Journal of Bodywork & Movement Therapies (2012) 16 , 456e463 Available online at www.sciencedirect.com
j o u r n a l h o m e p a g e : w w w . e l s e vi vi e r . c o m / j b m t
COMPARATIVE PILOT STUDY
Medical exercise therapy, and not arthroscopic surgery, resulted in decreased depression and anxiety in patients with degenerative meniscus injury ˚vard Østera ˚s, MSc, PT a,*, Berit Øste ˚s, MSc a, Ha Østera Tom Arild Torstensen, MSc (Hons) PT b a
Sør-Trøndelag University College, Faculty of Health Education and Social Work, Department of Physical Therapy, N-7004 Trondheim, Norway b Holten Institute, Lidingo¨ , Sweden
Received 1 February 2012; received in revised form 19 March 2012; accepted 30 March 2012
KEYWORDS Degenerative meniscus injury; Knee pain; Medical exercise therapy; Arthroscopic surgery
pilot study was to compare the effectiveness effectiveness of conservative conservative Summary The purpose of this pilot therapy involving involving medical exercise therapy (MET) versus arthroscopic arthroscopic surgery in patients with knee pain, with MRI-verified degenerative meniscus. The patients were randomly assigned either to MET (n 9) or to arthroscopic surgery ( n 8). Patients receiving MET had 3 treatments a week for 3 months, a total of 36 treatments. The arthroscopy arthroscopy consisted of meniscectomy with no structured conservative therapy after surgery. Assessment of pain, function, anxiety and depression were performed at inclusion and after 3 months. At the end of treatment, which was 3 months after inclusion, there were no statistical differences between the two groups regarding pain and function. However, anxiety and depression were significantly reduced in the MET group compared with the patients receiving arthroscopic surgery. Bearing in mind the low number of included patients in this pilot study, arthroscopy was found to be no better than MET regarding knee pain and overall daily function. The results from this pilot study are similar to other clinical studies, thereby demonstrating that conservative therapy is just as effective as surgery. ª 2012 Elsevier Ltd. All rights reserved. Z
* Corresponding author. Tel.: þ47 73 55 93 05; fax: þ47 73 55 93 51. E-mail address:
[email protected] (H.
[email protected] (H. Østera˚s). 1360-8592/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2012.04.003 doi:10.1016/j.jbmt.2012.04.003
Z
Medical exercise therapy resulting in decreased depression
Background Knee pain is one of the most common symptoms in middle age, and a degenerative meniscus is a normal finding in this patient category (Murphy ( Murphy et al., 2008). 2008). Affected individuals clinically clinically present with knee pain, stiffness, stiffness, swelling swelling and impaired impaired function function (Ericsson ( Ericsson et al., 2006). 2006 ). These These symptoms symptoms can be part of early osteoarthritis (Englund ( Englund et al., 2009), 2009 ), as menisc meniscal al tears tears are common common and a freque frequent nt incide incidenta ntall finding on knee MR imaging of middle-aged people. The surg surgic ical al rese resect ctio ion n of nonnon-ob obst stru ruct ctiv ive e dege degene nera rati tive ve meniscus lesions may only remove evidence of the disorder while the osteoarthritis and associated symptoms proceed. Using MRI imaging, Englund imaging, Englund et al. (2009) and (2009) and Bhattacharyya Bhattacharyya et al. (2003) demonstrated (2003) demonstrated that an injury of the medial or lateral meniscus is a common finding in elderly people, both with with or with withou outt symp sympto toms ms of knee knee oste osteoa oart rthr hrit itis is.. In patients with symptoms, the investigators found that 91% of the partici participan pants ts had an abnorm abnormal al menisc meniscus us defined defined as meniscus damage, and as many as 76% of the asymptomatic asymptomatic-matc -matched hed participants participants also had a damaged damaged meniscus as shown by MRI imaging. An injured meniscus can lead to impaired knee function and knee instability, which again again can result result in an increa increased sed risk of cartil cartilage age injury injury (Muellner et al., 1999). 1999 ). Clinic Clinical al studie studiess on the effect effective ivenes nesss of arthros arthroscop copic ic surgery for patients with osteoarthritis of the knee have shown that active surgery is no better than placebo surgery (Moseley et al., 2002), 2002 ), while two clinical studies ( Kirkley et al al., ., 20 2008 08;; Herrl Herrlin in et al al., ., 20 2007 07)) fail failed ed to show show any any benefit benefit from arthroscopi arthroscopicc surgery. surgery. Where patients patients were assigned to arthroscopic treatment in addition to physical ther therap apyy, ther there e was was no grea greate terr impr improv ovem emen entt when when compared with those who received only physical therapy. Desp Despit ite e the the incr increa easi sing ng evid eviden ence ce that that arth arthro rosc scop opic ic surger surgeryy is no better better than than conser conservat vative ive therapy therapy,, such such as differe different nt forms forms of physic physical al therapy therapy,, includ including ing exercis exercise e therap therapy, y, partial partial arthro arthrosco scopic pic menisc meniscect ectomy omy remain remainss a common common surgic surgical al proced procedure ure in patien patients ts with with menisc meniscus us injury, both with or without osteoarthritis. Postoperatively, many patients report less pain, better function and a better quality of life (Burks (Burks et al., 1997). 1997 ). Despite reduced knee pain and improved knee function, Roos et al. (2000) found that as many as 38% had reduced their level of physical activity 3 months after knee surgery compared with only 9% of the patients before surgery. Physical activity is a welldocume documente nted d form form of treatm treatment ent that that reduce reducess pain pain and improves the function and quality of life for patients with subacute and long-term knee pain with osteoarthritis of the knee knee (Bo rjes esso son n et al al., ., 199 19966 ; Matthews Matthews and St-Pi St-Pierre, erre, ¨rj 1996). 1996 ). The goal of exercise therapy is primarily to decrease the pain experience and swelling of the knee since both pain and swelling are two important factors leading to changes in muscle function, such as decreased muscle strength and coordination. When pain and swelling decrease, a second goal is to regain knee control, as well as increasing range of motion and muscle strength, while also improving activities of daily functioning. Many different exercise protocols exist for treating knee pain, although there is no consensus as to what type of exercise program is most effective. In a study
45 7 by Herrlin by Herrlin et al. (2007), (2007) , an exercise program was found to be just as effective as an exercise program plus arthroscopic surgery. The exercises used in the study were well described regarding the type of exercises and their grading. In Herrlin et al. (2007), (2007) , exercise therapy was carried out only two times a week for 8 weeks, while the exercises were performed with a low number of repetitions in sets. Over the 8 weeks of physical therapy, each treatment lasted from 20 to 40 min. We postulate that clinical outcomes are related to the exer exerci cise se dosa dosage ge give given n and and to a decr decrea ease se in pain pain and and swelling, thereby resulting in an improved neuromuscular function. Moreover, a high number of repetitions in sets (3 sets sets each each of 30 repe repeti titi tion ons) s) are are more more bene benefic ficia iall than than a fewer number of repetitions in sets (2 sets each of 10 repetition repetitions), s), which was shown by Østera˚s et al. (2009), (2009) , comparing two different exercise dosages in patients with long-term subacromial pain. In this randomized trial, highrepetition, high-dosage medical exercise therapy (MET) was clinically superior to a low-repetition, low-dosage exercise program. program. In Østera In Østera˚s et ˚s et al. (2009), (2009), the MET treatment consisted of 11 exercises, in which 8 of the exercises consisted of a high high numb number er of repe repeti titi tion onss invo involv lvin ingg 3 sets sets of 30 repetitions, whereas the last remaining 3 exercises were endura endurance nce type type exerci exercises ses using using a statio stationar naryy bike bike at the start of start of the treatment (20 min), in the middle (5 min) and at the end (10 (10 min min). Each Each MET MET tre treatme atment nt last laste ed for for 50e70 min, with all of the patients in the study in both intervention groups receiving 3 treatments a week for 12 weeks, a total of 36 treatments. MET MET was was first first prese present nted ed in 196 19677 by the the Norw Norweg egian ian physiotherapist and manual therapist, Oddvar Holten, who defined an exercise approach with its own specific criteria (Torstensen, 1997): 1997 ): 1) The The physio physiothe therap rapist ist is presen presentt in the exerci exercise se room room while the patient is treated/exercising; 2) Specific exercise equipment is used to meet the need of the patient in order to grade exercises according to their dysfunction, while starting exercising as early as possib possible le (using (using a pulley pulley apparat apparatus us with with the smalle smallest st weight being 0.5 kg and the highest 50 kg, while also using using an angle angle bench, bench, a mobili mobilizin zingg bench, bench, a multimultipurp purpos ose e benc bench h, a pull pulle ey and and othe ther pie pieces ces of equipment); 3) The assessment of the patient is the basis for designing the exercise exercise program; program; the exercise exercise therapy lasts for at least 60 min; 4) The exercise program/treatment is reassessed at least every third to fourth treatment; 5) Four to five patients are exercising at the same time, maki making ng a form form of grou group p ther therapy apy.. Howe Howeve verr, ever everyy patien patientt has his/he his/herr indivi individua dually lly design designed ed exerci exercise se progra program m (To Torsten rstensen, sen, 1997 1997). ). Treatin reatingg patien patients ts with with knee pain, the treatment consists of 11 exercises that combine global, semi-global and local exercises. Global exer exerci cise sess invo involv lve e dyna dynami mica call llyy work workin ingg the the whol whole e organism. Semi-global exercising involves working the entire entire lower limb in a closed closed chain activity activity such as squatting. A local exercise might only involve working the the knee knee loca locall llyy, as in a seat seated ed,, open open-c -cha hain in knee knee
45 8
H. Østera˚s et al. extension extension exercise. exercise. To optimize the dosage, dosage, global, global, semi-g semi-glob lobal al and local local exercis exercises es are combin combined, ed, thus thus making the treatment close to pain free. The goal of the highly repetitive, high-dosage exercise therapy is to modula modulate te the patien patients’ ts’ pain pain experi experienc ence, e, modifyi modifying ng homeostasis in the different tissues in the knee joint. To avoid or decrease the level of sensitization of the nervous system, we believe it is very important to grade the exercises as close to pain free as possible. Patients with knee pain who experience that an exercise session lasting from 50 to 70 min can be performed close to pain free often have a positive cognitive effect, giving the patien patientt contro controll over over the painfu painfull knee. knee. Hence, Hence, medical medical exercise exercise therapy is a biopsychoso biopsychosocial cial treatment approach, meeting the patient where the patient is, thereby increasing their level of self-efficacy. In this present study, our hypothesis is that the outcome for exercis exercise e therapy therapy in patien patients ts with with knee knee pain pain due to a ruptur ruptured ed degene degenerat rative ive menisc meniscus us would would be signifi signifi-cant cantly ly impr improv oved ed if a high higher er exer exerci cise se dosa dosage ge were were applied, and significantly better when compared with arthroscopic meniscus resection.
Methods Design Ethica Ethicall approv approval al was acquir acquired ed from the Human Human Sub Subjec jectt Review Committee (Trondheim, Norway), and all participants gave their written consent to participate in the study after receiving written information about the study. The tester was not blinded to which intervention the patient received. The subjects were informed about the length of the study, test procedures and treatment procedures, and were told that they could withdraw from the study at any time. Baseline data for all of the included subjects is presented in Table 1. 1. The included subjects were randomly assign assigned ed to either either a medica medicall exercis exercise e therap therapyy group group or arthroscopic surgery, and the randomization procedure was concealed concealed from the experiment experimenters ers and treating treating physiophysiotherapist. The medical exercise group was tested at baseline and after the 3-month intervention period, while the arthro arthrosco scopy py group group was tested tested at baseli baseline ne and 3 months months after after surger surgery. y. At these these visits visits,, all patien patients ts answer answered ed the questionna questionnaires ires and complete complete the functional functional-- and muscle muscle tests. The present research project could not afford to hire an additional assessor, thus one of the authors had to serve as the assessor.
Subjects The inclus inclusion ion criter criteria ia were were subjec subjects ts with with knee knee pain pain for more than 3 months, who were 35 e60 years old and eligible for an arthroscopic partial meniscectomy and MRI showing a degenerativ degenerative e meniscus meniscus tear. tear. The magnetic magnetic resonance resonance imaging (MRI) included coronal T1-weighted turbo spin echo (TSE) and T2-weighted fat saturated TSE, transversal T2weighted gradient echo and oblique sagittal T2-weighted fat saturated imaging sequences performed on a Siemens 1.5 Tesla Tesla Magnet Magnet (Symphony) (Symphony) before starting starting treatment treatment..
Baseline characteristic characteristicss of the study population, population, Table 1 Baseline given in mean values and standard deviation (SD) unless otherwise otherwise noted. Train group (n 9)
Surg group (n 8)
47.0 (10.4) 79 79.8 .8 (7.5 (7.5)) 1.6 (1.2)
52.7 (7.2) 49.7 (9.3) 82.3 82.3.8 .8 (10. (10.9) 9) 80.9 80.9 (9.0 (9.0)) 2 .1 ( 1 . 7 ) 1.8 (1.4)
Z
Age Body Body weig weight ht Duration Duration of symptoms Stage of arthritis Gender (% male) Number of treatments VAS FiveRM KOOS HAD Anxiety Depression
0.6 (0.7) 8 (88.9)
Z
0 .9 ( 1 . 0 )
Total (n 17) participants Z
0.7 (0.8)
5 (62.5)
13 (76.4)
3 .7 ( 0 . 9 ) 8 .6 ( 5 . 4 ) 48.4 (25.6) 4 .0 ( 2 . 6 ) 5 .0 ( 2 . 5 )
3.6 (1.4) 10.6 (5.9) 50.0 (24.2) 5.3 (3.2) 4.9 (2.2)
29.4 (6.2)
3.5 (1.7) 12.4 (6.1) 51.4 (24.4) 4.5 (3.1) 5.0 (2.9)
The exclus exclusion ion criter criteria ia were were ACL ruptur rupture e for indivi individua duals ls requiring requiring acute trauma trauma surgeries, surgeries, including including high-energ high-energyy traumas traumas with ligament injuries, injuries, osteoarthri osteoarthritis tis grade 3 e4 (KellgreneLawrence Lawrence classificati classification, on, Scot Scottt et al al., ., 19 1993 93), ), haemarthroses and acute cases of locking knee and symptomati tomaticc pain in contra contrary ry extrem extremiti ities, es, as well well as other other musculoske musculoskeletal letal comorbiditie comorbiditiess severely severely affecting affecting lower extremity muscle function that override the symptoms from the knee, and comorbidities excluding physical activities and and exer exerci cise se that that are are not not able able to spea speakk or read read the the language of interest. Patients were recruited from orthopedic surgeons in two hospitals in Norway over a period of one year. The intervention was formulated not to worsen the injury, and was implemente implemented d in accordance accordance with the known medical medical exercise cise therap therapyy princip principles les used used by physic physical al therapi therapists sts.. All participation was based on informed consent, voluntariness and the right to withdraw from the study without further consequenc consequences. es. Three physiother physiotherapists apists at three different different locations were involved in the study, and the same physiotherapist always dealt with the same subjects.
Sample Sample size Sample size calculation based on a predetermined difference between treatment groups of 20% change in pain on a 10 cm visual analog scale and a standard deviation of 1.5 cm, showed that 10 participants were required in each group to have 80% power to detect the 20% difference as statistically significant at the level of p < 0.05.
Outcome measures The The prim primar aryy outc outcom ome e was was pain pain in the the last last week week,, with with a subjec subjective tive score measur measured ed with with a visual visual analog analog scale scale (VAS) at rest recorded on a 0 e10 cm line. The extreme
Medical exercise therapy resulting in decreased depression
45 9
limits were marked by perpendicular lines using the verbal descriptors of “no pain” and the “worst pain I can imagine”, the higher the score, the more the pain. The subjects were not shown their previous markings at follow-ups, as the VAS has been shown to be a reliable tool for measuring pain (Husk Huskisson isson,, 1974 1974). ). The The seco second ndar aryy outc outcom ome e was was a self self-report reported ed compos composite ite measur measure e known known as a: “Knee “Knee Injury Injury and and Oste Osteoa oart rthr hrit itis is Outc Outcom ome e Scor Score” e” (KOO (KOOS) S),, whic which h is compris comprised ed of five differe different nt subsca subscales les:: a) Pain, Pain, b) Other Other sympto symptoms, ms, c) Activit Activities ies in daily daily living living,, d) Functi Functioni oning ng in sport and recreation, and e) Knee-related quality of life (Roos et al., 1998; 1998 ; Roos and Lohmander, 2003). 2003 ). The KOOS is a valid valid and reliab reliable le patien patient-r t-rele elevan vantt questi questionn onnaire aire for patien patients ts with with knee knee injury injury and knee knee osteoa osteoarth rthrit ritis is ( Roos et al., 1998) 1998) that was registered at baseline and with all tests during this study. Anxiety and depression are often seen in this group of pati patien ents ts,, which which may may affec affectt trea treatm tmen ent. t. Anxi Anxiet etyy and and depression were measured with the Hospital Anxiety and Depression Depression Scale (HAD) ( Bje Bjella lland nd et al. al.,, 2002 2002), ), which is a self-screening questionnaire for depression and anxiety. The patients were instructed not to take too long with their replies since their immediate reaction to each item would probab probably ly be more more accu accurat rate e than than a long long,, thou though ghtt-ou outt response. It consisted of 14 questions, 7 for anxiety and 7 for depression. Each item was answered by the patient on a 4-point (0 e3) response category, so the possible scores ranged from 0 to 21 for anxiety and 0 to 21 for depression. In both the KOOS and HAD questionnaires, a lower score indicates a better clinical status. Dynamic quadriceps muscle strength was measured with a leg extension bench (Holm ( Holm et al., 1995), 1995 ), and a protocol protocol in which the patients lifted a weight with a maximum external load using 5 repetitions (5RM). The test started at a 90 flexion and was accepted only when the leg reached full extension. The amount of weight was determined with 3 e5 sets, in which the patients received an increasing external load until they were not able to reach 5 repetitions repetitions in a set according to the full extension criterion.
and the program was a combination of the global aerobic exercises using a stationary ergometer cycle, a treadmill or a step machine, whereas semi-global and local exercises to modula modulate te pain pain and increa increase se range range of motion motion were were perperformed using specially designed exercise equipment. This incl includ uded ed wall wall pull pulley eyss and and quad quadri rice ceps ps and and hams hamstr trin ings gs muscle strength training apparatus, including squats to 90 of flexion, leg extension extension and leg flexion. Each Each trea treatm tmen entt in the the exer exerci cise se group group star starte ted d with with 15e20 min of aerobic work on a stationary ergometer cycle. After 4 exercises each of 3 sets of 30 repetitions halfway throug through h the exerci exercise se program program,, the subjec subjects ts cycled cycled for 10 min and again after the last 4 exercises, the subjects did anot anothe herr 10 min min on a stat statio iona nary ry ergo ergome mete terr cycl cycle. e. The The intensity during cycle exercises was moderate to high, i.e. a heart rate frequency of 70 e80% of the maximal heart rate. rate. The hypoth hypothesi esiss was that that the global global exerci exercises ses are import important ant to stimul stimulate ate the body’s body’s own pain pain modula modulatin tingg system through the gate control mechanism in the posterior horn horn of the spinal spinal cord cord and the releas release e of endoge endogenou nouss neuropeptides in the central nervous system.
Intervention A standard arthroscopic partial meniscectomy NGD 11 was applied as a surgical intervention, which was carried out at two hospita hospitals ls in Trondhe rondheim, im, Norway Norway and perfor performed med on patients who were fulfilling inclusion criteria and randomized ized to surgic surgical al treatm treatment ent.. Normal Normal proced procedure uress for this this surger surgeryy at the respec respectiv tive e hospit hospitals als were were follow followed, ed, the protocols did not differ between the hospitals, and there were two surgeons involved. An exercise program was developed for this particular study, with a focus on coordination and muscle function training, along with pain modification exercise therapy. The program was pragmatically adjusted for individual differences due to performance and progression. Based on clinical experience, the intervention period was 3 months, and the subjects performed the exercise program 3 times per week. Symptoms and clinical findings were the basis for choosing individual starting positions, range of motion and weight resistance for each exercise. The treatment goal in the exercise group was to perform 3 sets of 30 repetitions,
Statistical analyses All data were analyzed with the Statistical Package for the Social Sciences (PASW) 19.0, and descriptive statistics were used used to determ determine ine partic participa ipant nt charac character terist istics ics.. Prior Prior to statistical analysis, the Kolmogorov eSmirnov test was performed to assess the normality of the continuous data. A comparison of treatment groups at baseline with respect to demogr demograph aphic ic and possib possible le progno prognosti sticc factors factors was perperformed with the use of appropriate nonparametric tests. Main Main compar comparati ative ve analys analyses, es, both both within within and betwee between n groups, were performed by using the general linear model in which the pretest values of the outcome measures were applied as covariates.
Results All of the allocated patients completed the study, with the flow of the subjects subjects throug throughou houtt the study presen presented ted in Fig. 1. 1. There were no participants lost to the follow-up assessments, and the baseline characteristics of the study population are outlined in Table 1. 1. All possible efforts were made to enhance compliance and adherence with the program. On average, the subjects in the MET group completed 84% (range 77 e92%) of the rehabilitation program.
Primary outcome parameters and main comparison analyses The Kolmogorov eSmirnov test revealed normal test distributions for the continuous outcome data. Table 2 shows 2 shows the primary outcome measurements at baseline and at followup (at approxi approximat mately ely 3 months months), ), change change scores scores within within groups groups and adjust adjusted ed differe difference ncess betwee between n groups groups with with respect to the outcome parameters. Both the training group and the surgery group exhibited improvements at follow-up comp compar ared ed to basel baselin ine, e, and and ther there e were were no stat statis isti tica call differences between groups at follow-up with respect to
46 0
H. Østera˚s et al.
Figure 1
Subject flow diagram. diagram.
VAS, VAS, FiveRM and KOOS. However, However, there were significant significant differences differences ( p < 0.05) 0.05) betwee between n groups groups with with respec respectt to scores on HAD at follow-up in favor of the MET group. The final scores of the outcome parameters were all adjusted for baseline values.
patients with a non-traumatic meniscus tear. At the end of treatm treatment ent 3 months months after inclus inclusion ion,, there there were were no differe difference ncess betwee between n the two groups groups regardi regarding ng pain pain and functi function. on. Howeve Howeverr, there there was a signifi significan cantt differ differenc ence e between groups with less depression and anxiety in the MET group. This This is an impo import rtan antt findi finding ng beca becaus use e anxi anxiet etyy and and depression is a major factor for persistent pain, decreased function, social isolation and early death ( Turvey et al., 2009;; Bogner et al., 2011). 2009 2011 ). Today, there is good evidence that the symptoms of depression decrease with an appropriate dosage of endurance exercise therapy (Brown ( Brown et al.,
Discussion The purpose of the present pilot study was to compare the clinical clinical effects effects of high-repet high-repetition ition,, high-dosage high-dosage medical exerci exercise se therap therapyy (MET) (MET) versus versus surger surgeryy for middle middle-ag -aged ed
Table 2 groups.
(n
Outcome
Z
17) Mean (SD) of groups, mean (SD) difference within groups, and adjusted mean (95% CI) difference between Groups Baseline
* p
<
0.05.
Follow-up
Training (n 9)
Surgery (n 8)
Training (n 9)
Surgery (n 8)
3.5 (1.7) 51.4 (24.4) 4.5 (3.1) 5.0 (2.9) 12.4 (6.1)
3.7 (0.9) 48.4 (25.6) 4.0 (2.6) 5.0 (2.5) 8.6 (5.4)
2.0 (1.4) 39.7 (25.9) 3.5 (1.8) 3.6 (1.8) 16.7 (7.6)
2.6 (1.1) 40.9 (23.1) 3.9 (2.5) 4.2 (2.6) 11.0 (6.1)
Z
VAS KO O S HAD Anxiety Depression FiveRM
Difference within groups (change scores)
Z
Z
Train
Surgery
Adjusted difference between groups (final scores adjusted adjusted for baseline values)
Z
1.5
1.1
11.8
(0.8) (13.3) 1.0 (0.6) 1.4 (0.5) 4 .3 ( 2 . 6 )
7.5
(0.6) (8.2) 0.1 (0.2) 0.8 (0.3) 2.4 (2.3)
0.5 (1.2
to 0.2) to 7.8) 0.6* (1.5 to 0.2) 1.0* (1.4 to 0.3) 1 .4 ( 1.2 to 4.0) 3.9 (15.6
Medical exercise therapy resulting in decreased depression
46 1
2005;; Galper 2005 Galper et al. al.,, 2006 2006), ), as well well as in pati patien ents ts with with a chronic disease (Matthew (Matthew et al., 2012). 2012). There is a dose response effect, with higher exercise dosages being more effecti effective ve in decrea decreasin singg dep depres ressio sion n ( Du Dunn nn et al al., ., 200 2002, 2, 2005). 2005 ). Arthroscopic surgery did not result in a decrease in depression and anxiety, though MET did, thus suggesting that that MET, MET, and not arthro arthrosco scopic pic surger surgery, y, should should be the preferred treatment for non-traumatic meniscus tears in middle-aged patients. In two clinical studies ( Kirkley et al., 2008; 2008 ; Herrlin et al., 2007), 2007 ), conservative therapy, including physiotherapy, was compare compared d versus versus arthro arthrosco scopic pic surger surgery. y. There There is clear clear evidence from both studies that surgery is no better than conservative therapy (Kirkley ( Kirkley et al., 2008), 2008 ), and that exercise therapy plus arthroscopic surgery are no better than exercise therapy alone (Herrlin ( Herrlin et al., 2007). 2007 ). These findings confirm the findings from Moseley from Moseley et al. (2002) in (2002) in relation to classic RCT, in which active arthroscopic surgery was no better than placebo surgery. Kirkley et al. (2008) included (2008) included 188 patients with moderate to severe osteoarthritis of the knee, although those with large meniscal tears, malalignment, previous arthroscopic surg surger eryy or seve severe re bioc biocom ompa part rtme ment ntal al arth arthri riti tiss were were excluded. excluded. One interventi intervention on group received received arthroscop arthroscopic ic surgery (including a debridement of articular cartilage and menisc menisci, i, an excisi excision on of osteop osteophyt hytes es and the removal removal of loos loose e bodi bodies es and and medi medica call and and phys physio ioth ther erap apy) y).. The The comparison comparison group received received physiotherapy physiotherapy consisting consisting of 1 h of phys physio ioth ther erap apyy a week week and and twic twice e daily daily exer exerci cise sess in combination with NSAIDs and intra articular hyaluronic acid injections. At the 2-year follow-up, there were no differences ences betwee between n the groups groups regard regarding ing pain, pain, functi function on and quality of life, nor did surgery provide any benefit to the subgroup of patients with mechanical symptoms. Herrlin et al. (2007) included 99 middle-aged patients after after a non-tr non-traum aumati aticc medial medial menisc meniscal al tear tear that that were were diagnosed diagnosed with a radiological radiological examination examination and magnetic magnetic resonance imaging. In this randomized trial, patients in one grou group p rece receiv ived ed a part partia iall meni menisc scec ecto tomy my foll follow owed ed by a superv supervise ised d exercis exercise e progra program, m, while while the other other group group received supervised exercise only. Both intervention groups improv improved ed signifi significan cantly tly within within groups groups,, but there there was no difference difference between groups regarding regarding pain, function function and level level of physic physical al activi activity ty.. Based Based on these these result results, s, the authors recommend supervised exercise alone as the first choice of treatment. From Kirkle Kirkleyy et al. (200 (2008) 8),, we can assu assume me that that the the exercise dosage is very low, with only 1 h of supervised treatment a week for 12 weeks, thus comprising a total of 12 treatments. The patients also performed a home exercise program during both the intervention period, as well as after after this this period period had ended. ended. Unfort Unfortuna unatel telyy, there there is no information in their publication on the type of exercises and dosage. Herrlin dosage. Herrlin et al. (2007) have described the entire exercise program and the home exercise program in detail, which is very helpful for further research in relation to believing that clinical differences depend on the dosage applied such as the number of exercises, the number of sets and the number of repetitions of each set in combining global aerobic exercises with more local exercises for the knee. Moreover, Herrlin et al. (2007) stated that the exercises were performed twice a week for 8 weeks, for a total
of 16 treatments. Most of the exercises, eight in all, were perfo perform rmed ed doin doingg 3 sets sets of 10 repe repeti titi tion onss each each.. Othe Otherr exercises, such as using a stationary bike, were performed from 7 to 15 min, whereas stair walking and balancing on wobble board were performed for 3 min and jogging, jumps and landing on a rebounder were performed for 5 min. The entire program lasted for approximately 30 e45 min, with the goal of the exercise program being to reduce pain, restore a full range of motion and improve knee function. Patients also performed a home program consisting of oneleg standing for 1 min and a step down exercise, comprising 3 sets of 10 repetitions. In our study using high-repetition, high-dosage MET, the total exercise dosage was considerably higher compared to the dosage given in both Kirkley et al. (2008) and Herrlin and Herrlin et al. (2007). (2007). We used used a high high numb number er of repe repeti titi tion onss in sets sets,, such such as 3 sets sets of 30 repe repeti titi tion onss comb combin ined ed with with stationary bicycling at the start (20 min), in the middle (5e10 min) and at the end of the treatment (10 min). The other exercises were either performed doing 3 sets of 30 repetitions or changed to 5 min of continuous repetitions. This type of exercise treatment is endurance training that acts on the pain modulating systems in the central nervous syst system em.. In futu future re rese resear arch ch,, it is impo import rtan antt to make make a distinction between strength training, consisting of performing 2e3 sets of 10 repetitions, and pain modulating exerci exercise se therap therapy, y, consis consistin tingg of perfor performin mingg 3 sets sets of 30 repetitions. Because pain has such an inhibiting effect on motor drive on both the spinal- and cortical levels, this is an argument that argument that supports the use of a high number of repetitions type of exercise program such as in medical exercise therapy, which has been proven to be able to decrease the experi experienc ence e of pain, pain, thereb therebyy result resulting ing in an increa increased sed muscle muscle strength and range of motion motion in patients with longterm subacromial pain (Østera ( Østera˚s et al., 2009). 2009). Both anxiety and depression changes could indicate that limbic system changes had occurred which show higher center changes in addition to those of spinal origin. It might be wrong to focus on stre streng ngth th trai traini ning ng for for subj subjec ects ts with with pain pain sinc since e pain pain subjec subjects ts do not tolera tolerate te high-r high-resi esista stance nce exerci exercises ses with with a low low numb number er of repe repeti titi tion ons. s. To be able able to perfo perform rm “strength “strength training exercises”, exercises”, e.g. 3 10 repetition repetitionss in subj subjec ects ts with with dege degene nera rati tive ve knee knee pain pain,, ther there e will will be a compromise decreasing the resistance, hence resulting in a low total dosage with a less positive outcome. Training to strengthen the quadriceps muscle has been considered as an essential component in the rehabilitation of persons with knee injuries ( Thomee 1995). Results ` et al., 1995). from previous clinical trials in this patient group are mixed, as previo previous us studie studiess may not have have taken taken into into suffici sufficient ent account the fact that pain inhibits force development, thus limiti limiting ng the effect effectss of streng strength th traini training ng ( Østera˚s et al., 2009). 2009 ). Where training principles and dosing are provided, it turns out that there are few exercises used, including high stress and relatively few repetitions ( Witvrouw et al., 2000). 2000 ). It is only when pain is reduced that an increase in strength, strength, improved coordinatio coordination n and a normalizati normalization on of function can be expected (Butler ( Butler and Gifford, 1997). 1997). Future studies could investigate whether the pain improvements of the exercise group was as much to do with improvements in mood as it was to do with physiological improvements in musculoskeletal system.
46 2 Several studies point out that patients with knee pain develop compensatory movement strategies in functional tasks, probably as a result of pain, fear of pain or muscle failure failure (Thomee al., ., 199 19999; Salsi Salsich ch et al al., ., 200 20011). It ` et al appears appears that these compensat compensatory ory strategies strategies are permapermanent, even when the relevant functional tasks no longer trigger pain, therefore involving selective muscle wake and dysfun dysfuncti ction. on. In order order not to provok provoke e any inflamm inflammati ation, on, exercises should be as painless as possible ( Dye, 2001), 2001), with one way of accomplishing this being to utilize pain free, repetitive movements that are deemed beneficial to the healing of local tissue damage (Kjær, ( Kjær, 2003). 2003). Othe Otherr stud studie iess show show posi positi tive ve effe effect ctss usin usingg exer exerci cise se therapy (Herrlin (Herrlin et al., 2007), 2007 ), although the focus here is on strength training that only uses a few number of repetitions per set. The overal overalll anxiet anxietyy and dep depres ressio sion n level level (HAD) (HAD) has changed significantly in favor of the MET group in this study. The MET is “pain treatment”, in which the exercise dosage is varied in different ways in order to modulate the pain experience. The hypothesised gate control mechanism in the posterior horn of the spinal canal is possibly more highly acti activa vate ted d usin usingg the the exer exerci cise se progr program am,, whil while e anot anothe herr possib possible le mechan mechanism ism being being the releas release e of endoge endogenou nouss neuropeptides such as b-endorphin -endorphin and enkephali enkephalins ns in the pituit pituitary ary gland gland and other other parts parts of the centra centrall nervou nervouss syst system em.. The The rele releas ase e of neur neurop opep epti tide dess influ influen ence cess the the descending descending pain inhibitory inhibitory system. system. These neuropeptides neuropeptides have strong analgesic effects, and high-intensity exercise for 45 min has been revealed to have the same analgesic effect as 10 mg of morphine morphine administered administered intravenously intravenously (Janal et al., 1984). 1984). More research is needed in order to be able to make any conclusions regarding the possible physiological mechanisms of pain management in the exercising participants in this study. There There are difficul difficultie tiess in reliab reliably ly predic predictin tingg whethe whetherr menisc meniscal al tears tears and no other other struct structure uress on the knee are related to a patient’s problems since many meniscal tears without without reported knee problems are found through MRIs (Bhattacharyya et al., 2003), 2003 ), as the correlation between osteoa osteoarth rthrit ritis is and knee knee pain verifie verified d after after radiol radiologi ogical cal examinatio examination n has been reported reported to be low. Therefore, Therefore, it woul would d be logi logica call to not not rush rush too too earl earlyy into into a surg surgic ical al interventi intervention, on, which is supported supported by several several reports reports that suggest that degenerative menisci could be a part of an osteoarthritis process in the knee (e.g. Marx, 2008). 2008). On the other other hand, hand, it would would be of great great import importanc ance e in furthe furtherr studies to see whether a delay in surgery could possibly increase the patient’s problems, including an increase in the develo developme pment nt of osteoa osteoarth rthrit ritis. is. If a wait-a wait-andnd-see see-atti attitu tude de is chos chosen en,, howe howeve verr, it is sugg sugges este ted d from from the the results of this study that the patient should undergo an exercise and rehabilitation program. A limitation of this study is that the measurements were undert undertake aken n by the treati treating ng physio physiothe therap rapist istss and not by another person, though this was a multicenter study with four physiother physiotherapists apists.. The outcome outcome measureme measurements nts were also not obtained by a blinded assessor, which is a major limitation, as a blinded assessment is considered essential to help prevent bias and assure internal validity in a clinical trial. Two outcome measures were self-reports (VAS, the KOOS questionnaire), which were used so there would not
H. Østera˚s et al. be a blin blindin dingg to grou group p allo alloca cati tion on,, even even thou though gh we do acknowledge the lack of blinding as a limitation. From this pilot study, we are not able to indicate further details regarding a possible dose eresponse effect in therapeutic apeutic rehabilitat rehabilitation, ion, and another another therapeuti therapeuticc regimen regimen may have provided other clinical results. Hence, there is a stro strong ng need need for furt furthe herr rese researc arch h in the the field field of dosdoseeresponse effects in therapeutic rehabilitation, and an emphasis should be put on clinical trials comparing differences in rehabilitation protocols. Further trials should be adequately powered and address a blinding of the outcome assessor, along with follow-up data for at least one year.
Conclusion With the low number of participants in mind for patients with non-traum non-traumatic atic meniscal meniscal injury, injury, arthroscopy arthroscopy was not superior to medical exercise therapy alone in terms of knee pain and overall daily function. This study therefore indicates a need for further studies to elaborate the effect of medical exercise therapy compared to arthroscopy surgery for patients with chronic knee pain and verified degenerative meniscus. Further research should also be completed as randomized controlled trials that include postoperative treatment and osteoarthritis.
Conflicts of interest None.
Acknowledgments The authors wish to thank physiotherapists, Lasse Haugerud and Eivind Selven, for their contribution in interventions for the patients.
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