The effectiveness of pulsed electrical stimulation in the management of osteoarthritis of the knee

Osteoarthritis of the knee is a chronic disease leading to considerable burden on health. Pain, while not always present is the most prominent clinical feature and the cause of significant disability. There are a wide variety of treatment options available to patients, many with substantial side effects or contraindications for use. However, these options have modest effects at best and target symptoms rather than the disease.Pulsed electrical stimulation (PES) is an electrotherapy treatment modality using capacitively coupled, pulsed, monophasic current with a frequency of 100Hz, delivered at sub-sensory intensity. It has been reported to produce positive outcomes for pain, function and physician global assessment in short-term randomised controlled trials (four and 12 weeks) and longer term longitudinal studies. It is relatively inexpensive, non-pharmaceutical, non-invasive and has few side effects. Despite all this its use is not widespread. In addition, PES has a putative disease-modifying action through its ability to stimulate chondrocyte activity and type II collagen formation.The aim of this doctoral research was to investigate the effectiveness of PES in treating osteoarthritis of the knee by measuring pain, function, patient global assessment, quality of life and physical activity over a period of 26 weeks.In order to do this, an initial pilot study using commercially available PES equipment was conducted. The aims of this small study following three participants over 16 weeks were to investigate whether reported improvement was maintained over the longer period of time and to pilot test the materials, process and equipment being considered for a subsequent randomised controlled trial. This study provided evidence to suggest that the longer term randomised controlled trial was warranted.The next phase of this doctoral research centred around the development of the PES and placebo-PES equipment. Initial testing of the equipment that was made to replicate the parameters reported in the literature produced unacceptable adverse skin reactions. As a consequence, further consideration was given to electrical treatment parameters and a second prototype containing pulsed, asymmetrically biphasic current with a frequency of 100Hz was developed and tested.A cross-sectional study of 25 healthy adults with no contraindications to electrotherapy was undertaken to compare the rate of adverse skin reactions after using the replicated monophasic device with that after using the asymmetrically biphasic device. These rates were also compared with the rates of adverse skin reactions cited in the PES literature. Thirteen (52%) participants experienced an adverse skin reaction after using the monophasic prototype device, while one (4%) participant demonstrated an adverse skin reaction after using the biphasic prototype device. Additionally, the rate for the monophasic prototype differed significantly from the reported rates in three of the four published studies (p<0.04). These results gave strong support for the use of the biphasic current in the proposed randomised controlled trial.In order to investigate the effectiveness of PES in treating people with osteoarthritis of the knee, a double-blind, randomised, placebo-controlled, repeated measures trial was undertaken over 26 weeks. Seventy people were randomised to either the PES or placebo group. Outcome measures included pain, function, patient global assessment, quality of life, physical activity and global perceived effect. At the end of the study at 26 weeks, there was a statistically significant improvement in pain visual analogue scale (p≤0.001) in both groups. However, there was no difference between the groups (mean change difference 0.9mm; 95% confidence interval -11.7mm to 12.5mm). Similarly no differences were found between the groups in any of the other outcome variables. These results conclude that in this particular sample of people with mild to moderate symptoms and impairment, and moderate to severe radiographic osteoarthritis of the knee, PES used over 26 weeks was no better than placebo.Osteoarthritis of the knee is a chronic condition. People suffering pain and disability from the disease need to be able to make informed choices about best available treatment options. This doctoral research provides independent evidence of the effectiveness of PES. In doing so it adds to the body of evidence available to assist those with osteoarthritis and their health care providers in making treatment choices

Upper cervical instability associated with rheumatoid arthritis: What to 'know' and what to 'do'

This case report describes a patient who presented with cervical spinal pain and headaches associated with atlanto-axial subluxation (AAS) secondary to rheumatoid arthritis (RA). For physiotherapists, especially less experienced clinicians, the significant risks associated with using manual assessment and treatment techniques in such a patient require careful consideration right at the start of a consultation. The focus of the case is therefore on the recognition of AAS in this patient with RA, highlighting the clinical findings that alert clinicians to this possibility and explaining the requisite knowledge and skills required to safely and effectively manage this patient. The use of screening tools to help clinicians identify possible RA in its pre-diagnosis stage and the clinical signs and symptoms that raise the index of suspicion for AAS, are discussed. The relevant contraindications and precautions associated with manual treatments directed at the upper cervical spine, and which may have potentially serious negative consequences, including quadriplegia and mortality, are addressed. Finally, the implications for the use of manual assessment and treatment of patients with RA and co-morbid AAS are addressed

Translating policy into practice for community-based management of rheumatoid arthritis: Targeting professional development needs among physiotherapists.

Introduction: Contemporary health policy promotes delivery of community-based health services to people with musculoskeletal conditions, including rheumatoid arthritis (RA). This emphasis requires a skilled workforce to deliver safe, effective care. We aimed to explore physiotherapy workforce readiness to co-manage consumers with RA by determining the RA-specific professional development (PD) needs in relation to work and educational characteristics of physiotherapists in Western Australia (WA). Methods. An e-survey was sent to physiotherapists regarding their confidence in co-managing people with RA and their PD needs. Data including years of clinical experience, current RA clinical caseload, professional qualifications, and primary clinical area of practice were collected. Results. 273 physiotherapists completed the survey. Overall confidence in managing people with RA was low (22.7–58.2%) and need for PD was high (45.1–95.2%). Physiotherapists with greater years of clinical experience, a caseload of consumers with RA, postgraduate qualifications in musculoskeletal physiotherapy, or who worked in the musculoskeletal area were more confident in managing people with RA and less likely to need PD. Online and face-to-face formats were preferred modes of PD delivery. Discussion. To enable community-based RA service delivery to be effectively established, subgroups within the current physiotherapy workforce require upskilling in the evidence-based management of consumers with RA

Physiotherapy co-management of rheumatoid arthritis: Identification of red flags, significance to clinical practice and management pathways

Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune disease. Physiotherapy interventions for people with RA are predominantly targeted at ameliorating disability resulting from articular and periarticular manifestations of the disease and providing advice and education to improve functional capacity and quality of life. To ensure safe and effective care, it is critical that physiotherapists are able to identify potentially serious articular and peri-articular manifestations of RA, such as instability of the cervical spine. Additionally, as primary contact professionals, it is essential that physiotherapists area ware of the potentially serious extra-articular manifestations of RA. This paper provides an overview of the practice-relevant manifestations associated with RA that might warrant further investigation by a medical practitioner (red flags), their relevance to physiotherapy practice, and recommended management pathways

Upper back pain in postmenopausal women and associated physical characteristics

The physical characteristics of postmenopausal women that are associated with upper back pain are not well-understood. The aim of this cross-sectional study was to identify the physical characteristics associated with presence and severity of upper back pain in healthy postmenopausal women. Self-reported upper back pain presence (within the previous month) and severity (numerical rating scale) were examined against the physical characteristics: height; weight; body mass index; breast size; breast ptosis; upper back extensor muscle endurance (isometric chest raise test); head, shoulder and upper back posture (photogrammetry); thoracic extension mobility (photogrammetry); bone mineral density (dual-energy x-ray absorptiometry (DXA)); body composition (DXA); and thoracic kyphosis, thoracic osteoarthritis and thoracic vertebral fracture (all radiography). A multivariable logistic regression model, adjusted for age, was built using physical characteristics with a significant univariate association with upper back pain. Censored Tobit regression, adjusted for age, was used to examine each physical characteristic against upper back pain severity. Postmenopausal women (n = 119) with a mean (SD) age of 61.4 (7.0) years participated in the study. After adjusting for age, the physical characteristics independently associated with upper back pain were: height (OR: 0.50, 95% CI: 0.31–0.79); and upper back extensor muscle endurance (OR: 0.46, 95%CI: 0.28–0.75). This model explained 31% of the variance in upper back pain (p<0.001). After adjusting for age, being taller and having better upper back extensor muscle endurance were associated with lower odds for upper back pain. After adjusting for age, differences in upper back pain severity were explained by upper back extensor muscle endurance (p = <0.001) and lean mass (p = 0.01). Conclusion: As a modifiable physical characteristic of postmenopausal women with upper back pain, upper back extensor muscle endurance is worth considering clinically

Physiotherapy students' perspectives of online e-learning for interdisciplinary management of chronic health conditions: A qualitative study

© 2016 Gardner et al. Background: To qualitatively explore physiotherapy students' perceptions of online e-learning for chronic disease management using a previously developed, innovative and interactive, evidence-based, e-learning package: Rheumatoid Arthritis for Physiotherapists e-Learning (RAP-eL). Methods: Physiotherapy students participated in three focus groups in Perth, Western Australia. Purposive sampling was employed to ensure maximum heterogeneity across age, gender and educational background. To explore students' perspectives on the advantages and disadvantages of online e-learning, ways to enhance e-learning, and information/learning gaps in relation to interdisciplinary management of chronic health conditions, a semi-structured interview schedule was developed. Verbatim transcripts were analysed using inductive methods within a grounded theory approach to derive key themes. Results: Twenty-three students (78 % female; 39 % with previous tertiary qualification) of mean (SD) age 23 (3.6) years participated. Students expressed a preference for a combination of both online e-learning and lecture-style learning formats for chronic disease management, citing flexibility to work at one's own pace and time, and access to comprehensive information as advantages of e-learning learning. Personal interaction and ability to clarify information immediately were considered advantages of lecture-style formats. Perceived knowledge gaps included practical application of interdisciplinary approaches to chronic disease management and developing and implementing physiotherapy management plans for people with chronic health conditions. Conclusions: Physiotherapy students preferred multi-modal and blended formats for learning about chronic disease management. This study highlights the need for further development of practically-oriented knowledge and skills related to interdisciplinary care for people with chronic conditions among physiotherapy students. While RAP-eL focuses on rheumatoid arthritis, the principles of learning apply to the broader context of chronic disease management

The effectiveness of pulsed electrical stimulation (E-PES) in the management of osteoarthritis of the knee: a protocol for a randomised controlled trial

<p>Abstract</p> <p>Background</p> <p>Osteoarthritis (OA) of the knee is one of the main causes of musculoskeletal disability in the western world. Current available management options provide symptomatic relief (exercise and self-management, medication and surgery) but do not, in general, address the disease process itself. Moreover, adverse effects and complications with some of these interventions (medication and surgery) and the presence of co-morbidities commonly restrict their use. There is clearly a need to investigate treatments that are more widely applicable for symptom management and which may also directly address the disease process itself.</p> <p>In two randomised controlled trials of four and 12 weeks duration, pulsed electrical stimulation was shown to be effective in managing the symptoms of OA of the knee. Laboratory and animal studies demonstrate the capacity of externally applied electric and electromagnetic fields to positively affect chondrocyte proliferation and extracellular matrix protein production. This latter evidence provides strong theoretical support for the use of electrical stimulation to maintain and repair cartilage in the clinical setting and highlights its potential as a disease-modifying modality.</p> <p>Methods/Design</p> <p>A double-blind, randomised, placebo-controlled, repeated measures trial to examine the effectiveness of pulsed electrical stimulation in providing symptomatic relief for people with OA of the knee over 26 weeks.</p> <p>Seventy people will be recruited and information regarding age, gender, body mass index and medication use will be recorded. The population will be stratified for age, gender and baseline pain levels.</p> <p>Outcome measures will include pain (100 mm VAS and WOMAC 3.1), function (WOMAC 3.1), stiffness (WOMAC 3.1), patient global assessment (100 mm VAS) and quality of life (SF-36). These outcomes will be measured at baseline, four, 16 and 26 weeks. Activity levels will be measured at baseline and 16 weeks using accelerometers and the Human Activity Profile questionnaire. A patient global perceived effect scale (11-point Likert) will be completed at 16 and 26 weeks.</p> <p>Discussion</p> <p>This paper describes the protocol for a randomised, double-blind, placebo-controlled trial that will contribute to the evidence regarding the use of sub-sensory pulsed electrical stimulation in the management of OA of the knee.</p> <p>Trial registration</p> <p>Australian Clinical Trials Registry ACTRN12607000492459.</p

Monophasic electrical stimulation produces high rates of adverse skin reactions in healthy subjects.

Monophasic pulsed electrical stimulation (PES) has been reported to improve pain and function in osteoarthritis of the knee with few side effects. This use of monophasic current is contrary to conventional thinking where it is often associated with adverse skin reactions. The objectives of this study were to compare the rates of adverse skin reactions, using independently developed subsensory monophasic PES in healthy subjects, with those described in previous studies and compare the rate of adverse skin reactions after using the monophasic PES with that after using the same shaped electrical waveform that is asymmetrically biphasic. Healthy subjects (n=25) with no contraindications to electrical stimulation were administered subsensory, monophasic, and biphasic PES sequentially to the knee region for approximately 10 minutes each. Stimulation intensities; duration of stimulation; description of sensation reported; skin condition after intervention; and duration of skin reaction were all recorded. Fifty-two percent of subjects experienced adverse skin reactions using monophasic PES. This was significantly different from the reported rates in three of the four previous studies (p<0.04). Only one subject (4%) using the biphasic current demonstrated an adverse skin reaction. Results support the caution advised in the electrotherapy literature when using monophasic electrical stimulation

Is Breast Size Related to Prevalent Thoracic Vertebral Fracture? A Cross-Sectional Study.

Large breasts may increase the likelihood of thoracic vertebral fractures by increasing the mechanical loading of the spine. We examined breast size as a factor associated with prevalent thoracic vertebral fractures, also considering its relationship with thoracic kyphosis and upper back extensor muscle endurance. Using a cross-sectional study, the design measurements collected were thoracic vertebral fractures (≥20% loss in vertebral body height on lateral radiograph), breast size (bra size converted to an ordinal breast size score), BMD (g/cm2 averaged femoral neck, DXA), upper back extensor muscle endurance (isometric chest raise test), body composition (DXA), thoracic kyphosis (radiograph), and upper back pain (numerical rating scale). Correlations and multivariable logistic regression examined relationships between characteristics and their association with vertebral fracture. Participants were 117 healthy postmenopausal women. The 17 (15%) women with ≥1 thoracic vertebral fracture had larger breast size (mean difference [MD]: 2.2 sizes; 95% CI, 0.6 to 3.8 sizes), less upper back extensor muscle endurance (MD: -38.6 s; 95% CI, -62.9 to -14.3 s), and greater thoracic kyphosis (MD: 7.3°; 95% CI, 1.7° to 12.8°) than those without vertebral fracture. There were no between group differences in age, height, weight, and BMD. Breast size (r = -0.233, p = 0.012) and thoracic kyphosis (r = -0.241, p = 0.009) correlated negatively with upper back extensor muscle endurance. Breast size was unrelated to thoracic kyphosis (r = 0.057, p = 0.542). A (final) multivariable model containing breast size (OR 1.85; 95% CI, 1.10 to 3.10) and thoracic kyphosis (OR 2.04; 95%CI, 1.12 to 3.70) explained 18% of the variance in vertebral fracture. Breast size had a significant, but weak relationship with vertebral fracture (R2 = 0.10), which was independent of BMD and unrelated to thoracic kyphosis. Further work is needed to confirm larger breast size as a risk factor for vertebral fracture. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research