Artculo de Ingles

8/18/2019 Artculo de Ingles

1/6

Efectiveness o Manual Physical Therapy and Exercise

in Osteoarthritis o the Knee: A Randomized

!ontrolled Trial "REE

Arthritis has been identifed as the most common cause o disability in the

United States (1–2). Thirty-three percent o persons ! to "# years o a$e are

a%ected by osteoarthritis o the &nee' hich oten limits the ability to rise rom

a chair' stand comortably' al&' and use stairs (!–#).

Acetaminophen and nonsteroidal anti-inammatory dru$s (*SA+,s) are

commonly used to treat osteoarthritis. Use o *SA+,s can lead to $astric

complications' increased ris& or hospitaliation' and death (). /ther treatment

options or persons ith osteoarthritis o the &nee include physical therapy

e0ercise and treatment pro$rams' cortisone inections' and oint replacement

sur$ery.

uett and 3ri4n () re5ieed 1 controlled trials o nonmedicinal' nonin5asi5e

therapies or hip and &nee osteoarthritis rom 1" throu$h 1""! (). The

authors concluded that e0ercise reduces pain and impro5es unction in patients

ith osteoarthritis o the &nee' but the optimal e0ercise re$imen has not been

determined. 6itness al&in$' aerobic e0ercise' and stren$th trainin$ ha5e all

been reported to result in unctional impro5ement in patients ith

osteoarthritis o the &nee (–12). Unei$hted treadmill al&in$ has not been

shon to decrease pain associated ith osteoarthritis o the &nee (1!). /ther

researchers (1#–1) ha5e concluded that e0ercise may beneft patients ith

osteoarthritis but ad5ise that lon$-term studies are re7uired to determine the

appropriate amounts o e0ercise to a5oid acceleratin$ the underlyin$ processo arthritis.

Acti5e and passi5e ran$e-o-motion e0ercise is considered an important part o

rehabilitation pro$rams or patients ith osteoarthritis (1–18). hysical

therapists re7uently use manual therapy procedures as part o comprehensi5e

rehabilitation pro$rams to help patients re$ain oint mobility and unction (1").

9e e5aluated the e%ecti5eness o manual physical therapy or osteoarthritis o

the &nee' as applied by physical therapists ith ormal trainin$ in such an

approach (2:). /ur hypothesis as that physical therapy consistin$ o manual

therapy to the &nee' hip' an&le' and lumbar spine combined ith ran$e-o-motion' stren$thenin$' and cardio5ascular e0ercises ould be more e%ecti5e

than placebo or impro5in$ unction' decreasin$ pain and sti%ness' and

increasin$ the distance al&ed in minutes.

;ethods

;ethods < =esults < ,iscussion < 3lossary < =eerences


2/6

atients

>i$hty-three patients ith osteoarthritis o the &nee ere randomly assi$ned to

recei5e treatment (n ? #2@ 1 men and 2 omen Bmean a$e' : C 11 yearsD)

or placebo (n ? #1@ 1" men and 22 omen Bmean a$e' 2 C 1: yearsD). All

patients ere reerred by physicians to physical therapy or osteoarthritis o the

&nee. hysicians at the 5arious clinics in the medical center ho normally see

patients ith osteoarthritis o the &nee ere inormed o the study so that

appropriate reerrals could be made. + the patients met our inclusion criteria'

they ere o%ered the opportunity to participate. The main inclusion criterion

as a dia$nosis o osteoarthritis o the &nee based on ulfllment o one o the

olloin$ clinical criteria de5eloped by Altman and collea$ues B21DE 1) &nee

pain' a$e !8 years or youn$er' and bony enlar$ement@ 2) &nee pain' a$e !"

years or older' mornin$ sti%ness or more than !: minutes' and bony

enlar$ement@ !) &nee pain' crepitus on acti5e motion' mornin$ sti%ness or

more than !: minutes' and bony enlar$ement@ or #) &nee pain' crepitus on

acti5e motion' mornin$ sti%ness or more than !: minutes' and a$e !8 years orolder. Altman and collea$ues ound this criteria to be 8"F sensiti5e and 88F

specifc (21–2!).

atients ere re7uired to be eli$ible or military health care' ha5e had no

sur$ical procedure on either loer e0tremity in the past months' and ha5e no

physical impairment unrelated to the &nee that ould pre5ent sae

participation in a timed -minute al& test or any other aspect o the study.

atients had to ha5e su4cient >n$lish-lan$ua$e s&ills to comprehend all

e0planations and to complete the assessment tools. They ere also re7uired to

li5e ithin a 1-hour dri5e o the physical therapy clinic. atients ho could not

attend the re7uired number o 5isits or had recei5ed a cortisone inection to the

&nee oint ithin the pre5ious !: days ere not enrolled. atients ere

instructed to &eep ta&in$ any current medications and not to start ta&in$ ne

medications or osteoarthritis durin$ the clinical treatment and 8-ee& ollo-

up. Therapy ith any osteoarthritis medication must ha5e been initiated at

least !: days beore participation in the study.

The study as appro5ed by the institutional re5ie board o Groo&e Army

;edical Henter' 6ort Sam Iouston' Te0as. All patients completed an inormed

consent orm and ere ad5ised o the ris&s o the study' includin$ increased

symptoms' inuries rom alls' and cardio5ascular e5ents. *o e0ternal undin$as recei5ed or this study.

rocedure

atients ho met the inclusion criteria ere randomly assi$ned to one o to

$roups. Glan& olders ere numbered rom 1 to 1:: and ere $i5en concealed

codes or the $roup o assi$nment' determined by a random-number $enerator.


3/6

9hen a patient as eli$ible and $a5e consent to participate' the treatin$

therapist dre the ne0t older rom the fle' hich determined the $roup o

assi$nment.

The treatment $roup recei5ed a combination o manual physical therapy and

super5ised e0ercise. The placebo $roup recei5ed ultrasound at a

subtherapeutic intensity. *either $roup as aare o the treatment that the

other $roup as recei5in$. ,emo$raphic data collected or each patient

included a$e' se0' occupation' hei$ht' ei$ht' duration o symptoms' presence

o symptoms in one or both &nees' pre5ious &nee sur$ery' medications' and

present acti5ity le5el. Jnee radio$raphs ere obtained and read by a

radiolo$ist ho assi$ned a radio$raphic se5erity ratin$ or osteoarthritis (2#).

,ependent 5ariables measured in this study ere the 9estern /ntario and

;c;aster Uni5ersities /steoarthritis +nde0 (9/;AH) score (2) and distance

co5ered durin$ a timed -minute al& test. The 9/;AH /steoarthritis +nde0

consists o 2# 7uestions' each correspondin$ to a 5isual analo$ue scale. This

test has been shon to be a reliable' 5alid' and responsi5e multidimensional

outcome measure or e5aluation o patients ith osteoarthritis o the hip or

&nee (2). The timed -minute al& test measures the distance a patient al&s

in minutes and has been demonstrated to be a reliable measurement o

unctional e0ercise capacity (2). All measurements o dependent 5ariables

ere obtained by a trained research assistant ho as blinded to $roup

assi$nment.

Ater research assistants obtained pretreatment 5alues or the dependent5ariables' patients returned to the treatin$ physical therapist or thorou$h

standardied clinical e0amination o the &nee' hip' an&le' and lumbar spine.

Treatment as initiated accordin$ to $roup assi$nment. The treatment $roup

recei5ed manual physical therapy as indicated by the results o the

e0amination. The manual therapy treatment techni7ues' consistin$ o passi5e

physiolo$ic and accessory oint mo5ements' muscle stretchin$' and sot-tissue

mobiliation' ere applied primarily to the &nee. The same treatments ere

also administered to the lumbar spine' hip' or an&le i these areas shoed

limitation in acti5e or passi5e mo5ement' ere symptomatic' or ere

contributin$ to o5erall loer limb dysunction (28–!1). A minimal pain le5el as

not e0ceeded in any treatment.

The treatment $roup also perormed a closely super5ised standardied &nee

e0ercise pro$ram at each o the ei$ht treatment sessions. This pro$ram

consisted o acti5e ran$e-o-motion e0ercises or the &nee' muscle

stren$thenin$ e0ercises or the hip and &nee' muscle stretchin$ or the loer

limbs' and ridin$ a stationary bi&e. All o the acti5ities ere mutually


4/6

reinorcin$' ith repeated $entle challen$es to the end ran$es o mo5ement.

An outline o the e0ercise pro$ram is shon in the Appendi0 6i$ure. The

physical therapist increased the number o stren$thenin$ e0ercise bouts and

the stationary bi&e ridin$ time on the basis o patient tolerance. The current

literature pro5ides e4cient methods to produce the desired e%ects o

increasin$ stren$th' e0ibility' and ran$e o motion (!2–!). At each session'the physical therapist e0amined the patient or ad5erse si$ns and symptoms'

such as increased pain' oint e%usion' and increased s&in temperature o5er

&nee oints. These si$ns and symptoms o osteoarthritis had to be stable or

decreasin$ beore manual therapy or e0ercise as pro$ressed. atients

e0ercised in a painless or minimally painul manner. + any post-treatment or

e0ercise soreness lasted more than a e hours' the re$imen as decreased

accordin$ly or that patient.

The placebo $roup recei5ed treatment by the physical therapist that consisted

o subtherapeutic ultrasound or 1: minutes at an intensity o :.1 9Kcm2 and

1:F pulsed mode (loest settin$ and $reatest cycle interruption) to the area o &nee symptoms. The placebo $roup recei5ed the same subecti5e and hands-

on obecti5e ree5aluation beore and ater each session as the treatment

$roup. The amount o time directly spent ith the treatin$ therapist as

appro0imately !: minutes or both $roups. The treatment $roup re7uired an

additional !: to # minutes to perorm their e0ercises in the clinic. Goth $roups

ere treated tice ee&ly or # ee&s' or a total o ei$ht clinic treatments.

atients in the treatment $roup also perormed the same e0ercises at home'

e0cept or the closed-chain stren$thenin$ e0ercises' on the days on hich they

ere not treated in the physical therapy clinic. They also al&ed at home each

day at a comortable pace and distance. The treatin$ physical therapist

instructed each patient in the perormance o the e0ercises and pro5ided a

detailed handout containin$ instructions and photo$raphs o the e0ercises.

>ach patient maintained a home e0ercise pro$ram compliance lo$ or all

e0ercises. Hompliance as assessed by inspection o home e0ercise lo$s'

inter5ies ith patients at testin$ times' and re5iein$ treatment attendance

records. The home e0ercise treatment lo$s reected a hi$h de$ree o

compliance ith the home e0ercise sessions. +t is possible that the lo$s ere

completed in the absence o perormin$ the e0ercises@ hoe5er' the $eneral

&noled$e o the e0ercise pro$ram seemed consistent ith re$ular

perormance o the home e0ercises. Ater completin$ the ei$ht treatmentsessions' patients ere instructed to continue the home e0ercises and add the

closed-chain stren$thenin$ e0ercises (Appendi0 6i$ure). atients in the placebo

$roup ere instructed to continue their normal daily acti5ities.

Therapists and patients had no urther contact ater completion o the ei$ht

sessions. A post-treatment retest as scheduled by the testers at least 2 days

ater the last clinic treatment and at the same time o day as the pretreatment


5/6

test to allo ull stren$th reco5ery and account or daily uctuations in pain

and sti%ness.

Goth $roups o patients returned or additional tests at 1 year. At the 1-year

ollo-up 5isit' the number o patients in each $roup ho re7uired &nee sur$ery

as recorded. /rthopedic sur$eons ho ere unaare o $roup assi$nment or

the details o the study made the decisions or sur$ery. atients in both $roups

ho had not recei5ed inections in the &nee or a sur$ical inter5ention a$ain

completed the 9/;AH and -minute al& test.

Statistical Analysis

+ndependent t-tests' ;ann-9hitney U tests' and chi-s7uare tests ere used to

analye ratio' ordinal' and cate$orical 5ariables' respecti5ely' rom the initial

measurement session to detect si$nifcant di%erences beteen $roups. All data

analysis as perormed by usin$ SSS or 9indos' 5ersion . (SSS' +nc.'

Hhica$o' +llinois). ,escripti5e data analysis and tests or the assumptions o

normality and homo$eneity o 5ariance ere olloed by a 2 L ! mi0ed-model

multi5ariate analysis o 5ariance ith an M le5el o :.:. The independent

5ariables or the multi5ariate analysis o 5ariance ere $roup (to le5els) and

time (three le5els). The to dependent 5ariables ere 9/;AH scores and -

minute al& distances. Subse7uent post hoc 2 L ! uni5ariate analysis o

5ariance as perormed or each dependent 5ariable' ith a Gonerroni

corrected M le5el o :.:2. 6or uni5ariate analysis o 5ariance' the de$rees o

reedom ere conser5ati5ely adusted to compensate or potential 5iolations o

the homo$eneity-o-co5ariance assumption. ost hoc analyses o si$nifcant

$roup L time interaction e%ects ere perormed by usin$ the Tu&ey multiple

comparison procedure to e0amine pairise comparisons o mean scoresbeteen $roups and across the three data collection times. Analyses o -

minute al& distances and 9/;AH scores ere conducted on the subset o "

study patients or hom those data ere a5ailable at baseline' # ee&s' and 8

ee&s. aired t-tests ere used to compare a5era$e scores at 8 ee&s and 1

year or the study patients ho pro5ided data at those times. An intention-

to-treat chi-s7uare analysis as used to determine $roup di%erences in the

number o sur$ical inter5entions at 1 year amon$ all patients ho ere

entered into the study.

To in5esti$ate potential conoundin$ 5ariables' separate multiple re$ression

models ere created or each o the to dependent 5ariables. +n each

re$ression model' 1 possible predictors ere included in a orced-entry

analysisE treatment $roup assi$nment@ a$e@ hei$ht@ ei$ht@ se0@ duration o

symptoms@ sel-ratin$ o physical acti5ity le5el@ days per ee& o aerobic

acti5ity@ bilaterality o symptoms@ use o medications@ se5erity o radio$raphic

fndin$s@ and initial 9/;AH scores' -minute al& distances' &nee e0ion' and

e0tension ran$e-o-motion scores. Nalues rom the initial testin$ session ere


6/6

used or all 1 predictors. The 9/;AH scores and -minute al& distances

measured at ee& 8 ere entered as dependent 5ariables.

=esults

;ethods < =esults < ,iscussion < 3lossary < =eerences

/ the 8! patients initially enrolled in the study' !! in the treatment $roup and

! in the placebo $roup completed all treatment and testin$ at baseline' #

ee&s' and 8 ee&s. 6ourteen patients (1F@ " in the treatment $roup B21FD

and in the placebo $roup B12FD) dropped out o the study. +n the treatment

$roup' # patients ithdre because o unrelated medical reasons' 1 sustained

a &nee inury in an altercation' 2 had transportation di4culties' 1 as carin$ or

a terminally ill husband and declined to return' and 1 ithdre or un&non

reasons. +n the placebo $roup' 1 patient de5eloped cardiac problems' 1

ac7uired plantar asciitis' 1 as dis7ualifed ater recei5in$ a cortisone inection

to the &nee' and 2 had transportation di4culties. *o patients ere e0cluded

because o lac& o compliance ith or intolerance to either treatment re$imen.

The " patients ho completed the study attended all clinical appointments

and reported or testin$ at baseline' # ee&s' and 8 ee&s.

Gaseline characteristics o patients ho completed the study and those ho

did not are $i5en in Table 1. Table 2 shos mean 5alues ith "F H+s or the

dependent 5ariables measured at baseline' # ee&s' and 8 ee&s. ;edication

use is shon in Table !.

Artculo de Ingles

Documents

Transcript of Artculo de Ingles