THE EFFECTS OF MUD PACK THERAPY VERSUS HOT PACK …
Transcript of THE EFFECTS OF MUD PACK THERAPY VERSUS HOT PACK …
ABSTRACT
THE EFFECTS OF MUD PACK THERAPY VERSUS HOT PACK TREATMENT TO IMPROVE FUNCTIONALITY AND
DECREASE PAIN IN OLDER ADULTS SUFFERING WITH KNEE
OSTEOARTHRITIS
Objective: The purpose of this meta-analysis is to examine the effects of
mud pack therapy versus hot pack treatment to improve functionality and decrease
pain in older adults suffering with knee osteoarthritis.
Methods: Studies were analyzed to compare the increase in function and
decrease in pain with the use of mud pack therapy and hot pack treatment. The
studies were meta-analyzed to determine the novel intervention’s effect size and
homogeneity.
Results: Four studies were included in this meta-analysis. A medium effect
size was determined to improve function and decrease pain with the use of mud
pack therapy. Homogeneity was noted among the studies for function, while
studies were heterogeneous regarding the effects of pain in older adults suffering
with knee osteoarthritis.
Conclusion: This meta-analysis concludes mud pack therapy has a greater
treatment effect size to increase functionality and decrease pain in older adults
suffering with knee osteoarthritis compared to hot pack treatment.
Study Design: A meta-analysis of random control trial studies observing
the effects of mud pack therapy versus hot pack treatment to increase functionality
and decrease pain in older adults suffering from knee osteoarthritis.
Mario Ernesto Crespin May 2017
THE EFFECTS OF MUD PACK THERAPY VERSUS HOT PACK
TREATMENT TO IMPROVE FUNCTIONALITY AND
DECREASE PAIN IN OLDER ADULTS
SUFFERING WITH KNEE
OSTEOARTHRITIS
by
Mario Ernesto Crespin
A project
submitted in partial
fulfillment of the requirements for the degree of
Doctor of Physical Therapy
in the Department of Physical Therapy
College of Health and Human Services
California State University, Fresno
May 2017
APPROVED
For the Department of Physical Therapy:
We, the undersigned, certify that the project of the following student meets the required standards of scholarship, format, and style of the university and the student's graduate degree program for the awarding of the doctoral degree. Mario Ernesto Crespin
Project Author
Nupur Hajela (Chair) Physical Therapy
Jennifer Roos Physical Therapy
For the University Graduate Committee:
Dean, Division of Graduate Studies
AUTHORIZATION FOR REPRODUCTION
OF DOCTORAL PROJECT
X I grant permission for the reproduction of this project in part or in
its entirety without further authorization from me, on the
condition that the person or agency requesting reproduction
absorbs the cost and provides proper acknowledgment of
authorship.
Permission to reproduce this project in part or in its entirety must
be obtained from me.
Signature of project author:
ACKNOWLEDGMENTS
I would like to thank Dr. Nupur Hajela, Dr. Jennifer Roos, Dr. Monica
Rivera and Dr. Nicole Vitato for their support and guidance with the development
of this meta-analysis. As I earn my doctorate in physical therapy, I sincerely
express my deepest gratitude to my best friend, Jonathan de Vera, my parents, my
brother, and those I hold close to my heart for their unconditional love and
support. It gives me great pleasure to share this experience with the California
State University, Fresno, Doctor of Physical Therapy, Class of 2017 as we have
helped each other through adversity and celebrate our success collectively.
TABLE OF CONTENTS
Page
LIST OF TABLES .................................................................................................. vi
LIST OF FIGURES ................................................................................................ vii
BACKGROUND ...................................................................................................... 1
METHODS ............................................................................................................... 5
Search Strategy .................................................................................................. 5
Selection Criteria ............................................................................................... 5
Data Extraction .................................................................................................. 6
Statistical Analysis ............................................................................................ 6
RESULTS ................................................................................................................. 8
Study Characteristics ......................................................................................... 9
Synthesis of Results ........................................................................................ 10
DISCUSSION ......................................................................................................... 13
CONCLUSION ...................................................................................................... 17
REFERENCES ....................................................................................................... 18
TABLES ................................................................................................................. 22
FIGURES ............................................................................................................... 24
APPENDIX: PEDRO SCALE ............................................................................... 26
LIST OF TABLES
Page
Table 1. Study Characteristics ................................................................................ 23
LIST OF FIGURES
Page
Figure 1. Data analysis-pain ................................................................................... 25
Figure 2. Data-analysis-function ............................................................................ 25
BACKGROUND
Osteoarthritis (OA) is one of the most common clinical syndromes seen by
clinicians mainly affecting older adults and is associated with defective articular
cartilage integrity, changes of subchondral bone, and articulating joint margins.1
More than 100 different types of arthritic conditions have been identified, though
OA currently affects over 30 million people in the United States.2 Recent data
from the National Health and Nutrition Examination Survey reported
approximately 35% of women and men over the age of 60 years old are most
commonly affected with radiographic knee osteoarthritis.3-5 Currently, the lifetime
cost of symptomatic knee osteoarthritis management in the United States averages
$12,400 per person every year due to medical visits, pharmaceutical use, physical
therapy, purchase of braces, orthotics, and loss time of occupation productivity.4
Knee pain is a strongly associated subjective response with the progression of the
degenerative joint disease.1 The articular changes due to OA often lead to pain,
loss of mobility, muscle strength, impaired function, and decreased quality of
life.2-5 Dynamic balance deficits, impaired proprioception, altered postural control,
and reduced range of motion drastically increases the risk for falls among older
adults.1,6 Muscle weakness is a known risk factor for falls, and studies report a
76% decrease of eccentric quadriceps and hip muscle strength when comparing
elderly fallers and non-fallers.7
Although the etiology of knee osteoarthritis is not entirely understood, the
cause of osteoarthritis is multifactorial and several risk factors have been
identified, such as excessive weight bearing activities, traumatic events, high body
mass index, with the natural aging process being the most common predisposing
factor.1 Some studies have suggested biochemical markers of arthritis are
2 2
molecules detectable in synovial fluid that may reflect the underlying degenerative
or inflammatory response of joint disease.8,9 Increased levels of YKL-40, a
secreted glycoprotein, along with interlukin-6 and tumor necrosis factor-alpha,
cytokines released by macrophages were detected in older adults with active
rheumatoid arthritis and severe knee OA compared to healthy adults.10
Pharmacological treatment is an intervention aimed to reduce pain and
increase function for older adults suffering with symptomatic knee OA. It is
important to note non-steroidal anti-inflammatory drug (NSAID) therapy and
opioids have gastrointestinal side effects, with significant financial and health-
economic consequences.4 As drug therapy becomes less effective for pain
management, corticosteroid or hyaluronic acid injections are considerable
alternatives for immediate pain relief. However, people receiving repeated
injections may notice the period of pain relief minimizes over time with the
progressive degradation of cartilage.11 Physicians may recommend the surgical
intervention of a knee replacement for people with advance stages of knee OA.
Older adults are considered candidates for the orthopedic surgical procedure once
the integrity of the knee joint has been severely compromised causing functional
limitations and the impairment of pain is intolerable. However, patients may make
a personal choice to seek out conservative interventions in order to avoid surgery.
Several studies have advocated for the conservative management of
supervised physical therapy as an alternative to surgery to prevent or delay the
impact of disability associated with osteoarthritis.1,12-14 Physical therapy offers a
multimodal conservative approach consisting of therapeutic exercise, patient
education, shoe modifications, weight management, and thermal agents.
The previously mentioned interventions are commonly used in the field of
physical therapy as conservative treatments, though patient satisfaction is
3 3
infrequently achieved regarding pain management and improvement of function.
A physical therapy modality commonly used for treating knee OA symptoms is
hot pack application. Moist hot packs are cost effective and easily applied to
treatment in the outpatient physical therapy setting. Hot packs contain a clay
substance containing zinc oxide, talc, glycerol, activated carbon, and purified
distilled water in a nylon covering. The moist heating effect of hot packs have
been shown to offer instant and temporary relief for people suffering from knee
osteoarthritis.15
In an effort to advance the field of physical therapy there must be a shift in
the paradigm of conservative thermal treatments for knee osteoarthritis. Mud pack
therapy has been used in many European countries since the early 1800’s for the
treatment of musculoskeletal disorders branching from the intervention of
balneotherapy.15 Balneotherapy is the practice of immersing a subject in mineral
water or mineral infused mud and has traditionally been used in baths for the
treatment of osteoarthritis.15,16 Medical muds, known as peloids, have a high heat
storage capacity due to its volcanic sediment components providing long-lasting
heat by conduction with finely granulated organic and/or inorganic materials of
natural origin, minerals, and salts.16 The European League Against Rheumatism
(EULAR) has recommended mud pack therapy one of the non-pharmacological
interventions for joint dysfunction and pain management caused by knee
osteoarthritis.17
The Visual Analog Scale (VAS) is an assessment tool used to quantify and
objectively measure pain levels perceived by patients. The VAS uses a line
measured from 0-10 cm as 0 indicates no pain and 10 denotes the highest pain
possible perceived by a patient.18 The Western Ontario and McMaster Universities
(WOMAC) Osteoarthritis Index measures Pain (5 items), Stiffness (2 items), and
4 4
Physical Function (17 items). Five Likert responses, ranging from 0=none to
4=extreme, were available for each item.19 The Kellgren Lawrence (K-L) Scale is
an assessment tool used to determine the severity of an arthritic knee on a plain
radiograph. The grades range from 0 to 4, as grade 0 indicates no radiographic
features of osteoarthritis and 4 represents large osteophytes, marked joint space
narrowing, severe sclerosis, and definite bony deformity.19
The purpose of this meta-analysis is to bridge the gap in the literature as no
current meta-analysis exists comparing the efficacy of mud pack therapy versus
hot pack treatment in order to improve functionality and decrease pain in older
adults. The null hypothesis for this meta-analysis states mud pack therapy will
have no statistical significance compared to hot pack treatment. With the
application of mud pack therapy, it is hypothesized there will be a statistical
significance in favor of mud pack therapy to decrease pain intensity measured by
the VAS and decrease disability using the WOMAC for people suffering with
knee osteoarthritis.
METHODS
Search Strategy
The design of the meta-analysis used the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA) as professional guidelines. An
electronic search began August 2016 and concluded September 2016. One
reviewer completed a computerized search using the following databases:
CINAHL, PubMed, and Science Direct. The search terms used to retrieve related
publications were: mudpack therapy, mud pack therapy AND knee osteoarthritis,
balneotherapy, balneotherapy AND knee osteoarthritis, mud compress, and
peloids. To specify the search for appropriate articles, filters were applied in each
database to locate available abstracts, full text, and peer-reviewed articles with
randomized control trials published in English from January 2010 to September
2016.
Selection Criteria
The inclusion criteria for this meta-analysis comprised of men and women
between the ages of 45-80 years old. Studies were included if the participants were
diagnosed with knee osteoarthritis with a grade of 1-4 using the Kellgren
Lawrence (K-L) scale, which categorizes the severity of OA.20 Studies with direct
comparison between mud-pack therapy and hot pack treatment were accepted with
outcome measures to evaluate pain levels using the Visual Analog Scale (VAS)
and improvements of function measured by the Western Ontario McMaster
Universities Arthritis Index (WOMAC).18,19 After reading the titles of the articles,
duplicate records were expelled from the search. Studies containing abstracts,
which did not relate to mud pack therapy and knee osteoarthritis were also
eliminated. Studies were excluded if subjects presented with a medical history of
6 6
surgery on the involved knee joint, subjects who received intra-articular injections,
or received physical therapy in the last 6 months. Studies with subjects presenting
with dermatological diseases or secondary inflammatory symptoms that are
contraindicated for receiving hot or mud pack application were also excluded.
Data Extraction
Data collected to assess pain level and function for subjects with knee
osteoarthritis were extracted from the tables within the results section of each
article. The experimental group received the application of mud pack therapy
while the control group was treated with hot packs. In order to conduct the
statistical analysis for the meta-analysis, the sample sizes, means, and standard
deviations for the experimental and the control groups were extracted from the
articles and inputted into the Metaanalyst 3.13 software. Tefner et al collected data
2.5 months post-treatment, Sarsan et al. and Gungen et al. collected data 3 months
following treatment, while Antunez et al. recorded results immediately after the
completion of the 11th treatment session.
Statistical Analysis
This meta-analysis has combined statistical data from the selected studies in
order to determine the grand effect size of the interventions, the confidence
interval, as well as the Q statistic and its associated p-value. The combined effect
size is quantifiable information gathered from a collection of studies used to
determine the effectiveness and how well an intervention will improves outcomes
compared to the control treatment. A small effect is indicated by an effect size less
than 0.3, a medium effect size ranges between 0.3 to 0.8, and an effect size above
0.8 represents the experimental intervention has a large effect to decrease pain and
improve function. The confidence interval, also known as the margin of error
7 7
determines statistical significance of the effect size if the zero y-axis is not
included within its range. Statistical significance indicates with 95% confidence an
intervention will have the determined effect size with the use of the experimental
intervention. The Q-statistic and its associated p-value establish the studies used in
the meta-analysis are homogeneous or heterogeneous. If the Q-statistic generated
is less than 2 degrees of freedom for this meta-analysis and the p-value is greater
than 0.05, the studies are considered to be conducted in a similar manner, reducing
variability and are noted as being homogeneous. Statistical data generating a Q-
statistic greater than 2 degrees of freedom and a p-value of less than 0.05 represent
the studies were designed with method inconsistencies and variability.
RESULTS
A search was completed through the computerized databases CINAHL,
PubMed, and Science Direct using the keywords: mud pack therapy, medical
peloids, and knee osteoarthritis. A total number of 869 articles were found with
the search terms, though only 37 abstracts were screened and considered
appropriate for the meta-analysis. Articles were excluded based on the titles,
which did not pertain to mud pack therapy nor published in English. From the
remaining abstracts, 21 full text articles were assessed for eligibility of the meta-
analysis. Sixteen articles were excluded from the meta-analysis if the desired
outcomes measures were not utilized, the publications were older than 5 years,
studies did not state age ranges for subject selection, or the means and standards
deviations were not provided in the studies. Once the search was finalized, 4
articles were acceptable, consisting of studies by Sarsan et al., Tefner et al.,
Antunez et al., and Gungen et al. Figure 1 displays a consort of all included and
excluded trials for the article search. Each study was appropriate for this meta-
analysis due to the subject population, outcome measures, study design, statistical
means, and standard deviations. All studies were selected as they fulfilled the
criteria for the established PICO.
The PEDro scale (see Appendix) was used to critically appraise the selected
articles for this meta-analysis in order to determine the quality of internal validity.
The 4 studies’ scores ranged from 5/10 to 8/10 with the common categories not
met: allocation concealment, blinding of subjects, blinding of therapists, blinding
of assessor, and intention to treat. In order to assess the strength and limitations of
each study, PEDro scores must be considered when reviewing statistical results.
The PEDro scores for the studies used in this meta-analysis are shown in Table 1.
9 9
Study Characteristics
Articles included in this meta-analysis were from Sarsan et al., Gungen et
al., Antunez et al., and Tefner et al. All the studies in the meta-analysis met the
standards set by the PICO criteria. These studies were appropriate to determine the
efficacy of mud pack therapy in the field of physical therapy based on the
population, study design, outcome measures, and the availability of means and
standard deviations.
The study by Sarsan et al.21 scored a 6/10 on the PEDro scale. The design
of the study compared the efficacy of mature mud pack and hot pack therapies on
patients with knee osteoarthritis that received a home exercise program for knee
active range of motion and isometric quadriceps strengthening. Outcome measures
recorded the subjects’ pain level and function 3 months post-treatment once 10
sessions were completed in 2 weeks. For this study, mud pack therapy did not
present with statistical significance, though a moderate effect size is noted to
reduce pain while only having minimal effect size to improve function. However,
mud pack therapy was favored compared to hot pack treatment to reduce pain and
increase function.
Gungen et al.22 scored a 5/10 on the PEDro scale. The study aimed to
evaluate the effectiveness of mud pack therapy to hot packs in a two-week
treatment. The outcome measures assessed pain intensity values and total physical
function scores 3 months after treatment. In regards to subjective pain response,
mud pack therapy had no statistical significance and a minimal effect size, which
was favored compared to the control group. Mud pack therapy was statistically
significant and was the favored intervention with a moderate effect size in order to
improve function 3 months after treatment.
10 10
Antunez et al.16 scored a 5/10 on the PEDro scale. The study analyzed the
effects of mud therapy application compared to a control group receiving drug
therapy after 11 consecutive sessions. After the intervention was provided on the
last session, statistical significance was noted, with a large effect size favoring the
intervention of mud therapy. In this study, a reduction of analgesic drug use was
observed in the experimental group compared to the control group after 11
treatments.
Tefner et al.24 received a score of 8/10 on the PEDro scale. The study
evaluated the effects of mud pack therapy compared to a control sham mud-pack
therapy on quality of life and function of patients with knee osteoarthritis. Subjects
were treated 5 consecutive days for 2 weeks. Data of the outcome measure
assessing the improvement of function and quality of life were collected 2.5
months after of the application of both thermal modalities. Although mud pack
therapy was favored as an alternative intervention for improving function among
older adults suffering with knee OA, this study was not statistically significant
with a minimal effect size.
Synthesis of Results
The Q-statistic value measuring perceived pain with the VAS in this meta-
analysis was 8.621, which is larger than the 2 degrees of freedom, while the p-
value was 0.013 determining the studies were heterogeneous. Mud pack therapy
has a least 95% confidence to provide moderate grand effect size (ES= -0.656)
when compared to hot pack treatment for the reduction of knee osteoarthritis pain.
The 3 studies used to determine the efficacy of mud pack therapy to decrease pain
have individual effect sizes ranging from a small to a medium effect size. Sarsan
et al. and Gungen et al. have confidence intervals that include the zero y-axis,
11 11
therefore are individually not statistically significant. Antunez et al is the noted
outlier with a medium effect size compared to the other studies. (Figure 2) As
previously reported, these studies are heterogeneous with variability in their
methods. Antunez et al. was the only study with a large sample size, though only
collected post-treatment data after the 11th visit. Subjects were allowed to use
analgesics throughout the trial, and the K-L grade levels were not reported for the
subjects diagnosed with knee OA.
The statistical analysis results for the WOMAC across the studies
determine the Q-statistic value of 1.464 and p-value of 0.481 signifying
homogeneity among the studies. The combined effect size (ES= -0.383), which
indicates mud pack therapy has a medium grand effect size on improving function
compared to hot pack treatment. The 3 studies used to analyze the effectiveness of
functional improvement using mud pack therapy determined individual effect
sizes ranging from a small to medium effect size as noted on the negative x-axis to
decrease disability on the WOMAC data analysis (Figure 2). The Metaanalyst
software reported Sarsan et al. and Tefner et al. are individually not statistically
significant, while the zero y-axis is not included in the confidence interval for the
study conducted by Gungen et al. As previously stated, homogeneity was
determined with minimal variability as all 3 studies had similar sample sizes,
using subjects within the same age range, collecting data 2.5 to 3 months post-
treatment, with comparable methods (Figure 2).
A decrease in pain level using the VAS and an improvement in function
with the WOMAC are represented by a negative effect size on the x-axis in the
forest plots (Figures 1 & 2). The confidence intervals for the grand effect sizes
analyzing pain and function outcome measures do not include the zero y-axis,
which indicates statistical significance. Mud pack therapy has statistical
12 12
significance with 95% confidence to decrease pain and improve functionality for
older adults suffering from knee osteoarthritis. Therefore, the alternative
hypothesis is accepted for this meta-analysis.
DISCUSSION
The purpose of this meta-analysis was to investigate the effectiveness of
mud pack therapy versus hot pack treatment in order to reduce pain and improve
functionality for older adults suffering with knee osteoarthritis. The meta-analysis
intended to bridge the gap in the literature as mud pack therapy is not currently
utilized in the field of physical therapy in the United States.17 It is important to
consider additional conservative treatments as surgical options are not readily
available for early stages of knee OA and patients in the later stages do not always
agree to a total knee arthoplasty.25 The degenerative joint disease has no effective
remedy and is considered the leading cause of pain and functional limitation
among older adults. 2,14-17 Therefore, introducing and investigating additional
interventions may improve the quality of life for the older adult population
affected by knee osteoarthritis.2
The data extracted from the selected articles for the VAS and WOMAC
outcome measures were inputted into the Metaanalyst 3.13 software in order to
generate collective statistical results. The meta-analysis indicates moderate grand
effectiveness for treating knee OA patients compared to the application of hot
pack treatment. The effects of mud pack therapy to relieve knee joint pain resulted
in a Q-statistic of 8.621, which is greater than the 2 degrees of freedom.
Heterogeneity was determined among the studies to investigate the reduction of
knee OA pain using of mud pack therapy. Therefore, a random-effect model was
applied to estimate the mean of distribution of the statistical data. While mud pack
therapy has not been extensively studied in the United States for the efficacy of
treating knee osteoarthritis; the analyzed data from this meta-analysis contains
meaningful findings as a viable physical therapy intervention. Mud pack therapy
14 14
has been reported to save approximately $730 (672 Euro) annually in healthcare
costs per patient, reducing medical visits, corticosteroid injections, and the
purchase of analgesics.26 The addition of mud pack therapy as a conservative,
topical thermal agent can be applied to the practice of physical therapy. It is easily
administered, increasing patient satisfaction, and optimizing compliance during
continued physical therapy treatment.
Although mud pack therapy has statistical significance in favor of
decreasing pain and improving function with a medium grand effect size, the
results must be interpreted with caution. It is necessary to address the limitations
causing variability among the selected studies as heterogeneity was previously
stated regarding the statistical analysis for pain management. One of the
limitations to recognize is the lack of studies used for this meta-analysis. Since
mud pack therapy has been studied in other countries outside of the United States,
it must be considered that quality studies were excluded from this meta-analysis
because they were not published in the English language.
Sample sizes for 3 out of the 4 studies used a small number of subjects
ranging between 15-26 participants for both the experimental and the control
groups. Antunez et al. was the only study in this meta-analysis with a considerably
large sample sizes selecting 61 subjects for the experimental group and 60 subjects
for the control group. The severity of knee osteoarthritis using the Kellgren-
Lawrence scale among the subjects varied due to the constraint in population
sizes. Tefner et al. accepted subjects with a K-L grade from 1 to 3, while Sarsan et
al. used subjects with a grade of 2 to 3 on the K-L scale. Gungen et al. conducted
the study using participants with advanced stages of K-L 3 to 4. Antunez et al.
stated the participants were diagnosed with osteoarthritis of the knee, but omitted
the stage of progression for the degenerative disease.21-24
15 15
Another limitation in the design across all 4 studies was the variation of
standardization for intervention parameters and protocols. In order to assess
internal validity, the selected randomized control trials were critically appraised
for their quality. The PEDro scores ranged between 5 to 8, from an average to
moderately high quality appraisal posing a threat to internal validity. The value of
the studies and threat to internal validity are also a factor in heterogeneity as the
analysis revealed a large difference between the upper and lower confidence
intervals. Since patients were not blinded in 3 out of the 4 studies, patients could
have possibly been biased when reporting self-perceived scores disrupting the
purpose of optimizing patient outcomes. Temperature and time duration of the
treatment application for both mud pack therapy and hot pack treatments varied
minimally between 30 to 45°C with a time duration from 20 to 30 minutes. Many
authors have studied the role and the mechanism of heat therapy as serum beta-
endorphin levels increase together as pain decreases, suggesting the role of
endogenous opoids.27-30 The lack of consistency to administer the experimental
and control interventions at a standard temperature and timeframe are factors
which may have resulted in heterogeneity among the studies.
Recommendations for the future direction on the effects of mud pack
therapy would need to be considered in order to implement this novel intervention
into the field of physical therapy. Objective functional outcome measures would
better quantify the improvements of physical function, increased distance, and
speed by using the 6-minute walk test and gait velocity. Currently, studies
attempting to record an improvement in functionality and quality of life utilize
surveys that are self-rated by the subjects. Although the Visual Analog Scale
quantifies pain, there is an absence of a gold standard as subjects perceive pain
differently, thus criterion validity cannot be evaluated appropriately.18 Antunez et
16 16
al. and Tefner et al. noted a decrease of NSAIDS and drug use such as
paracetamol for pain management. The experimental group receiving mud pack
therapy showed a continuous downward trend at the subsequent post-treatment
visit and were significant by the last visit compared to baseline.23,24 Therefore,
future studies should log the intake of analgesics from base line to post treatment
to objectively measure an improvement in pain management. Contrary to the
studies conducted by Antunez et al. and Tefner et al., the effect sizes for the VAS
and WOMAC in the study by Gungen et al. were the outliers in the data analysis.
The small effect size for perceived pain (ES= -0.125) has no correlation to the
moderate improvement in function (ES= -0.695) the subjects gained with the
application of mud pack therapy. Studies should also focus on noting the quantity
of biochemical markers at the cellular level. Bellometti et al. reported mud pack
treatments decrease chemical biomarkers serum levels affect the integrity of the
knee articulation.30,31 Therefore, data collected 6 to 12 months after treatment will
help determine if mud pack therapy would have a carry-over effect to delay the
onset of inflammation, pain, and cartilage degradation caused by interlukin-6,
tumor necrosis factor-alpha, and YKL-40.22,27-29,31
CONCLUSION
This meta-analysis determined the use of mud pack therapy to be
statistically significant to reduce pain and improve functionality for people
suffering with knee osteoarthritis. The medium grand effect size reported from the
statistical analysis demonstrates mud pack therapy would optimize patient
outcomes. However, due to the novelty of the intervention in the United States, it
is important to recognize more studies are needed with larger sample sizes,
improved methodological processes, and longer follow-up periods. In order to
mitigate the affects of knee OA, it is important to continue evaluating the clinical
efficacy of mud pack therapy as a conservative treatment to advance the field of
physical therapy.
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TABLES
23 23
Table 1. Study Characteristics
Criterion
Meta-Analysis Studies
Antunez et
al.
Gungen et
al.
Sarsan et
al.
Tefner et
al.
1. Random Allocation of
subjects
X
X
X
X
2. Allocation concealed
3. Similar groups at
baseline
X
X
X
X
4. Subjects blinded
X
5. Therapists
administering treatment
blinded
6. Assessors blinded
X
X
7. One key outcome
obtained from 85% of
subjects
X
X
X
X
8. Data of one key
outcome was analyzed by
“intention to treat”
X
9. Between-group
statistics for one key
outcome reported
X
X
X
X
10. Point measure and
measure of variability
for one key outcome
X
X
X
X
Total Score 5 5 6 8
FIGURES
25 25
Figure 1. Data analysis-pain
Figure 2. Data-analysis-function
APPENDIX: PEDRO SCALE
27 27
28 28