Whole-body vibration strengthening compared to traditional strengthening during physical therapy in individuals with total knee arthroplasty

The effects of whole-body vibration exercises with and without conventional physical therapy modalities in patients with knee osteoarthritis: A prospective, randomized-controlled study

Objectives

This study aims to examine the effects of whole-body vibration (WBV) therapy + home-based exercise (HBE) therapy; physical therapy modalities (PTMs)+HBE; and WBV+PTM+HBE on pain severity, physical performance, and functional status in patients with knee osteoarthritis (OA).

Patients and methods

This single-center, single-blind, three-armed, prospective, randomized-controlled study included a total of 65 patients (3 males, 62 females; mean age: 56.0±6.3 years; range, 45 to 70 years) who were diagnosed with knee OA between February 2014 and July 2014. The participants were randomly divided into three groups. Group 1 (n=22) received WBV+HBE, Group 2 (n=22) received WBV+PTM+HBE, and Group 3 (n=21) received PTM+HBE alone. The primary outcome measure was functional physical performance, while the secondary outcome measures were pain intensity and functional status. All the measurements were evaluated by a single blinded investigator before and after treatment.

Results

All the functional physical performance tests (p<0.01), pain intensity (p<0.01), and functional status (p<0.01) showed statistically significant effects in terms of time and group × time interaction, but no significant difference was observed among the groups (p>0.05). We observed statistically and clinically significant improvement in all of the functional physical performance tests, pain, and functional status for Group 2. There was a statistically and clinically significant improvement only in the functional physical performance tests for Group 1. In Group 3, no clinical or statistical significance was achieved in any outcome measurements.

Conclusion

Treatment program consisting of WBV+PTM+HBE can yield clinically and statistically favorable results by improving all of the pain, functional status and physical performance parameters of the patients with knee OA, while WBV+HBE can be clinically and statistically effective only in the physical performance parameters of the patients.

Effect of 10-Week Whole-Body Vibration Training on Falls and Physical Performance in Older Adults: A Blinded, Randomized, Controlled Clinical Trial with 1-Year Follow-Up

Whole-body vibration training (WBV) training has shown positive effects on bone strength, muscle strength, and balance, but the evidence on fall prevention is not yet persuasive. This study aimed to evaluate the effectiveness of WBV training in preventing falls and improving physical performance among older adults at fall risk. The study was an assessor- and participant-blinded, randomized, and controlled 10-week training trial with a 10-month follow-up. One hundred and thirty older adults (mean age 78.5 years, 75% women) were randomly allocated into the WBV group (n = 68) and the low-intensity wellness group (n = 62). Falls were prospectively collected using monthly returned and verified diaries. Physical performance was evaluated at baseline before randomization, after the intervention, and follow-up with established methods. The data were analyzed on an intention-to-treat basis. Negative binomial regression was used to estimate the incidence rate ratios for falls, and Cox regression models were used to calculate the hazard ratios for fallers. Between-group differences in physical performance were estimated by generalized linear mixed models. The retention rate was 93%, and the mean adherence to the WBV training was 88% and 86% to the wellness training. Sixty-eight participants fell at least once, and there were 156 falls in total. In the WBV group, the incidence rate of falls was 1.5 (95% confidence interval 0.9 to 2.5) compared to the wellness group (p = 0.11). The hazard ratio for fallers in the WBV group was 1.29 (0.78 to 2.15) (p = 0.32). There was no between-group difference in physical performance after the training period, but by the end of the follow-up, WBV-related benefits appeared. The chair-rising capacity was maintained in the WBV group, while the benefit disappeared in the wellness group (p = 0.004). Also, the 0.5-point difference in short physical performance battery (SPPB) score favored WBV training (p = 0.009). In conclusion, progressive side-alternating WBV training was feasible and well-tolerated among fall-prone older adults. During the one-year follow-up, WBV training was associated with improved physical performance but did not prevent falls compared to chair-based group exercises.

Rehabilitation Techniques Before and After Total Knee Arthroplasty for a Better Quality of Life

The most important gold standard treatment following advanced knee osteoarthritis is total knee arthroplasty. Following surgery of total knee replacement, the majority of patients report decreased pain and successful long-term results, but recovery is unpredictable, and most patients continue to exhibit muscle weakness in their lower limbs and functional limitations in comparison to similarly aged control individuals. The goal of this review article was to systematically review different articles containing controlled and randomized studies to find out the effectiveness of outpatient care postoperatively on short- and long-term functional recovery. The purpose of this review article is to investigate the possible advantages of pre- and postoperative rehabilitation as well as the value of exercise regimen recommendations following total knee replacement. The following interventions after total knee arthroplasty are discussed in this review article: preoperative education and exercises, continuous passive movement, strengthening interventions, aquatic therapy, balanced training, tourniquet exposure, use of alignment and implants, role of apps in phones and different wearable devices, influence of postoperative protocols, knee bracing, neuromuscular electrical stimulation, and clinical environment. Strengthening and intense functional exercises for patients above 45 years of age, in land or water programs like aquatic activities, with the increasing intensity of the exercises in accordance with the patient's progress, should be included in the best outpatient physical therapy protocols. Because these exercises are so precisely personalized, the best long-term effects after surgery may come from outpatient physiotherapy performed in a clinical setting under the supervision of a registered physiotherapist or medical professional. This review article also includes the change in the quality and well-being of a patient's life who has undergone total knee arthroplasty and practiced the rehabilitation techniques.

Effects of 24 Weeks of a Supervised Walk Training on Knee Muscle Strength and Quality of Life in Older Female Total Knee Arthroplasty: A Retrospective Cohort Study

Poor supervision, impaired exercise adherence, and low compliance with exercise regimens result in inconsistent effects regarding exercise interventions. A supervised-walk training regimen (9 km/week) may have a positive effect on functional recovery in female total knee arthroplasty (TKA). This study aimed to evaluate the effect of a supervised walking regimen on lower limb muscle strength, functional fitness, and patient-reported outcomes in female TKA. Twenty-eight female TKA were allocated into a control (CON) (n = 14) or walk training (WT) (n = 14) group. WT on treadmills was initiated 12 weeks after TKA. All patients were examined for lower muscle strength (including extension and flexion of hip and knee), physical function (including a 6-min walk test, 8-foot up-and-go test, and 30-s chair stand test), and Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. Knee flexor (WT: CON; 64.4 ± 4.1 nm/kg: 43.7±3.3 nm/kg; p = 0.001; effect size: 5.62) and extensor strengths (WT: CON; 73.1 ± 7.5 nm/kg: 48.2 ± 2.4 nm/kg; p = 0.001; effect size: 4.47) statistically increased in the WT group compared to the CON group. The 6-min walk test (from 341.3 ± 20.5 m to 405.5 ± 30.7 m; p = 0.001; effect size: 2.46) and 8-foot up-and-go test (from 9.5 ± 0.7 s to 8.3 ± 0.7 s; p = 0.002; effect size: 1.71) tests also showed significant improvements in the WT group in the follow-up compared to the baseline. An increase in quality of life score according to the KOOS questionnaire (WT: CON; 91.0 ± 2.8: 68.1 ± 5.8; p = 0.001; effect size: 5.02) was noted in the WT group compared to the CON group in the follow-up. WT facilitated improvements in knee muscle strength and functional outcomes in TKA patients.

Examination of exclusion criteria in total knee arthroplasty rehabilitation trials: influence on the application of evidence in day-to-day practice

OBJECTIVE

Total knee arthroplasty (TKA) rehabilitation trials use exclusion criteria, which may limit their generalizability in practice. We investigated whether patients seen in routine practice who meet common exclusion criteria recover differently from TKA compared to research-eligible patients. We hypothesized that research-ineligible patients would demonstrate poorer average postoperative function and slower rate of functional recovery compared to research-eligible patients.

METHODS

Patient characteristics and exclusion criteria were extracted and summarized from trials included in the three most recent systematic reviews of TKA rehabilitation. Trial participant characteristics were compared to a clinical dataset of patient outcomes collected in routine TKA rehabilitation. Where possible, individual exclusion criterion from the trials were applied to the clinical dataset to determine "eligible" and "ineligible" groups for research participation. Postoperative functional outcomes including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Timed Up and Go (TUG) were compared between "eligible" and "ineligible" groups using mixed effects models.

RESULTS

2,528 participants from 27 trials were compared to 474 patients from the clinical dataset. Research participants were older, with lower Body Mass Index than patients in the clinical dataset. Many patients in the clinical dataset would be "ineligible" for research participation based upon common exclusion criteria from the trials. Differences were observed in average postoperative functioning between some "eligible" and "ineligible" groups in the clinical dataset. However, no differences were observed in functional recovery rate between groups, except for patients with diabetes whose TUG recovered more slowly than their "eligible" counterparts.

CONCLUSIONS

Many patients in the clinical dataset were "ineligible" for research participation based upon common TKA rehabilitation trial exclusion criteria. However, the postoperative recovery rate did not differ between "eligible" and "ineligible" groups based on individual exclusion criterion-except for individuals with diabetes. This suggests that both clinical and research populations may recover similarly from TKA.

Reporting of post-operative rehabilitation interventions for Total knee arthroplasty: a scoping review

OBJECTIVE

The aim of this study was to evaluate the completeness of reporting of exercise adherence and exercise interventions delivered as part of clinical trials of post-operative total knee replacement (TKA) rehabilitation.

DESIGN

Scoping review LITERATURE SEARCH: A literature search was conducted in PubMed, EMBASE, AMED, CINAHL, SPORTDiscus and Cochrane Library.

STUDY SELECTION CRITERIA

All randomized controlled trials (RCT) that examined post-operative exercise-based interventions for total knee arthroplasty were eligible for inclusion. Studies that were multifactorial or contained exercise interventions for both hip and knee arthroplasty were also included.

DATA SYNTHESIS

The definition, type of measurement used and outcome for exercise adherence were collected and analyzed descreptively. Quality of reporting of exercise interventions were assessed using the Consensus for Exercise Reporting Tool (CERT) and the Cochrane Risk of Bias Tool.

RESULTS

There were a total of 112 RCTs included in this review. The majority of RCTs (63%, n = 71) did not report exercise adherence. Only 23% (n = 15) of studies provided a definition of adherence. RCTs were of poor quality, with 85% (n = 95) of studies having high or unclear risk of bias. Reporting of exercise interventions was poor, with only 4 items (of 19) (21%) of the CERT adequately reported (88-99%), with other items not fulfilled on at least 60% of the RCTs. There were no RCTs that had fulfilled all the criteria for the CERT.

CONCLUSION

The RCTs included in this study poorly reported exercise adherence, as well as description of the post-operative TKA rehabilitation intervention. Future RCTs should use valid and reliable measures of adherence and a proper tool for reporting of exercise interventions (e.g., CERT, TiDER).

PRE-REGISTRATION

OSF: https://osf.io/9ku8a/.

The influence of resistance training on neuromuscular function in middle-aged and older adults: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Deterioration of neuromuscular function is a major mechanism of age-related strength loss. Resistance training (RT) improves muscle strength and mass. However, the effects of RT on neuromuscular adaptations in middle-aged and older adults are unclear.

METHODS

Randomised controlled RT interventions (≥2 weeks) involving adults aged ≥50 years were identified. Primary outcome measures were voluntary activation (VA), electromyographic (EMG) activity during maximal voluntary contraction (MVC), and antagonist coactivation. Data were pooled using a weighted random-effect model. Sub-analyses were conducted by muscle or muscle group and health status of participants. Sensitivity analysis was based on study quality. P < 0.05 indicated statistical significance.

RESULTS

Twenty-seven studies were included. An effect was found for VA (standardised mean difference [SMD] 0.54, 0.01 to 1.07, P = 0.04), This result remained significant following sensitivity analysis involving only studies that were low risk of bias. Subgroup analyses showed an effect for plantar flexor VA (SMD 1.13, 0.20 to 2.06, P = 0.02) and VA in healthy participants (SMD 1.04, 0.32 to 1.76, P = 0.004). There was no effect for EMG activity or antagonist coactivation of any muscle group (P > 0.05).

DISCUSSION

Resistance training did not alter EMG activity or antagonist coactivation in older adults. Sensitivity analysis resulted in the effect for VA remaining significant, indicating that this finding was not dependent on study quality. Studies predominantly involved healthy older adults (78%), limiting the generalisability of these findings to clinical cohorts. Future research should determine the effects of RT on neuromuscular function in people with sarcopenia and age-related syndromes.

The Effect of Progressive Dynamic Balance Training on Physical Function, The Ability to Balance and Quality of Life Among Elderly Women Who Underwent a Total Knee Arthroplasty: A Double-Blind Randomized Control Trial

Total knee arthroplasty (TKA) is used to treat end-stage osteoarthritis. However, this surgical procedure affects the mechanical receptor function and impairs the ability to balance. Dynamic balance training has been reported to improve stability and self-confidence and safely yield increased physical activity. This study aimed to investigate the effect of dynamic balance training on physical function, the ability to balance and quality of life among patients who underwent TKA. Thirty-eight participants were assigned to either the progressive dynamic balance training (PDBT) with physical therapy group (n = 19) or the control group (n = 19). The experimental group undertook a dynamic balance program with physical therapy for 30 minutes per day, five times per week for six weeks, while the control group undertook physical therapy only. A continuous passive motion exercise was performed for 20 minutes after training by both groups. The outcomes were evaluated using the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, pain pressure threshold (PPT), range of motion (ROM), Knee Outcome Survey-Activities of Daily Living (KOS-ADLS), Multifunction Force Measuring Plate, timed up and go (TUG) test and Short-Form Health Survey 36 (SF-36). Physical function (WOMAC Osteoarthritis Index, ROM and KOS-ADLS score) and the ability to balance (TUG test score, confidence ellipse area, path length and average velocity) significantly improved (p < 0.05) in the experimental group compared with the control group. In contrast, the physical component summary score for the SF-36 regarding quality of life significantly improved (p < 0.05); however, the mental component summary score for the SF-36 and PPT did not significantly differ between the groups. Therefore, we suggest that PDBT with physical therapy has positive effects on physical function, the ability to balance and quality of life among patients who underwent TKA.

Periarticular injection of tranexamic acid promotes early recovery of the range of knee motion after total knee arthroplasty

PURPOSE

Tranexamic acid (TXA) is a commonly used compound that reduces postoperative blood loss. Periarticular injection of TXA is a recently reported procedure with some advantages such as cost-effectiveness and the ease of performance over an intravenous or topical administration. However, its association with functional recovery remains unclear. This study aimed to examine the effect of periarticular injection of TXA on early postoperative recovery of knee functionality after total knee arthroplasty (TKA).

METHODS

Eighty-four patients who underwent primary unilateral TKA from February 2013 to August 2016 were classified into two groups based on whether they received TXA injection (44 cases each in the TXA and control groups). Patients in the TXA group received periarticular injection of TXA (1000 mg) just prior to incision closure. Ten-meter walk test (s), pain visual analog scale, knee extension muscle force (N), range of motion (ROM) (maximum flexion angle, maximum extension angle, and motion arc), and blood loss (mL) were assessed.

RESULTS

The maximum flexion angle and maximal extension angle on postoperative day (POD) 4, POD7, POD10, and POD14 in the TXA group were significantly larger than those in the control group. The postoperative drained blood in the TXA group was significantly less than that of the control group (543.9 ± 464.3 mL and 814.9 ± 481.4 mL, respectively, p < 0.05). No significant difference was observed in the other parameters at any time point.

CONCLUSION

Periarticular injection of TXA significantly promotes early recovery of knee ROM after TKA. Level of Evidence: Level IV, therapeutic case series.

Efficacy and Safety of Lower Limb Progressive Resistance Exercise for Patients With Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To evaluate the efficacy and safety of progressive resistance exercise (PRE) for patients with total knee arthroplasty (TKA) in a meta-analysis.

DATA SOURCES

PubMed, MEDLINE, Cochrane's Library, and EMBASE databases.

STUDY SELECTION

Randomized controlled trials evaluating the effect of PRE on mobility and function in patients with TKA.

DATA EXTRACTION

A random-effects model was applied if significant heterogeneity was detected; otherwise, a fixed-effects model was applied.

DATA SYNTHESIS

Seven randomized controlled trials. Compared with a rehabilitation program without PRE, physiotherapy including PRE was associated with improvements in the 6-minute walking test (weighed mean difference [WMD], 19.22m; P=.04) with a wide confidence interval (CI, 0.48∼37.95). However, sensitivity analysis by omitting 1 study with preoperative rehabilitation revealed nonsignificant results (WMD, 15.15m; P=.16). Moreover, PRE did not significantly improve the maximal walking speed (WMD, 0.05m/s, 95% CI, 0.00∼0.11; P=.05). However, PRE was associated with improved knee strength of extension (standardized mean difference [SMD], 0.72; 95% CI, 0.47∼0.96; P<.001) and flexion (SMD, 0.47; 95% CI, 0.19∼0.74; P<.001) but not self-reported physical function (SMD, -0.17; 95% CI, -0.37∼0.03; P=.10) or changes in pain score (SMD, 0.11; 95% CI, -0.15∼0.37; P=.40). PRE did not increase the risk of adverse events (risk ratio, 1.19; 95% CI, 0.52∼2.71; P=.68).

CONCLUSIONS

PRE may lead to improvements in physical function among patients receiving a TKA. PRE leads to higher ultimate strength in the surgical knee and is safe to perform.

Pain After Whole-Body Vibration Exposure Is Frequency Dependent and Independent of the Resonant Frequency: Lessons From an In Vivo Rat Model

Occupational whole-body vibration (WBV) increases the risk of developing low back and neck pain; yet, there has also been an increased use of therapeutic WBV in recent years. Although the resonant frequency (fr) of the spine decreases as the exposure acceleration increases, effects of varying the vibration profile, including peak-to-peak displacement (sptp), root-mean-squared acceleration (arms), and frequency (f), on pain onset are not known. An established in vivo rat model of WBV was used to characterize the resonance of the spine using sinusoidal sweeps. The relationship between arms and fr was defined and implemented to assess behavioral sensitivity-a proxy for pain. Five groups were subjected to a single 30-min exposure, each with a different vibration profile, and a sham group underwent only anesthesia exposure. The behavioral sensitivity was assessed at baseline and for 7 days following WBV-exposure. Only WBV at 8 Hz induced behavioral sensitivity, and the higher arms exposure at 8 Hz led to a more robust pain response. These results suggest that the development of pain is frequency-dependent, but further research into the mechanisms leading to pain is warranted to fully understand which WBV profiles may be detrimental or beneficial.

Neurostructural correlates of strength decrease following total knee arthroplasty: A systematic review of the literature with meta-analysis

Recent literature suggests that alterations in both neural and structural components of the neuromuscular system are major determinants of knee extensor muscle weakness after total knee arthroplasty (TKA). Therefore, the goal of this study was to investigate the maximal voluntary strength (MVS), voluntary muscle activation (VMA), and the cross-sectional area (CSA) of the muscle, up to 33 months after the TKA.  We searched relevant scientific databases and literature for outcomes of interest, including quadriceps MVS, VMA, and CSA. Ten studies met the inclusion criteria and involved a total of 289 patients. The quality of the studies was evaluated by Methodological Index for Non-Randomized Studies (MINORS). Results showed that quadriceps MVS markedly declines in the early postoperative period, after which it slowly and linearly recovers over time. However, the same phenomenon was not observed for VMA and CSA, which were not significantly altered after the TKA. Furthermore, a meta-regression analysis revealed that the change in VMA accounted for 39% of the relative change in quadriceps strength (R2=0.39; p=0.015) in the early postoperative period. Patients treated with TKA had considerable weakness of the quadriceps muscle, which was detectable up to 3 months after surgery. Although the change in VMA largely explains quadriceps weakness, this change and CSA differences were not significant, suggesting that other neural correlates, such as hamstrings coactivation, might alter quadriceps muscle function. Thus, more attention should be paid to address VMA failure and coactivation of antagonist muscles.  More comprehensive rehabilitation approaches may be required to target the whole neural circuit controlling the motor action.

Early Post-Operative Intervention of Whole-Body Vibration in Patients After Total Knee Arthroplasty: A Pilot Study

(1) Background: Knee osteoarthritis causes pain, weakness, muscle atrophy, and disability. The application of whole-body vibration in patients with knee osteoarthritis can improve strength, balance, and functional activities. The purpose of the study is to evaluate the effects of early whole-body vibration intervention in patients after total knee arthroplasty. (2) Method: A single-blinded randomized control trial. Fifty-two patients with knee osteoarthritis post total knee replacement from a medical center in southern Taiwan were randomly assigned to either a whole-body vibration group or control group. Main outcome measures included pain severity, leg circumference, knee range of motion, knee extensor strength, a five-times sit to stand test, and a timed up and go test. (3) Results: Immediately post treatment, the patients in the vibration group showed a significant increase in knee extensor strength and improvement in calf swelling compared to the control group. A trend toward decrease in pain severity and improvement in functional performance were observed in both groups without a significant difference between the groups. There was no significant difference in knee range of motion (ROM) and functional performance between the groups. (4) Conclusions: The whole-body vibration intervention in patients early post total knee arthroplasty showed significant immediate effect in increasing knee extensor strength and decreasing calf swelling.

Use of home neuromuscular electrical stimulation in the first 6 weeks improves function and reduces pain after primary total knee arthroplasty: a matched comparison

Background

The use of neuromuscular electrical stimulation (NMES) after total knee arthroplasty (TKA) has been demonstrated to facilitate quadriceps muscle recovery and to reduce pain. However, to our knowledge, this therapeutic modality has not been directly tested in patients who receive muscle stimulators for home use immediately after surgery. Therefore, the purpose of this study was to assess the effect of NMES use at home in addition to standard therapy program in patients after primary TKA surgery, and to compare the early functional results to a matching group of post TKA patients who did not receive home NMES units.

Methods

A total of 41 patients scheduled for a primary TKA during April 1^st, 2017 to January 31^st, 2018 were identified as being eligible for the study. There were 15 patients deemed ineligible to be part of the study, resulting in 26 patients who were fitted either 1 week before or within 1 week of surgery a home NMES device. The device was controlled by a smart phone. Patients were asked to use the NMES device daily for 20 minutes, 3 times a day, for 6 weeks after surgery. As their ability to activate their quadriceps muscle improved, patients were encouraged to increase their exercise regimens. The NMES patients were compared to a matched cohort of 26 patients who had a TKA performed between June 1^st, 2015 and July 31^st, 2016, but did not receive home an NMES device. Comparative outcomes included: timed up and go (TUG) test, single limb stance (SLS) time, time to ascend and descend one flight of stairs, quadriceps lag, active and passive range of motion (ROM), 2-minute walking distance, and pain rating on a visual analog scale (VAS). A P value of 0.05 was set as the threshold for statistical significance for the matched comparison.

Results

Patients in the home NMES had significantly better scores for quadriceps lag (P<0.001), TUG (P<0.001), time to ascend and descend one flight of stairs (P=0.001), SLS time (P<0.001). They also experienced significantly lower resting pain (P<0.001) and lower worst reported pain scores (P<0.001) compared to the control cohort. Additionally, there were a higher percentage of patients in the control cohort that could not use stairs reciprocally compared to the home NMES group (53.85% vs. 23.08%). Furthermore, passive range of motion for flexion was statistically better in the home NMES group (P=0.037).

Conclusions

This matched comparison of primary TKA patients demonstrated significant pain reductions both at rest and lower worst reported pain scores and improved function with use of the home-based NMES units for the sub-acute phase of recovery. Patients walked longer distances safely as shown by improvements in TUG, quadriceps lag, and single limb support time. Larger proportions of patients in home NMES group were able to negotiate stairs reciprocally and faster than the matched control group. These findings may have important economic and functional implications for the post-operative care of TKA patient.

Long-Term Effects of Whole-Body Vibration on Human Gait: A Systematic Review and Meta-Analysis

Background: Whole-body vibration is commonly used in physical medicine and neuro-rehabilitation as a clinical prevention and rehabilitation tool. The goal of this systematic review is to assess the long-term effects of whole-body vibration training on gait in different populations of patients.

Methods: We conducted a literature search in PubMed, Science Direct, Springer, Sage and in study references for articles published prior to 7 December 2018. We used the keywords “vibration,” “gait” and “walk” in combination with their Medical Subject Headings (MeSH) terms. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was used. Only randomized controlled trials (RCT) published in English peer-reviewed journals were included. All patient categories were selected. The duration of Whole-Body Vibration (WBV) training had to be at least 4 weeks. The outcomes accepted could be clinical or biomechanical analysis. The selection procedure was conducted by two rehabilitation experts and disagreements were resolved by a third expert. Descriptive data regarding subjects, interventions, types of vibration, training parameters and main results on gait variables were collected and summarized in a descriptive table. The quality of selected studies was assessed using the PEDro scale. Statistical analysis was conducted to evaluate intergroup differences and changes after the WBV intervention compared to the pre-intervention status. The level of evidence was determined based on the results of meta-analysis (effect size), statistical heterogeneity (I²) and methodological quality (PEDro scale).

Results: A total of 859 studies were initially identified through databases with 46 articles meeting all of the inclusion criteria and thus selected for qualitative assessment. Twenty-five studies were included in meta-analysis for quantitative synthesis. In elderly subjects, small but significant improvements in the TUG test (SMD = −0.18; 95% CI: −0.32, −0.04) and the 10MWT (SMD = −0.28; 95% CI: −0.56, −0.01) were found in the WBV groups with a strong level of evidence (I² = 7%, p = 0.38 and I² = 22%, p = 0.28, respectively; PEDro scores ≥5/10). However, WBV failed to improve the 6MWT (SMD = 0.37; 95% CI: −0.03, 0.78) and the Tinetti gait scores (SMD = 0.04; 95% CI: −0.23, 0.31) in older adults. In stroke patients, significant improvement in the 6MWT (SMD = 0.33; 95% CI: 0.06, 0.59) was found after WBV interventions, with a strong level of evidence (I² = 0%, p = 0.58; PEDro score ≥5/10). On the other hand, there was no significant change in the TUG test despite a tendency toward improvement (SMD = −0.29; 95% CI: −0.60, 0.01). Results were inconsistent in COPD patients (I² = 66%, p = 0.03), leading to a conflicting level of evidence despite a significant improvement with a large effect size (SMD = 0.92; 95% CI: 0.32, 1.51) after WBV treatment. Similarly, the heterogeneous results in the TUG test (I² = 97%, p < 0.00001) in patients with knee osteoarthrosis make it impossible to draw a conclusion. Still, adding WBV treatment was effective in significantly improving the 6 MWT (SMD = 1.28; 95% CI: 0.57, 1.99), with a strong level of evidence (I² = 64%, p = 0.06; PEDro score ≥5/10). As in stroke, WBV failed to improve the results of the TUG test in multiple sclerosis patients (SMD = −0.11; 95% CI: −0.64, 0.43). Other outcomes presented moderate or even limited levels of evidence due to the lack of data in some studies or because only one RCT was identified in the review.

Conclusions: WBV training can be effective for improving balance and gait speed in the elderly. The intervention is also effective in improving walking performance following stroke and in patients with knee osteoarthrosis. However, no effect was found on gait quality in the elderly or on balance in stroke and multiple sclerosis patients. The results are too heterogenous in COPD to conclude on the effect of the treatment. The results must be taken with caution due to the lack of data in some studies and the methodological heterogeneity in the interventions. Further research is needed to explore the possibility of establishing a standardized protocol targeting gait ability in a wide range of populations.

Twenty-four-week hospital-based progressive resistance training on functional recovery in female patients post total knee arthroplasty

BACKGROUND

After total knee arthroplasty (TKA) surgery, a decline in muscle strength is associated with a decrease in function. The aim of this study was to demonstrate the effect of a further 24 weeks of hospital-based resistance training under supervision, and precise dose on knee functional recovery and daily activities for female TKA patients.

METHODS

Twenty-nine patients who underwent unilateral primary TKA were allocated into either resistance training (RT) (n = 14) or control (CON) (n = 15) groups. All patients were assessed, with an isokinetic dynamometer, for hip and knee flexor and extensor muscle strength, physical function test, and Knee Injury and Osteoarthritis Outcome Score (KOOS). Resistance training was initiated three months after index surgery. The assessments were performed before exercise (Baseline), in the middle of the resistance training at 12 weeks (Mid-exercise), completion of the resistance training (Post-exercise), and 12 weeks after resistance training completion (Follow-up). A statistical test was performed by using generalized estimating equations.

RESULTS

Patients in RT had more of an increase in both knee extensor and flexor muscle strength than those in CON at the Post-exercise assessment. The six-minute walk test distance was more in RT compared with CON at the same Post-exercise assessment. Furthermore, the RT group had increases in Activities of daily living and Sports subscales compared to the CON group.

CONCLUSIONS

A further 24 weeks of hospital-based progressive resistance training facilitated improvement in knee muscle strength and functional outcome in TKA patients. Active hospital-based progressive resistance training is recommended for rehabilitation following TKA surgery.

The Effects of Balance Training on Balance Performance and Functional Outcome Measures Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Several studies have examined the effects of balance training in elderly individuals following total knee arthroplasty (TKA), although findings appear to be equivocal.

OBJECTIVES

This systematic review and meta-analysis examined the effects of balance training on walking capacity, balance-specific performance and other functional outcome measures in elderly individuals following TKA.

METHODS

Data sources: Pubmed, PEDro, Cinahl, SportDiscus, Scopus. Eligibility criteria: Data were aggregated following the population-intervention-comparison-outcome (PICO) principles. Eligibility criteria included: (1) randomised controlled trials; (2) studies with comparative groups; (3) training interventions were incorporated post-TKA; and (4) outcome measures included walking capacity, balance-specific performance measures, subjective measures of physical function and pain and knee range-of-motion.

PARTICIPANTS

Elderly individuals (65 + years) who underwent total knee arthroplasty.

INTERVENTIONS

Balance interventions that consisted of balance exercises, which were compared to control interventions that did not involve balance exercises, or to a lesser extent. Participants also undertook usual physiotherapy care in conjunction with either the balance and/or control intervention. The intervention duration ranged from 4 to 32 weeks with outcome measures reported immediately following the intervention. Of these, four studies also reported follow-up measures ranging from 6 to 12 months post-interventions. Study appraisal: PEDro scale.

SYNTHESIS METHODS

Quantitative analysis was conducted by generating forest plots to report on standardised mean differences (SMD; i.e. effect size), test statistics for statistical significance (i.e. Z values) and inter-trial heterogeneity by inspecting I². A meta-regression was also conducted to determine whether training duration predicted the magnitude of SMD.

RESULTS

Balance training exhibited significantly greater improvement in walking capacity (SMD = 0.57; Z = 6.30; P < 0.001; I² = 35%), balance-specific performance measures (SMD = 1.19; Z = 7.33; P < 0.001; I² = 0%) and subjective measures of physical function (SMD = 0.46; Z = 4.19; P < 0.001; I² = 0%) compared to conventional training immediately post-intervention. However, there were no differences in subjective measures of pain (SMD = 0.77; Z = 1.63; P > 0.05; I² = 95%) and knee range-of-motion (SMD = 0.05; Z = 0.39; P > 0.05; I² = 1%) between interventions. At the 6- to 12-month follow-up period, improvement in combined measures of walking capacity and balance performance (SMD = 041; Z = 3.55; P < 0.001; I² = 0%) were significantly greater for balance training compared to conventional training, although no differences were observed for subjective measures of physical function and pain (SMD = 0.26; Z = 2.09; P > 0.05; I² = 0%). Finally, the training duration significantly predicted subjective measures of pain and physical function (r² = 0.85; standardised β = 0.92; P < 0.001), although this was not observed for walking capacity and balance-specific performance measures (r² = 0.02; standardised β = 0.13; P = 0.48).

LIMITATIONS

A number of outcome measures indicated high inter-trial heterogeneity and only articles published in English were included.

CONCLUSION

Balance training improved walking capacity, balance-specific performance and functional outcome measures for elderly individuals following TKA. These findings may improve clinical decision-making for appropriate post-TKA exercise prescription to minimise falls risks and optimise physical function.

Systematic Review of Three Electrical Stimulation Techniques for Rehabilitation After Total Knee Arthroplasty

BACKGROUND

The comparative effectiveness of neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and electroacupuncture (EA) for improving patient rehabilitation following total knee arthroplasty (TKA) is controversial. Therefore we conducted this systematic review to assess the available evidence.

METHODS

The PubMed, OVID, and ScienceDirect databases were comprehensively searched and studies were selected and analyzed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Data were extracted and qualitatively synthesized for several outcomes.

RESULTS

Data were analyzed from 17 randomized controlled trials involving 1285 procedures: 8 NMES studies (608 procedures), 7 TENS studies (560 procedures), and 2 EA studies (117 procedures). Qualitative analysis suggested that NMES was associated with higher quadriceps strength and functional recovery after TKA. Recovery benefits were maximal when the stimulation was performed once or twice a day for 4-6 weeks at an intensity of 100-120 mA and frequency of 30-100 Hz. The electrode should be sufficiently large (100-200 cm²) to reduce discomfort. TENS at an intensity of 15-40 mA and frequency of 70-150 Hz provided effective analgesia after TKA. EA at an intensity of 2 mA and frequency of 2 Hz may also provide postoperative analgesia of TKA.

CONCLUSION

As adjunct modalities, NMES and TENS can effectively improve rehabilitation after TKA without triggering significant intolerance, and maximal benefits depend on optimized parameters and intervention protocols. EA may be an effective adjunct modality for analgesia after TKA.

The acute effects of stretching with vibration on dynamic flexibility in young female gymnasts

BACKGROUND

While stretching with vibration has been shown to improve static flexibility; the effect of stretching with vibration on dynamic flexibility is not well known. The purpose of this study was to examine the effectiveness of stretching with vibration on acute dynamic flexibility and jump height in novice and advanced competitive female gymnasts during a split jump.

METHODS

Female gymnast (N.=27, age: 11.5±1.7 years, Junior Olympic levels 5-10) participated in this cross-over study. Dynamic flexibility during gymnastic split jumps were video recorded and analyzed with Dartfish software. All participants completed both randomized stretching protocols with either the vibration platform turned on (VIB) (frequency of 30 Hz and 2 mm amplitude) or off (NoVIB) separated by 48 h. Participants performed 4 sets of three stretches on the vibration platform. Each stretch was held for 30 seconds with 5 seconds rest for a total of 7 minutes of stretch.

RESULTS

Split jump flexibility decreased significantly from pre to post measurement in both VIB (-5.8±5.9°) (P<0.001) and NoVIB (-2.6±6.1°) (P=0.041) conditions (adjusted for gymnast level). This effect was greatest in lower skill level gymnasts (P=0.003), while the highest skill level gymnasts showed no significant decrease in the split jump (P=0.105). Jump height was not significantly different between conditions (P=0.892) or within groups (P=0.880).

CONCLUSIONS

An acute session of static stretching with or without vibration immediately before performance does not alter jump height. Stretching with vibration immediately prior to gymnastics competition decreases split jump flexibility in lower level gymnasts more than upper level gymnasts.

Effects of whole-body vibration on postural control in elderly: An update of a systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to offer an updated overview of the current studies on all types of whole-body vibration (WBV), to determine the effects of WBV on balance in Go-Go (active, independent), Slow-Go (some physical activity limitations) and No-Go (in need of care) elderly and to provide recommendations on available evidence on WBV for clinicians and researchers. An electronic literature search was conducted in PubMed, Cochrane Register of Controlled Trials, Physiotherapy Evidence Database (PEDro) and CINAHL (Ebsco Host) to identify studies on WBV therapy in Go-Goes, Slow-Goes and No-Goes. Outcomes were static, dynamic and functional balance. Thirty-tree studies were included in this systematic review. Pooling was possible for static balance and dynamic balance. Effect size (SMD) of WBV on static balance was 0.34 (95% CI 0.18, 0.49) in Go-Goes. Effect size (SMD) of WBV on dynamic balance was -0.15 (95% CI -0.44, 0.15) in Slow-Go and -0.90 (95% CI -1.63, -0.17) in No-Go elderly people respectively. The results of this current meta-analysis suggest that WBV can be used for improving static balance in Go-Go elderly and that it has the potential to positively influence dynamic balance in Slow-Go and No-Go elderly.

Greek Physiotherapists' Perspectives on Rehabilitation Following Total Knee Replacement: a Descriptive Survey

BACKGROUND AND PURPOSE

In Greece, as in many countries, there is a scarcity of evidence in the type of physiotherapy services offered for the rehabilitation of total knee replacement (TKR). Despite the number of TKRs annually performed in Greece (over 10,000), there are no available clinical guidelines as to the content of best physiotherapy practice. The aim of this nationwide survey undertaken by physiotherapists treating TKR patients post-operatively was to record standard practice and services available in Greece.

METHODS

Design: cross-country survey Ten per cent of all registered physiotherapists working in public/private sectors were recruited. The developed survey comprised of questions regarding therapists' profile, protocols implemented at different stages of rehabilitation and the aims and modalities used.

RESULTS

A 58.7% response rate was achieved, where 36% (47/132) of respondents were treating patients in the inpatient phase and 64% (85/132) after hospital discharge. Patients in Greece are discharged with a home-based exercise program (56.7%) and, to a lesser extent, are referred to rehabilitation centres (13.3%). Strengthening, range of movement and functionality seemed to be the primary goals especially in the inpatient phase, whereas in the outpatient phase, apart from the larger differences identified, functionality and balance training were more frequently reported.

CONCLUSIONS

No significant variations in practice were found during inpatient rehabilitation, whilst there seemed to be diversity across outpatient physiotherapy programs. The current survey suggests that patient's general health and psychological and behavioural issues are the criteria by which physiotherapists select the volume of implemented exercise and progression. However, no specific guidelines were followed. Copyright © 2016 John Wiley & Sons, Ltd.

The effect of adding whole body vibration training to strengthening training in the treatment of knee osteoarthritis: A randomized clinical trial

Strengthening training (ST) and whole body vibration training (WBV) alone may improve symptoms of osteoarthritis of the knee. In this study, we investigated the effect of adding WBV training to quadriceps and hamstring muscles strengthening training on functional activity, pain, quality of life and muscle strength in patients with knee osteoarthritis. 28 volunteers were randomly allocated to two groups; 1) quadriceps and hamstring muscles strengthening training (ST group, 13 patients) and 2) quadriceps and hamstring muscles strengthening training along with WBV training (ST + WBV group, 15 patients). The treatment protocol for both groups involved 3 sessions per week for 8 weeks. All measurements were performed before and after intervention. The measurements included: pain by means of a visual analogue scale (VAS), quality of life by means of the WOMAC scale, functional activity by the 2 min walking test (2MWT), time up & go test (TUGT) and 50-foot walking test (50FWT) and the muscle peak torque (MPT), total work (TW) and muscle power (MP) as muscle performance of quadriceps and hamstring muscles by an Isokinetic Biodex machine. After intervention, the comparison of mean changes between two groups showed improvement in the WBV + ST group in terms of 2MWT, MPT, TW and MP variables (P < 0.05). However, no significant difference was found between the experimental groups in term of pain, quality of life, TUGT and 50FWT. These results suggest that adding whole body vibration training to strengthening training may provide better treatment effects for patients with knee osteoarthritis.

Progressive resistance training before and after total hip and knee arthroplasty: a systematic review

OBJECTIVE

To investigate the effect of progressive resistance training (PRT) on muscle strength and functional capacity before and/or after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The effects of THA and TKA upon quality of life and the rate of adverse events were also investigated.

DATA SOURCES

Literature from nine databases.

REVIEW METHODS

Studies were included if 1) the effect of a PRT intervention was compared with no intervention or another type of intervention; 2) the outcomes included muscle strength and/or functional capacity; 3) all participants were scheduled for or had just undergone THA or TKA; 4) they were randomized, controlled trials (RCT); and 5) only full-length papers in English were studied. Data on patient characteristics, training regime, controls, and outcome measures were extracted.

RESULTS

Four RCT studies on PRT and THA including 136 patients and three RCT studies on PRT and TKA including 284 patients were identified and rated according to the PEDro scale. The general methodological quality of the studies was low. No adverse events were reported in any of the studies. Weak evidence of a beneficial effect of PRT before and/or after THA on muscle strength and functional capacity was found. No effect of PRT before TKA on muscle strength and functional capacity was found. The results of postoperative PRT were too heterogeneous to allow conclusions.

CONCLUSION

PRT is safe and feasible before and/or after THA. PRT is safe, but the methodological quality of existing evidence permits no conclusion on the effectiveness of PRT before and/or after TKA.

Within- and between-session reliability of the maximal voluntary knee extension torque and activation

A ratio between the torque generated by maximal voluntary isometric contraction (MVIC) and exogenous electrical stimulus, central activation ratio (CAR), has been widely used to assess quadriceps function. To date, no data exist regarding between-session reliability of this measurement. Thirteen neurologically sound volunteers underwent three testing sessions (three trials per session) with 48 hours between-session. Subjects performed MVICs of the quadriceps with the knee locked at 90° flexion and the hip at 85°. Once the MVIC reached a plateau, an electrical stimulation from superimposed burst technique (SIB: 125 V with peak output current 450 mA) was manually delivered and transmitted directly to the quadriceps via stimulating electrodes. CAR was calculated by using the following equation: CAR = MVIC torque/MVIC + SIB torque. Intraclass correlation coefficients (ICC) were calculated within- (ICC((2,1))) and between-session (ICC((2,k))) for MVIC torques and CAR values. Our data show that quadriceps MVIC and CAR are very reliable both within- (ICC((2,1)) = 0.99 for MVIC; 0.94 for CAR) and between-measurement sessions (ICC((2,k)) = 0.92 for MVIC; 0.86 for CAR) in healthy young adults. For clinical research, more data of the patients with pathological conditions are required to ensure reproducibility of calculation of CAR.

The effects of whole-body vibration training on gait and walking ability - a systematic review comparing two quality indexes

BACKGROUND

Whole-body vibration (WBV) training has been introduced in the last decade and become a popular training method and may increase muscle performance.

OBJECTIVES

To evaluate the evidence degree of the effect of WBV training on gait and walking ability by a critical examination of scientific studies. In addition, a minor objective was to compare two quality indexes.

METHOD

Literature search in Scopus; quality assessments with The Risk of Bias and The PEDro Scale; and evidence appraisal according to GRADE.

RESULT

Ten studies with varying populations using gait-related measurements after at least 1-month WBV intervention were included. Only two studies report significant positive effects. This is defined as low-quality evidence. Eighty percent and 90% of the studies were rated as high quality according to The PEDro Scale and The Risk of Bias, respectively.

DISCUSSION

The low-quality evidence indicates a need for further research. A standardized training protocol would make comparisons and conclusions of WBV training more reliable and feasible.

CONCLUSION

There is low-quality evidence for WBV training having effects on gait and walking ability. Further research is needed. The evidence did not alter between the quality indexes.

Effects of whole-body vibration on postural control in elderly: a systematic review and meta-analysis

BACKGROUND

This systematic review was performed to summarize the current evidence for whole body vibration (WBV) interventions on postural control in elderly.

METHODS

English and German language papers in Medline, PEDro, Cinahl and the Cochrane databases were searched. Two reviewers extracted data on patients' characteristics, type of WBV intervention and outcomes. Two independent reviewers rated the methodological quality of these studies. Data were pooled using random-effects meta-analysis.

RESULTS

Fifteen papers reporting quantitative data were included. Results from 15 papers could be pooled for a meta-analysis. The studies involved 933 participants. In 7 studies the authors investigated the effects of vibration plates generating vertical sinusoidal vibrations (VS-WBV) and 7 papers described the use of side-alternating sinusoidal vibrations (SS-WBV). One study investigated both VS-WBV and SS-WBV.Weak to moderate evidence of an overall effect as a result of VS-WBV and SS-WBV was observed for (a) static balance for post-intervention values with a standardized mean difference (SMD) -0.06, 95% CI -0.31 to 0.18 and for change values SMD -0.26, 95% CI -1.09 to 0.57, and (b) dynamic balance for post-intervention-values SMD -0.34, 95% CI -0.60 to -0.08. For functional balance (c) an overall outcome for post-intervention values with SMD of 0.34, 95% CI -0.19 to 0.87 was found.

CONCLUSIONS

The 15 studies reviewed were of moderate methodological quality. In summary, SS-WBV seems to have a beneficial effect on dynamic balance in elderly individuals. However, the current results should be interpreted with caution because of the observed heterogeneity of training parameters and statistical methods. Future studies are warranted to evaluate the effects of WBV on postural control in an elderly population.