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Rehabilitation and Outcomes - Year in Review
- 1. Monica Maly, PT PhD Associate Professor Department of Kinesiology, University of Waterloo, Waterloo Ontario Canada Disclosure Information I have no financial relationships with commercial interests to disclose AND My presentation does not include discussion of off-label or investigational use.
- 2. Year in Review: Rehabilitation and Outcomes Kendal A. Marriott,*1 Jaclyn N. Hurley,*2,3 Monica R. Maly1 *equal authorship 1University of Waterloo, 2McMaster University & 3York University 2
- 3. Motivation 1Martel-Pelletier J, Nat Rev Dis Primer, 2016; 2Hochberg M, Arthritis Care Res, 2012 (ACR); 3McAlindon T, OAC, 2014 (OARSI); 4Fernandes L, Ann Rheum Dis, 2013 (EULAR) Obesity Inactivity Biomechanics MODIFIABLE RISKS1 CORE TREATMENTS2,3,4 DIET EXERCISE Modifiable risk factors are key targets for rehabilitation 3
- 4. Purpose Highlight intervention parameters and effect sizes of exercise and lifestyle diet interventions on clinical outcomes for people with osteoarthritis (OA). 4
- 5. Methods Systematic Search • Medline (Pubmed, OVID), Scopus, CINAHL, Embase • Jan 1 2018 – Apr 1 2019 • OA, Exercise/Physical Activity, Diet/Nutrition (exploded) • Human, English, Full-text 5
- 6. Methods Search Strategy • Randomized controlled • Pilot and feasibility • Systematic reviews • Meta-analyses • Secondary • Retrospective • Qualitative • Narrative • Protocols • Case-studies • Post-surgical • Medication • Nutraceuticals, vitamins, additives • Electrothermal modalities • Devices • No OA-specific analyses 6
- 7. Methods 1Foley N, Phys Ther, 2006; 2deMorton N, Aust J Physiother, 2009; 3Hoffman T, BMJ, 2014; 4Yamato T, JOSPT, 2016 Systematic Reviews, Meta-AnalysesRandomized Controlled Trials Methodological Quality (PEDro)1,2 Intervention Description (TIDieR)3,4 Number of Sessions Duration of 1 session (min) Duration of care (w) Effect Size (pain, function, mobility, strength) Summarized 7
- 8. Results 313 Titles Retrieved 140 Full-text Review 53 Included* 38 Randomized Controlled Trials* 15 Systematic Reviews/Meta-analyses 5 mixed3 knee 2 hand + 1 knee+hip32 knee 1 hip 3 hand + 1 knee+hip 1 mixed * Awaiting 1 RCT 8
- 9. Results Randomized Controlled Trials: Exercise (38) Articles Baseline n Exercise + Other Care (PT, consult) 11 1,464 Exercise with Technology (online resources, biofeedback) 4 748 Resistance/Sensory-motor 6 460 Exercise + Modality (paraffin, phototherapy, laser) 4 243 Aerobic 3 150 Aquatic 2 140 Balance 2 132 Mind-body (yoga, pilates, Tai Chi) 3 120 Gait Retraining 2 102 Participatory Ergonomics 1 75 9
- 10. Results Randomized Controlled Trials • Methodological quality: High (20), Moderate (15), Low (3) • Challenges: Participant, interventionist blinding; clarity on intention-to-treat analysis • Intervention description: 1-10 (of 12) TIDieR criteria completed • Challenges: Intervention materials, procedures; delivery parameters; adherence (plan & report) 10
- 11. -2 -1 0 1 2 3 4 5 6 0 10 20 30 40 50 60 70 EffectSize Total # Exercise Sessions WOMAC Function WOMAC Pain 11 Results Improvement
- 12. -2 -1 0 1 2 3 4 5 6 0 2 4 6 8 10 12 14 16 EffectSize Exercise Frequency per Week WOMAC Function WOMAC Pain Results 12 Improvement
- 13. Exercise with Other Care Interdisciplinary Intervention for Hand OA1 • @8w: Grip strength increased in Functional Consultation + Exercise, decreased in Standard Care Hand OA (n=151) Functional Consultation + Exercise 1 session, ? min, 1 call 10 exercises, 10+ reps each, 8w Standard Care + Placebo ? sessions, ? min, ?w Referral as necessary 1Stoffer-Marx M, Arthritis Res Ther, 2018 13
- 14. Exercise with Other Care Self-Management (Ple2no) Program for Knee OA1 • @12w: Pain, symptoms no different btw groups • @12w: 6min walk, sit-to-stand better in self-management Knee OA (n=80) Self-management + Exercise 24 sessions, 90 min, 12w Education 3 sessions, ? min, ? duration 1Marconcin P, Clinical Rehab, 2018 14
- 15. Exercise with Technology Internet-Based Exercise for Knee OA1 • @16w, 52w: No differences btw IBET or PT with Wait List Knee OA (n=350) Internet-based Exercise Training (IBET) 24 sessions, ? min, 8w PT Up to 8 sessions, 60 min, 16w Wait List 1Allen K, Osteoarthritis Cart, 2018 15
- 16. Exercise with Technology Internet-based Pain Coping Skills + Exercise (HOPE Trial)1 • @24w: No btw group differences; both improved pain, WOMAC • @8w, 24w, 52w: Better pain coping in pain coping group Hip OA (n=144) Internet-based Pain Coping Skills before PT-led home exercise 61 sessions, 30-45 min, 24w Online Education before PT-led home exercise 61 sessions, 30 min, 24w 1Bennell K, Pain, 2018 16
- 17. Resistance Exercise High v Low Intensity Resistance + Blood Flow Restriction1 • @12w: Leg press, 1RM, quad cross-sectional area, chair stands greater in High Intensity & Low Intensity with Blood Flow Restriction than Low Intensity Knee OA (n=48 women) High Intensity (80% 1RM) 24 sessions, ? min, 12w Low Intensity (30% 1RM) 24 sessions, ? min, 12w Low Intensity & Blood Flow Restriction 24 sessions, ? min, 12w 1Ferraz R, Med Sci Sports Exerc, 2018 17
- 18. Aerobic Exercise High v Moderate Intensity Cycling1 • @8w: WOMAC improved in both groups • @8w: Timed Up&Go improved more in High than Moderate • Withdrawal rate 37% Knee OA (n=27) High Intensity (90s bouts “quite difficult” to talk) 32 sessions, 25 min, 8w Moderate Intensity (talk in complete sentences) 32 sessions, 25 min, 8w 1Keogh J, Peer J, 2018 18
- 19. Results Randomized Controlled Trials – Main Points • Adequate dosage, adherence • Delivering exercise via technology may require support (e.g., face-to-face?) • Higher intensity likely confers greater benefit – if tolerated 19
- 20. Results Systematic Reviews, Meta-analyses • 2 EULAR recommendations • Pain management for Inflammatory Arthritis & OA • Hand OA • 1 umbrella review • 7 meta-analyses • 11 systematic reviews 20
- 21. Diet Only Diet+Exercise Systematic Reviews Diet-Induced Weight Loss in Obese with Knee OA1 • Meta-analysis (n=16); Total n=2,140 • Pain: 1Hall M, Seminar Rheum Dis, 2018 Diet only does not reduce pain 21
- 22. Systematic Reviews Impact of Exercise on Knee Structure1 • Meta-analysis (n=5); Best evidence (n=2); Total n=1,082 • Moderate quality • No change radiographic • Low quality/ limited evidence • No change cartilage morphology or synovitis/effusion • Slight increase bone marrow lesion severity in obese • Protective effects on patellar cartilage Exercise unlikely to harm structure 1VanGinckel A, Seminar Rheum Dis, 2018 22
- 23. Systematic Reviews Specify Exercise Doses in Knee Disorders1 • 24 sessions, 8-12 w durations produced large effects on pain, physical function in knee OA • 1 session/w has no effect 1Young J, J Ortho Sports Phys Ther, 2018 Adequate dosing required to realize exercise benefits in knee OA 23
- 24. Key Messages Obesity Inactivity MODIFIABLE RISKS CORE TREATMENTS DIET EXERCISE • No new RCT data in 2018 • Diet alone ineffective for pain • Dose requires 24 sessions, 8-12 w but ?intensity, ?frequency per week • Exercise may worsen BML in obese but no other evidence of structural damage 24
- 25. Key Messages Challenges to tackle next? • Nutrition determinants of obesity, clinical outcomes • Hand and hip • Intervention parameters, dosage • Quality of life (including psychosocial) as primary outcomes 25
Notas del editor
- I have no disclosures.
- To start, I’d like to thank the organizing committee for this opportunity. I would also like to acknowledge Drs. Marriott and Hurley for their unwavering dedication to this review. I have the privilege to share our work here.
- Despite the heterogeneity of OA, the literature is consistent that obesity, inactivity and abnormal biomechanics are risk factors for the worsening of OA, and likely its initiation. For this review, we focused on rehabilitation strategies that directly address obesity and inactivity (we leave the biomechanics risk factor for the review by Dr. Hunt). Since both diet and exercise are considered core treatments for people with OA, our goal was to highlight literature that can help our community optimize care for people with OA.
- Our purpose was to highlight intervention parameters and effect sizes of exercise and lifestyle diet interventions on clinical outcomes in OA that were published since the last congress. We hoped that this review would yield a pattern in the range of parameters that optimize the effect size of diet and exercise interventions.
- Our search strategy targeted diet and exercise. We defined exercise as being planned, structured, and repeated. We defined lifestyle diet as any structured guide to the kinds of foods a person would habitually eat.
- We narrowed our search to Randomized Controlled trials and synthesis papers including systematic reviews and meta-analyses.
- Among the RCTs we identified for the review, we Evaluated methodological quality with the Physiotherapy Evidence Database methdological rating scale. We also reviewed each trial using the Template for Intervention Description and Replication to standardize the reporting of intervention parameters. We extracted dosage data, including the # of sessions, the duration of 1 session and the duration of care. and extracted effect sizes for outcomes of pain, self-reported physical function, mobility and strength measures reported in the trial. Among the systematic reviews and meta-analyses, we aimed to summarize and highlight key findings from these synthesis papers.
- After removing duplicates, 313 titles were identified by our search. Applying our exclusion criteria reduced this number to 53 RCTs and systematic reviews. Please note that we have ordered but not yet received one RCT. This review contains 38 RCTs, the majority focusing on knee OA; and 15 systematic reviews or meta analyses which reflect knee, hand and mixed populations. Let me give you more details first about the RCTs.
- This table breakdowns the types of interventions included in the 38 papers. *The most important item to note is that none dealt with lifestyle diet. Many papers examined exercise in combination with other care, including PT or a medical consultation. These complementary interventions include manipulation/mobilization, brace, taping, self-management, motivational interviewing. *Includes a large cluster design with a model OA consultation “NICE guidelines” in England (Dziedzic, 2018) Exercise with Modality (dry needling, phototherapy, laser, paraffin) **Present data for the top three categories: Exercise + other care; Exercise with technology; Resistance exercise
- Given that the inclusion criteria for this review required only RCTs, it is not surprising that the methodological quality was generally good, with the majority scoring 7 (of 10) or greater on the PEDro scale. The most common challenges within these studies were blinding of the participant or interventionist which is understandably extremely difficult to achieve in rehabilitation studies. Because we were interested in details of the intervention itself, we also used the TIDieR template to review the reporting of the intervention. We saw a broad range here, with studies satisfying anywhere between 1 and 10 of the 12 questions on this template. The most common challenges were unclear descriptions of the intervention material and procedures, delivery parameters and an a priori plan for adherence tracking.
- We also evaluated the relationship between dosage and effect size. Here you can see the range of total number of exercise sessions on the X axis; and effect size where improvement is positive on the Y axis. WOMAC Pain is orange; WOMAC function is blue. The most frequent dosage was a total of 12 exercise sessions. There is no discernable pattern between this dosage and effect size.
- This is a similar graph, except we’ve presented the exercise frequency per week along the X axis. It may appear that more frequent exercise was associated with better effect size.
- One of the 3 hand OA RCTs examined the effectiveness of a “functional consultation and exercises” compared to standard care in 151 participants with hand OA from a rheumatology clinic in Austria. Functional Consultation + Exercise group received: Assessment of pain, ADLs Pain management (meds, thermal) Assistive devices (Dycem and thumb orthosis prn) Hand exercises (5 exercises AROM,5 on grip strength exercises using therapy putty) ***Exercises were home based. Participants were asked to start with 10 reps of each exercise and gradually the increase the number of reps over the next 8 weeks. There was a written document and a online video for participants to refer to for the exercise instructions. 8 week follow-up call Tracked adherence by viewing use of the putty Standard care (n=77) Included a placebo massage ball (roll the ball gently) Referral based on need Results: at the 8 week follow-up, participants receiving the functional consultation and exercise showed increased grip strength; while the control group actually had a decrease in grip strength. This consultation plus home exercise program could be useful in primary care
- Within the category of exercise embedded within other care, we picked another paper examining the effectiveness of a self- management program, delivered to older adults with knee OA in 4 centres in Lisbon Portugal – 2 universities, a community centre and a church. The Self-Management program included 30 min self-management component focused on bolstering self-efficacy and content includes self-management, exercise and physical activity, communication, healthy eating, managing medicines. 60 min exercise component emphasized strength, flexibility and balance The Education group received Book contains descriptions for managing knee OA and exercise information Telephone calls 3 education sessions Primary outcomes of pain and symptoms were no different between groups at the 12 week follow-up. However, 6 min walk and sit-to-stand performance were significantly better in the self-management group relative to education alone.
- Several studies used technologies to either facilitate exercise as an intervention for knee OA. This large trial compared the effectiveness of an internet-based exercise training program and face-to-face physiotherapy versus a wait list in 350 adults with radiographic knee OA. The IBET was developed by multidisciplinary team (PT, MD, patient). Participants in this group were encouraged to complete strengthening and stretching exercise 3 times a week at least, and aerobic daily. Tailored Exercise (7 exercises) Exercise progression Video and photographs of exercises Automated reminders Progress tracking There was no face-to-face contact in this study arm and adherence to this program was not tracked. The PT program included strength, flexibility, mobility, balance exercises, assessment for assistive devices, home program, activity pacing. Up to 8 visits were available but the average was 5.7 visits and nearly all received therapeutic exercise. No group differences were noted at 16 or 52 weeks in any study outcomes, including the WOMAC. The dosage was likely too low (below the ACSM guidelines). PLEASE TAKE NOTE OF THE DOSAGE HERE.
- The only study on hip OA we included offered PT-led home exercise to all 144 participants with clinical hip OA. All participants were asked to complete home exercise 3x/w for 16 weeks and this home exercise program was supported by 5 face-to-face sessions with a PT. In the 8 weeks prior to initiating the home exercise, the study compared the effectiveness of online programs initiated BEFORE the exercise: either pain coping skills training or education. The pain coping skills module was automated and included skills in relaxation, activity-rest cycling, pleasant activity scheduling and imagery, distraction and problem-solving. Both groups experienced improved pain during walking and WOMAC score. Those in the pain coping group also experienced improved pain coping skills.
- The next two studies we selected because they explored the concept of exercise intensity. People with OA may not be able to produce high intensity muscle contractions required to overload the muscle to stimulate positive adaptation. This study examined whether blood flow restriction could enhance low intensity muscle contractions to yield the same benefits. The idea is that permitting arterial flow, while restricting venous return, will stimulate greater EMG activation, protein synthesis, metabolic overload that mimics effects of high intensity exercise on pH, or alterations in gene expression. 48 women with knee OA were split into 3 groups. All were offered supervised exercise on a leg press, and knee extension twice per week for 12 weeks. The high intensity group completed contractions at 80% 1RM; low intensity at 30% 1RM. The final group repeated the low intensity training at 30% 1RM with an air cuff at the inguinal fold. Indeed improvements in several outcomes including cross-sectional area and chair stands in the blood flow restriction group mimicked that observed in the high intensity group, and exceed the low intensity group.
- Feasibility trial 27 adults with knee OA were randomized to conduct high intensity versus moderate intensity bicycling 4 times per week over an 8 weeks. The exercise was unsupervised and home-based. Of the 27 participants, 17 completed the trial (37% withdrawal rate). 2 adverse events occurred in the moderate group; 26 adverse events occurred in the high group with one individual reporting 24 of these events, related to a Baker’s cyst. Appears that health-related quality of life measurements improved in both groups, but greater mobility achieved in the high intensity exercise group.
- Realistically exercise should be integrated with other evidence-based care but in doing so, it is important to ensure that the dosage for exercise is adequate. While a technology delivered exercise program appears feasible, it likely requires elements of face-to-face support. Higher intensity exercise may produce greater benefit but more data are necessary to determine if the greater benefit is worth the potential risk for adverse events. In this case, adherence is likely a key target to ensure exercise is integrated into a lifestyle change.
- I will now move onto the 15 synthesis papers included. Of these, there were 2 EULAR recommendations, 1 umbrella review, 7 meta-analysis which were in some cases combined with 11 systematic reviews.
- One of the only papers we reviewed focused on diet was a systematic review that highlighted that diet-induced weight loss, on its own, did not improve pain. Exercise must be integrated with diet – suggesting again that combining exercise with other care improves outcomes. The forest plot on the left shows that diet only did not improve meaningfully improve pain in the short term (top) or long term (bottom). However, on the right the forest plot shows that diet combined with exercise improves pain. Nevertheless, this review also highlighted that diet alone was effective in improving function.
- A systematic review also tackled the question of the impact of exercise on knee structure. While this meta-analysis did not include a great number of studies, the results are encouraging. Moderate quality evidence suggests that exercise does not affect radiographic evidence of disease. More sensitive markers of disease progression captured on MRI seem to corroborate this by suggesting no change in knee cartilage morphology or synovitis as a result of exercise, and perhaps some protective effects on patellar cartilage. However, some evidence suggests that among obese individuals, bone marrow lesions may worsen. These results should be interpreted with caution, though.
- Finally, we were intrigued to find a review on knee disorders examined the exercise doses associated with clinical improvements. This review included an OA specific analysis that showed that large effects on pain and physical function were most frequently associated with 24 total exercise sessions and 8-12 week durations. The review also identified that exercise frequency of 1 session per week has no effect on these clinical outcomes. This review emphasizes that adequate doing is required to realize exercise benefits in knee OA.
- QoL refers to the physical, psychological and social domains of health that are influenced by a person’s experiences, beliefs, expectations and perception
- Thank you to the organizing committee Safe journeys to all