The Effects of Physical Exercise on Pain Management in Patients with Knee Osteoarthritis: A Systematic Review with Metanalysis

Rocha, Thiago Casali; Ramos, Plínio dos Santos; Dias, Alessandra Germano; Martins, Elaine Angélica

doi:10.1055/s-0039-1696681

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Revista Brasileira de Ortopedia

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Sumário

Systematic Review, Knee • Rev. bras. ortop. 55 (5) • Sep-Oct 2020 • https://doi.org/10.1055/s-0039-1696681 copy

The Effects of Physical Exercise on Pain Management in Patients with Knee Osteoarthritis: A Systematic Review with Metanalysis^* * Work developed at Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital e Maternidade Therezinha de Jesus, Juiz de Fora, MG, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

The present study verified, through a systematic review with meta-analysis, the effects of a rehabilitation, physical training program for the treatment of pain and muscle strength in knee osteoarthritis (OA).

Methods

We analyzed studies published between 2008 and 2018 referenced at the Medline (National Library of Medicine) database, selecting 7 randomized controlled clinical trials about exercise programs to improve pain and muscle strength in patients with knee OA with Physiotherapy Evidence Database (PeDro) score higher than 8. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematization was used to prepare this review, and a meta-analysis was carried out to obtain mathematical evidence the outcomes of physical exercise on pain.

Results

The studies included in the analysis contained a total of 934 participants aged 40 to 73 years-old, with 34.90% males. Most of the exercise sets offered in OA treatment had a significantly positive outcome result in both criteria, but mainly for pain relief (statistically significant difference, p < 0.003).

Conclusion

We infer that there was an improvement of pain in all articles that performed muscle strengthening, but there is still an obstacle to the protocols used.

Keywords
pain; muscle strength; osteoarthritis of knee; exercise and movement techniques

PEDro Scale
Study	C1	C2	C3	C4	C5	C6	C7	C8	C9	C10	C11	Score
Boon-Whatt Lim et al., 2008 ³³33 Lim BW, Hinman RS, Wrigley TV, Sharma L, Bennell KL. Does knee malalignment mediate the effects of quadriceps strengthening on knee adduction moment, pain, and function in medial knee osteoarthritis? A randomized controlled trial. Arthritis Rheum 2008;59(07):943–951	1	1	1	1	0	0	1	1	1	1	1	8/10
K.L. Bennell et al., 2010 ²⁵25 Bennell KL, Hunt MA, Wrigley TV, et al. Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment: a randomised controlled trial. Osteoarthritis Cartilage 2010;18(05):621–628	1	1	1	1	0	0	1	1	1	1	1	8/10
G. Kelley Fitzgerald et al., 2011 ²⁰20 Fitzgerald GK, Piva SR, Gil AB, Wisniewski SR, Oddis CV, Irrgang JJ. Agility and perturbation training techniques in exercise therapy for reducing pain and improving function in people with knee osteoarthritis: a randomized clinical trial. Phys Ther 2011;91(04): 452–469	1	1	1	1	1	0	1	0	1	1	1	8/10
Saccomanno MF et al., 2016 ²¹21 Saccomanno MF, Donati F, Careri S, Bartoli M, Severini G, Milano G. Efficacy of intra-articular hyaluronic acid injections and exercisebased rehabilitation programme, administered as isolated or integrated therapeutic regimens for the treatment of knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2016;24(05): 1686–1694	1	1	1	1	0	0	1	1	1	1	1	8/10
Palmer S et al., 2014²²22 Palmer S, Domaille M, Cramp F, et al. Transcutaneous electrical nerve stimulation as an adjunct to education and exercise for knee osteoarthritis: a randomized controlled trial. Arthritis Care Res (Hoboken) 2014;66(03):387–394	1	1	1	1	1	0	1	0	1	1	1	8/10
Holsgaard-Larsen A et al., 2017²³23 Holsgaard-Larsen A, Clausen B, Sêndergaard J, Christensen R, Andriacchi TP, Roos EM. The effect of instruction in analgesic use compared with neuromuscular exercise on knee-joint load in patients with knee osteoarthritis: a randomized, single-blind, controlled trial. Osteoarthritis Cartilage 2017;25(04):470–480	1	1	1	1	0	0	1	1	1	1	1	8/10
Jorge RT et al., 2015²⁴24 Jorge RT, Souza MC, Chiari A, et al. Progressive resistance exercise in women with osteoarthritis of the knee: a randomized controlled trial. Clin Rehabil 2015;29(03):234–243	1	1	1	1	0	0	1	1	1	1	1	8/10

Items	Boon-Whatt Lim et al., 2008 ³²32 Segal NA, Glass NA, Felson DT, et al. Effect of quadriceps strength and proprioception on risk for knee osteoarthritis. Med Sci Sports Exerc 2010;42(11):2081–2088	K.L. Bennell et al., 2010 ²⁴24 Jorge RT, Souza MC, Chiari A, et al. Progressive resistance exercise in women with osteoarthritis of the knee: a randomized controlled trial. Clin Rehabil 2015;29(03):234–243	G. Kelley Fitzgerald et al., 2011 ¹⁹19 Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17(01):1–12	Sacco manno MF et al., 2016 ²⁰20 Fitzgerald GK, Piva SR, Gil AB, Wisniewski SR, Oddis CV, Irrgang JJ. Agility and perturbation training techniques in exercise therapy for reducing pain and improving function in people with knee osteoarthritis: a randomized clinical trial. Phys Ther 2011;91(04): 452–469	Palmer S et al., 2014²¹21 Saccomanno MF, Donati F, Careri S, Bartoli M, Severini G, Milano G. Efficacy of intra-articular hyaluronic acid injections and exercisebased rehabilitation programme, administered as isolated or integrated therapeutic regimens for the treatment of knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2016;24(05): 1686–1694	Holsgaard-Larsen A et al., 2017²²22 Palmer S, Domaille M, Cramp F, et al. Transcutaneous electrical nerve stimulation as an adjunct to education and exercise for knee osteoarthritis: a randomized controlled trial. Arthritis Care Res (Hoboken) 2014;66(03):387–394	Jorge RT et al., 2015²³23 Holsgaard-Larsen A, Clausen B, Sêndergaard J, Christensen R, Andriacchi TP, Roos EM. The effect of instruction in analgesic use compared with neuromuscular exercise on knee-joint load in patients with knee osteoarthritis: a randomized, single-blind, controlled trial. Osteoarthritis Cartilage 2017;25(04):470–480
Was the study described as randomized?	1	1	1	1	1	1	1
Was there a description of randomization? Was it adequate?	1	1	1	1	1	1	1
Were there comparisons and results?	1	1	1	1	1	1	1
Was there a description of comparisons and results? Were they adequate?	1	1	1	1	1	1	1
Was there a description of withdrawals and dropouts?	1	1	1	1	1	1	1
TOTAL	5	5	5	5	5	5	5

Study	SAMPLE				GI	GC	Duration	Analyzed variables
	SAMPLE	MEN	AGE	GROUPS				PAIN	MUSCLE STRENGTH
Lim et al., 2008³³33 Lim BW, Hinman RS, Wrigley TV, Sharma L, Bennell KL. Does knee malalignment mediate the effects of quadriceps strengthening on knee adduction moment, pain, and function in medial knee osteoarthritis? A randomized controlled trial. Arthritis Rheum 2008;59(07):943–951	107	48	53-73 years old	GI: 54 GC: 53	Quadriceps strengthening with weighted shin sleeves and Theraband	No intervention	12 weeks	Significant pain improvement in the group with better knee alignment	NA
K.L. Bennell et al., 2010²⁵25 Bennell KL, Hunt MA, Wrigley TV, et al. Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment: a randomised controlled trial. Osteoarthritis Cartilage 2010;18(05):621–628	102	51	62-73 years old	GI: 51 GC: 51	Hip strengthening l (quadriceps adduction, external rotation, extension and isometry)	No intervention	12 weeks	Pain improvement in GI compared to GC	Significant hip and quadriceps strength improvement compared to the control group
G. Kelley Fitzgerald et al., 2011²⁰20 Fitzgerald GK, Piva SR, Gil AB, Wisniewski SR, Oddis CV, Irrgang JJ. Agility and perturbation training techniques in exercise therapy for reducing pain and improving function in people with knee osteoarthritis: a randomized clinical trial. Phys Ther 2011;91(04): 452–469	183	61	63-73 years old	GI:92 GC: 91	The agility and disturbance group received the same standard exercise program with the addition of training techniques on agility and disturbance	Standard exercise program: an exercise program including muscle stretching, strengthening and walking on a treadmill	4 years and 2 months	Both groups presented modest improvements, but with no significant differences between them	NA
Saccomanno MF et al., 2016²¹21 Saccomanno MF, Donati F, Careri S, Bartoli M, Severini G, Milano G. Efficacy of intra-articular hyaluronic acid injections and exercisebased rehabilitation programme, administered as isolated or integrated therapeutic regimens for the treatment of knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2016;24(05): 1686–1694	165	44	40-70 years-old	GI-1: 53 GI-2:53 GC: 51	GI-1: three hyaluronic acid (HA) injectionsGI- 2: HA injections + knee exercises	Knee exercises	6 months	At the 1^st month, GI-2 scores were significantly better compared to GI-1. GC and GI-2 presented a significant reduction at the 1^st and the 6^th month	NA
Palmer S et al., 2014²²22 Palmer S, Domaille M, Cramp F, et al. Transcutaneous electrical nerve stimulation as an adjunct to education and exercise for knee osteoarthritis: a randomized controlled trial. Arthritis Care Res (Hoboken) 2014;66(03):387–394	224	83	60-72 years old	GI:73 GC-1: 74 GC-2: 77	Active TENS (continuous mode, - 110 Hz, 50 µs) + knee exercises	GC-1: fictional TENS + knee exercises GC-2: knee exercises (30 minutes of education + 30 minutes of exercises)	6 weeks	Each score from each group significantly improved over time	NA
Holsgaard-Larsen A et al., 2017²³23 Holsgaard-Larsen A, Clausen B, Sêndergaard J, Christensen R, Andriacchi TP, Roos EM. The effect of instruction in analgesic use compared with neuromuscular exercise on knee-joint load in patients with knee osteoarthritis: a randomized, single-blind, controlled trial. Osteoarthritis Cartilage 2017;25(04):470–480	93	39	40-70 years old	GI: 47 GC: 46	Warming up (10 minutes), functional, proprioceptive training, resistance strengthening and cooling down	Information about analgesic and anti-inflammatory agents	8 weeks	There were no significant differences between groups	NA
Jorge RT et al., 2015²⁴24 Jorge RT, Souza MC, Chiari A, et al. Progressive resistance exercise in women with osteoarthritis of the knee: a randomized controlled trial. Clin Rehabil 2015;29(03):234–243	60	NA	40-70 years old	GI: 29 GC:31	Warming up, 5 minutes at bike. Progressive resistance exercise (knee extension/flexion and hip adduction and abduction with light weights).	No intervention	13 weeks	Pain in the GI group was significantly lower in 45 and 90 days	Significant differences for hip adduction between groups from T0 until the end of the study

Study	N1	N2	TOTAL	SMD	95% IC
Lim et al., 2008	54	53	107	-0.165	-0.549 to 0.219
Bennell et al., 2010	51	51	102	-0.481	-0.880 to -0.0824
Jorge et al., 2015	29	31	60	-0.122	-1.788 to -0.655
Saccomanno et al., 2016	51	53	104	-0.126	-0.516 to 0.263
Palmer et al., 2014	73	74	147	0.000	-0.326 to 0.326
Total (fixed effect)	258	262	520	-0.275	-0.450 to -0.101
Total (randomized effect)	258	262	520	-0.357	-0.712 to -0.00181
Significance level	P = 0.0031

Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br

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[1] Address for correspondence Thiago Casali Rocha, Master, Faculdade de CiênciasMédicas e da Saúde de Juiz de Fora, Hospital e Maternidade Therezinha de Jesus, Alameda Salvaterra, 200, Salvaterra, Juiz de Fora, MG, 36033-003, Brazil (e-mail: thiagocasali@physio10.com.br).

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The Effects of Physical Exercise on Pain Management in Patients with Knee Osteoarthritis: A Systematic Review with Metanalysis* * Work developed at Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital e Maternidade Therezinha de Jesus, Juiz de Fora, MG, Brazil.

Abstract

Objective

Methods

Results

Conclusion

The Effects of Physical Exercise on Pain Management in Patients with Knee Osteoarthritis: A Systematic Review with Metanalysis^* * Work developed at Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital e Maternidade Therezinha de Jesus, Juiz de Fora, MG, Brazil.