The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part three: aerobic exercise programs

Appraisal of quality and analysis of the similarities and differences between osteoarthritis Clinical Practice Guideline recommendations: A systematic review

OBJECTIVE

Clinical Practice Guidelines (CPGs) aim to support management of hip and knee osteoarthritis (OA), but recommendations are often conflicting and implementation is poor, contributing to evidence-to-practice gaps. This systematic review investigated the contextual and methodological factors contributing to conflicting recommendations for hip and knee OA.

METHOD

Our systematic review appraised CPGs for managing hip and knee OA in adults ≥18 years (PROSPERO CRD42021276635). We used AGREE-II and AGREE-REX to assess quality and extracted data on treatment gaps, conflicts, biases, and consensus. Heterogeneity of recommendations was determined using Weighted Fleiss Kappa (K). The relationship between (K) and AGREE-II/AGREE-REX scores was explored.

RESULTS

We identified 25 CPGs across eight countries and four international organisations. The ACR, EULAR, NICE, OARSI and RACGP guidelines scored highest for overall AGREE-II quality (83%). The highest overall AGREE-REX scores were for BMJ Arthroscopy (80%), RACGP (78%) and NICE (76%). CPGs with the least agreement for pharmacological recommendations were ESCEO and NICE (-0.14), ACR (-0.08), and RACGP (-0.01). The highest agreements were between RACGP and NICE (0.53), RACGP and ACR (0.61), and NICE and ACR (0.91). Decreased internal validity determined by low-quality AGREE scores(<60%) in editorial independence were associated with less agreement for pharmacological recommendations.

CONCLUSION

There were associations between guideline quality and agreement scores. Future guideline development should be informed by robust evidence, editorial independence and methodological rigour to ensure a harmonisation of recommendations. End-users of CPGs must recognise the contextual factors associated with the development of OA CPGs and balance these factors with available evidence.

Effectiveness of Rehabilitation for Osteoarthritis of the Knee: A Scoping Review of Network Meta-Analyses

BACKGROUND

 Although an increasing number of network meta-analyses have been conducted on the effectiveness of conservative therapy for knee osteoarthritis, these may have been poorly planned and executed.We aimed to review the qualities of a comprehensive set of network meta-analyses on rehabilitation therapies for knee osteoarthritis and provide an overview of the effectiveness of each therapy.

METHODS

The eligibility criteria were as follows: (i) conservative rehabilitation was the primary treatment in the intervention group, (ii) included patients were diagnosed with knee osteoarthritis, and (iii) patient groups were aged ≤75 years, and rehabilitation interventions comprised exercise, orthotic, or physical therapies or patient education. Two independent reviewers screened the titles and abstracts of the identified records and selected the eligible reviews; their full texts were further assessed for eligibility. Then, a checklist derived from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension statement for the reporting of systematic reviews incorporating network meta-analyses of healthcare Interventions was used to validate the completeness of the reporting of each network meta-analysis. Furthermore, the statistical and outcome data regarding the quality of life, knee joint function and pain, adverse events, and physical functions were extracted using a customized spreadsheet.

RESULTS

Overall, 2701 titles and abstracts were screened, and eight network meta-analyses were ultimately selected. Nearly all reviews adequately addressed the PRISMA extension checklist, and the completeness of reporting was adequate; therefore, all expected information could be extracted. However, the methodology used to confirm the transitivity assumption was insufficient in many reviews. The following interventions were effective in reducing pain and improving physical function: (i) strengthening, flexibility, aerobic, and mind-body exercises, (ii) pulsed ultrasound, (iii) focused and radial extracorporeal shockwave therapy, and (iv) continuous ultrasound. The following interventions were effective in improving the quality of life: (i) strengthening, (ii) mixed, and (iii) mind-body exercises.

CONCLUSIONS

Our results suggested that exercise therapies, including muscle-strengthening, aerobic, flexibility, and mind-body exercises, are likely to be effective for pain relief and functional improvement in knee osteoarthritis. This may be the first review to provide a comprehensive perspective for considering priorities for future rehabilitation interventions for knee osteoarthritis.

Effects of intra-articular injection of platelet-rich plasma on the inflammatory process and histopathological characteristics of cartilage and synovium in animals with osteoarthritis: a systematic review with meta-analysis

BACKGROUND

Osteoarthritis (OA) affects the entire joint, causing structural changes in articular cartilage, subchondral bone, ligaments, capsule, synovial membrane, and periarticular muscles that afflicts millions of people globally, leading to persistent pain and diminished quality of life. The intra-articular use of platelet-rich plasma (PRP) is gaining recognition as a secure therapeutic approach due to its potential regenerative capabilities. However, there is controversial clinical data regarding efficacy of PRP for OA treatment. In this context, gathering scientific evidence on the effects of PRP in treating OA in animal models could provide valuable insights into understanding its impact on aspects like cartilage health, synovial tissue integrity, and the inflammatory process in affected joints. Thus, the objective of this study was to assess the effects of PRP injections on inflammation and histopathological aspects of cartilage and synovium in animal models of OA through a comprehensive systematic review with meta-analysis.

METHODS

A electronic search was conducted on Medline, Embase, Web of Science, The Cochrane Library, LILACS, and SciELO databases for relevant articles published until June 2022. A random-effects meta-analysis was employed to synthesize evidence on the histological characteristics of cartilage and synovium, as well as the inflammatory process. The GRADE approach was utilized to categorize the quality of evidence, and methodological quality was assessed using SYRCLE's RoB tool.

RESULTS

Twenty-one studies were included in the review, with twelve of them incorporated into the meta-analysis. PRP treatment demonstrated superior outcomes compared to the control group in terms of cartilage histology (very low quality; p = 0.0002), synovium histology (very low quality; p < 0.0001), and reductions in proinflammatory markers, including IL-1 (low quality; p = 0.002), IL-6 (very low quality; p < 0.00001), and TNF-α (very low; p < 0.00001). However, PRP treatment did not yield a significant impact on PDGF-A levels (very low quality; p = 0.81).

CONCLUSION

PRP appears capable of reducing proinflammatory markers (IL-1, IL-6, TNF-α) and mitigating cartilage and synovium damage in animals with OA. However, the levels of evidence of these findings are low to very low. Therefore, more rigorous studies with larger samples are needed to improve the quality of evidence.

PROSPERO REGISTRATION

CRD42022250314.

Efficacy of acupuncture combined with active exercise training in improving pain and function of knee osteoarthritis individuals: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to investigate the clinical efficacy of acupuncture combined with active exercise training in improving pain and function of knee osteoarthritis (KOA) individuals.

DATA SOURCES

PubMed, EMBASE, The Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wan Fang Data, Technology Periodical Database and China Biology Medicine were searched from their inceptions to April 5, 2023.

REVIEW METHODS

We analyzed trials of acupuncture combined with active exercise training for KOA. The included studies were of high quality (Jadad ≥ 4) and RCTs. Study selection, data extraction, risk of bias and quality assessment were independently performed by two reviewers. We performed systematic analyses based on different outcome measures, including total efficiency rate, visual analogue scale (VAS), the Western Ontario and Mcmaster Universities Osteoarthritis Index (WOMAC), the Lysholm Knee Scale (LKS) and range of motion (ROM). We used Review Manager 5.3 and Stata/MP 14.0 to analyze the data. And it was verified by trial sequence analysis (TSA). If I2 > 50% and p < 0.05, we performed sensitivity analysis and subgroup analysis to find the source of heterogeneity. Publication bias was studied by funnel plot and Egger's test was used to verify it.

RESULTS

Full 11 high-quality studies (Jadad ≥ 4) including 774 KOA individuals were included in this review for meta-analysis. The results showed that acupuncture combined with active exercise training (combined group) was superior to the acupuncture group in improving the total effective rate [RR = 1.13, 95%CI (1.05, 1.22), I2 = 0%, P = 0.70], reducing the pain level (VAS) [MD = - 0.74, 95%CI (- 1.04,  - 0.43), I2 = 68%, P < 0.05], improving knee joint function (WOMAC) [MD =  - 6.97, 95%CI (- 10.74, - 3.19), I2 = 76%, P < 0.05] and improving joint range of motion (ROM) [MD = 6.25, 95%CI (2.37, 10.04), I2 = 0%, P = 0.71]. Similarly, the combined group showed significant improvements in the total effective rate [RR = 1.31, 95% CI (1.18, 1.47), I2 = 48%, P = 0.10], pain (VAS) [MD = 1.42, 95% CI (- 1.85, - 1.00), I2 = 65%, P = 0.02] and knee function (WOMAC) [MD = 7.05, 95% CI (- 11.43, - 2.66), I2 = 86%, P < 0.05] compared with the non-acupuncture group.

CONCLUSION

The combined effect of all studies showed significant benefits of acupuncture combined with active exercise training in improving the total effective rate, reducing pain, promoting recovery of knee function and expanding range of motion. However, some evaluation indicators are highly subjective and need to be further confirmed by more objective and evidence-based high-quality RCTs in future.

SYSTEMATIC REVIEW REGISTRATION

[PROSPERO], identifier [No. CRD42023425823].

Adapting a Clinical Practice Guideline for Management of Patients with Knee and Hip Osteoarthritis by Hong Kong Physiotherapists

Knee and hip osteoarthritis are common disabling conditions globally. Although numerous international clinical practice guidelines exist to guide physiotherapy management, not all recommendations issued from these guidelines can be translated to other contexts without considering the cultural acceptability and clinical implementability of targeted countries. Because the ADAPTE framework provides a robust methodology to adapt guidelines to the local context, this study used its methodology to adapt high-quality guideline recommendations to promote optimal physiotherapy care for knee and hip osteoarthritis in Hong Kong. The ADAPTE framework was used and modified to complete the adaptation process. International clinical practice guidelines were identified from eight guideline clearinghouses and six electronic databases. Two independent reviewers critically appraised the eligible guidelines using the AGREE II tool. We extracted and tabulated recommendations from high-quality guidelines. A voting-based consensus among interdisciplinary experts was conducted to decide on suitable recommendations for the Hong Kong context and whether there was a need to modify them. Pertinent recommendations were then translated into the traditional Chinese language. Our team members suggested modifying four tools and adding one to explore the patient's feedback on the recommendations, to the ADAPTE framework. The adaptation was performed on three high-quality guidelines. We adapted 28 and 20 recommendations for treating knee and hip osteoarthritis, respectively. We recommend a multimodal treatment for managing knee and hip osteoarthritis. Land- and aquatic-based exercises, patient education, and self-management were strongly recommended for patients with knee osteoarthritis. Land- and aquatic-based exercises were strongly recommended for patients with hip osteoarthritis. This is the first adaptation study in Hong Kong. It provides guidance to local physiotherapists on managing patients with knee and hip osteoarthritis. Future studies should test the effectiveness of implementing this adapted guideline to improve local physiotherapy care in Hong Kong.

Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines

OBJECTIVES

Guideline adherence for hip and knee osteoarthritis management is often poor, possibly related to the quality and/or inconsistent recommendations. This systematic review of hip and knee osteoarthritis guidelines aimed to appraise the quality and consistency in recommendations across higher-quality guidelines.

METHODS

Eight databases, guideline repositories, and professional associations websites were searched on 27/10/2022. Guideline quality was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II tool) (six domains). Higher quality was defined as scoring ≥60% for domains 3 (rigour of development), 6 (editorial independence), plus one other. Consistency in recommendations across higher-quality guidelines was reported descriptively. This review was registered prospectively (CRD42021216154).

RESULTS

Seven higher-quality and 18 lesser-quality guidelines were included. AGREE II domain scores for higher-quality guidelines were > 60% except for applicability (average 46%). Higher-quality guidelines consistently recommended in favour of education, exercise, and weight management and non-steroidal anti-inflammatory drugs (hip and knee), and intra-articular corticosteroid injections (knee). Higher quality guidelines consistently recommended against hyaluronic acid (hip) and stem cell (hip and knee) injections. Other pharmacological recommendations in higher-quality guidelines (e.g., paracetamol, intra-articular corticosteroid (hip), hyaluronic acid (knee)) and adjunctive treatments (e.g., acupuncture) were less consistent. Arthroscopy was consistently recommended against in higher-quality guidelines. No higher-quality guidelines considered arthroplasty.

CONCLUSION

Higher-quality guidelines for hip and knee osteoarthritis consistently recommend clinicians implement exercise, education, and weight management, alongside consideration of Non-Steroidal Anti-Inflammatory Drugs and intra-articular corticosteroid injections (knee). Lack of consensus on some pharmacological options and adjunctive treatments creates challenges for guideline adherence. Future guidelines must prioritise providing implementation guidance, considering consistently low applicability scores.

Identifying strategies that support equitable person-centred osteoarthritis care for diverse women: content analysis of guidelines

INTRODUCTION

Women are disproportionately impacted by osteoarthritis (OA) but less likely than men to access early diagnosis and management, or experience OA care tailored through person-centred approaches to their needs and preferences, particularly racialized women. One way to support clinicians in optimizing OA care is through clinical guidelines. We aimed to examine the content of OA guidelines for guidance on providing equitable, person-centred care to disadvantaged groups including women.

METHODS

We searched indexed databases and websites for English-language OA-relevant guidelines published in 2000 or later by non-profit organizations. We used manifest content analysis to extract data, and summary statistics and text to describe guideline characteristics, person-centred care (PCC) using a six-domain PCC framework, OA prevalence or barriers by intersectional factors, and strategies to improve equitable access to OA care.

RESULTS

We included 36 OA guidelines published from 2003 to 2021 in 8 regions or countries. Few (39%) development panels included patients. While most (81%) guidelines included at least one PCC domain, guidance was often brief or vague, few addressed exchange information, respond to emotions and manage uncertainty, and none referred to fostering a healing relationship. Few (39%) guidelines acknowledged or described greater prevalence of OA among particular groups; only 3 (8%) noted that socioeconomic status was a barrier to OA care, and only 2 (6%) offered guidance to clinicians on how to improve equitable access to OA care: assess acceptability, availability, accessibility, and affordability of self-management interventions; and employ risk assessment tools to identify patients without means to cope well at home after surgery.

CONCLUSIONS

This study revealed that OA guidelines do not support clinicians in caring for diverse persons with OA who face disadvantages due to intersectional factors that influence access to and quality of care. Developers could strengthen OA guidelines by incorporating guidance for PCC and for equity that could be drawn from existing frameworks and tools, and by including diverse persons with OA on guideline development panels. Future research is needed to identify multi-level (patient, clinician, system) strategies that could be implemented via guidelines or in other ways to improve equitable, person-centred OA care.

PATIENT OR PUBLIC CONTRIBUTION

This study was informed by a team of researchers, collaborators, and thirteen diverse women with lived experience, who contributed to planning, and data collection, analysis and interpretation by reviewing study materials and providing verbal (during meetings) and written (via email) feedback.

Core Recommendations for Osteoarthritis Care: A Systematic Review of Clinical Practice Guidelines

OBJECTIVE

To evaluate the quality of clinical practice guidelines (CPGs) for interventions in management of osteoarthritis (OA) and to provide a synthesis of high-quality CPG recommendations.

METHODS

Five databases (OvidSP Medline, Cochrane, Cumulative Index to Nursing and Allied Health Literature [CINAHL], Embase, and the Physiotherapy Evidence Database [PEDro]) and 4 online guideline repositories were searched. CPGs for the management of OA were included if they were 1) written in English and published from January 2015 to February 2022, focused on adults age ≥18 years, and met the criteria of a CPG as defined by the Institute of Medicine; and 2) were rated as high quality on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. CPGs for OA were excluded if they were available via institutional access only, only addressed recommendations for the system/organization of care and did not include interventional management recommendations, and/or included other arthritic conditions.

RESULTS

Of 20 eligible CPGs, 11 were appraised as high quality and included in the synthesis. Of interest were the hip, knee, hand, and glenohumeral joints and/or polyarticular OA. Consistent recommendations were that care should be patient centered and include exercise, education, and weight loss (where appropriate). Nonsteroidal antiinflammatory drugs and surgical interventions were recommended for disabling OA that had not improved with nonsurgical care. Hand orthoses should be recommended for patients with hand OA.

CONCLUSION

This synthesis of high-quality CPGs for OA management offers health care providers with clear, simple guidance of recommended OA care to improve patient outcomes.

Quality indicators for osteoarthritis pain management in the primary care setting

BACKGROUND

Development of valid and feasible quality indicators (QIs) is needed to track quality initiatives for osteoarthritis pain management in primary care settings.

METHODS

Literature search identified published guidelines that were reviewed for QI extraction. A panel of 14 experts was assembled, including primary care physicians, rheumatologists, orthopedic surgeons, pain specialists, and outcomes research pharmacists. A screening survey excluded QIs that cannot be reliably extracted from the electronic health record or that are irrelevant for osteoarthritis in primary care settings. A validity screening survey used a 9-point Likert scale to rate the validity of each QI based on predefined criteria. During expert panel discussions, stakeholders revised QI wording, added new QIs, and voted to include or exclude each QI. A priority survey used a 9-point Likert scale to prioritize the included QIs.

RESULTS

Literature search identified 520 references published from January 2015 to March 2021 and 4 additional guidelines from professional/governmental websites. The study included 41 guidelines. Extraction of 741 recommendations yielded 115 candidate QIs. Feasibility screening excluded 28 QIs. Validity screening and expert panel discussion excluded 73 QIs and added 1 QI. The final set of 15 prioritized QIs focused on pain management safety, education, weight-management, psychological wellbeing, optimizing first-line medications, referral, and imaging.

CONCLUSION

This multi-disciplinary expert panel established consensus on QIs for osteoarthritis pain management in primary care settings by combining scientific evidence with expert opinion. The resulting list of 15 prioritized, valid, and feasible QIs can be used to track quality initiatives for osteoarthritis pain management.

Rehabilitation interventions in osteoarthritis

The goals of the management of osteoarthritis (OA) are to relieve joint pain and stiffness, maintain or increase joint mobility and stability, improve activities and participation, and enhance quality of life. The first step in the management is to make a comprehensive holistic assessment to understand the impact of the disease on the individual. Then, an individualized management plan can be set via a shared-decision making process between the patient and the clinician taking into account all components of functioning affected by the disease. Rehabilitation interventions serve as the basis of OA management whereas pharmacological modalities are usually administered for additional symptom control. This study aimed to overview the rehabilitation interventions used for people with OA with an update of the recent evidence. First, core management approaches that include patient education, physical activity and exercises, and weight loss were addressed; then adjunctive treatments including biomechanical interventions (e.g. orthoses, assistive devices) and physical modalities were overviewed.

Effect of an Integrated Physiotherapy Protocol on Knee Osteoarthritis Patients: A Preliminary Study

BACKGROUND

Exercise therapy can potentially relieve symptoms and improve functional status of the knee osteoarthritis population. Despite the proved practical benefits, there is no standard, comprehensive physiotherapeutic protocol available targeting the physical and physiological impairment cluster associated with disease. Osteoarthritis is a whole joint disease, affecting joint cartilage, ligaments, menisci and joint associated muscles, from variable pathophysiological processes. Hence, there is a need to develop a physiotherapy protocol to address the multi-structural physical, physiological and functional impairments associated with the disease.

OBJECTIVE

The objective of the present study is to evaluate the efficacy of designed, therapist supervised, patient education, progressive resistance exercises, passive stretching exercises, soft tissue manipulation, muscle energy technique, Maitland mobilization, aerobic exercise, and neuromuscular training physiotherapy protocol on pain, disability, balance, and physical functional performance in knee osteoarthritis patients.

METHODOLOGY

The preliminary study was conducted on a (n = 60) sample of convenience. The samples were randomly allocated into two study groups, intervention, and control group. The control group was advised on a basic home program. On the other hand, the treatment of the intervention group was designed with a therapist supervised Physiotherapy Protocol. The outcome variables studied were the Visual Analogue Scale, Modified WOMAC Scale, Timed Up and Go Test, Functional Reach Test, 40 m Fast Paced Walk Test, Stair Climb Test, 30 s Chair Stand Test.

RESULTS

The results of the study revealed a significant improvement among most of the studied outcome measures in the intervention group, hence the designed supervised physiotherapy protocol was found effective in relieving multiple physiological impairments associated with this whole joint disease.

Influence of routine exercise on the peripheral immune system to prevent and alleviate pain

Routine physical activity reduces the onset of pain and exercise is a first line treatment for individuals who develop chronic pain. In both preclinical and clinical research regular exercise (routine exercise sessions) produces pain relief through multiple mechanisms such as alterations in the central and peripheral nervous system. More recently, it has been appreciated that exercise can also alter the peripheral immune system to prevent or reduce pain. In animal models, exercise can alter the immune system at the site of injury or pain model induction, in the dorsal root ganglia, and systemically throughout the body to produce analgesia. Most notably exercise shows the ability to dampen the presence of pro-inflammatory immune cells and cytokines at these locations. Exercise decreases M1 macrophages and the cytokines IL-6, IL-1β, and TFNα, while increasing M2 macrophages and the cytokines IL-10, IL-4, and IL-1ra. In clinical research, a single bout of exercise produces an acute inflammatory response, however repeated training can lead to an anti-inflammatory immune profile leading to symptom relief. Despite the clinical and immune benefits of routine exercise, the direct effect of exercise on immune function in clinical pain populations remains unexplored. This review will discuss in more detail the preclinical and clinical research which demonstrates the numerous ways through which multiple types of exercise alter the peripheral immune system. This review closes with the clinical implications of these findings along with suggestions for future research directions.

The role of the therapeutic physical exercise and the complex recovery treatment for the patients with chronic degenerative diseases during the COVID-19 pandemic

Abstract: Background: Osteoarthritis is one of the most common causes of pain and musculoskeletal disability and mainly affects the middle-aged and the elderly. The condition is chronic and disabling, it diminishes the patients' quality of life. Purpose. The study had the purpose of pointing out a possible connection between physical ac-tivity and the reduction of pain accompanied by the increased functional capacity in patients with chronic degenerative diseases during the COVID-19 pandemic. Material and method: The study was conducted on an outpatient basis for a period of 6 months on a number of 40 patients diagnosed with osteoarthritis. The evaluation of the pa-tients was made at the beginning of the treatment and at its end (after 4 weeks), as well as at the control after 12 weeks. Results: The study included a number of 40 patients over 45 years old, divided into 2 study groups: in group L1-knee osteoarthritis and in group L2 -hip osteoarthritis. The therapeutic physical exercise reduced pain and stiff-ness, and it also improved the functional capacity. Conclusions: Therapeutic physical exercise has an important role in the reduction of pain and disability, as well as in the increase in the quality of life, if it is done properly. Keywords: osteoarthritis, therapeutic physical exercise, pain, pandemic COVID-19

Interactive multiobjective optimization for finding the most preferred exercise therapy modality in knee osteoarthritis

BACKGROUND

There are no explicit guidelines or tools available to support clinicians in selecting exercise therapy modalities according to the characteristics of individual patients despite the apparent need.

OBJECTIVE

This study develops a methodology based on a novel multiobjective optimization model and examines its feasibility as a decision support tool to support healthcare professionals in comparing different modalities and identifying the most preferred one based on a patient's needs.

METHODS

Thirty-one exercise therapy modalities were considered from 21 randomized controlled trials. A novel interactive multiobjective optimization model was designed to characterize the efficacy of an exercise therapy modality based on five objectives: minimizing cost, maximizing pain reduction, maximizing disability improvement, minimizing the number of supervised sessions, and minimizing the length of the treatment period. An interactive model incorporates clinicians' preferences in finding the most preferred exercise therapy modality for each need. Multiobjective optimization methods are mathematical algorithms designed to identify the optimal balance between multiple conflicting objectives among available solutions/alternatives. They explicitly evaluate the conflicting objectives and support decision-makers in identifying the best balance. An experienced research-oriented physiotherapist was involved as a decision-maker in the interactive solution process testing the proposed decision support tool.

RESULTS

The proposed methodology design and interactive process of the tool, including preference information, graphs, and exercise suggestions following the preferences, can help clinicians to find the most preferred exercise therapy modality based on a patient's needs and health status; paving the way to individualize recommendations.

CONCLUSIONS

We examined the feasibility of our decision support tool using an interactive multiobjective optimization method designed to help clinicians balance between conflicting objectives to find the most preferred exercise therapy modality for patients with knee osteoarthritis. The proposed methodology is generic enough to be applied in any field of medical and healthcare settings, where several alternative treatment options exist.KEY MESSAGESWe demonstrate the potential of applying Interactive multiobjective optimization methods in a decision support tool to help clinicians compare different exercise therapy modalities and identify the most preferred one based on a patient's needs.The usability of the proposed decision support tool is tested and demonstrated in prescribing exercise therapy modalities to treat knee osteoarthritis patients.

Effects of computer-aided rowing exercise systems on improving muscle strength and function in older adults with mild knee osteoarthritis: a randomized controlled clinical trial

Background

Osteoarthritis (OA) is common in aged adults and can result in muscle weakness and function limitations in lower limbs. Knee OA affects the quality of life in the elderly. Technology-supported feedback to achieve lower impact on knee joints and individualized exercise could benefit elderly patients with knee OA. Herein, a computer-aided feedback rowing exercise system is proposed, and its effects on improving muscle strength, health conditions, and knee functions of older adults with mild knee OA were investigated.

Methods

Thirty-eight older adults with mild knee OA and satisfying the American College of Rheumatology (ACR) clinical criteria participated in this randomized controlled clinical trial. Each subject was randomly assigned to a computer-aided rowing exercise (CRE) group (n = 20) or a control group (CON) (n = 18) that received regular resistance exercise programs two times per week for 12 weeks. Outcome measurements, including the Western Ontario and MacMaster Universities (WOMAC), muscle strength and functional fitness of the lower limbs, were evaluated before and after the intervention.

Results

Participants’ functional fitness in the CRE group exhibited significantly higher adjusted mean post-tests scores, including the WOMAC (p = 0.006), hip abductors strength (kg) (MD = 2.36 [1.28, 3.44], p = 5.67 × 10^–5), hip adductors strength (MD = 3.04 [1.38, 4.69], p = 0.001), hip flexors strength (MD = 4.01 [2.24, 5.78], p = 6.46 × 10⁻⁵), hip extensors strength (MD = 2.88 [1.64, 4.12], p = 4.43 × 10⁻⁵), knee flexors strength (MD = 2.03 [0.66, 3.41], p = 0.005), knee extensors strength (MD = 1.80 [0.65, 2.94], p = 0.003), and functional-reach (cm) (MD = 3.74 [0.68, 6.80], p = 0.018), with large effect sizes (η² = 0.17–0.42), than those in the CON group after the intervention.

Conclusions

Older adults with knee OA in the CRE group exhibited superior muscle strength, health conditions, and functional fitness improvements after the 12-week computer-aided rowing exercise program than those receiving the conventional exercise approach.

Trial registration

The Institutional Review Board of the Taipei Medical University approved the study protocol (no. N201908020, 27/05/2020) and retrospectively registered at ClinicalTrials.gov (trial registry no. NCT04919486, 09/06/2021).

Resistance training protects against muscle pain through activation of androgen receptors in male and female mice

ABSTRACT

Resistance training-based exercise is commonly prescribed in the clinic for the treatment of chronic pain. Mechanisms of aerobic exercise for analgesia are frequently studied, while little is known regarding resistance training mechanisms. We developed a resistance training model in mice and hypothesized resistance training would protect against development of muscle pain, mediated through the activation of androgen receptors. Activity-induced muscle hyperalgesia was produced by 2 injections of pH 5.0 stimuli with fatiguing muscle contractions. Resistance training was performed by having mice climb a ladder with attached weights, 3 times per week. Resistance training acutely increased blood lactate and prolonged training increased strength measured via forepaw grip strength and 1 repetition maximum, validating the exercise program as a resistance training model. Eight weeks of resistance training prior to induction of the pain model blocked the development of muscle hyperalgesia in both sexes. Resistance training initiated after induction of the pain model reversed muscle hyperalgesia in male mice only. A single resistance training bout acutely increased testosterone in male but not female mice. Administration of the androgen receptor antagonist flutamide (200 mg pellets) throughout the 8-week training program blocked the exercise-induced protection against muscle pain in both sexes. However, single administration of flutamide (1, 3, 10 mg/kg) in resistance-trained animals had no effect on existing exercise-induced protection against muscle pain. Therefore, resistance training acutely increases lactate and testosterone and strength overtime. Eight weeks of resistance training prevents the development of hyperalgesia through the activation of androgen receptors in an animal model of muscle pain.

Effect of a programme of muscular endurance, balance and gait exercises with and without the use of flexible and minimalist shoes in older women with medial knee osteoarthritis: study protocol for a randomised controlled trial

INTRODUCTION

Studies have indicated that gait intervention programmes with minimalist shoes are effective for reducing pain, improving functionality and reducing knee joint overload in older women with knee osteoarthritis (OA). Other clinical trials with knee and foot muscle strength training and/or dynamic balance training have also shown clinical and functional effectiveness. Despite promising strategies, there is no evidence of the combination of shoes with gait intervention programmes. Thus, the objective of this randomised clinical trial is to investigate the effects of therapeutic programme of muscular resistance, balance and gait exercises with and without the use of low-cost, flexible shoes on the clinical, functional and biomechanical aspects of older women with medial knee OA.

METHODS AND ANALYSIS

This randomised controlled trial with blinded evaluators will involve 36 older women. Twenty-four older women with knee OA (medial compartment) will be randomised to the intervention groups with minimalist shoes (GIC; n=12) or in a barefoot condition (GID; n=12), and 12 older women to the control group (n=12). The intervention protocol will consist of knee-foot muscle resistance and static balance training, reactive and proactive dynamic balance training, and gait training with visual feedback. The intervention will have a duration of two consecutive months, twice a week, totalling 16 sessions. The primary outcomes will be walking pain measured by Visual Analogue Scale and questionnaires: Western Ontario McMaster Universities Osteoarthritis Index and Lequesne Algofunctional. The secondary outcomes will be: 6-min walk test, Falls Risk Awareness Questionnaire, Timed Up and Go Test, and distribution of plantar load during gait and balance by pressure platform. Data will be analysed according to an intention-to-treat approach.

ETHICS AND DISSEMINATION

This study involves human participants and was approved by the ethics committee of the Universidade Santo Amaro, School Medicine, São Paulo/SP, Brazil (N°4.091.006). Participants gave informed consent to participate in the study before taking part. Investigators will communicate trial results to participants and healthcare professionals through scientific databases, social media, publications and conferences.

TRIAL REGISTRATION NUMBER

RBR-10j4bw25 in Brazilian Clinical Trial Registry.

Physical Therapists Prioritize Providing Education About Exercise Therapy and to Dispel Misconceptions About Radiology for People With Knee Osteoarthritis: A Concept Mapping Study

OBJECTIVE

To (1) identify the education priorities that physical therapists have for people with knee osteoarthritis, including perceived importance and capability to provide, and (2) match priorities to education-specific content recommendations in knee osteoarthritis guidelines.

DESIGN

Concept mapping methodology.

METHODS

Physical therapists generated, sorted (based on themes), and rated (5-point Likert scales: importance and capability) patient education priorities. Priorities were matched against education-specific content recommendations in knee osteoarthritis guidelines. Additional education-specific content recommendations were added from guidelines and expert opinion if necessary. Multidimensional scaling and hierarchical cluster analysis produced a cluster map with overarching domains.

RESULTS

Physical therapists (brainstorming, n = 41; sorting, n = 20; rating, n = 22) generated 56 priorities, with 13 added (n = 2 from guidelines, n = 11 from expert opinion). Few priorities were clearly included as education-specific content recommendations in guidelines (ACR [2%, n = 1/56], EULAR [14%, 8/56], NICE [11%, 6/56], and OARSI [0%, 0/56]). An 8-cluster map emerged with 3 overarching domains: (i) first-line care (exercise therapy, lifestyle modification and general health, and weight management), (ii) knowledge formation and countering misconceptions (radiology misconceptions, understanding and managing pain and disability, and general beliefs and understanding about osteoarthritis), and (iii) decision making for medical management (surgery and medications). The exercise therapy cluster was rated the highest for both importance (3.84/5) and capability (4.00). The medications and weight management clusters were rated the lowest for importance (2.54) and capability (2.82), respectively.

CONCLUSION

Physical therapists prioritize a range of education topics for people with knee osteoarthritis, focusing on exercise therapy. Physical therapists feel least capable of providing weight management education. J Orthop Sports Phys Ther 2022;52(9):607-619. Epub: 17 June 2022. doi:10.2519/jospt.2022.11090.

Aerobic exercise combined with glucosamine hydrochloride capsules inhibited the apoptosis of chondrocytes in rabbit knee osteoarthritis by affecting TRPV5 expression

OBJECTIVE

This study aimed to investigate the effect of aerobic exercise combined with glucosamine (OTL) on the apoptosis of chondrocytes of rabbit knee osteoarthritis (KOA) by affecting the expression of TRPV5.

METHODS

After the KOA white rabbit model was established, aerobic training and OTL treatment were performed, then the model joints were evaluated by Mankin, HE staining was used to observe the pathological changes of articular cartilage, TUNEL and immunohistochemistry were used to detect chondrocyte apoptosis. Knee chondrocytes were isolated and identified by Alcian Blue and type II collagen fiber staining. The cells were treated with iodoacetic acid (MIA) to simulate osteoarthritis in vitro, and then the effect of TRPV5 on apoptosis was detected by flow cytometry, in addition, apoptosis-related proteins and TRPV5 were detected by western blotting and qRT-PCR.

RESULTS

Both aerobic exercise and OTL treatment could significantly reduce the Mankin score of KOA model, and could effectively inhibit chondrocyte apoptosis in the KOA model, and inhibit the expression of caspase 3 and caspase 9 in the KOA model. TRPV5 expression was significantly increased in the model, while both aerobic exercise and OTL could reverse its expression. The low-expression of TRPV5 significantly reversed the role of MIA in promoting apoptosis and apoptosis-related proteins of knee chondrocytes, while overexpressing TRPV5 promoted MIA-induced apoptosis and apoptosis-related proteins.

CONCLUSION

Aerobic exercise combined with glucosamine hydrochloride capsules inhibited the apoptosis of chondrocytes in rabbit KOA by affecting the expression of TRPV5.

Role and Effectiveness of Intra-articular Injection of Hyaluronic Acid in the Treatment of Knee Osteoarthritis: A Systematic Review

Osteoarthritis (OA) is a degenerative joint disease that causes persistent joint pain and stiffness of mainly the large peripheral weight-bearing joints. It is a leading cause of functional disability and poor quality of life. Various modalities of therapy are recommended by different research organizations at different stages of OA including non-pharmacological, pharmacological, and surgical interventions. Intra-articular injections of hyaluronic acid (HA) is widely used for over three decades in the treatment of OA. However controversies exist regarding its safety and efficacy, the number of injections and courses, type of preparation, duration of its effects, and combining it with other drugs or molecules. This study aimed to review the most recent data available in the published literature to address these.

Electronic databases like Medline, Embase, ProQuest, and Google Scholar were searched for articles using keywords, intraarticular injections, hyaluronic acid, and osteoarthritis knee. The review was carried out as per PRISMA guidelines.

Thirty-eight randomized control trials (RCTs) investigating the efficacy and safety of intra-articular injection of HA were included in the systematic review. Out of the 38 studies, 22 (57.9%) were double-blind, eight (21%) single-blind, three (7.9%) non-blind, four (10%) with simple randomization, and one (2.7%) was open-labeled. Total 5,025 patients were included in these studies. The mean age of the patients was 60.28 years and the osteoarthritis grade of the knee joint was 1 to 3. HA was studied as a test preparation in 19 (50%) while in another 19 (50%) it was studied as a control. In 24 (63.2%) studies, HA was used as high molecular weight preparation in eight (21%) as low molecular weight preparation while in six studies the information was not available. HA was used as a standalone preparation in 31 studies, in two studies it was injected with platelet-rich plasma (PRP) and with either low-level laser therapy (LLLT), triamcinolone (TA), betamethasone (CS), poly deoxyribonucleotide (PDRN) or dexamethasone (DX) in one study each. In the majority of the studies, HA was given as a single injection (52.6% studies) or weekly three injections (28.9% studies). In 13.2 %, it was given as weekly 5 injections and in 5.3% as weekly two injections.

IA-HA injections have a limited role in the treatment of knee osteoarthritis in those patients who do not have sufficient pain relief with topical or oral medication and physical therapy. It is safe and effective except for minor side effects such as local pain and swelling lasting for a few days. Severe allergic reactions are extremely rare. They provide adequate pain relief and functional improvement for up to six months irrespective of a number of injections and type of preparations used. The combination formulations with corticosteroids or PRP or MSCs show better results than HA alone. Combining HA with newer molecules such as peptides or diclofenac for sustained and disease-modifying effects requires more studies in the future.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

A systematic review of clinical practice guidelines for persons with osteoarthritis. A "Best Evidence for Rehabilitation" (be4rehab) paper to develop the WHO's Package of Interventions for Rehabilitation: A systematic review of Clinical Practice Guidelines for persons with osteoarthritis for the identification of best evidence for rehabilitation

AIM

Identifying existing interventions for rehabilitation and related evidence presents a crucial step in developing the World Health Organization's (WHO) Package of Interventions for Rehabilitation. This paper reports the results of a systematic search that aimed to identify clinical practice guidelines (CPGs) relevant to the rehabilitation of people with osteoarthritis and presents the CPG recommendations and the current state of evidence available for the interventions in the CPGs.

METHODS

This paper is part of the "Best Evidence for Rehabilitation" (be4rehab) series, developed according to the methodology presented in the WHO's Package of Interventions for Rehabilitation introductory paper by Rauch et al, published in 2019. It is a systematic review of the existing CPGs on osteoarthritis published between 2009 and 2019. Identified CPGs were screened taking into consideration conflict of interest, the provision of information regarding the strength of recommendation(s), and quality to be selected. Quality of CPGs was assessed using the AGREE II tool.

RESULTS

After title and abstract screening, 51 CPGs were identified. Considering the inclusion/exclusion criteria, 26 CPGs were selected. After checking for quality, comprehensiveness, multi-professionality, and publication date, five CPGs were finally included in the review. The strong recommendations for people with knee and hip osteoarthritis consistently included in all the selected CPGs, sometimes called "core treatments", were patient education, exercise training, and weight reduction if overweight or obese. Generally, recommendations overlap in the CPGs.

CONCLUSION

The systematic search revealed high-quality CPGs on osteoarthritis for the identification of "Best Evidence for Rehabilitation (be4rehab)" regarding interventions for rehabilitation of people with osteoarthritis.

Benefits and Mechanisms of Exercise Training for Knee Osteoarthritis

Knee osteoarthritis is a chronic degenerative disease. Cartilage and subchondral bone degeneration, as well as synovitis, are the main pathological changes associated with knee osteoarthritis. Mechanical overload, inflammation, metabolic factors, hormonal changes, and aging play a vital role in aggravating the progression of knee osteoarthritis. The main treatments for knee osteoarthritis include pharmacotherapy, physiotherapy, and surgery. However, pharmacotherapy has many side effects, and surgery is only suitable for patients with end-stage knee osteoarthritis. Exercise training, as a complementary and adjunctive physiotherapy, can prevent cartilage degeneration, inhibit inflammation, and prevent loss of the subchondral bone and metaphyseal bone trabeculae. Increasing evidence indicates that exercise training can improve pain, stiffness, joint dysfunction, and muscle weakness in patients with knee osteoarthritis. There are several exercise trainings options for the treatment of knee osteoarthritis, including aerobic exercise, strength training, neuromuscular exercise, balance training, proprioception training, aquatic exercise, and traditional exercise. For Knee osteoarthritis (KOA) experimental animals, those exercise trainings can reduce inflammation, delay cartilage and bone degeneration, change tendon, and muscle structure. In this review, we summarize the main symptoms of knee osteoarthritis, the mechanisms of exercise training, and the therapeutic effects of different exercise training methods on patients with knee osteoarthritis. We hope this review will allow patients in different situations to receive appropriate exercise therapy for knee osteoarthritis, and provide a reference for further research and clinical application of exercise training for knee osteoarthritis.

Quality assessment of conventional and traditional oriental medicine clinical practice guidelines for knee osteoarthritis using AGREE II instrument

INTRODUCTION

Knee osteoarthritis is a degenerative disease and its prevalence tends to increase. Clinical practice guidelines (CPGs) are evidence-based recommendations for treatment that help policymakers, practitioners, and patients make more appropriate and efficient decisions during the course of management. This study aimed to evaluate the quality of knee osteoarthritis CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

METHOD

The retrieval engines and websites were utilized from January 2010 to December 2020. The search words were "Clinical practice guideline" OR "Critical practice guideline" OR "guideline∗" AND "Osteoarthritis." The quality of the CPGs was independently examined by four appraisers using the AGREE II instrument. Consequently, the selected CPGs were graded as Classes A, B, and C according to the level of recommendation.

RESULT

In this study, 13 CPGs for knee osteoarthritis were selected and evaluated qualitatively using the AGREE II instrument. The overall quality percentage score was as follows: clarity of presentation, 72.6%, scope and purpose, 62.6%, rigor of development, 54.2%, stakeholder investment, 50.5%, editorial independence, 46.5%, applicability, 22.5%.

CONCLUSION

Auxiliary materials for the treatment process of knee OA should be supplemented in future revised versions for quality improvement of knee OA CPGs. Also, more evidence should be accumulated to support the recommendation of traditional oriental medical treatments in the clinical field. From the perspective of integrative medicine, along with conventional pharmacological treatment, exercise, weight loss, and acupuncture can be combined together in clinical situations.

Numerical Modeling of Shockwave Treatment of Knee Joint

Arthritis is a degenerative disease that primarily affects the cartilage and meniscus of the knee joint. External acoustic stimulation is used to treat this disease. This article presents a numerical model of the knee joint aimed at the computer-aided study of the regenerative effects of shockwave treatment. The presented model was verified and validated. A numerical analysis of the conditions for the regeneration of the tissues of the knee joint under shockwave action was conducted. The results allow us to conclude that to obtain the conditions required for the regeneration of cartilage tissues and meniscus (compressive stresses above the threshold value of 0.15 MPa to start the process of chondrogenesis; distortional strains above the threshold value of 0.05% characterized by the beginning of the differentiation of the tissues in large volumes; fluid pressure corresponding to the optimal level of 68 kPa to transfer tissue cells in large volumes), the energy flux density of therapeutic shockwave loading should exceed 0.3 mJ/mm².

The basis of information to guide clinical decision-making in knee osteoarthritis management: A survey with Brazilian physical therapists

RATIONALE, AIMS AND OBJECTIVES

Several health information sources are available to assist physical therapists in the clinical decision-making process, with a notable increase in the importance of using evidence-based practice (EBP). The aim of this study is to investigate the health information sources most used by Brazilian physical therapists to guide their clinical decision making for knee osteoarthritis (OA) management, use of Physiotherapy Evidence Database (PEDro), knowledge about the existence of clinical practice guidelines (CPGs), and associated factors.

METHODS

A cross-sectional study using an electronic survey was conducted. Physical therapists registered in a Regional Physical Therapy Council in Brazil were invited to participate. Sociodemographic data, professional training, health information sources, frequency of use of PEDro, and knowledge about CPGs were collected. Descriptive analysis of the data was performed, and the chi square test and multinomial and binary logistic regression were used to verify association between the variables.

RESULTS

The survey was completed by 370 professionals. The three health information sources most used by Brazilian physical therapists were clinical experience, courses, and books. Among these professionals, only 12.1% use PEDro frequently, and 60.5% know that CPGs for knee OA management exist. Level of education was associated with PEDro use and knowledge about the existence of CPGs (P < .05).

CONCLUSIONS

The study results indicated a significant deficiency in engagement with research evidence by Brazilian physical therapists to guide their clinical decision making for knee OA. Further investigations on educational needs and the development of new strategies to narrow the gap between research evidence and clinical practice should be performed.

Effects of variable frequencies of kinesthesia, balance and agility exercise program in adults with knee osteoarthritis: study protocol for a randomized controlled trial

Background

Knee osteoarthritis (OA) is a common painful and disabling condition that affects older individuals. Proprioceptive training programs in the form of kinesthesia, balance and agility (KBA) exercises have been reported to be beneficial for individuals with knee OA. However, the most optimal training dosage of KBA exercises is still unclear. The aim of this study is to determine the effects of different frequencies of KBA training (i.e., twice-weekly or thrice-weekly) in adults with knee OA.

Methods

A single (assessor) blind, three-arm parallel, multi-center randomized controlled trial will be conducted. One hundred twenty adults with knee OA will be recruited from four tertiary hospitals in Northwestern Nigeria and randomly assigned into one of three intervention groups; twice-weekly KBA (n = 40), thrice-weekly KBA (n = 40), and conventional physiotherapy (n = 40) in the ratio of 1:1:1. Participants in the conventional physiotherapy group will receive two sessions of brief patient education, and sixteen sessions of ultrasound therapy, and stretching and strengthening exercises for 8 weeks. Participants in the two different KBA groups will receive KBA training according to the designed sessions for 8 weeks in addition to the conventional physiotherapy program. All groups will be assessed pre-intervention, immediately post-intervention and at 3 months, 4 months, and 6 months post-randomization. The primary outcome will be physical function (Ibadan Knee and Hip Osteoarthritis Outcome Measure) whereas the secondary outcomes will be pain intensity (Visual Analogue Scale for pain), knee stability (Knee Outcome Survey-Activities of Daily Living Scale), proprioception (electronic goniometer), and quality of life (Osteoarthritis Knee and Hip Quality of Life Questionnaire).

Discussion

The findings of this study may provide evidence on the effectiveness of KBA exercise training and the ideal number of sessions needed to achieve the highest effectiveness in adults with knee OA.

Trial registration

Pan African Clinical Trials Registry (PACTR201810713260138). Registered on 28 November 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05386-3.

Arthroscopy Association of Canada Position Statement on Exercise for Knee Osteoarthritis: A Systematic Review of Guidelines

BACKGROUND

Exercise is widely regarded to improve pain and function in patients with knee osteoarthritis (OA) through building supportive muscle mass, facilitating weight loss, and through the other beneficial effects associated with it.

PURPOSE

To explore literature that presents clinical guidelines for the use of exercise in the treatment of knee OA to inform an evidence-based position statement for the Arthroscopy Association of Canada.

STUDY DESIGN

Position statement.

METHODS

PubMed, MEDLINE, Embase, and Cochrane databases were searched for guidelines commenting on the role of exercise for knee OA. The search was limited to guidelines published in the last 10 years. Articles were screened for relevance, focusing on recently published research with clinical guidelines. Inclusion criteria involved all articles providing clinical guidelines for exercise and knee OA.

RESULTS

Eight guidelines were identified. All eight recommended exercise as an important component of treatment for knee OA, with 6/8 strongly recommending it.

CONCLUSION

Exercise is an effective and important component of the non-pharmacological management of knee OA. The Arthroscopy Association of Canada strongly recommends the use of exercise in the management of knee OA.

Non-Surgical Treatment of Knee Osteoarthritis: Multidisciplinary Italian Consensus on Best Practice

The aim of this document is to provide a set of indications on the national best practice management of knee osteoarthritis based on an analysis of the existing literature and the contribution of experts in the field. During the first phase of the project, in agreement with the multidisciplinary panel of experts, the main guidelines on the topic were selected. Each guideline was assessed through the AGREEII system to identify their strong/weak points and a summary of the recommendations contained in the various documents was drawn up. The panel drew up a list of therapeutic options to be included in the document and some of these topics were selected for in-depth analysis and review. The search strategy for the required literature reviews was constructed using the PICOS approach. The results obtained from the literature reviews, the in-depth analyses conducted by the members of the scientific societies involved and the analysis of the existing guidelines enabled an initial draft of the consensus document to be elaborated. This document was examined at the consensus conference held on 28 May 2019, in the presence of a multidisciplinary group consisting of members of the various scientific societies involved. Single recommendations were discussed in work groups with a view to combining the indications given by the literature examined with the experience of the specialists involved. The recommendations discussed were then put to the vote in a plenary assembly. The final document contains 26 practice recommendations which leading specialists involved in the management of knee OA in Italy agree upon.

The effects on pain, physical function, and quality of life of quadriceps strengthening exercises combined with Baduanjin qigong in older adults with knee osteoarthritis: a quasi-experimental study

BACKGROUND

Exercise is recommended as a principal treatment for individuals with knee osteoarthritis (KOA). However, the best choice for an optimal exercise program able to promote long-term compliance in KOA patients is not clear. This study aims to compare the effect of combined exercise (CE: quadriceps strengthening exercises (QSE) and Baduanjin qigong training (BDJ)) versus QSE alone and BDJ alone on older adults with KOA.

METHODS

A three-arm, quasi-experimental trial with repeated measurements was used. As a cluster randomized trial, participants from three community centers were assigned respectively to QSE group, BDJ group and CE group. We assessed pain intensity, physical function, self-efficacy, and health-related quality-of-life (HRQoL) using standardized instruments at baseline, 3 months and 6 months follow-up.

RESULTS

One hundred and twenty-eight participants with KOA aged over 60 completed the study. Over the 6 months, there were significant group interaction effects on pain intensity (F = 28.888, P < 0.001), physical function (F = 26.646, P < 0.001), and self-efficacy (F = 22.359, P < 0.001), and, based on a short form-12 item health survey questionnaire (SF-12), physical component summary (F = 7.470, P < 0.001), and mental component summary (F = 10.207, P < 0.001). Overall, the CE group exhibited significantly greater improvement in all outcomes when compared to the QSE group and the BDJ group.

CONCLUSIONS

CE treatment is more effective than QSE and BDJ in pain relief, increasing physical function, improving self-efficacy, and raising quality-of-life in community-dwelling KOA older adults. Moreover, it promotes long-term compliance in KOA community patients.

TRIAL REGISTRATION

Chinese Clinical Trails Registry number ChiCTR2000033387 (retrospectively registered). Registered 30 May 2020.

The mechanism of aerobic exercise combined with glucosamine therapy and circUNK in improving knee osteoarthritis in rabbits

AIMS

Both aerobic exercise and glucosamine hydrochloride capsules (OTL) have a therapeutic effect on knee osteoarthritis, but their joint application has not been investigated. This study clarified the mechanism of the combined treatment in knee osteoarthritis.

MAIN METHODS

Aerobic exercise and OTL were used alone or in combination to treat papain-induced knee osteoarthritis model rabbits. Pathological changes of cartilage tissues, inflammatory cytokine content, glycosaminoglycan, and expressions of collagen II, cartilage differentiation-related genes and circUNK were analyzed by hematoxylin-eosin staining, Mankin score, Enzyme-linked immunosorbent assay, toluidine blue staining, Immunohistochemistry and qRT-PCR. The extracted chondrocytes were identified by Alcian Blue staining and immunohistochemistry and induced by iodoacetic acid (MIA) to establish osteoarthritis model. Effects of overexpressing or silencing circUNK on cell function and molecular changes in chondrocytes were analyzed by cell function experiments, qRT-PCR and Western blot. Rabbit modeling and intervention treatment were marked.

KEY FINDINGS

Aerobic exercise or OTL treatment alone relieved the damage caused by knee osteoarthritis in terms of cartilage tissue lesions, Mankin score, inflammatory cytokine content, glycosaminoglycan, and expressions of collagen II, cartilage differentiation-related genes and circUNK. Combined application of aerobic exercise and OTL showed better synergistic treatment effects. Transfection of overexpressed circUNK could attenuate the MIA-induced effect on cell viability and apoptosis in chondrocytes by regulating genes related to differentiation and apoptosis. Aerobic exercise combined with glucosamine had a synergistic therapeutic effect on knee osteoarthritis.

SIGNIFICANCE

Overexpressing circUNK protected osteoarthritis model cells by regulating cartilage differentiation- and apoptosis-related genes.

Effects of exercise on knee osteoarthritis: A systematic review

BACKGROUND

Knee osteoarthritis is the most common joint disease and a major cause of functional limitation and pain in adults. The aim of this literature review is to review the existing evidence regarding the impact of exercise in people with knee osteoarthritis concerning physical and functional outcomes. The secondary aim is to provide both healthcare professionals and patients with updated and high-quality recommendations for the management of this condition.

METHODS

A systematic search was performed at Pubmed, Scopus and Web of Science databases, limiting the studies to English, French and Portuguese language, from 2010 to May 2020. Eligible studies were randomized control trials or clinical control trials that compared an intervention consisting of an exercise programme in adult participants with knee osteoarthritis against no intervention.

RESULTS

A total of 4499 studies were retrieved and 19 articles met the inclusion criteria. Beneficial effects of exercise were found on pain and strength. Regarding function, functional performance and quality of life, evidence is controversial. Both strengthening and aerobic exercise showed positive effects and both aquatic and land-based programmes presented improvement of pain, physical function and quality of life. Relatively to stretching, plyometric and proprioception training, no concrete conclusions can be taken.

CONCLUSION

Exercise programmes appear to be safe and effective in knee osteoarthritis patients, mainly regarding pain and strength improvement. Pilates, aerobic and strengthening exercise programmes performed for 8-12 weeks, 3-5 sessions per week; each session lasting 1 h appear to be effective. Both aquatic and land-based programmes show comparable and positive effects.

Quality and content analysis of clinical practice guidelines which include nonpharmacological interventions for knee osteoarthritis

RATIONALE, AIMS, AND OBJECTIVES

Clinical practice guidelines (CPGs) for knee osteoarthritis (OA) guide the provision of high-quality healthcare for people with knee OA, which may improve outcomes. Our aim was to evaluate the quality of and content within recently published CPGs for people with knee OA.

METHODS

CPGs (2014-2019) that described recommendations for nonpharmacological interventions for knee OA were included in the analysis. Two pairs of evaluators used the Appraisal of Guidelines Research and Evaluation II instrument (AGREE II) to assess the quality of guideline development. CPG content was reviewed and summarized for comparison.

RESULTS

Ten CPGs were identified for inclusion in the quality and content analysis (seven newly developed and three recently updated). Overall CPG scores ranged between 42% and 100%. Six CPGs were found to be high-quality. Exercise was the only intervention recommended by all CPGs that we appraised. Weight-management and education were the next most frequently recommended interventions. Inter-rater reliability scores were high in domain 1: scope and purpose, (P-value = .001, intraclass correlation coefficient [ICC] = 0.90, 95% confidence interval [CI] = 0.62-0.98), domain 3: rigor of development (P-value = .000, ICC = 0.95, 95% CI = 0.80-0.99) and domain 5: applicability (P-value = .001, ICC = 0.91, 95% CI = 0.64-0.98).

CONCLUSION

Several CPGs have been developed or recently updated since 2014. Over half of the ten CPGs we appraised were deemed to be high-quality. Exercise, education, and weight-management advice are interventions that were most commonly recommended by CPGs.

Clinical prediction rule for early recovery of knee range of motion after total knee arthroplasty: A prospective cohort study

OBJECTIVE

To derive a clinical prediction rule for early recovery of knee range of motion after total knee arthroplasty.

METHODS

This prospective cohort study evaluated the data of 273 individuals undergoing primary total knee arthroplasty. The individual factors, the physical and motor function data were assessed preoperatively upon admission as a baseline survey. The knee joint extension angle and knee joint flexion angle were re-evaluated on postoperative day 14 as a follow-up. The recovery group comprised individuals with a knee joint extension angle of more than -5 degrees and knee joint flexion angle of more than 110 degrees on postoperative day 14. The other patients constituted the non-recovery group. Multivariate logistic regression analysis was used for deriving a clinical prediction rule.

RESULTS

The results indicated that the use of a cane, knee joint extension and flexion angles, and Timed Up and Go test time were significant factors for predicting early recovery of knee range of motion after total knee arthroplasty. Furthermore, a clinical prediction rule was derived and included the use of a cane, knee joint extension angle ≥ -15 degrees, knee joint flexion angle ≥ 125 degrees, and a Timed Up and Go test time < 11.2 s. A total clinical prediction rule score ≥ 8 indicated a positive likelihood ratio of more than 10 for a successful outcome and the post-test probability was approximately 95%.

CONCLUSIONS

The derived clinical prediction rule might be a useful screening tool for proper postoperative goal setting and the establishment of individualized physical therapy programs.

Determining the feasibility of a trial to evaluate the effectiveness of phototherapy versus placebo at reducing pain during physical activity for people with knee osteoarthritis: a pilot randomized controlled trial

BACKGROUND

Although practice guidelines recommend physical activity and exercise for the management of knee osteoarthritis, pain is a common barrier to participation. Phototherapy has been shown to reduce pain intensity for people with knee osteoarthritis, but it is unclear if it reduces pain during physical activity or contributes to improved rehabilitation outcomes.

OBJECTIVE

The aim of this study is to assess the feasibility of performing a fully powered randomized controlled trial (RCT) comparing an active phototherapy intervention versus placebo on pain during physical activity for people with knee osteoarthritis.

METHODS

A pilot RCT was conducted to test the feasibility of a trial comparing 8-sessions (4 weeks) of active phototherapy versus placebo. People were able to participate if they (1) were an English speaking adult (> 18 years of age), (2) had received a diagnosis of knee osteoarthritis from a physician, and (3) self-reported experiencing pain and disability related to their knee osteoarthritis for > 3 months. Primary outcomes were the feasibility of participant recruitment, retention, assessment procedures, and maintaining high treatment fidelity. Secondary outcomes piloted for a full trial included pain during physical activity (primary outcome of full trial); self-reported pain severity, physical function, stiffness, adherence to prescribed exercise, global rating of change, patient satisfaction, and adverse events; 6-min walk test; and pressure pain threshold.

RESULTS

Twenty participants (4 men; 16 women) with knee osteoarthritis and a mean age of 63.95 (SD: 9.27) years were recruited over a 3-week period (6.7 participants per week). Fifteen out of 20 (75%) of participants completed the primary outcome assessment at 4 weeks and 19/20 (95%) of participants were retained and completed the final 16-week assessment. Overall, 89% of all assessment items were completed by participants across all time-points. Fifteen out of 20 participants (75%) completed all 8 treatment sessions. Treatment fidelity was 100% for all completed treatment sessions. No adverse events were reported by participants in either group.

CONCLUSIONS

Results suggest that the trial methodology and intervention are feasible for implementation in a fully powered randomized controlled trial to determine the effectiveness of phototherapy at reducing pain during physical activity for people with knee osteoarthritis.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04234685 , January 21, 2020-Retrospectively registered.

Baduanjin exercise for patients with knee osteoarthritis: A protocol for systematic review and meta-analysis

BACKGROUND

Knee osteoarthritis (KOA) is a common chronic degenerative disorder with an increasingly prevalence among the older individuals and the leading cause of pain in the elderly. Baduanjin, one of the ancient traditional Chinese mind-body exercise routine, has been recognized to have clinical benefits for KOA. We aim to evaluate the efficacy and safety of Baduanjin for patients with KOA through this systematic review and meta-analysis.

METHODS

Four English databases (Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and Web of Science), and 4 Chinese databases (China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chinese Scientific Journal Database, and Wanfang Database), will be searched from establishment of the database until October 2020. The reference lists and the citation lists of studies meeting the inclusion criteria will also be searched to identify further studies for inclusion. The search languages are English and Chinese. The randomized controlled trials of Baduanjin training for patients with KOA will be included. The primary outcome will be assessed according to the Western Ontario and McMaster Universities Osteoarthritis Index. Meta-analysis will be conducted with the use of RevMan 5.3.

RESULTS

The results of this research will be submitted to a peer-reviewed publications.

CONCLUSION

This systematic review aims to present evidence for whether Baduanjin training is an effective intervention which can improve both physical condition and life quality in patients suffering KOA.

INPLASY REGISTRATION NUMBER

INPLASY202090051.

Guidelines for the diagnosis and treatment of osteoarthritis in China (2019 edition)

Osteoarthritis (OA) is a degenerative disease of middle-aged and elderly people, contributed a higher burden of disease in China and the world. In 2017, under the support of the Rheumatology and Immunology Expert Committee of the Cross-Strait Medical and Health Exchange Association. The objective was to develop an evidence-based diagnosis and treatment guideline for OA in China based on emerging new evidence. The guideline was registered at International Practice Guidelines Registry Platform (IPGRP-2018CN028). The grading of recommendations assessment, development and evaluation (GRADE) approach was used to rate the quality of evidence and the strength of recommendations, and the RIGHT (Reporting Items for Practice Guidelines in Healthcare) checklist was followed to report the guideline. The guideline provides recommendations for the OA diagnosis, disease risks monitoring and evaluate, treatment purpose and physical, medical and surgical interventions. This guideline is intended to serve as a tool for Chinese clinicians for the best decisions-making on diagnosis and treatment of OA.

Mechanism of exercise-induced analgesia: what we can learn from physically active animals

Physical activity has become a first-line treatment in rehabilitation settings for individuals with chronic pain. However, research has only recently begun to elucidate the mechanisms of exercise-induced analgesia. Through the study of animal models, exercise has been shown to induce changes in the brain, spinal cord, immune system, and at the site of injury to prevent and reduce pain. Animal models have also explored beneficial effects of exercise through different modes of exercise including running, swimming, and resistance training. This review will discuss the central and peripheral mechanisms of exercise-induced analgesia through different modes, intensity, and duration of exercise as well as clinical applications of exercise with suggestions for future research directions.

Nonpharmacological and nonsurgical approaches in OA

Osteoarthritis (OA) is a chronic, disabling, and common disease. Nonpharmacological and nonsurgical treatments are seen as the core treatments for OA. This paper presents an overview of the recommendations from international guidelines on nonpharmacological and nonsurgical interventions. Education, advice, or information about the etiology, progression, prognosis, and treatment options of OA are recommended to be an ongoing and integral part of care. Weight loss (if overweight) is an important core treatment in knee and hip OA. Exercise is a key core treatment in knee, hip, and hand OA and should be considered regardless of age, structural disease severity, functional status, pain levels, or the presence of comorbidities. Walking aids/devices are recommended for both hip and knee OA, while orthoses are recommended for patients with carpometacarpal (CMC) joint OA. Trained healthcare providers with the skills to provide the core treatments are essential. In addition, there should be a proactive management from the first consultation for OA symptoms. Tools for such proactive management and for better uptake of the core interventions are discussed.

Evaluation of an educational course for primary care physiotherapists on comorbidity-adapted exercise therapy in knee osteoarthritis: an observational study

Objective

The objectives of the present study were to: (1) evaluate the effect of an educational course on competence (knowledge and clinical reasoning) of primary care physical therapists (PTs) in treating patients with knee osteoarthritis (KOA) and comorbidity according to the developed strategy; and (2) identify facilitators and barriers for usage.

Method

The present research was an observational study with a pretest‐posttest design using mixed methods. PTs were offered a postgraduate course consisting of e‐learning and two workshops (blended education) on the application of a strategy for exercise prescription in patients with KOA and comorbidity. Competences were measured by questionnaire on knowledge (administered before and 2 weeks after the course), and a patient vignette to measure clinical reasoning (administered before the course and after a 6 month period of treating patients). Facilitators and barriers for using the strategy were assessed by a questionnaire and semi‐structured interviews.

Results

Thirty‐four PTs were included. Competence (knowledge and clinical reasoning) improved significantly (p < 0.01). Fourteen out of 34 PTs had actually treated patients with KOA and comorbidity, during a 6‐month period. The strategy was found to be feasible in daily practice. The main barriers included the limited number of (self‐) referrals of patients, limited number of reimbursed treatment sessions by insurance companies and a suboptimal collaboration with (referring) physicians.

Conclusion

A blended course on exercise therapy for patients with KOA and comorbidity seems to improve PTs' competence through increasing knowledge and clinical reasoning skills. Identified barriers should be solved before large‐scale implementation of exercise therapy can take place in these complex patients.

Are we missing the target? Are we aiming too low? What are the aerobic exercise prescriptions and their effects on markers of cardiovascular health and systemic inflammation in patients with knee osteoarthritis? A systematic review and meta-analysis

Objectives

We systemically reviewed published studies that evaluated aerobic exercise interventions in patients with knee osteoarthritis (OA) to: (1) report the frequency, intensity, type and time (FITT) of exercise prescriptions and (2) quantify the changes in markers of cardiovascular health and systemic inflammation.

Data sources

PubMed, CINAHL, Scopus; inception to January 2019.

Eligibility criteria

Randomised clinical trials (RCT), cohort studies, case series.

Design

We summarised exercise prescriptions for all studies and calculated effect sizes with 95% CIs for between-group (RCTs that compared exercise and control groups) and within-group (pre-post exercise) differences in aerobic capacity (VO2), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and inflammatory markers (interleukin-6 (IL-6), tumour necrosis factor-alpha). We pooled results where possible using random effects models.

Results

Interventions from 49 studies were summarised; 8% (4/49) met all FITT guidelines; 16% (8/49) met all or most FITT guidelines. Fourteen studies (10 RCTs) reported at least one marker of cardiovascular health or systemic inflammation. Mean differences (95% CI) indicated a small to moderate increase in VO2 (0.84 mL/min/kg; 95% CI 0.37 to 1.31), decrease in HR (−3.56 beats per minute; 95% CI −5.60 to −1.52) and DBP (−4.10 mm Hg; 95% CI −4.82 to −3.38) and no change in SBP (−0.36 mm Hg; 95% CI −3.88 to 3.16) and IL-6 (0.37 pg/mL; 95% CI −0.11 to 0.85). Within-group differences were also small to moderate.

Conclusions

In studies of aerobic exercise in patients with knee OA, very few interventions met guideline-recommended dose; there were small to moderate changes in markers of cardiovascular health and no decrease in markers of systemic inflammation. These findings question whether aerobic exercise is being used to its full potential in patients with knee OA.

PROSPERO registration number

CRD42018087859.

Relative difference in muscle strength between patients with knee osteoarthritis and healthy controls when tested bilaterally and joint-inclusive: an exploratory cross-sectional study

Background

To improve the goal-directedness of strength exercises for patients with knee osteoarthritis (KOA), physical rehabilitation specialists need to know which muscle-groups are most substantially weakened across the kinetic chain of both lower extremities. The purpose was to improve the knowledge base for strength exercise therapy. The objective was to explore the relative differences in muscle strength in the main directions bilaterally across the hip, knee, and ankle joints between patients with light-to-moderate symptomatic and radiographic KOA and people without knee complaints.

Methods

The design was an exploratory, patient vs. healthy control, and cross-sectional study in primary/secondary care. Twenty-eight patients with mild to moderate KOA (18 females, mean age 61) and 31 matched healthy participants (16 females, mean age 55), participated. Peak strength was tested concentrically or isometrically in all main directions for the hip, knee, and ankle joints bilaterally, and compared between groups. Strength was measured by a Biodex Dynamometer or a Commander II Muscle Tester (Hand-Held Dynamometer). Effect sizes (ES) as Cohen’s d were applied to scale and rank the difference in strength measures between the groups. Adjustment for age was performed by analysis of covariance.

Results

The most substantial muscle weaknesses were found for ankle eversion and hip external and internal rotation in the involved leg in the KOA-group compared to the control-group (ES [95% CI] −0.73 [−1.26,-0.20], − 0.74 [−1.26,-0.21], −0.71 [−1.24,-0.19], respectively; p < 0.01). Additionally, smaller but still significant moderate muscle weaknesses were indicated in four joint–strength directions: the involved leg’s ankle inversion, ankle plantar flexion, and knee extension, as well as the uninvolved leg’s ankle dorsal flexion (p < 0.05). There was no significant difference for 17 of 24 tests.

Conclusions

For patients with KOA between 45 and 70 years old, these explorative findings indicate the most substantial weaknesses of the involved leg to be in ankle and hip muscles with main actions in the frontal and transverse plane in the kinetic chain of importance during gait. Slightly less substantial, they also indicate important weakness of the knee extensor muscles. Confirmatory studies are needed to further validate these exploratory findings.

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.

Osteoarthritis year in review 2018: rehabilitation and outcomes

OBJECTIVE

Conduct a systematic review of systematic reviews and randomised controlled trials (RCTs) from the past year evaluating rehabilitation for people with osteoarthritis, and provide narrative synthesis of findings focused on core recommended treatments for osteoarthritis (exercise, education, biomechanical interventions, weight loss).

DESIGN

A comprehensive search strategy was used to search PubMed, EMBASE and Cochrane databases (16^th May 2017 to 22^nd March 2018). Search terms included 'osteoarthritis', 'rehabilitation', 'systematic review', and 'randomised controlled trial'. Inclusion criteria were: (1) RCT, or systematic review of randomised clinical trials (RCTs); (2) human participants with osteoarthritis (any joint); (3) evaluation of rehabilitation intervention; and (4) at least one patient-reported measure. Methodological quality was evaluated using the Assessment of Multiple Systematic Reviews (AMSTAR) tool (systematic reviews) and PEDro rating scale (RCTs). Narrative synthesis mapped findings to core recommendations from existing osteoarthritis clinical guidelines.

RESULTS

From 1994 records, 13 systematic reviews and 36 RCTs were included. 73% of these evaluated knee osteoarthritis (36 studies). The remaining studies evaluated hand osteoarthritis (6 studies), hip, hip/knee and general osteoarthritis (each 2 studies), and neck osteoarthritis (1 study). Exercise was the most common intervention evaluated (31%). Updated recommendations for exercise prescription and preliminary guidance for psychological interventions are provided.

CONCLUSION

Level 1 and 2 osteoarthritis rehabilitation literature continues to be dominated by knee osteoarthritis studies. Consistent with current clinical guidelines, exercise should be a core treatment for osteoarthritis, but future studies should ensure that exercise programs follow published dose guidelines. There is a clear need for research on rehabilitation for hip, hand, foot/ankle, shoulder and spine osteoarthritis.

Is aquatic exercise more effective than land-based exercise for knee osteoarthritis?

BACKGROUND

This study aimed to systemically review the effectiveness of aquatic exercise (AQE) compared to land-based exercise (LBE) in treating knee osteoarthritis (OA).

METHODS

The Medline, Embase, Web of Science, Cochrane Central Register of Controlled Clinical Trials, CINAHL, and psyclNFO databases were comprehensively searched for randomized controlled trials (RCTs) evaluating the effectiveness of AQE and LBE for knee OA from their inception date to September 24, 2018. The risk of bias was examined using the Cochrane Collaboration Tool, and Review Manager 5.3 was used for data collation and analysis.

RESULTS

Eight RCTs were included, involving a total of 579 patients. The meta-analysis showed that there was no significant difference between AQE and LBE for pain relief, physical function, and improvement in the quality of life, for both short- and long-term interventions, in patients with knee OA. However, the adherence and satisfaction level for AQE was higher than for LBE. Compared to no intervention, AQE showed a mild effect for elevating activities of daily living (standardized mean difference [SMD]: -0.55, 95% confidence interval [CI] [-0.94, -0.16], P = .005) and a high effect for improving sports and recreational activities (SMD: -1.03, 95% CI [-1.82, -0.25], P = .01).

CONCLUSION

AQE is comparable to LBE for treating knee OA.