Physiotherapy - Research Publications
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ItemStrength Training for Arthritis Trial (START): design and rationale(BMC, 2013-07-15)BACKGROUND: Muscle loss and fat gain contribute to the disability, pain, and morbidity associated with knee osteoarthritis (OA), and thigh muscle weakness is an independent and modifiable risk factor for it. However, while all published treatment guidelines recommend muscle strengthening exercise to combat loss of muscle mass and strength in knee OA patients, previous strength training studies either used intensities or loads below recommended levels for healthy adults or were generally short, lasting only 6 to 24 weeks. The efficacy of high-intensity strength training in improving OA symptoms, slowing progression, and affecting the underlying mechanisms has not been examined due to the unsubstantiated belief that it might exacerbate symptoms. We hypothesize that in addition to short-term clinical benefits, combining greater duration with high-intensity strength training will alter thigh composition sufficiently to attain long-term reductions in knee-joint forces, lower pain levels, decrease inflammatory cytokines, and slow OA progression. METHODS/DESIGN: This is an assessor-blind, randomized controlled trial. The study population consists of 372 older (age ≥ 55 yrs) ambulatory, community-dwelling persons with: (1) mild-to-moderate medial tibiofemoral OA (Kellgren-Lawrence (KL) = 2 or 3); (2) knee neutral or varus aligned knee ( -2° valgus ≤ angle ≤ 10° varus); (3) 20 kg.m-2 ≥ BMI ≤ 45 kg.m-2; and (3) no participation in a formal strength-training program for more than 30 minutes per week within the past 6 months. Participants are randomized to one of 3 groups: high-intensity strength training (75-90% 1Repetition Maximum (1RM)); low-intensity strength training (30-40%1RM); or healthy living education. The primary clinical aim is to compare the interventions' effects on knee pain, and the primary mechanistic aim is to compare their effects on knee-joint compressive forces during walking, a mechanism that affects the OA disease pathway. Secondary aims will compare the interventions' effects on additional clinical measures of disease severity (e.g., function, mobility); disease progression measured by x-ray; thigh muscle and fat volume, measured by computed tomography (CT); components of thigh muscle function, including hip abductor strength and quadriceps strength, and power; additional measures of knee-joint loading; inflammatory and OA biomarkers; and health-related quality of life. DISCUSSION: Test-retest reliability for the thigh CT scan was: total thigh volume, intra-class correlation coefficients (ICC) = 0.99; total fat volume, ICC = 0.99, and total muscle volume, ICC = 0.99. ICC for both isokinetic concentric knee flexion and extension strength was 0.93, and for hip-abductor concentric strength was 0.99. The reliability of our 1RM testing was: leg press, ICC = 0.95; leg curl, ICC = 0.99; and leg extension, ICC = 0.98. Results of this trial will provide critically needed guidance for clinicians in a variety of health professions who prescribe and oversee treatment and prevention of OA-related complications. Given the prevalence and impact of OA and the widespread availability of this intervention, assessing the efficacy of optimal strength training has the potential for immediate and vital clinical impact. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01489462.
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ItemA physiotherapist-delivered integrated exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a randomised controlled trial protocol(BioMed Central, 2012-07-24)BACKGROUND: Knee osteoarthritis (OA) is a prevalent chronic musculoskeletal condition with no cure. Pain is the primary symptom and results from a complex interaction between structural changes, physical impairments and psychological factors. Much evidence supports the use of strengthening exercises to improve pain and physical function in this patient population. There is also a growing body of research examining the effects of psychologist-delivered pain coping skills training (PCST) particularly in other chronic pain conditions. Though typically provided separately, there are symptom, resource and personnel advantages of exercise and PCST being delivered together by a single healthcare professional. Physiotherapists are a logical choice to be trained to deliver a PCST intervention as they already have expertise in administering exercise for knee OA and are cognisant of the need for a biopsychosocial approach to management. No studies to date have examined the effects of an integrated exercise and PCST program delivered solely by physiotherapists in this population. The primary aim of this multisite randomised controlled trial is to investigate whether an integrated 12-week PCST and exercise treatment program delivered by physiotherapists is more efficacious than either program alone in treating pain and physical function in individuals with knee OA. METHODS/DESIGN: This will be an assessor-blinded, 3-arm randomised controlled trial of a 12-week intervention involving 10 physiotherapy visits together with home practice. Participants with symptomatic and radiographic knee OA will be recruited from the community in two cities in Australia and randomized into one of three groups: exercise alone, PCST alone, or integrated PCST and exercise. Randomisation will be stratified by city (Melbourne or Brisbane) and gender. Primary outcomes are overall average pain in the past week measured by a Visual Analogue Scale and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale. Secondary outcomes include global rating of change, muscle strength, functional performance, physical activity levels, health related quality of life and psychological factors. Measurements will be taken at baseline and immediately following the intervention (12 weeks) as well as at 32 weeks and 52 weeks to examine maintenance of any intervention effects. Specific assessment of adherence to the treatment program will also be made at weeks 22 and 42. Relative cost-effectiveness will be determined from health service usage and outcome data. DISCUSSION: The findings from this randomised controlled trial will provide evidence for the efficacy of an integrated PCST and exercise program delivered by physiotherapists in the management of painful and functionally limiting knee OA compared to either program alone.
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ItemAddition of telephone coaching to a physiotherapist-delivered physical activity program in people with knee osteoarthritis: A randomised controlled trial protocol(BMC, 2012-12-11)BACKGROUND: Knee osteoarthritis (OA) is one of the most common and costly chronic musculoskeletal conditions world-wide and is associated with substantial pain and disability. Many people with knee OA also experience co-morbidities that further add to the OA burden. Uptake of and adherence to physical activity recommendations is suboptimal in this patient population, leading to poorer OA outcomes and greater impact of associated co-morbidities. This pragmatic randomised controlled trial will investigate the clinical- and cost-effectiveness of adding telephone coaching to a physiotherapist-delivered physical activity intervention for people with knee OA. METHODS/DESIGN: 168 people with clinically diagnosed knee OA will be recruited from the community in metropolitan and regional areas and randomly allocated to physiotherapy only, or physiotherapy plus nurse-delivered telephone coaching. Physiotherapy involves five treatment sessions over 6 months, incorporating a home exercise program of 4-6 exercises (targeting knee extensor and hip abductor strength) and advice to increase daily physical activity. Telephone coaching comprises 6-12 telephone calls over 6 months by health practitioners trained in applying the Health Change Australia (HCA) Model of Health Change to provide behaviour change support. The telephone coaching intervention aims to maximise adherence to the physiotherapy program, as well as facilitate increased levels of participation in general physical activity. The primary outcomes are pain measured by an 11-point numeric rating scale and self-reported physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale after 6 months. Secondary outcomes include physical activity levels, quality-of-life, and potential moderators and mediators of outcomes including self-efficacy, pain coping and depression. Relative cost-effectiveness will be determined from health service usage and outcome data. Follow-up assessments will also occur at 12 and 18 months. DISCUSSION: The findings will help determine whether the addition of telephone coaching sessions can improve sustainability of outcomes from a physiotherapist-delivered physical activity intervention in people with knee OA. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference: ACTRN12612000308897.
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ItemSelf-reported knee joint instability is related to passive mechanical stiffness in medial knee osteoarthritis(BIOMED CENTRAL LTD, 2013-11-20)BACKGROUND: Self-reported knee joint instability compromises function in individuals with medial knee osteoarthritis and may be related to impaired joint mechanics. The purpose of this study was to evaluate the relationship between self-reported instability and the passive varus-valgus mechanical behaviour of the medial osteoarthritis knee. METHODS: Passive varus-valgus angular laxity and stiffness were assessed using a modified isokinetic dynamometer in 73 participants with medial tibiofemoral osteoarthritis. All participants self-reported the absence or presence of knee instability symptoms and the degree to which instability affected daily activity on a 6-point likert scale. RESULTS: Forward linear regression modelling identified a significant inverse relationship between passive mid-range knee stiffness and symptoms of knee instability (r = 0.27; P < 0.05): reduced stiffness was indicative of more severe instability symptoms. Angular laxity and end-range stiffness were not related to instability symptoms (P > 0.05). CONCLUSIONS: Conceivably, a stiffer passive system may contribute toward greater joint stability during functional activities. Importantly however, net joint stiffness is influenced by both active and passive stiffness, and thus the active neuromuscular system may compensate for reduced passive stiffness in order to maintain joint stability. Future work is merited to examine the role of active stiffness in symptomatic joint stability.
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ItemThe effects of neuromuscular exercise on medial knee joint load post-arthroscopic partial medial meniscectomy: 'SCOPEX' a randomised control trial protocol(BIOMED CENTRAL LTD, 2012-11-27)BACKGROUND: Meniscectomy is a risk factor for knee osteoarthritis, with increased medial joint loading a likely contributor to the development and progression of knee osteoarthritis in this group. Therefore, post-surgical rehabilitation or interventions that reduce medial knee joint loading have the potential to reduce the risk of developing or progressing osteoarthritis. The primary purpose of this randomised, assessor-blind controlled trial is to determine the effects of a home-based, physiotherapist-supervised neuromuscular exercise program on medial knee joint load during functional tasks in people who have recently undergone a partial medial meniscectomy. METHODS/DESIGN: 62 people aged 30-50 years who have undergone an arthroscopic partial medial meniscectomy within the previous 3 to 12 months will be recruited and randomly assigned to a neuromuscular exercise or control group using concealed allocation. The neuromuscular exercise group will attend 8 supervised exercise sessions with a physiotherapist and will perform 6 exercises at home, at least 3 times per week for 12 weeks. The control group will not receive the neuromuscular training program. Blinded assessment will be performed at baseline and immediately following the 12-week intervention. The primary outcomes are change in the peak external knee adduction moment measured by 3-dimensional analysis during normal paced walking and one-leg rise. Secondary outcomes include the change in peak external knee adduction moment during fast pace walking and one-leg hop and change in the knee adduction moment impulse during walking, one-leg rise and one-leg hop, knee and hip muscle strength, electromyographic muscle activation patterns, objective measures of physical function, as well as self-reported measures of physical function and symptoms and additional biomechanical parameters. DISCUSSION: The findings from this trial will provide evidence regarding the effect of a home-based, physiotherapist-supervised neuromuscular exercise program on medial knee joint load during various tasks in people with a partial medial meniscectomy. If shown to reduce the knee adduction moment, neuromuscular exercise has the potential to prevent the onset of osteoarthritis or slow its progression in those with early disease. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference: ACTRN12612000542897.
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ItemThe relationship between patellofemoral and tibiofemoral morphology and gait biomechanics following arthroscopic partial medial meniscectomy(SPRINGER, 2013-05)PURPOSE: To examine the relationship between tibiofemoral and patellofemoral joint articular cartilage and subchondral bone in the medial and gait biomechanics following partial medial meniscectomy. METHODS: For this cross-sectional study, 122 patients aged 30-55 years, without evidence of knee osteoarthritis at arthroscopic partial medial meniscectomy, underwent gait analysis and MRI on the operated knee once for each sub-cohort of 3 months, 2 years, or 4 years post-surgery. Cartilage volume, cartilage defects, and bone size were assessed from the MRI using validated methods. The 1st peak in the knee adduction moment, knee adduction moment impulse, 1st peak in the knee flexion moment, knee extension range of motion, and the heel strike transient from the vertical ground reaction force trace were identified from the gait data. RESULTS: Increased knee stance phase range of motion was associated with decreased patella cartilage volume (B = -17.9 (95% CI -35.4, -0.4) p = 0.045) while knee adduction moment impulse was associated with increased medial tibial plateau area (B = 7.7 (95% CI 0.9, 13.3) p = 0.025). A number of other variables approached significance. CONCLUSIONS: Knee joint biomechanics exhibited by persons who had undergone arthroscopic partial meniscectomy gait may go some way to explaining the morphological degeneration observed at the patellofemoral and tibiofemoral compartments of the knee as patients progress from surgery. LEVEL OF EVIDENCE: III.
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ItemNo Preview AvailableChronic Disease Management A Review of Current Performance Across Quality of Care Domains and Opportunities for Improving Osteoarthritis Care(W B SAUNDERS CO-ELSEVIER INC, 2013-02)Osteoarthritis is the most prevalent chronic joint disease worldwide. The incidence and prevalence are increasing as the population ages and lifestyle risk factors such as obesity increase. There are several evidence-based clinical practice guidelines available to guide clinician decision making, but there is evidence that care provided is suboptimal across all domains of quality: effectiveness, safety, timeliness and appropriateness, patient-centered care, and efficiency. System, clinician, and patient barriers to optimizing care need to be addressed. Innovative models designed to meet patient needs and those that harness social networks must be developed, especially to support those with mild to moderate disease.
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ItemMeasurement properties of performance-based measures to assess physical function in hip and knee osteoarthritis: a systematic review(ELSEVIER SCI LTD, 2012-12)OBJECTIVES: To systematically review the measurement properties of performance-based measures to assess physical function in people with hip and/or knee osteoarthritis (OA). METHODS: Electronic searches were performed in MEDLINE, CINAHL, Embase, and PsycINFO up to the end of June 2012. Two reviewers independently rated measurement properties using the consensus-based standards for the selection of health status measurement instrument (COSMIN). "Best evidence synthesis" was made using COSMIN outcomes and the quality of findings. RESULTS: Twenty-four out of 1792 publications were eligible for inclusion. Twenty-one performance-based measures were evaluated including 15 single-activity measures and six multi-activity measures. Measurement properties evaluated included internal consistency (three measures), reliability (16 measures), measurement error (14 measures), validity (nine measures), responsiveness (12 measures) and interpretability (three measures). A positive rating was given to only 16% of possible measurement ratings. Evidence for the majority of measurement properties of tests reported in the review has yet to be determined. On balance of the limited evidence, the 40 m self-paced test was the best rated walk test, the 30 s-chair stand test and timed up and go test were the best rated sit to stand tests, and the Stratford battery, Physical Activity Restrictions and Functional Assessment System were the best rated multi-activity measures. CONCLUSION: Further good quality research investigating measurement properties of performance measures, including responsiveness and interpretability in people with hip and/or knee OA, is needed. Consensus on which combination of measures will best assess physical function in people with hip/and or knee OA is urgently required.
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ItemOARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis(ELSEVIER SCI LTD, 2013-08)OBJECTIVES: To recommend a consensus-derived set of performance-based tests of physical function for use in people diagnosed with hip or knee osteoarthritis (OA) or following joint replacement. METHODS: An international, multidisciplinary expert advisory group was established to guide the study. Potential tests for consideration in the recommended set were identified via a survey of selected experts and through a systematic review of the measurement properties for performance-based tests. A multi-phase, consensus-based approach was used to prioritize and select performance-based tests by applying decision analysis methodology (1000Minds software) via online decision surveys. The recommended tests were chosen based on available measurement-property evidence, feasibility of the tests, scoring methods and expert consensus. RESULTS: Consensus incorporated the opinions of 138 experienced clinicians and researchers from 16 countries. The five tests recommended by the advisory group and endorsed by Osteoarthritis Research Society International (OARSI) were the 30-s chair-stand test, 40 m fast-paced walk test, a stair-climb test, timed up-and-go test and 6-min walk test. The first three were recommended as the minimal core set of performance-based tests for hip or knee OA. CONCLUSION: The OARSI recommended set of performance-based tests of physical function represents the tests of typical activities relevant to individuals diagnosed with hip or knee OA and following joint replacements. These tests are complementary to patient-reported measures and are recommended as prospective outcome measures in future OA research and to assist decision-making in clinical practice. Further research should be directed to expanding the measurement-property evidence of the recommended tests.
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ItemMedial arch supports do not significantly alter the knee adduction moment in people with knee osteoarthritis(ELSEVIER SCI LTD, 2013-01)OBJECTIVE: This study aimed to evaluate the immediate effects of medial arch supports on indices of medial knee joint load (the peak external knee adduction moment (KAM) and knee adduction angular (KAA) impulse) and knee pain during walking in people with medial knee osteoarthritis (OA). DESIGN: Twenty-one people with medial compartment OA underwent gait analysis in standardised athletic shoes wearing (1) no medial arch supports and (2) prefabricated medial arch supports, in random order. Outcomes were the first and second peaks in the external KAM, the KAA impulse and severity of knee pain during testing. Outcomes were compared across conditions using paired t tests (gait data) and Wilcoxon Signed Ranks test (pain data). RESULTS: There were no significant changes in either first or second peak KAM, or in the KAA impulse, with the addition of medial arch supports (all P > 0.05). Considerable individual variation in response to the arch supports was observed across participants. There was no immediate change in knee pain during walking when medial arch supports were worn (P = 0.56). CONCLUSIONS: This study showed no mean change in any of the measured indices of medial knee load with medial arch supports. No immediate changes in knee pain were evident.