Alison R. Harmer

Exercise for osteoarthritis of the knee: a Cochrane systematic review

Objective To determine whether land-based therapeutic exercise is beneficial for people with knee osteoarthritis (OA) in terms of reduced joint pain or improved physical function and quality of life. Methods Five electronic databases were searched, up until May 2013. Randomised clinical trials comparing some form of land-based therapeutic exercise with a non-exercise control were selected. Three teams of two review authors independently extracted data and assessed risk of bias for each study. Standardised mean differences immediately after treatment and 2–6 months after cessation of formal treatment were separately pooled using a random effects model. Results In total, 54 studies were identified. Overall, 19 (35%) studies reported adequate random sequence generation, allocation concealment and adequately accounted for incomplete outcome data. However, research results may be vulnerable to selection, attrition and detection bias. Pooled results from 44 trials indicated that exercise significantly reduced pain (12 points/100; 95% CI 10 to 15) and improved physical function (10 points/100; 95% CI 8 to 13) to a moderate degree immediately after treatment, while evidence from 13 studies revealed that exercise significantly improved quality of life immediately after treatment with small effect (4 points/100; 95% CI 2 to 5). In addition, 12 studies provided 2-month to 6-month post-treatment sustainability data which showed significantly reduced knee pain (6 points/100; 95% CI 3 to 9) and 10 studies which showed improved physical function (3 points/100; 95% CI 1 to 5). Conclusions Among people with knee osteoarthritis, land-based therapeutic exercise provides short-term benefit that is sustained for at least 2–6 months after cessation of formal treatment.

Land-Based Versus Water-Based Rehabilitation Following Total Knee Replacement : A Randomized, Single-Blind Trial

OBJECTIVE To compare outcomes between land-based and water-based exercise programs delivered in the early subacute phase up to 6 months after total knee replacement (TKR). METHODS Two weeks after surgery (baseline), 102 patients were randomized to participate in either land-based (n = 49) or water-based (n = 53) exercise classes. Treatment parameters were guided by current clinical practice protocols. Therefore, each study arm involved 1-hour sessions twice a week for 6 weeks, with patient-determined exercise intensity. Session attendance was recorded. Outcomes were measured at baseline and at 8 and 26 weeks postsurgery. Outcomes included distance on the 6-Minute Walk test, stair climbing power (SCP), the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index (n = 85 English-proficient patients), visual analog scale for joint pain, passive knee range of motion, and knee edema (circumference). Planned orthogonal contrasts, with an intent-to-treat approach, were used to analyze the effects of time and time-group interactions. RESULTS Compliance in both groups was excellent with 81% attending 8 or more sessions. Loss to followup was 5%. Significant improvements were observed across time in all outcomes at 8 weeks, with further improvements evident in all variables (except WOMAC pain) at 26 weeks. Minor between-group differences were evident for 4 outcomes (SCP, WOMAC stiffness, WOMAC function, and edema) but these appear clinically insignificant. CONCLUSION A short-term, clinically pragmatic program of either land-based or water-based rehabilitation delivered in the early phase after TKR was associated with comparable outcomes at the end of the program and up to 26 weeks postsurgery.

Sprint Training Increases Muscle Oxidative Metabolism During High-Intensity Exercise in Patients With Type 1 Diabetes

OBJECTIVE—To investigate sprint-training effects on muscle metabolism during exercise in subjects with (type 1 diabetic group) and without (control group) type 1 diabetes. RESEARCH DESIGN AND METHODS—Eight subjects with type 1 diabetes and seven control subjects, matched for age, BMI, and maximum oxygen uptake (V̇o2peak), undertook 7 weeks of sprint training. Pretraining, subjects cycled to exhaustion at 130% V̇o2peak. Posttraining subjects performed an identical test. Vastus lateralis biopsies at rest and immediately after exercise were assayed for metabolites, high-energy phosphates, and enzymes. Arterialized venous blood drawn at rest and after exercise was analyzed for lactate and [H+]. Respiratory measures were obtained on separate days during identical tests and during submaximal tests before and after training. RESULTS—Pretraining, maximal resting activities of hexokinase, citrate synthase, and pyruvate dehydrogenase did not differ between groups. Muscle lactate accumulation with exercise was higher in type 1 diabetic than nondiabetic subjects and corresponded to indexes of glycemia (A1C, fasting plasma glucose); however, glycogenolytic and glycolytic rates were similar. Posttraining, at rest, hexokinase activity increased in type 1 diabetic subjects; in both groups, citrate synthase activity increased and pyruvate dehydrogenase activity decreased; during submaximal exercise, fat oxidation was higher; and during intense exercise, peak ventilation and carbon dioxide output, plasma lactate and [H+], muscle lactate, glycogenolytic and glycolytic rates, and ATP degradation were lower in both groups. CONCLUSIONS—High-intensity exercise training was well tolerated, reduced metabolic destabilization (of lactate, H+, glycogenolysis/glycolysis, and ATP) during intense exercise, and enhanced muscle oxidative metabolism in young adults with type 1 diabetes. The latter may have clinically important health benefits.

Severe other joint disease and obesity independently influence recovery after joint replacement surgery: an observational study

QUESTIONS Are either severe other joint disease or obesity associated with a slower rate of recovery after total hip or knee replacement surgery? Are they associated with less absolute recovery up to one year post-surgery? DESIGN Prospective, longitudinal, observational study over 12 months. PARTICIPANTS Ninety-nine patients (knee=55, hip=44) stratified according to the presence of severe other joint disease and obesity. OUTCOME MEASURES Pain in operated joint, and 15-m Walk Test and Timed Up and Go Test measured pre- and at 2, 6, 12, 26, and 52 weeks post-surgery. Walking aid utilisation and global improvement were measured at 52 weeks. RESULTS For rate of recovery, the participants with severe other joint disease recovered more slowly than the non-severe group in terms of mobility (15-m Walk Test p=0.005). For absolute recovery, participants with severe other joint disease walked 0.27 m/s (95% CI 0.15 to 0.40) more slowly on the 15-m Walk Test, took 4.0 s (95% CI 2.3 to 5.8) longer on the Timed Up and Go Test, and had 6.8 times greater chance (95% CI 2.8 to 16.5) of using a walking aid than the non-severe group at 52 weeks. This profile was similar for the obese group compared with the non-obese group. At 52 weeks, the majority (95%) of participants reported significant (better/much better) global improvement. CONCLUSION Severe other joint disease and obesity are associated with poorer recovery after surgery. Clinician and patient expectations, rehabilitation, and benchmarking can be guided by these findings.

Moderate concentrations of supplemental oxygen worsen hypercapnia in obesity hypoventilation syndrome: a randomised crossover study

Introduction In people with obesity hypoventilation syndrome (OHS), breathing 100% oxygen increases carbon dioxide (PCO2), but its effect on pH is unknown. This study investigated the effects of moderate concentrations of supplemental oxygen on PCO2, pH, minute ventilation (VE) and physiological dead space to tidal volume ratio (VD/VT) among people with stable untreated OHS, with comparison to healthy controls. Methods In a double-blind randomised crossover study, participants breathed oxygen concentrations (FiO2) 0.28 and 0.50, each for 20 min, separated by a 45 min washout period. Arterialised-venous PCO2 (PavCO2) and pH, VE and VD/VT were measured at baseline, then every 5 min. Data were analysed using general linear model analysis. Results 28 participants were recruited (14 OHS, 14 controls). Among OHS participants (mean±SD arterial PCO2 6.7±0.5 kPa; arterial oxygen 8.9±1.4 kPa) FiO2 0.28 and 0.50 maintained oxygen saturation 98–100%. After 20 min of FiO2 0.28, PavCO2 change (ΔPavCO2) was 0.3±0.2 kPa (p=0.013), with minimal change in VE and rises in VD/VT of 1±5% (p=0.012). FiO2 0.50 increased PavCO2 by 0.5±0.4 kPa (p=0.012), induced acidaemia and increased VD/VT by 3±3% (p=0.012). VE fell by 1.2±2.1 L/min within 5 min then recovered individually to varying degrees. A negative correlation between ΔVE and ΔPavCO2 (r=−0.60, p=0.024) suggested that ventilatory responses were the key determinant of PavCO2 rises. Among controls, FiO2 0.28 and 0.50 did not change PavCO2 or pH, but FiO2 0.50 significantly increased VE and VD/VT. Conclusion Commonly used oxygen concentrations caused hypoventilation, PavCO2 rises and acidaemia among people with stable OHS. This highlights the potential dangers of this common intervention in this group.

EFFICACY OF A FITNESS CENTRE-BASED EXERCISE PROGRAMME COMPARED WITH A HOME-BASED EXERCISE PROGRAMME IN TRAUMATIC BRAIN INJURY: A RANDOMIZED CONTROLLED TRIAL

OBJECTIVE To compare the effects of a supervised fitness centre-based exercise programme with an unsupervised home-based exercise programme on cardiorespiratory fitness and psychosocial functioning in people with traumatic brain injury. DESIGN Multi-centre, assessor-blinded, parallel group, randomized controlled trial. PARTICIPANTS Sixty-two participants with severe traumatic brain injuries, who could walk at a speed exceeding 1 m/sec, discharged from 3 brain injury units. INTERVENTIONS The fitness centre group completed a combined fitness and strength training exercise programme supervised by a personal trainer in a local fitness centre 3 times per week for 12 weeks. The home group completed a similar exercise programme unsupervised at home. MAIN OUTCOME MEASURE Cardiorespiratory fitness measured using the modified 20-m shuttle test. RESULTS Both groups improved in fitness: the maximal velocity achieved on the modified 20-m shuttle test increased with intervention and was maintained at follow-up. However, the difference between groups was not significant (mean between-group difference (95% confidence interval) 0 m/sec (-0.6 to 0.6) at the end of intervention). There were also no between-group differences in psychosocial functioning at the end of intervention or at follow-up. CONCLUSION Both interventions were equally effective at improving cardiorespiratory fitness in adults with traumatic brain injuries.

Early Rehabilitation After Total Knee Replacement Surgery: A Multicenter, Noninferiority, Randomized Clinical Trial Comparing a Home Exercise Program With Usual Outpatient Care

To determine, at 6 weeks postsurgery, if a monitored home exercise program (HEP) is not inferior to usual care rehabilitation for patients undergoing primary unilateral total knee replacement (TKR) surgery for osteoarthritis.

Is discharge knee range of motion a useful and relevant clinical indicator after total knee replacement? Part 2.

OBJECTIVE Knee range of motion (ROM) at discharge from acute care is used as a clinical indicator following total knee replacement (TKR) surgery. This study aimed to assess the clinical relevance of this indicator by determining whether discharge knee ROM predicts longer-term knee ROM and patient-reported knee pain and function. METHODS A total of 176 TKR recipients were prospectively followed after discharge from acute care. Outcomes assessed included knee ROM and Oxford knee score post rehabilitation and 1 year post surgery. Discharge ROM and other patient factors were identified a priori as potential predictors in multiple linear regression modelling. RESULTS A total of 133 (76%) and 141 (80%) patients were available for follow-up post rehabilitation [mean postoperative week 8.1 (SD 2.7)] and at 1 year [mean postoperative month 12.1 (SD 1.4)], respectively. Greater discharge knee flexion was a significant (P < 0.001) predictor of greater post-rehabilitation flexion but not 1-year knee flexion (P < 0.083). Better discharge knee extension was a significant predictor of better post-rehabilitation (P = 0.001) and 1-year knee extension (P = 0.013). Preoperative Oxford score and post-rehabilitation knee flexion independently predicted post-rehabilitation Oxford score, and gender predicted 1-year Oxford score. Discharge ROM did not significantly predict Oxford score in either model. CONCLUSION The finding that early knee range predicts longer-term range provides clinical evidence favouring the relevance of discharge knee ROM as a clinical indicator. Although longer-term patient-reported knee pain and function were not directly associated with discharge knee ROM, they were associated with ROM when measured concurrently in the sub-acute phase. No causal effect has been demonstrated, but the findings suggest it may be important for physiotherapists to maximize range in the early and sub-acute periods.

Glucose tolerance and physical activity level in people with spinal cord injury.

Study design:Cross-sectional, observational study.Objectives:To evaluate the associations of physical activity and neurological lesion level with glucose tolerance in people with spinal cord injury (SCI).Setting:New South Wales, Australia.Methods:Twenty-five people (5 women, 20 men) with SCI (>6 months post-injury) aged between 18 and 65 years were recruited. Exclusion criteria included known coronary heart disease, stroke or diabetes. Participants underwent an oral glucose tolerance test. Fasting and 2-h plasma glucose concentrations were classified according to the World Health Organization categories of glycemia. Participants also completed the Physical Activity Scale for Individuals with Physical Disabilities and mean MET-hours day−1 was calculated. Associations with the 2-h plasma glucose concentration were calculated through multiple and stepwise regressions.Results:Participants presented with complete or incomplete tetraplegia (n=11 TETRA) or complete or incomplete paraplegia (n=14 PARA) with neurological lesion levels ranging from C3/4 to T12. Mean 2-h plasma glucose was 7.13±2.32 mmol l−1. Nine participants had disordered glycemia (n=6 TETRA; n=3 PARA) and the remaining participants had normal glucose tolerance. Those participants with normal glucose tolerance participated in more moderate-vigorous and strength exercise and undertook more non-exercise-related mobility than those with disordered glycemia. Physical activity and age, but not lesion level were independent determinants of 2-h plasma glucose concentration (r=0.683, P=0.001), explaining 47% of the variance.Conclusion:Physical activity level is independently associated with glucose tolerance in people with SCI. Non-exercise activity may also be important for maintaining normal glycemia.

Validity of the modified 20-metre shuttle test: assessment of cardiorespiratory fitness in people who have sustained a traumatic brain injury

Primary objective: To validate the modified 20-metre shuttle test in adults who have sustained a traumatic brain injury (TBI). Design: Single-sample validity study. Setting: Brain injury rehabilitation unit. Participants: Twenty-four adults with severe TBI, discharged from hospital for at least 6-months. Protocol: Participants attended the facility for a familiarization session, followed by a symptom-limited treadmill test and a modified shuttle test on two separate days. The treadmill test was based on an individualised protocol which used a physiotherapist-selected speed and increments in gradient every minute until volitional fatigue. The modified shuttle test was externally-paced and commenced with a speed of 2.4 km h−1which increased every minute until volitional fatigue. Main measures: Four primary measures were taken from both tests: peak oxygen uptake, peak heart rate, maximal velocity and rating of perceived exertion. Results: All participants completed the study. There were no adverse events. A high correlation was observed between the modified shuttle test and the treadmill test for peak oxygen uptake, peak heart rate and maximal velocity (r = 0.96, r = 0.80, r = 0.82, respectively; p < 0.001), but not for rating of perceived exertion (r = 0.013, p = 0.952). Conclusion: The modified shuttle test is a valid measure of cardiorespiratory fitness in people who have sustained a TBI.