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Meta-analysis
ACE Report #4172

Exercise and ultrasonography are effective in treating adults with knee osteoarthritis


Study Type:Meta-analysis/Systematic Review
OE Level Evidence:1
Journal Level of Evidence:N/A

Physical therapy interventions for knee pain secondary to osteoarthritis: A systematic review

Ann Intern Med. 2012 Nov 6;157(9):632-44. doi: 10.7326/0003-4819-157-9-201211060-00007

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Synopsis

This meta-analysis and systematic review included 193 studies (84 randomized controlled trials were assessed in the meta-analysis) comparing physical therapy to a control group in patients with knee osteoarthritis (OA). The most effective interventions were ultrasonography, and aerobic, aquatic, strengthening, and proprioception exercise. Education, orthotics, taping, tai chi, and pulsed electromagnetic fields had no clinically significant effect on any of the patient-centered or functional outcomes of interest. Few adverse events occurred in the studies.

Publication Funding Details +
Funding:
Non-Industry funded
Sponsor:
AHRQ
Conflicts:
Other

Risk of Bias

9.5/10

Reporting Criteria

19/20

Fragility Index

N/A

Were the search methods used to find evidence (original research) on the primary question or questions stated?

Was the search for evidence reasonably comprehensive?

Were the criteria used for deciding which studies to include in the overview reported?

Was the bias in the selection of studies avoided?

Were the criteria used for assessing the validity of the included studies reported?

Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?

Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?

Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?

Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?

How would you rate the scientific quality of this evidence?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.

4/4

Introduction

4/4

Accessing Data

4/4

Analysing Data

4/4

Results

3/4

Discussion

Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Although osteoarthritis (OA) is already one of the foremost causes of disability among noninstitutionalized adults today, its prevalence continues to increase as the population ages. Nonsurgical treatments for OA such as physical therapy are prescribed in the hopes of reducing pain and disability, and improving function and quality of life. This meta-analysis and systematic review aimed to be the first to evaluate the effectiveness of different exercise types and nonsurgical interventions in order to determine which physical therapy treatments are best for patients with osteoarthritis of the knee.

What was the principal research question?

Is physical therapy more effective than a control treatment with respect to patient-centered outcomes, function, and complications in patients with osteoarthritis of the knee?

Study Characteristics -
Data Source:
A search was conducted for articles from 1970 to February 29, 2012 using MEDLINE, the Cochrane Library, the Physiotherapy Evidence Database, Scirus, Allied and Complementary Medicine, and the Health and Psychosocial Instruments bibliography database. The reference lists from systematic reviews and eligible studies were searched manually. A search of ClinicalTrials.gov was also done, and sponsors of ongoing trials were contacted for more information.
Index Terms:
The following Medical Subject Headings (MeSH) terms and text words were used: osteoarthritis knee, physical therapy modalities, pain measurement, activities of daily living, quality of life.
Study Selection:
Studies included were English randomized controlled trials comparing physical therapy to a sham treatment, usual care, or no treatment in adult patients with knee OA. Outcomes of interest were pain, disability, quality of life, perceived health status, global effectiveness, gait function, strength, transfers, joint function, and composite function. Nonrandomized clinical trials, case series, and observational cohort or case-control studies were also included to assess adverse events. Eligibility was determined by at least 2 investigators.
Data Extraction:
One reviewer extracted the data and second assessed the accuracy of the data. Disagreements were documented, resolved through discussion.
Data Synthesis:
Stata was used to compile the data from 84 of the randomized controlled trials. Continuous outcomes were expressed as standardized mean differences (SMD). Statistical heterogeneity was calculated with the chi squared and I2 test. Random effects models were used for the analysis.

What were the important findings?

  • Education, orthotics, taping, tai chi, and pulsed electromagnetic fields had no clinically significant effect on any of the outcomes of interest
  • There was a significant reduction in pain when patients received proprioception exercise (4 studies; SMD, -0.71 [95% CI, -1.31 to 0.11]) or diathermy (5 studies; significant at 1 month only; SMD, -0.53 [CI, -0.96 to -0.10]); the two interventions did not demonstrate significant effects for any other outcomes
  • Massage led to a significant improvement in composite function (3 studies; SMD, -0.55 [CI, -0.93 to -0.18])
  • Aquatic exercise resulted in significantly reduced disability (3 studies; SMD, -0.28 [CI, -0.51 to -0.05])
  • According to 11 studies, aerobic exercise significantly reduced long term pain (SMD, -0.21 [CI, -0.35 to -0.08]; this was not clinically significant), disability (SMD, -0.21 [CI, -0.37 to -0.04]), composite function within 3 months (WOMAC function score -15.4 [CI -24.8 to -5.92]), and gait function over 12 months (walking speed difference -0.11 m/s [CI, -0.17 to -0.05])
  • Results from 9 studies demonstrated that strengthening exercise resulted in clinically significant reduction in pain (SMD, 0.68 [CI, -1.23 to -0.14]) and improvement in composite function (SMD, -1.00 [CI, -1.95 to 0.05])
  • electrical stimulation significantly improved global assessment scores in two studies and muscle strength at 3 months in two studies (values not provided)
  • According to 6 studies, ultrasonography led to clinically significant improvement in pain (SMD, -0.74 [CI, 0.95 to -0.53]), composite function (SMD, -1.14 [CI, 1.85 to -0.42]), and gait function (SMD, -1.48 [CI, 2.08 to -0.89])

What should I remember most?

Aerobic, aquatic, strengthening, and proprioception exercise, as well as ultrasonography were shown to be effective in improving patient-centered outcomes and/or function.

How will this affect the care of my patients?

This study demonstrated with low-strength evidence that aerobic and aquatic exercise improved disability and that aerobic exercise, strengthening exercise, and ultrasonography reduced pain and improved function. However, further investigation is required based on the limited evidence for individualized treatment decisions.

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