short-term and long-term consequences for patients across the whole course of the condition, their occurrence and optimal management are not fully understood. This article provides a contemporary perspective on defining OA flares and their potential triggers, and offers suggestions for how health professionals might explore flare patterns with patients in clinical practice and frame timely best-practice treatment approaches.

An Exercise and Educational and Self-management Program Delivered With a Smartphone App (CareHand) in Adults With Rheumatoid Arthritis of the Hands: Randomized Controlled Trial

BACKGROUND

Rheumatoid arthritis (RA) is a prevalent autoimmune disease that usually involves problems of the hand or wrist. Current evidence recommends a multimodal therapy including exercise, self-management, and educational strategies. To date, the efficacy of this approach, as delivered using a smartphone app, has been scarcely investigated.

OBJECTIVE

This study aims to assess the short- and medium-term efficacy of a digital app (CareHand) that includes a tailored home exercise program, together with educational and self-management recommendations, compared with usual care, for people with RA of the hands.

METHODS

A single-blinded randomized controlled trial was conducted between March 2020 and February 2021, including 36 participants with RA of the hands (women: 22/36, 61%) from 2 community health care centers. Participants were allocated to use the CareHand app, consisting of tailored exercise programs, and self-management and monitoring tools or to a control group that received a written home exercise routine and recommendations, as per the usual protocol provided at primary care settings. Both interventions lasted for 3 months (4 times a week). The primary outcome was hand function, assessed using the Michigan Hand Outcome Questionnaire (MHQ). Secondary measures included pain and stiffness intensity (visual analog scale), grip strength (dynamometer), pinch strength (pinch gauge), and upper limb function (shortened version of the Disabilities of the Arm, Shoulder, and Hand questionnaire). All measures were collected at baseline and at a 3-month follow-up. Furthermore, the MHQ and self-reported stiffness were assessed 6 months after baseline, whereas pain intensity and scores on the shortened version of the Disabilities of the Arm, Shoulder, and Hand questionnaire were collected at the 1-, 3-, and 6-month follow-ups.

RESULTS

In total, 30 individuals, corresponding to 58 hands (CareHand group: 26/58, 45%; control group: 32/58, 55%), were included in the analysis; 53% (19/36) of the participants received disease-modifying antirheumatic drug treatment. The ANOVA demonstrated a significant time×group effect for the total score of the MHQ (F_1.62,85.67=9.163; P<.001; η²=0.15) and for several of its subscales: overall hand function, work performance, pain, and satisfaction (all P<.05), with mean differences between groups for the total score of 16.86 points (95% CI 8.70-25.03) at 3 months and 17.21 points (95% CI 4.78-29.63) at 6 months. No time×group interaction was observed for the secondary measures (all P>.05).

CONCLUSIONS

Adults with RA of the hands who used the CareHand app reported better results in the short and medium term for overall hand function, work performance, pain, and satisfaction, compared with usual care. The findings of this study suggest that the CareHand app is a promising tool for delivering exercise therapy and self-management recommendations to this population. Results must be interpreted with caution because of the lack of efficacy of the secondary outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04263974; https://clinicaltrials.gov/ct2/show/NCT04263974.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-04713-4.

Reporting of Adverse Events in Randomized Controlled Trials of Therapeutic Exercise for Hip Osteoarthritis: A Systematic Review

OBJECTIVE

The purpose of this study was to describe adverse events (AEs) and dropouts (DOs) in randomized controlled trials of therapeutic exercise for hip osteoarthritis (HOA) and to identify whether Consolidated Standards of Reporting Trials (CONSORT) guidelines were followed.

METHODS

The Cochrane Library, Embase, PubMed, and CINAHL databases were searched. Randomized controlled trials of therapeutic exercise for HOA published in English from January 1, 1980 to August 1, 2020 were included. Studies were excluded if other interventions were provided, if participants had previous hip arthroplasty, or if AEs and DOs for HOA participants were not reported separately. The internal validity of each study (Physiotherapy Evidence Database [PEDro] scoring) was assessed, participant and intervention characteristics were extracted, and the existence of a clear statement and reasons for AEs and DOs was reported. Descriptive statistics characterized results. Data heterogeneity prohibited the use of meta-analysis.

RESULTS

Fourteen studies (mean PEDro score = 7.4; range = 6-10) from 10 countries were included, with 707 participants exercising. Exercise intensity was unspecified in 72.2% of exercise arms. Six studies (42.9%) included a statement of AEs, and 32 AEs were reported. All studies had a DO statement, but 29.0% of DOs occurred for unknown reasons. Six studies (42.9%) gave reasons for DOs that could be classified as AEs in 9 participants; 41 participants (5.8%) experienced exercise-related AEs.

CONCLUSION

Reports of AEs were inconsistent, some DOs were potentially misclassified, and primary components of exercise interventions were frequently unreported. Despite these limitations, the overall low number of nonserious AEs suggests that the exercise-related risk of harm is minimal for individuals with HOA.

IMPACT

Understanding the risk of harm associated with exercise for HOA can better inform safe dosing of exercise, clinical implementation, and replicability. Informative, consistent reporting of AEs, DOs, and exercise is needed. Greater use of the CONSORT harms-reporting checklist is warranted.

The effect of exercise intensity on exercise-induced hypoalgesia in cancer survivors: A randomized crossover trial

Pain is experienced by people with cancer during treatment and in survivorship. Exercise can have an acute hypoalgesic effect (exercise-induced hypoalgesia; EIH) in healthy individuals and some chronic pain states. However, EIH, and the moderating effect of exercise intensity, has not been investigated in cancer survivors. This study examined the effect of low- and high-intensity aerobic exercise on EIH in cancer survivors after a single exercise session as well as a brief period of exercise training (2-weeks, three exercise sessions per week). Participants (N = 19) were randomized to low- (30%-40% Heart Rate Reserve (HRR) or high- (60%-70% HRR) intensity stationary cycling for 15-20 min. Pressure pain thresholds (PPT) were assessed over the rectus femoris and biceps brachii before and after a single exercise session and again after a short training period at the assigned intensity. Then, following a 6-week washout period, the intervention was repeated at the other intensity. After the first exercise session, high-intensity exercise resulted in greater EIH over the rectus femoris than low intensity (mean difference ± SE: -0.51 kg/cm2  ± 0.15, Cohen's d = 0.78, p = 0.004). After a 2-week training period, we found no difference in EIH between intensities (0.01 kg/cm2  ± 0.25, d = 0.00 p = 0.99), with comparable moderate effect sizes for both low- and high-intensity exercise, indicative of EIH. No EIH was observed over the biceps brachii of the arm at either low or high intensity. Low-intensity exercise training may be a feasible option to increase pain thresholds in cancer survivors.

Best-practice clinical management of flares in people with osteoarthritis: A scoping review of behavioral, lifestyle and adjunctive treatments

INTRODUCTION

Transient episodes of increased pain, stiffness or swelling are common in people with osteoarthritis (OA). Yet, evidence-based management strategies for lessening the impact of OA flares are rarely covered in clinical guidelines and have been identified as a gap by clinicians delivering OA care. We aimed to identify evidence on behavioral, lifestyle or other adjunctive flare management strategies that could be used by clinicians or consumers.

MATERIALS AND METHODS

A literature search between 1990-2020 was performed in three databases using a scoping methodology. We included qualitative or quantitative studies, and reviews that examined OA flare management, or that reported OA flare outcomes at timepoints ≤2 weeks post-intervention. Outcomes included any physical or psychological OA outcome treatable with a therapeutic intervention.

RESULTS

We included 9 studies, all of which examined the relationship between therapeutic exercise/ physical activity and OA flares. All studies reported pain outcomes at the knee. Two also included the hip. Only two studies examined specific management strategies for OA flares. Both favorably reported the benefits of undertaking an exercise program modified accordingly during an episode, but the quality of the evidence was low.

DISCUSSION

This scoping review highlights the paucity of evidence available on non-pharmacological treatments of OA flare management that could influence clinical practice. At present, there is no robust evidence to support or reject any specific therapies for OA flare management in clinical practice. Future work is needed, particularly around outcomes beyond pain, trajectories of symptom improvement, and for joints other than the knee.

Impact of educational level and employment status on short-term and long-term pain relief from supervised exercise therapy and education: an observational study of 22 588 patients with knee and hip osteoarthritis

OBJECTIVES

To investigate the impact of educational level and employment status on change in pain intensity after treatment among patients with knee and hip osteoarthritis (OA).

DESIGN

A prospective cohort study.

SETTING AND PARTICIPANTS

We analysed 22 588 patients participating in the Good Life with osteoArthritis in Denmark (GLA:D). GLA:D consists of two patient education sessions and 12 supervised exercise sessions.

PRIMARY OUTCOME

Baseline educational level and employment status were used as exposures. We investigated the impact of both exposures separately on mean change in pain intensity (visual analogue scale 0-100 mm) from baseline to immediately after treatment (approximately 3 months) and at 12 months, using linear mixed models.

RESULTS

On average, all patients improved in pain intensity. The average improvement in pain did not differ by educational level, except for one group. Patients with long-term education had less improvement after treatment (2.0 mm, 95% CI 0.8 to 3.1) and at 12 months (2.0 mm, 95% CI 0.6 to 3.4) compared with primary school only (reference). According to employment status, patients on sick leave had the greatest improvement in pain after treatment (-3.4, 95% CI -4.9 to -1.9) and at 12 months (-4.5, 95% CI -6.4 to -2.6) compared with retired patients (reference).

CONCLUSIONS

On average, all patients reported improvement in pain at short-term and long-term follow-up. Change in pain intensity did not substantially differ by educational level or employment status, as the absolute differences were small and most likely not clinically important.

Neuromuscular exercise for chronic musculoskeletal pain in older people: a randomised controlled trial in primary care in Hong Kong

Background

Exercise therapy is commonly prescribed by primary care physicians (PCPs) in the management of chronic musculoskeletal (MSK) pain.

Aim

To evaluate the clinical effectiveness of a supervised neuromuscular (NM) exercise programme in older people with chronic MSK pain.

Design and setting

This was a 12-week, two-arm, randomised controlled trial comparing 6 weeks of supervised NM exercise versus waiting list controls. The authors enrolled 72 participants with chronic MSK pain at seven public primary care clinics.

Method

Participants were randomly allocated in block sizes of 12 to the NM (n = 36) and control groups (n = 36) in a 1:1 ratio. Data were collected at baseline, 6, and 12 weeks. The primary outcome was the Brief Pain Inventory (BPI) pain severity score at 6 weeks post-intervention. Secondary outcomes included the BPI interference score; Pain Self-Efficacy Questionnaire (PSEQ), Short Form Health Survey (SF-12), 7-item Generalised Anxiety Disorder (GAD-7), and 9-item Patient Health Questionnaire (PHQ-9) scores; and functional measurements using the Timed-Up- and-Go test and handgrip strength.

Results

At 6 weeks, the NM group demonstrated a significantly greater improvement in the BPI pain severity score (between-group difference = −1.27; 95% confidence interval [CI] = −2.08 to −0.45; P<0.01), PSEQ (between-group difference = 6.5; 95% CI = 2.22 to 10.77; P<0.01), and SF-12 physical scores (between-group difference = 3.4; 95% CI = 0.05 to 6.75; P<0.05) compared with the control group. Statistically significant overall trends of improvement were also observed for the BPI interference and PHQ-9 scores.

Conclusion

NM exercise has the potential to reduce pain and improve self-efficacy and physical function in older people with chronic MSK pain. It can be an option for PCPs in exercise prescriptions.

Is being barefoot, wearing shoes and physical activity associated with knee osteoarthritis pain flares? Data from a usually barefoot Sri Lankan cohort

AIM

To identify the association between hours of being barefoot/wearing footwear, physical activity (PA) and knee osteoarthritis pain flares (KOAF).

METHODS

Persons with a diagnosis of knee osteoarthritis, who reported previous KOAF, were followed up in a 3 months long telephone-based case-crossover study. Exposures to risk factors were assessed every 10 days and whenever the participants experienced a KOAF. Conditional logistic regression examined associations of KOAF with following: hours of being barefoot/using footwear and PA performed (P < .05).

RESULTS

There were 260 persons recruited, of whom 183 continued longitudinal follow up. Of them, 120 persons had at least one valid KOAF and control period. Participants were female (90%) with mean (SD) age and body mass index of 59.9 (7.0) years, 28.0 (5.0) kg/m² respectively. Participants were barefoot for a mean duration of 12.7 hours (SD 4.6) and used footwear for 5.1 (SD 4.7) hours daily; 99% wore heel heights <2.5 cm. Duration of being barefoot, 1 and 2 days before, demonstrated reduced multivariate odds of KOAF (odds ratio [OR] = 0.85; 95% CI 0.80-0.90). Moderate PA performed 1, 2 days prior was associated with a significantly increased risk of KOAF (multivariate OR 4.29; 2.52-7.30 and OR 3.36; 2.01-5.61). Similarly, hours of using footwear 1 and 2 days before flare demonstrated increased odds of KOAF (OR 1.15; 1.07-1.23 and 1.10; 1.03-1.18).

CONCLUSIONS

Increased duration of being barefoot 1 to 2 days before is associated with reduced risk of KOAF. Performing moderate PA 1 to 2 days before was associated with an increased risk of KOAF.

Trajectories of perceived exertion and pain over a 12-week neuromuscular exercise program in patients with knee osteoarthritis

BACKGROUND

Exercise programs rely on the overload principle, yet patients with knee osteoarthritis (OA) may not adequately progress exercises due to fear of exacerbating symptoms.

OBJECTIVE

To describe trajectories for perceived exertion and exercise-induced knee pain during a neuromuscular exercise program for patients with knee OA.

DESIGN

Participants with knee OA completed a 12-week neuromuscular exercise program consisting of weekly supervised sessions plus home exercises. During each supervised session, the Borg's rating of perceived exertion (RPE; 6 = no exertion, 20 = maximal exertion) and knee pain (pre, post, max) using Numeric Rating Scales (NRS; 0 = no pain, 10 = worst imaginable pain) were completed. Mean changes in RPE and pain from weeks 1-12 were calculated. Mixed effects regression was used to investigate trajectories over time (weeks) for RPE, and maximum pain (pre-to-max) and pain-change (pre-to-post) during exercise.

RESULTS

56 patients (95%) completed the program. From week 1-12, RPE increased by 2.6 (95%CI, 1.7 to 3.5), from 'somewhat hard' to 'very hard', while max pain decreased by 1.0 NRS (95%CI, 0.5 to 1.3) and pain-change decreased by 0.9 NRS (95%CI, 0.4 to 1.3). Linear mixed effects regression showed a quadratic increase for RPE over time until between weeks 9 and 10, then RPE plateaued. Maximum pain decreased linearly over time. Pain-change showed a quadratic decrease over time until approximately week 9, then pain-change plateaued.

CONCLUSIONS

In patients with knee OA participating in a 12-week neuromuscular exercise program, perceived exertion during exercise progressed from 'somewhat hard' to 'very hard' at 9 weeks, while exercise-induced knee pain decreased. Patients were able to work harder while experiencing decreases rather than increases in pain.

Co-existing patterns of MRI lesions were differentially associated with knee pain at rest and on joint loading: a within-person knee-matched case-controls study

BACKGROUND

To assess the association of co-existing MRI lesions with knee pain at rest or on joint loading.

METHODS

We included participants from Osteoarthritis Initiative whose pain score, measured by WOMAC sub-scales, differed by ≥1 point at rest (in bed at night, sitting/lying down) or on joint loading (walking, stairs) between two knees. Cartilage morphology, bone marrow lesions, meniscus extrusion, meniscus morphology, Hoffa's synovitis and synovitis-effusion were assessed using the compartment-specific MRI Osteoarthritis Knee Score. We performed latent class analyses to identify subgroups of co-existing MRI lesions and fitted a conditional logistic regression model to examine their associations with knee pain.

RESULTS

Among 130 eligible participants, we identified five subgroups of knees according to patterns of co-existing MRI lesions: I. minimal lesions; II. mild lesions; III. moderate morphological lesions; IV. moderate multiple reactive lesions; and V. severe lesions. Compared with subgroup I, the odds ratios (ORs) and 95% confidence intervals (CI) of greater pain in bed at night were 1.6 (0.3, 7.2), 2.2 (0.5, 9.5), 6.2 (1.3, 29.6) and 11.2 (2.1, 59.2) for subgroups II-V, respectively. A similar association was observed between aforementioned subgroups and pain with sitting/lying down. The ORs (95% CI) of greater pain with walking were 1.0 (reference), 1.7 (0.5, 6.1), 0.7 (0.2, 2.3), 5.0 (1.4, 18.6) and 7.9 (2.0, 31.5) for subgroup I-V, respectively. The corresponding analysis for pain on stairs showed similar results.

CONCLUSIONS

Distinct patterns of co-existing MRI lesions have different implications for the pathogenesis of osteoarthritic knee pain occurring with/without joint loading.

Exercise-induced hypoalgesia after acute and regular exercise: experimental and clinical manifestations and possible mechanisms in individuals with and without pain

This review describes methodology used in the assessment of the manifestations of exercise-induced hypoalgesia in humans and previous findings in individuals with and without pain. Possible mechanisms and future directions are discussed.

Exercise and physical activity is recommended treatment for a wide range of chronic pain conditions. In addition to several well-documented effects on physical and mental health, 8 to 12 weeks of exercise therapy can induce clinically relevant reductions in pain. However, exercise can also induce hypoalgesia after as little as 1 session, which is commonly referred to as exercise-induced hypoalgesia (EIH). In this review, we give a brief introduction to the methodology used in the assessment of EIH in humans followed by an overview of the findings from previous experimental studies investigating the pain response after acute and regular exercise in pain-free individuals and in individuals with different chronic pain conditions. Finally, we discuss potential mechanisms underlying the change in pain after exercise in pain-free individuals and in individuals with different chronic pain conditions, and how this may have implications for clinical exercise prescription as well as for future studies on EIH.

Guidance for implementing best practice therapeutic exercise for people with knee and hip osteoarthritis: what does the current evidence base tell us?

OBJECTIVE

Therapeutic exercise is a recommended first-line treatment for people with knee and hip osteoarthritis. However, there is little specific advice or practical resources to guide clinicians in its implementation. As the first in a series of projects by the Osteoarthritis Research Society International Rehabilitation Discussion Group to address this gap, we aim to synthesize current literature informing the implementation of therapeutic exercise for people with knee and hip osteoarthritis.

METHODS

Narrative review focusing on evidence from systematic reviews and randomized controlled trials.

RESULTS

Therapeutic exercise is safe for people with knee and hip osteoarthritis. Numerous types of therapeutic exercise (including aerobic, strengthening, neuromuscular, mind-body exercise) may be utilised at varying doses and in different settings to improve pain and function. Benefits from therapeutic exercise appear greater when dosage recommendations from general exercise guidelines for healthy adults are met. However, interim therapeutic exercise goals may also be useful, given that many barriers to achieving these dosages exist among this patient group. Theoretically-informed strategies to improve adherence to therapeutic exercise, such as patient education, goal setting, monitoring and feedback, may help maintain participation and optimise clinical benefits over the longer-term. Sedentary behaviour is also a risk factor for disability and lower quality of life in people with knee and hip osteoarthritis, although limited evidence exists regarding how best to reduce this behaviour.

CONCLUSION

Current evidence can be used to inform how to implement best practice therapeutic exercise, at a sufficient and appropriate dose, for people with knee and hip osteoarthritis.

Heavy shoulder strengthening exercise in people with hypermobility spectrum disorder (HSD) and long-lasting shoulder symptoms: a feasibility study

Background

People with hypermobility spectrum disorder (HSD) are in great risk of experiencing shoulder symptoms, but evidence for treatment is sparse. Therefore, the objective was to evaluate the feasibility of 16-week shoulder strengthening programme for improving shoulder strength and function in people with HSD and shoulder symptoms for more than 3 months to inform a future randomised controlled trial (RCT).

Methods

Twelve participants (11 females, 39.3 ± 13.9 years) with HSD and shoulder instability and/or pain for more than 3 months underwent a 16-week heavy shoulder strengthening exercise programme three times weekly using exercises targeting scapular and rotator cuff muscles. Primary outcomes were pre-defined research progression criteria including recruitment rate (acceptable, 6 participants/month), assessment duration (acceptable: < 120 min), participant retention (acceptable: > 80% complete intervention), training adherence (acceptable: > 75% adhere to > 36 training sessions) and adverse events (acceptable: minor events with no participants discontinuing the study), besides participant and physiotherapist feedback. Secondary treatment outcomes were assessed using the Western Ontario Shoulder Instability Index (WOSI, 0–2100 better to worse), self-reported pain, kinesiophobia and fatigue, isometric shoulder strength, besides clinical tests for instability, hypermobility, laxity, and proprioception.

Results

Recruitment rate was 5.6/month, assessment duration (mean ± SD) 105 ± 9 min, retention 100%, adherence 83%, and four participants experienced short-lasting soreness or pain. Participant feedback was positive, and physiotherapists found the intervention relevant and applicable to the population. The WOSI total score showed an improvement by 51% (mean ± SD, points: baseline 1037 ± 215; Follow up 509 ± 365; mean change (95% CI), − 528 (− 738, − 318)), and participants reported reduced pain, kinesiophobia and fatigue. Shoulder strength measurements improved by 28–31% (mean change (95% CI), Nm/kg: scaption 0.51 (0.23, 0.78); internal rotation 1.32 (0.70, 1.95) and external rotation 0.89 (0.37, 1.40)), and clinical tests indicated decreased shoulder laxity/instability.

Conclusions

The shoulder strengthening exercise programme was feasible and safe for people with HSD and long-lasting shoulder symptoms. A future RCT, with an improved recruitment strategy, will demonstrate whether the exercise programme is also effective in improving symptoms and muscle-tendon function in this population.

Trial registration

ClinicalTrials.gov: NCT03547570. Registered on May 3, 2018.

Prevalence, Severity, and Correlates of Pain Flares in Response to a Repeated Sit-to-Stand Activity: A Cross-sectional Study of 14 902 Patients With Knee and Hip Osteoarthritis in Primary Care

OBJECTIVE

To determine prevalence, severity, and clinical correlates of pain flares in response to a repeated sit-to-stand activity.

DESIGN

Cross-sectional.

METHODS

The analyses included 11 013 patients with knee osteoarthritis (OA) and 3889 patients with hip OA who completed a 30-second chair-stand test before starting the Good Life with osteoArthritis in Denmark treatment program. Prevalence and severity of pain flares were evaluated by change in self-reported joint pain intensity on an 11-point numeric rating scale after the test. Correlates with pain flares (an increase on the numeric rating scale of 2 points or greater) were assessed using regression analyses.

RESULTS

One out of 3 patients with knee OA and 1 out of 5 patients with hip OA experienced pain flares (numeric rating scale of 2 or greater). Low knee/hip confidence, 3 or more painful body sites, fewer than 12 chair stands in 30 seconds, and body mass index of 30 kg/m² or greater were associated with pain flares in response to the 30-second chair-stand test in patients with knee and hip OA. Low self-efficacy and joint stiffness were associated with pain flares in patients with knee OA. Using pain medication was associated with pain flares in patients with hip OA.

CONCLUSION

Pain flares in response to a repeated sit-to-stand activity were common in patients with knee and hip OA. The clinical correlates associated with pain flares included joint confidence, functional performance, and body mass index, and are potentially modifiable with patient education, exercise therapy, and weight loss, respectively. J Orthop Sports Phys Ther 2020;50(6):309-318. Epub 6 Sep 2019. doi:10.2519/jospt.2019.9125.

Longitudinal study of the relationship between physical activity and knee pain and functional limitation in community-dwelling older adults

AIMS

To describe the associations between interindividual (between-person) and intraindividual (within-person) variability in physical activity (PA) and knee pain and functional limitation among older adults. We also investigated the potential bidirectional association of between-person and within-person variability in knee pain and functional limitation with PA.

METHOD

Participants (N = 1064; 51% women; mean age 63 ± 7.4 years) were measured at baseline, 2.5, and 5 years. PA was measured using pedometers. Knee pain and functional limitation were assessed using the WOMAC scale. A two-part hurdle model, with adjustment for confounders, estimated the association of between-person and within-person variability in PA with knee pain/functional limitation (as the outcome). Linear mixed effect regression models described the association of between-person and within-person variability in knee pain and functional limitation with PA (as the outcome).

RESULTS

Between-person effects showed that participants with a higher 5-year average PA had lower average WOMAC scores (β= -1.17, 95% CI: -1.82, -0.51). Within-person effects showed that at time-points when participants had a higher PA level than average, they also had lower WOMAC scores (β= -0.85, 95% CI: -1.36, -0.35). Conversely, both between-person (β= -15.6, 95% CI: -22.5, -8.8) and within-person increase (β= -7.4, 95% CI: -13.5, -1.4) in WOMAC scores were associated with lower PA.

CONCLUSION

These findings suggest that PA and knee pain/dysfunctional contribute to the development of one another. Pain can lead to changes in inter- and intraindividual PA levels, but the reverse is also possible - changes in PA results in changes in inter- and intraindividual pain/dysfunctional levels.

Power of Words: Influence of Preexercise Information on Hypoalgesia after Exercise-Randomized Controlled Trial

PURPOSE

Exercise increases pressure pain thresholds (PPT) in pain-free individuals, known as exercise-induced hypoalgesia (EIH). Positive preexercise information can elicit higher EIH responses, but the effect of positive versus negative preexercise information on EIH is unknown. The primary aim of this randomized controlled trial was to compare EIH at the exercising thigh muscle after an isometric squat exercise between individuals receiving positive versus negative preexercise information about the effect of exercise on pain. Secondary aims were to compare EIH at nonexercising muscles between groups, and to investigate the relationship between participants' expectations and EIH.

METHODS

Eighty-three participants were randomly assigned to brief positive (n = 28), neutral (n = 28) or negative (n = 27) verbal information. The neutral information group was included in the study as a reference group. Pressure pain thresholds at the thigh and trapezius muscles were assessed before and after the intervention (i.e., preexercise information+squat exercise). Expectations of pain relief were assessed using a numerical rating scale (-10 [most negative] to 10 [most positive]).

RESULTS

Change in quadriceps and trapezius PPT after the squat exercise showed a large difference between the positive and negative information groups (quadriceps, 102 kPa; 95% confidence interval, 55-150; effect size, 1.2; trapezius, 41 kPa; 95% confidence interval, 16-65; effect size:, 0.9). The positive information group had a 22% increase in quadriceps PPT whereas the negative information group had a 4% decrease. A positive correlation was found between expectations and increase in PPT.

CONCLUSIONS

Negative preexercise information caused hyperalgesia after the wall squat exercise, whereas positive or neutral preexercise information caused hypoalgesia. Positive preexercise information did not change the magnitude of EIH compared with neutral information.

The Relationship Between Daily Physical Activity and Pain in Individuals with Knee Osteoarthritis

Objective

Investigate the association between physical activity and pain severity in individuals with knee osteoarthritis.

Design

Cross-sectional; systematic review with meta-analyses.

Methods

Thirty-one participants with knee osteoarthritis underwent assessment of symptoms via self-report questionnaires and quantitative sensory testing. Following testing, physical activity and symptoms were monitored for seven days using accelerometers and logbooks. Cross-correlation analyses were performed on fluctuations in symptoms and physical activity across the week to detect the relative timing of the strongest association between pain and activity. These data were complemented by meta-analyses of studies that examined correlations between pain from knee osteoarthritis and physical activity or fitness.

Results

Pain severity at baseline correlated with moderate to vigorous physical activity (r2 = 0.161–0.212, P &lt; 0.05), whereby participants who were more physically active had less pain. Conversely, the peak of the cross-correlation analyses was most often positive and lagging, which indicated that pain was increased subsequent to periods of increased activity. These superficially discrepant findings were supported by the results of a meta-analysis of 13 studies and 9,363 participants, which identified significant heterogeneity for associations between physical activity and pain (I2 = 91%). Stronger inverse associations were found between fitness and pain.

Conclusions

Associations between physical activity and pain in people with knee osteoarthritis are variable and dynamic. These results reflect the beneficial impact of an active lifestyle and accompanying higher fitness. Yet, the side effect of acute periods of physical activity to transiently exacerbate pain may influence the behavior of some people to avoid activity because of pain.

Impact of Exercise Therapy on Molecular Biomarkers Related to Cartilage and Inflammation in Individuals at Risk of, or With Established, Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To investigate the impact of exercise therapy on molecular biomarkers related to cartilage and inflammation in individuals at risk of, or with established, knee osteoarthritis by conducting a systematic review of randomized controlled trials (RCTs).

METHODS

We conducted a literature search up to September 2017 in 5 major databases with no restriction on publication year or language. Data were extracted from the first available follow-up time point, and we performed a narrative synthesis for the effect of exercise therapy on molecular biomarkers related to cartilage and inflammation. A subset of studies reporting sufficient data was combined in a meta-analysis, using an adjusted random-effects model.

RESULTS

Twelve RCTs involving 57 study comparisons at 4 to 24 weeks following an exercise-therapy intervention were included. Exercise therapy decreased molecular biomarkers in 17 study comparisons (30%), had no effect in 36 (63%), and increased molecular biomarkers in 4 study comparisons (7%). Meta-analyses of 9 biomarkers showed that exercise therapy was associated with nonsignificant reductions of the C-reactive protein level, C-terminal crosslinking telopeptide of type II collagen, tumor necrosis factor (TNF), soluble TNF receptors 1 and 2, C2C neoepitope of type II collagen, and cartilage oligomeric matrix protein, compared to nonexercising control groups, and exercise therapy had no effect on interleukin-6 and soluble interleukin-6 receptor.

CONCLUSION

Exercise therapy is not harmful, because it does not increase the concentration of molecular biomarkers related to cartilage turnover and inflammation, implicated in osteoarthritis progression. The overall quality of evidence was downgraded to low because of the limited number of RCTs available.

Best Evidence Rehabilitation for Chronic Pain Part 5: Osteoarthritis

Osteoarthritis (OA) is a leading cause of chronic pain and disability in older adults, which most commonly affects the joints of the knee, hip, and hand. To date, there are no established disease modifying interventions that can halt or reverse OA progression. Therefore, treatment is focused on alleviating pain and maintaining or improving physical and psychological function. Rehabilitation is widely recommended as first-line treatment for OA as, in many cases, it is safer and more effective than the best-established pharmacological interventions. In this article, we describe the presentation of OA pain and give an overview of its peripheral and central mechanisms. We then provide a state-of-the-art review of rehabilitation for OA pain—including self-management programs, exercise, weight loss, cognitive behavioral therapy, adjunct therapies, and the use of aids and devices. Next, we explore several promising directions for clinical practice, including novel education strategies to target unhelpful illness and treatment beliefs, methods to enhance the efficacy of exercise interventions, and innovative, brain-directed treatments. Finally, we discuss potential future research in areas, such as treatment adherence and personalized rehabilitation for OA pain.

Current trends in sport and exercise hip conditions: Intra-articular and extra-articular hip pain, with detailed focus on femoroacetabular impingement (FAI) syndrome

Musculoskeletal conditions, such as hip pain are leading causes of pain and disability. Hip pain is the second most common cause of lower limb musculoskeletal pain, and is commonly seen in active individuals. Hip and groin pain may have intra-articular and extra-articular causes. Femoroacetabular impingement (FAI) syndrome and the associated pathologies are common intra-articular causes of hip and groin pain in active individuals. There are also a number of extra-articular causes of pain, which include musculotendinous conditions, extra-articular impingements and the clinical entities of groin pain described in the Doha agreement. This chapter will describe these, with a detailed focus on FAI syndrome. Specifically, it addresses: 1. What is and what causes FAI syndrome; 2. How do I diagnose FAI syndrome; and 3. What is the evidence-based approach to managing FAI syndrome?

Exercise-Induced Hypoalgesia in Pain-Free and Chronic Pain Populations: State of the Art and Future Directions

Exercise is considered an important component of effective chronic pain management and it is well-established that long-term exercise training provides pain relief. In healthy, pain-free populations, a single bout of aerobic or resistance exercise typically leads to exercise-induced hypoalgesia (EIH), a generalized reduction in pain and pain sensitivity that occurs during exercise and for some time afterward. In contrast, EIH is more variable in chronic pain populations and is more frequently impaired; with pain and pain sensitivity decreasing, remaining unchanged or, in some cases, even increasing in response to exercise. Pain exacerbation with exercise may be a major barrier to adherence, precipitating a cycle of physical inactivity that can lead to long-term worsening of both pain and disability. To optimize the therapeutic benefits of exercise, it is important to understand how EIH works, why it may be impaired in some people with chronic pain, and how this should be addressed in clinical practice. In this article, we provide an overview of EIH across different chronic pain conditions. We discuss possible biological mechanisms of EIH and the potential influence of sex and psychosocial factors, both in pain-free adults and, where possible, in individuals with chronic pain. The clinical implications of impaired EIH are discussed and recommendations are made for future research, including further exploration of individual differences in EIH, the relationship between exercise dose and EIH, the efficacy of combined treatments and the use of alternative measures to quantify EIH. PERSPECTIVE: This article provides a contemporary review of the acute effects of exercise on pain and pain sensitivity, including in people with chronic pain conditions. Existing findings are critically reviewed, clinical implications are discussed, and recommendations are offered for future research.

Gait mechanics contribute to exercise induced pain flares in knee osteoarthritis

Background

Exercise-induced pain flares represent a significant barrier for individuals with knee osteoarthritis to meet physical activity recommendations. There is a need to understand factors that contribute to pain flares and the potential for the motor system to adapt and reduce joint loading should a flare occur. The study aim was to examine the impact of a bout of exercise on self-reported pain, walking mechanics and muscle co-contraction for participants with knee osteoarthritis.

Methods

Thirty-six adults (17 healthy older and 19 knee osteoarthritis) participated in this study. Self-reported pain, joint mechanics and muscle co-activation during gait at two self-selected speeds were collected before and after a 20-min preferred pace treadmill walk (20MTW).

Results

Eight of nineteen osteoarthritis participants had a clinically significant pain flare response to the 20MTW. At baseline the participants that did not experience a pain flare had smaller knee flexion and total reaction moments compared to both the participants with pain flares (p = 0.02; p = 0.05) and controls (p < 0.001; p < 0.001). In addition, the 2nd peak knee adduction (p = 0.01) and internal rotation (p = 0.001) moments were smaller in the no flares as compared to controls. The pain flare participants differed from controls with smaller knee internal rotation moments (p = 0.03), but greater relative hamstrings (vs. quadriceps) and medial (vs. lateral) muscle activation (p = 0.04, p = 0.04) compared to both controls and no flare participants (p = 0.04, p = 0.007). Following the 20MTW there were greater decreases in the 1st and 2nd peak knee adduction (p = 0.03; p = 0.02), and internal rotation (p = 0.002) moments for the pain flare as compared to the no flare group. In addition, for the pain flare as compared to controls, greater decreases in the knee flexion (p = 0.03) and internal rotation (p = 0.005) moments were found.

Conclusions

Individuals who adapt their gait to reduce knee joint loads may be less susceptible to exercise-induced pain flares. This highlights a potential role of gait biomechanics in short-term osteoarthritis pain fluctuations. The results also suggest that despite the chronic nature of osteoarthritis pain, the motor system’s ability to respond to nociceptive stimuli remains intact.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2493-4) contains supplementary material, which is available to authorized users.

A 12-week supervised exercise therapy program for young adults with a meniscal tear: Program development and feasibility study

OBJECTIVE

To describe the development and feasibility of an exercise therapy program for treatment of young adults (18-40 years of age) with a meniscal tear.

METHODS

Researchers and experienced physical therapists developed a 12-week supervised neuromuscular and strengthening exercise therapy program based on clinical expertise and available evidence. Six patients (age range 22-39 years) considered eligible for meniscal surgery by an orthopedic surgeon underwent the program. Patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and evaluated the program during a semi-structured qualitative interview. Feedback from patients was included to finalize the exercise therapy program.

RESULTS

Median improvements (Range) in KOOS subscales were 15 (0-33) for Pain, 11 (-11 to 50) for Symptoms, 16 (3-37) for Function in daily living, 23 (10-45) for Function in sport and recreation, and 9 (-6 to 31) for Quality of life. The patients found the program relevant and effective with only a few short-lasting adverse events and important clinical improvements after four to ten weeks. Physical therapist supervision was considered important. No patients wanted surgery up to 6 month after the exercise therapy program.

CONCLUSION

A neuromuscular and strengthening exercise therapy program was feasible and showed important improvement in a small group of young adults with meniscal tears.

Physical Activity and Exercise Therapy Benefit More Than Just Symptoms and Impairments in People With Hip and Knee Osteoarthritis

Synopsis Osteoarthritis (OA) of the hip and knee is among the leading causes of global disability, highlighting the need for early, targeted, and effective treatment. The benefits of exercise therapy in people with hip and knee OA are substantial and supported by high-quality evidence, underlining that it should be part of first-line treatment in clinical practice. Furthermore, unlike other treatments for OA, such as analgesia and surgery, exercise therapy is not associated with risk of serious harm. Helping people with OA become more physically active, along with structured exercise therapy targeting symptoms and impairments, is crucial, considering that the majority of people with hip and knee OA do not meet physical activity recommendations. Osteoarthritis is associated with a range of chronic comorbidities, including type 2 diabetes, cardiovascular disease, and dementia, all of which are associated with chronic low-grade inflammation. Physical activity and exercise therapy not only improve symptoms and impairments of OA, but are also effective in preventing at least 35 chronic conditions and treating at least 26 chronic conditions, with one of the potential working mechanisms being exercise-induced anti-inflammatory effects. Patient education may be crucial to ensure long-term adherence and sustained positive effects on symptoms, impairments, physical activity levels, and comorbidities. J Orthop Sports Phys Ther 2018;48(6):439-447. Epub 18 Apr 2018. doi:10.2519/jospt.2018.7877.

Patients' views toward knee osteoarthritis exercise therapy and factors influencing adherence - a survey in China

OBJECTIVES

To understand the views toward exercise therapy for knee osteoarthritis (KOA) in China and to analyze factors affecting treatment adherence.

METHODS

A survey-based study, which included multiple choice and open-ended questions on knee OA exercise therapy was conducted in a Chinese population. The content included the respondents' attitudes and beliefs, willingness to receive treatment, and reasons why they could or could not adhere to the treatment. We used Chi-squared tests to compare cognitive differences between the patients and non-patient groups.

RESULTS

A total of 1,069 people responded to the questionnaire, and the response rate was 81.8%. A total of 93.6% of the patients thought that they could adhere to the exercise treatment if they received professional advice and prescriptions. The following questionnaire items achieved consensus: 'Increasing the strength of the muscles around the knee stops the knee pain from getting worse,' 'It is the person's own responsibility to continue doing their exercise program,' 'How helpful the exercise program will be determines how well a person sticks to it,' 'Health professionals should educate patients with knee pain about how to change their lifestyle for the better,' and 'Exercise for knee pain is most helpful when it is designed for each person, to suit their own particular needs.' Patient adherence was affected by multiple factors, and some negative factors included 'forgetfulness,' 'getting joint symptoms improved after therapy,' 'professional guidance, subsequent monitoring and supervision,' 'willing to enhance overall health and quality of life,' 'having no time,' 'occupational factors,' 'considering that the pain would worsen while/after exercise,' and 'family factors.'

CONCLUSIONS

A general Chinese population accepted exercise therapy for treating KOA in our survey. Education is necessary because patients were uncertain and had misunderstandings regarding the potential benefits of exercise therapy. Some factors related to treatment adherence were also analyzed.

Study protocol for a randomised controlled trial of meniscal surgery compared with exercise and patient education for treatment of meniscal tears in young adults

INTRODUCTION

Arthroscopic surgery is a very common orthopaedic procedure. While several trials have investigated the effect of knee arthroscopy for middle-aged and older patients with meniscal tears, there is a paucity of trials comparing meniscal surgery with non-surgical treatment for younger adults. The aim of this randomised controlled trial (RCT) is to investigate if early arthroscopic surgery is superior to exercise therapy and education, with the option of later surgery if needed, in improving pain, function and quality of life in younger adults with meniscal tears.

METHODS AND ANALYSIS

This is a protocol for a multicentre, parallel-group RCT conducted at six hospitals across all five healthcare regions in Denmark. 140 patients aged 18-40 years with a clinical history and symptoms consistent with a meniscal tear, verified on MRI, found eligible for meniscal surgery by an orthopaedic surgeon will be randomly allocated to one of two groups (1:1 ratio). Participants randomised to surgery will undergo either arthroscopic partial meniscectomy or meniscal repair followed by standard postsurgical care, while participants allocated to exercise and education will undergo a 12-week individualised, supervised neuromuscular and strengthening exercise programme and patient education. The primary outcome will be difference in change from baseline to 12 months in the mean score on four Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, function in sports and recreation and quality of life (Knee Injury and Osteoarthritis Outcome Score (KOOS₄)) supported by the individual subscale scores allowing clinical interpretation. Alongside, the RCT an observational cohort will follow patients aged 18-40 years with clinical suspicion of a meniscal tear, but not fully eligible or declining to participate in the trial.

ETHICS AND DISSEMINATION

Results will be presented in peer-reviewed journals and at international conferences. This study is approved by the Regional Committees on Health Research Ethics for Southern Denmark.

REGISTRATION DETAILS

ClinicalTrials.gov (NCT02995551).

Room for improvement: a randomised controlled trial with nested qualitative interviews on space, place and treatment delivery

OBJECTIVE

Healthcare-oriented design in hospitals can promote better clinical outcomes. Creating optimal facilities may increase treatment effects. We investigated the influence of the treatment room on effects of exercise therapy.

METHODS

In a mixed-method randomised controlled double-blind trial, middle-aged individuals reporting knee or hip pain performed 8 weeks of exercise therapy in (1) a newly built physically enhanced environment, (2) a standard environment or (3) were waitlisted, receiving no intervention. Participants and therapists were blind to study aim. Primary outcome was participants' Global Perceived Effect (GPE; seven-point Likert scale). Six nested focus group interviews with participants (n=25) and individual interviews with therapists (n=2) explored experiences of the environments.

RESULTS

42 people exercised in the physically enhanced environment, 40 in the standard environment, 21 were waitlisted. Contrary to our hypothesis, the treatment response seemed greater in the standard environment for GPE (0.98, 95% CI0.5 to 1.4) than for the physically enhanced environment (0.37, 95% CI -0.2 to 0.9), between-group difference (0.61, 95% CI -0.1 to 1.3) did not reach statistical significance (p=0.07). Waitlist group reported no improvement (-0.05 95% CI -0.5 to 0.4). In interviews, participants from the standard environment expressed greater social cohesion and feeling at home. Qualitative themes identified; reflection, sense of fellowship and transition. Secondary patient-reported outcomes and qualitative findings supported the primary finding, while improvements in muscle strength and aerobic capacity did not differ between exercise groups.

CONCLUSION

Results suggest that the physical environment contributes to treatment response. Matching patients' preferences to treatment rooms may improve patient-reported outcomes.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT02043613.