Philadelphia panel evidence-based clinical practice guidelines on selected rehabilitation interventions for knee pain. (Specail Issue).INTRODUCTION Chronic knee pain is one of the most common reasons for visits to a family practitioner. Acute knee pain usually follows injury or surgery. Chronic knee pain can be related to disease such as osteoarthritis or associated with overuse or untreated injuries to muscles, ligaments, or tendons. Prospective studies show that knee pain improves with time, regardless of therapy. The most common practice for general practitioners is a referral for a variable number of sessions of physical therapy. There is a need to provide clinicians with evidence for informed decision making regarding treatment options. The Philadelphia Panel was convened to evaluate 8 selected rehabilitation interventions for knee pain: thermotherapy, therapeutic massage, therapeutic exercises, electromyographic (EMG) biofeedback, ultrasound, transcutaneous electrical nerve stimulation (TENS), electrical stimulation, and combined rehabilitation interventions. The purpose of this article is to describe the evidence-based clinical practice guidelines (EBCPGs) developed by the panel about rehabilitation interventions for knee pain. The aim of the developing the EBCPGs was to improve appropriate use of rehabilitation interventions for knee pain. The target users of these guidelines are physical therapists, physiatrists, orthopedic surgeons, rheumatologists, family physicians, and neurologists. METHODS The detailed methods of the EBCPGs development process are summarized in an accompanying article in this issue ("Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions: Overview and Methodology"). Briefly, an a priori protocol was defined that was followed for the conduct of separate systematic reviews for each intervention. Studies were eligible if they were randomized controlled trials (RCTs), nonrandomized controlled clinical trials (CCTs), or case control or cohort studies that evaluated the intervention of interest in a population with knee conditions including chondromalacia chondromalacia /chon·dro·ma·la·cia/ (kon?dro-mah-la´shah) abnormal softening of cartilage. chon·dro·ma·la·cia (k  n dr patellae
(patellofemoral syndrome), postsurgical conditions, knee osteoarthritis,
and tendinitis. Rheumatoid arthritis was excluded. The types of patients
seen postsurgery included those who had meniscectomy, total knee
replacement, anterior cruciate ligament reconstruction, and arthroscopic
surgery for removal of loose bodies or plica.The outcomes of interest were defined by the Philadelphia Panel as functional status, pain, ability to work, patient global assessment, patient satisfaction, and quality of life. The interventions included massage, thermal therapy (hot or cold packs), electrical stimulation, EMG biofeedback, TENS, therapeutic ultrasound, therapeutic exercises, and combinations of these rehabilitation interventions. Studies where control groups received active treatments were not considered sufficient evidence for recommendations. Concurrent treatments were allowed if they were given in the same way to both the experimental and control groups (eg, home exercises, educational booklets, advice on posture). However, concurrent therapy that was given to one group but not the other group was not accepted (eg, education by means of lectures for the control group were not accepted). No limitations based on methodological quality were imposed. Only English-, French-, and Spanish-language articles were accepted. Abstracts were not included. Although most of these knee conditions have pain as the primary outcome, patients with these conditions also seek physical therapy for limitations other than pain such as functional limitations, instability, and weakness. The Philadelphia Panel evaluated the effects of interventions on outcomes considered to be clinically meaningful and validated, as described in the accompanying methods paper ("Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions: Overview and Methodology"). Some outcomes such as flexibility and strength were not considered by the members of the Philadelphia Panel to be sufficient evidence to warrant a clinical recommendation. However, functional assessment, quality of life, and patient global assessment were considered sufficient for a recommendation and have been evaluated when reported in the trials. If other outcomes were available, the results are described in the sections titled "Efficacy." A structured literature search was developed based on the sensitive search strategy for RCTs recommended by the Cochrane Collaboration (1) and modifications proposed by Haynes et al. (2) The search strategy was expanded to identify case control, cohort, and nonrandomized studies. The search was conducted in the electronic databases of MEDLINE, EMBASE, Current Contents, CINAHL CINAHL - Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Controlled Trials Register up to July 1, 2000. In addition, the registries of the Cochrane Field of Rehabilitation and Related Therapies and the Cochrane Musculoskeletal Group and the Physiotherapy Evidence Database (PEDro) were searched. The references of all included trials were searched for relevant studies. Content experts were contacted for additional studies. Two independent reviewers (VAR, JP) appraised the titles and abstracts of the literature search, using a checklist with the a priori defined selection criteria. Relevant studies were retrieved and the full articles were assessed for inclusion by 2 independent reviewers. Data were extracted by 2 independent reviewers from included articles, using predetermined extraction forms regarding the population characteristics, details of the interventions, trial design, allocation concealment, and outcomes. Methodological quality was assessed with a 5-point validated scale that assigns 2 points each for randomization and double-blinding and 1 point for description of withdrawals. (3,4) Differences in data extraction and quality assessment were resolved by consensus. Data were analyzed at 3 approximate time points post-therapy: 1 month, 6 months, and 12 months. If outcomes were reported at different intervals, the closest time was used for these time points. Because several etiologies of knee pain exist, different conditions were analyzed separately. Chondromalacia patellae (patellofemoral pain syndrome), postsurgical conditions, osteoarthritis, and tendinitis were analyzed separately. STATISTICAL ANALYSIS Where possible, data from individual trials were combined using meta-analysis. Data were analyzed using the Review Manager (RevMan) computer program, Version 4.1 for Windows. * Continuous data were analyzed using weighted mean differences (WMDs) between the treatment and control groups at the end of study, where the weight is the inverse of the variance. Where an outcome was measured with different scales (eg, pain, functional status), the data were analyzed with standardized mean differences, calculated using the mean and standard deviation. Dichotomous data were analyzed using relative risks. Heterogeneity was tested using a chi-square statistic. When heterogeneity was not significant, fixed-effects models were used. With significant heterogeneity, random-effects models were used. To calculate clinical improvement (defined as 15% improvement relative to a control), the absolute benefit and the relative difference in the change from baseline were calculated. Absolute benefit was calculated as the improvement in the treatment group less the improvement in the control group, in the original units. Relative difference in the change from baseline was calculated as the absolute benefit divided by the baseline mean (weighted for the treatment and control groups). For dichotomous data, the relative percentage of improvement was calculated as the difference in the percentage of improvement in the treatment and control groups. The recommendations were graded by their level of evidence (I or II) and by the strength of evidence (A, B, or C). This grading system is shown in Table 1 and is described more fully elsewhere (see article titled "Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions: Overview and Methodology"). Briefly, grade A recommendations indicate that a clinically important benefit was shown in one or more RCTs. Grade B recommendations were assigned for interventions with a clinically important benefit shown in nonrandomized trials. Because there is less confidence in the results of nonrandomized studies, grade B recommendations required that the study be assigned a quality score of 3 or more out of 5. Grade C recommendations were assigned to interventions that have been compared with a control and have shown no evidence of effect in controlled trials. A master grid showing each rehabilitation intervention assessed and the strength and level of evidence is presented in Table 2. The report follows the same order as this grid (from left to right, top to bottom) for these interventions for which eligible studies where found. A clinically important benefit was shown for 2 interventions for knee osteoarthritis (TENS and exercise) (Tab. 3). No evidence of clinically important benefit was shown in studies of 5 other interventions (Tab. 4). Insufficient data were available for 9 interventions (Tab. 5). The Philadelphia Panel EBCPGs are compared with other published guidelines in Appendix 1. A survey questionnaire was sent to 324 practitioners for feedback on the 2 grade A recommendations. Their comments were reviewed by the Philadelphia Panel and were incorporated into this EBCPG document. Of the 324 practitioners surveyed from the American Academy of Family Physicians (AAFP), American Academy of Orthopaedic Surgeons (AAOS), American College of Physicians (ACP), American Physical Therapy Association (APTA), American College of Rheumatology Health Professionals (ARHP ARHP - Association of Reproductive Health Professionals), and Physiatric Association of Spine, Sports, and Occupational Rehabilitation (PASSOR), 9 were inappropriately sampled (wrong specialty) and 21 could not be reached due to incorrect addresses. Of the 294 practitioners who were appropriately sampled and received the questionnaire, 149 responded (51% response rate). Of these, 11 refused to participate (4%) and 138 completed the survey (47%). RESULTS Literature Search The literature search identified 5,330 articles related to the knee conditions described above. Of these articles, 184 were considered potentially relevant based on the selection criteria checklist. Of these 184 articles, 29 met the selection criteria and were included (Appendix 2). The included trials are shown for each of the interventions for knee pain in the "cityscape" shown in Figure 1. [FIGURE 1 OMITTED] PATELLOFEMORAL PAIN SYNDROME Therapeutic Ultrasound for Patellofemoral Pain Syndrome, Level I (RCT), Grade C for Patient Global Assessment (No Evidence of Clinically Important Benefit) Summary of Trials: One RCT (N=29) of ice and therapeutic ultrasound versus ice alone was included. (5) All patients had palpable tenderness on extension. Efficacy: None demonstrated. There was no difference in number of patients who rated their knee pain as improved with continuous therapeutic ultrasound and ice therapy compared with ice alone (Fig. 2). There was a large loss to follow-up (45%, 19 of 42 patients). [FIGURE 2 OMITTED] Strength of Published Evidence in Comparison With Other Guidelines: The Philadelphia Panel found good scientific evidence (level I, RCT) regarding therapeutic ultrasound for patellofemoral pain. Therapeutic ultrasound has not been assessed by other guidelines for patellofemoral pain syndrome. Clinical Recommendations Compared With Other Guidelines: The Philadelphia Panel recommends that there is poor evidence to include or exclude therapeutic ultrasound alone (grade C for patient global assessment) as an intervention for patellofemoral pain syndrome. POSTSURGERY KNEE PAIN Preoperative Exercises for Postsurgery Knee Pain, Level I (RCT), Grade C for Pain and Function (No Clinically Important Benefit) Summary of Trials: One RCT (N=20) was identified of preoperative strengthening and stretching versus usual care prior to unilateral knee replacement in patients with rheumatoid arthritis or osteoarthritis. (6) One RCT was excluded due to lack of a control group (closed versus open kinetic chain exercises). (7) Efficacy: None demonstrated. The only outcome measure was a knee rating scale (0-100) that measures pain, function, range of motion (ROM), muscle strength, flexion deformity, and instability. There was no difference in the knee rating between the usual care and strengthening exercise groups at 3, 12, 24, or 48 weeks postsurgery (Fig. 3). [FIGURE 3 OMITTED] Strength of Published Evidence in Comparison With Other Guidelines: The Philadelphia Panel found good scientific evidence (level I, RCT) regarding preoperative strengthening exercises in patients undergoing unilateral knee arthroplasty. Clinical Recommendations Compared With Other Guidelines: The Philadelphia Panel recommends that there is poor evidence to include or exclude preoperative strengthening exercises alone (grade C for pain and function) prior to unilateral knee arthroplasty surgery. Thermotherapy for Postsurgery Knee Pain, Level I (RCT), Grade C for Pain (No Evidence of Clinically Important Benefit) Summary of Trials: One RCT (N=45) of cold gel packs in patients who had been prescribed home exercises after knee surgery was included. (8) Efficacy: None demonstrated. There was no difference after 1 week of therapy between cold packs and no cold pack therapy on the McGill Pain Scale (Fig. 4), for ROM or strength. [FIGURE 4 OMITTED] Strength of Published Evidence in Comparison With Other Guidelines: The Philadelphia Panel found good scientific evidence (level I, RCT) regarding ice packs, but none for hot packs. No other guidelines have assessed thermotherapy postsurgery. Clinical Recommendations Compared With Other Guidelines: The Philadelphia Panel recommends that there is poor evidence to include or exclude cryotherapy cryotherapy /cryo·ther·a·py/ (-ther´ah-pe) the therapeutic use of cold. cry·o·ther·a·py (kr  (grade C for pain) as an adjunct intervention to
home exercises after knee surgery.TENS for Postsurgery Rehabilitation, Level I (RCT), Grade C for Pain (No Evidence of Clinically Important Benefit) Summary of Trials: One RCT (N=90) of TENS (70 Hz) compared with placebo TENS and with a group that received no therapy was included. (9) Efficacy: None demonstrated. The trial demonstrated that there was no significant difference between TENS and placebo for pain, ROM, or muscle force. However, there was a significant benefit of TENS on pain relief compared with no therapy. The data from this trial cannot be presented graphically due to lack of data (standard deviations not reported). Strength of Published Evidence in Comparison With Other Guidelines: The Philadelphia Panel found good scientific evidence (level I, RCT) regarding TENS after knee surgery. Transcutaneous electrical nerve stimulation after knee surgery has not been assessed by other guidelines. Clinical Recommendations Compared With Other Guidelines: The Philadelphia Panel recommends that there is poor evidence to include or exclude TENS alone (grade C for pain) as an intervention after knee surgery. KNEE OSTEOARTHRITIS Therapeutic Exercises, Level I (RCT), Grade A for Pain and Patient Global Assessment, Grade C+ for Function (Clinically Important Benefit) Summary of Trials: Four RCTs (N=318) of strengthening, stretching, and functional exercises versus no therapy were included. (10-13) One RCT (N=201) of strength exercise versus usual general practitioner care was included. (14) One RCT (N=41) of repeated straight leg raises was included. (15) Three RCTs (N=79) were excluded because no outcomes were included that met the Philadelphia Panel criteria for clinical importance and validity (strength outcomes only). (16-18) One RCT was excluded because manual therapy was used as the comparison intervention. (19) Efficacy: Clinically important benefit on pain and patient global assessment. Pain relief was 38% greater with strength exercises relative to placebo in one RCT (N=201). (14) Similarly, pain relief was greater with strengthening exercises relative to untreated control groups by 16%, (13) 42%, (12) and 78% (10) (P < .05, Tab. 6, Fig. 5). [FIGURE 5 OMITTED] The improvement in patient-assessed global disease activity was clinically important relative to a control in 2 RCTs (N=268), with risk differences of 21% (11) and 27% (20) (Tab. 7, Fig. 6). [FIGURE 6 OMITTED] Functional status did not show a clinically important benefit consistently across all trials (7%, (12) 18%, (13) 26% (11)). Furthermore, the results of the pooled meta-analysis were not statistically significant. One RCT of straight leg raises for knee osteoarthritis showed a clinically important improvement in function relative to a control (24%). (15) Strength of Published Evidence in Comparison With Other Guidelines: The Philadelphia Panel found level I (RCT) evidence that showed a clinically important benefit of strength exercises on knee osteoarthritis pain. The British Medical Journal (BMJ) (21) guidelines reported that there was limited evidence of benefit, with few well-designed RCTs. They based this finding on 3 systematic reviews (with 1997 as the most recent search date) and 3 RCTs. The RCTs were excluded from the Philadelphia Panel systematic review because they did not include a placebo group (2 trials) or included manual therapy (1 trial). Clinical Recommendations Compared With Other Guidelines: The Philadelphia Panel recommends that there is good evidence to include strengthening, stretching, and functional exercises alone (grade A for pain and patient global assessment, grade C+ for function) as interventions for knee osteoarthritis pain. This recommendation agrees with American College of Rheumatology (ACR) guidelines for the management of osteoarthritis that recommend the use of ROM, strength exercise, and aerobic exercise. (22) The BMJ guidelines (21) based their results on a published meta-analysis (14) and concluded that exercises are likely to be beneficial for both pain relief and function. Practitioner Agreement * Response rate for this EBCPG: 49% * Percentage of practitioners giving comments for this EBCPG: 19% * Agree with recommendation: 98% * Think a majority of my colleagues would agree: 94% * Will (or already) follow this recommendation: 96% Practitioner Comments 1. Exercises should be modified to avoid exacerbation, especially if patient is obese or has pronated feet; may need to consider aquatic exercises. 2. Other options for knee osteoarthritis are better. 3. Consider RCT by Deyle et al. (19) Panel's Response: Modifications based on individual needs were not described in the included trials and therefore cannot be addressed in this guideline. The Philadelphia Panel assessed only selected rehabilitation interventions. Furthermore, the Philadelphia Panel did not rank therapies, but rather evaluated whether the evidence supports the use of the interventions assessed when compared with no therapy or a placebo. The trial by Deyle et al (19) was excluded because the intervention group received manual therapy. Thermotherapy for Knee Osteoarthritis, Level I (RCT), Grade C for Pain (No Evidence of Clinically Important Benefit) Summary of Trials: One RCT (N=50) of ice massage versus a placebo for knee osteoarthritis was identified. (23) The treatment was applied 5 times per week for 20 minutes each session for 2 weeks. Efficacy: None demonstrated. Ice massage of 4 acupoints acupoint /acu·point/ (ak´u-point) any of the specific sites for needle insertion in acupuncture; also used in other therapies, including acupressure and moxibustion. Most are areas of high electrical conductance on the body surface. (SP-9 yinlingquan, GB-34 yanglingquan, ST-34 liangqui, and ST-35 dubi) using a wood block was not different from placebo TENS for pain or stiffness relief (Tab. 8). Strength of Published Evidence in Comparison With Other Guidelines: The Philadelphia Panel found good evidence (level I, RCT) of no effect of ice massage on acupoints in knee osteoarthritis pain. Ice massage on acupoints has not been assessed by other knee osteoarthritis pain guidelines. Clinical Recommendations Compared With Other Guidelines: The Philadelphia Panel recommends that there is poor evidence to include or exclude ice massage alone (grade C for pain) as an intervention for knee osteoarthritis. Therapeutic Ultrasound for Knee Osteoarthritis, Level I (RCT), Grade C for Pain (No Evidence of Clinically Important Benefit) Summary of Trials: One RCT (N=74) of therapeutic ultrasound versus a placebo for knee osteoarthritis was identified. (24) One CCT (N=120) was excluded because the comparison intervention was "galvanic current." (25) Efficacy: None demonstrated. The therapeutic ultrasound group reported less pain than the placebo group after 4 weeks of therapy, but the difference was not statistically significant (WMD=1.3 cm on a 10-cm VAS, 95% confidence interval [CI] = -0.07 to 2.7 cm). This difference corresponded to an 11% relative difference between groups in the change from baseline. At 3 months follow-up, there was no difference between groups. Strength of Published Evidence in Comparison With Other Guidelines: The Philadelphia Panel found good evidence (level I, RCT) of the effects of therapeutic ultrasound in knee osteoarthritis. Therapeutic ultrasound has not been assessed by other knee osteoarthritis guidelines. Clinical Recommendations Compared With Other Guidelines: The Philadelphia Panel recommends that there is poor evidence to include or exclude therapeutic ultrasound alone (grade C for pain) as an intervention for knee osteoarthritis. TENS for Knee Osteoarthritis, Level I (RCT), Grade A for Pain and Patient Global Assessment (Clinically Important Benefit) Summary of Trials: Seven placebo-controlled RCTs (N = 184) evaluated TENS versus a placebo for knee osteoarthritis. (23,26-31) Four RCTs were excluded due to inappropriate populations of patients with postsurgery knee conditions, (9) myalgia, (32) and low back pain. (33) One RCT used of a non-TENS device, described as producing "pulsed electrical stimulation." (34) Efficacy: Clinically important benefit on pain and patient global assessment. Three RCTs (N = 87) demonstrated a significant difference in number of patients with pain improvement of 20% to 46% relative to the control group after 1 month of therapy (30,31,35) (Tab. 9). Pain assessed by visual analog scale was statistically significantly improved in our meta-analysis of the 5 RCTs of greater than 3 weeks' duration. The pooled estimate was equivalent to an improvement in pain of 41% from baseline relative to placebo (23) (Tab. 10, Fig. 7). The absolute change from baseline ranged from 57% to 83% of baseline in the TENS group. One RCT of the immediate effects of 30 minutes of TENS showed that there was no difference between TENS and placebo TENS on immediate pain relief. (27) Three RCTs demonstrated clinically important and statistically significant improvements in patient-assessed overall improvement relative to a control of 29% at 1 month, (29) 17% at 1 month, (28) and 48% at 3 months (4) (Tab. 11, Fig. 8). Functional status was not assessed using validated measurement scales such as the Health Assessment Questionnaire (HAQ), Lee Index, WOMAC, or Arthritis Impact and Measurement Scale (AIMS) in any of the included trials. [FIGURES 7-8 OMITTED] Strength of Published Evidence in Comparison With Other Guidelines: There is good evidence (level I, RCT) of TENS alone for the management of knee osteoarthritis that showed a benefit on pain and patient global assessment. Transcutaneous electrical nerve stimulation has not been assessed by other guidelines for knee osteoarthritis. Clinical Recommendations Compared With Other Guidelines: The Philadelphia Panel recommends that there is good evidence to include TENS as an intervention for pain associated with knee osteoarthritis (grade A for pain and patient global assessment). Practitioner Agreement * Response rate for this EBCPG: 49% * Percentage of practitioners giving comments for this EBCPG: 36% * Agree with recommendation: 73% * Think a majority of my colleagues would agree: 50% * Will (or already) follow this recommendation: 56% Practitioner Comments 1. Other interventions are better (eg, exercises, non-steroidal anti-inflammatory drugs); use TENS only if these interventions fail. 2. Other studies of TENS for other types of chronic pain have shown no effect. 3. No lasting effect of TENS. 4. Limited evidence for improvements in functional status (only patient global assessment improved). Panel's Response: Practitioner agreement is lower than with other guidelines (73%), possibly because there is more conflicting evidence (ie, some trials showed no statistical significance). Specifically, the grade A rating was achieved only for patient global assessment, and the effect on pain was not statistically significant (grade C+). These guidelines do not rank interventions in comparison with each other, but rather indicate the efficacy when compared with a placebo. The Philadelphia Panel has also shown no effect of TENS on other types of chronic pain (eg, postsurgery knee pain, chronic low back pain). This difference in efficacy may relate to the method of TENS application. In particular, the trials that used low-frequency, high-intensity TENS on acupoints(23,35) demonstrated the greatest benefit on pain and patient global assessment. Acupuncture-like TENS was not used in the trials of chronic low back pain. The EBCPGs have been modified to specify the length of follow-up in these trials. Benefit is specified for pain and patient global assessment, but not for functional status. Electrical Stimulation for Knee Osteoarthritis, Level I (RCT), Grade C for Function (No Clinically Important Benefit Demonstrated) Summary of Trials: One RCT (N=30) of patterned neuromuscular electrical stimulation of the quadriceps femoris muscle in elderly patients with knee osteoarthritis was included. (36) Efficacy: None demonstrated. The timed sit-to-stand test and walking velocity were statistically significantly improved when compared with placebo stimulation. However, the percentage of change from baseline was less than 15%, thus not meeting the criteria for clinical relevance. The results cannot be displayed graphically because inadequate data were reported (standard deviations were printed in graphical format only). No strength outcomes were reported. Strength of Published Evidence in Comparison With Other Guidelines: The Philadelphia Panel found good evidence (level I, RCT) of the effects of electrical stimulation in knee osteoarthritis. Electrical stimulation has not been assessed by other knee osteoarthritis guidelines. Clinical Recommendations Compared With Other Guidelines: The Philadelphia Panel recommends that there is poor evidence to include or exclude electrical stimulation alone (grade C for function) as an intervention for knee osteoarthritis. Because electrical stimulation is usually used to improve strength, this recommendation is inconclusive until evidence of effects on strength have been shown in clinical trials. TENDINITIS Massage for Knee Tendinitis, Level I (RCT), Grade C for Pain (No Evidence of Clinically Important Benefit) Summary of Trials: One RCT (N=20) of deep transverse friction massage compared with no therapy for patients with iliotibial band syndrome was included. (37) Efficacy: None demonstrated. Pain while running was not different between groups that received massage and no treatment. A daily pain diary showed a clinically unimportant difference in pain of 8% between groups (Fig. 9). [FIGURE 9 OMITTED] Strength of Published Evidence in Comparison With Other Guidelines: The Philadelphia Panel found good scientific evidence (level I, RCT) regarding deep friction massage for iliotibial tendinitis. There were no other clinical practice guidelines for tendinitis. There was no evidence regarding other types of massage for different types of tendinitis (eg, patellar tendinitis). Clinical Recommendations Compared With Other Guidelines: The Philadelphia Panel recommends that there is poor evidence to include or exclude deep friction massage alone (grade C for pain) as an intervention for iliotibial band syndrome. Insufficient Evidence Therapeutic exercises for knee tendinitis have been assessed in one RCT, but no validated, clinically relevant outcomes (as defined by the Philadelphia Panel) were measured. (38) Electrical stimulation for the knee postsurgery has been compared with exercises and EMG biofeedback but has not been compared with a placebo with sufficient sample size. (39) For chondromalacia patellae (patellofemoral pain syndrome), different types of therapeutic exercises (isokinetic, isometric, closed chain, open chain) have been compared. (40) However, the only RCT with an untreated control group did not measure any outcomes of interest (ROM and strength only). (41) After knee surgery, several types of therapeutic exercise have been compared: closed versus open kinetic chain, (42) functional versus isometric exercises, (43) and exercise versus electrical stimulation. (18) However, there have been no comparisons with placebo (or untreated) control groups. Electromyographic biofeedback after knee surgery lacks placebo-controlled trials. (44,45) DISCUSSION A standardized, rigorous methodology was applied to developing EBCPGs based on Cochrane systematic reviews of the literature, and using a transdisciplinary expert panel and methods group. Practitioner feedback has been included in the guidelines. Two EBCPGs were developed by the Philadelphia Panel based on the clinically important benefits found with TENS for knee osteoarthritis and therapeutic exercises for knee osteoarthritis. The major implication of this work is that there is methodologically poor evidence to support the use of a number of widely accepted interventions. The trials identified were often inconclusive because of lack of a placebo group, use of nonvalidated outcomes, use of population diagnoses that are not widely applicable to the population, and inadequate sample size. Within specific interventions, the characteristics of the intervention also may play a role in the lack of a clinically important benefit. For example, deep friction massage was evaluated for knee iliotibial tendinitis. However, several other forms of massage that are in use in practice (eg, effleurage effleurage /ef·fleu·rage/ (ef?loo-rahzh´) [Fr.] a stroking movement in massage., acupressure, trigger point therapy) have not been evaluated. As another example, therapeutic ultrasound for patellofemoral pain syndrome has been evaluated in a trial where all patients received ice. It is possible that therapeutic ultrasound alone would have beneficial effects compared with placebo therapeutic ultrasound. This highlights the need to investigate the specific mode of use that is used in clinical practice and most likely to show benefits. The presence of home exercises as an adjunct intervention for many of these trials complicates the interpretation of results, particularly because the adherence to a program of home exercises is rarely reported in the trials. Differential adherence may confound the treatment effect. The therapeutic application of several rehabilitation interventions is based on empirical experience. (46-48) Research on rehabilitation interventions is further complicated by the multitreatment model used in clinical practice. A patient usually receives several rehabilitation interventions in one session. Furthermore, the types of therapy will be chosen according to the phase of recovery. For example, the first phase of recovery for an acute injury is characterized by rest, ice, and compression. The second phase is characterized by stretching, mobility exercises, and electrotherapy such as therapeutic ultrasound or TENS to relieve pain and inflammation. (46) The third phase involves strengthening, continued stretching, and continued use of electrotherapy for the breakup of scar tissue. The practice of rehabilitation requires a better theoretical Basis (49,50) and well-designed controlled research. (51) The measurement of the effects of rehabilitation interventions is complex. (52,530 Standardized measurement of outcomes is needed to facilitate scientific advances in clinical care for knee conditions. (14,54) The Philadelphia Panel agreed that the primary outcomes of clinical importance are: pain, functional status, patient global assessment, quality of life, return to work, and patient satisfaction. Furthermore, the Philadelphia Panel required that these outcomes be measured with a scale whose measurements have established reliability and validity. Although pain is usually the primary outcome, other limitations such as reduced ROM, swelling, and muscle weakness and instability affect patients with various knee conditions. These limitations are sometimes the primary cause for physical therapist consultation. These limitations are captured by the Philadelphia Panel outcomes for functional status, patient global assessment, quality of life, and return to work. Physical factors (55-57) and psychosocial factors (20,58,59) have an impact on the effectiveness of rehabilitation interventions for knee pain. Because of these factors, a multidimensional clinical evaluation is recommended in knee pain management, especially among patients with osteoarthritis and rheumatoid arthritis. (58-60) It was not possible to examine these risk factors in this review. Potential methodological biases could have been introduced in trials on effectiveness of rehabilitation interventions for the management of knee pain. A misclassification bias related to the knee condition studied is present with the lack of ,precise medical and physical therapy diagnoses observed. (57,61-66) Selection bias could have occurred with the presence of heterogeneity of clinical characteristics such as age, prevalent versus incident cases, stages of the disease, level of pain, and presence or absence of inflammation. However, differences in disease duration were minimized in these guidelines by excluding studies with a mix of acute and chronic conditions or mixed diagnoses. Characteristics of the device parameters and of the therapeutic application (49) also could make a difference in the effect size. Publication bias may be a problem if only trials with positive findings have been published. (67) The effect of publication bias could not be assessed because of the small number of trials. A language bias was introduced because the Philadelphia Panel reviewed only studies published in English, French, or Spanish. The methodological quality of studies on knee pain rarely reached 3 out of 5 or greater on the Jadad scale (3,4) (Appendix 2). Randomization (17/31 studies) was rarely fully adequate (ie, performed using computerized random number lists). Insufficient information was noted in several RCTs regarding the treatment assignment procedure. Inappropriate blinding (21/31 studies) also could lead to information bias. Blinding is an issue with physical rehabilitation interventions. Complete blinding is difficult to achieve because of visual and other sensory differences between treatment and placebo groups as well as unintended communication between patient and evaluator. (68) The use of an unblinded, untreated control group can lead to an overestimate of the treatment effect. This was demonstrated by one trial reviewed for these guidelines that showed no difference between TENS and placebo TENS but demonstrated a significant benefit on pain relief of TENS compared with an untreated, unblinded control group. (9) Few investigators (13/31 studies) reported adequate information regarding withdrawals and loss to follow-up or indicated whether they were considered in the data analysis. These weaknesses contribute to the lower-quality assessment scores in many of the systematic reviews conducted on rehabilitation interventions for knee pain. The Philadelphia Panel agreed that clinical importance be defined as an improvement of 15% or more relative to a control (see article rifled "Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions: Overview and Methodology" in this issue). Both clinical importance and statistical significance were required for grade A or B recommendations. With these requirements, inconclusive results were reached for several interventions (grade C). Ottenbacher (69) lists several difficulties for rehabilitation specialists: (1) discrimination between clinical and statistical significance, (2) low statistical power in detecting minimal clinically important differences (MCIDs), and (3) lack of replication of rehabilitation studies to strengthen evidence-based practice. Some studies (18/25 studies) did not use adequate sample sizes to detect important differences with confidence (Appendix 2). These issues have led to inconclusive results in other systematic reviews. (14,54) The Philadelphia Panel EBCPGs for the management of knee pain are mainly in agreement with previous and recent EBCPGs (21,23) and clinical practice guidelines (70) for knee pain described in Tables 8 and 9, especially for therapeutic exercises. The Philadelphia Panel EBCPGs for knee pain have the advantage that they were developed based on a systematic grading of the evidence determined by an expert panel, and the evidence was deifived from systematic reviews and meta-analyses using the Cochrane Collaboration methodology. The finalized EBCPGs were circulated for feedback from practitioners to verify their applicability and ease of use for practicing clinicians. This rigorous methodological procedure provides considerable credibility for rehabilitation specialists who intend to use these EBCPGs for knee management in their daily practice. Therapeutic Exercises The main aim of therapeutic exercises is to improve functional status by increasing muscle strength, improving flexibility, and increasing pulmonary function of the client, depending on the type of exercise (usually functionally specific). Our meta-analysis showed that traditional therapeutic exercises are beneficial for pain relief and patient global assessment in people with knee osteoarthritis (grade A for pain and patient global assessment). Improved function was shown in 3 RCTs, but did not reach statistical significance, and was assigned a grade C+ recommendation. These exercises included combinations of strengthening, stretching, and functional exercises. (71-74) In contrast, preoperative strengthening exercises showed no benefit on postsurgery knee function. There was no evidence regarding acute knee pain. The current results for knee conditions are in agreement with recent reviews for traditional therapeutical exercises. (14,74-78) Furthermore, the feedback survey showed that 98% of the respondents agreed with the guideline. Therapeutic exercises may compensate for arthrogenic impairment in quadriceps femoris muscle sensorimotor function, diminished proprioceptive acuity, and decreased postural stability associated with reduced functional performance of patients with osteoarthritis. (55) Strengthening exercises also improve gait and attenuate knee pain in activities of daily living among patients with osteoarthritis. (79) Types of exercises, intensity, and progression need to be clarified according to patient-specific classification of physical dysfunction, needs, treatment goals, and outcomes. (14,54,72,78,80-84) The lack of a statistically significant effect on function warrants further research because therapeutic exercises are often prescribed to address functional limitations, muscle weakness, and instability. Insufficient evidence was found for use of therapeutic exercise for knee tendinitis and chondromalacia patellae. Therapeutic Ultrasound Therapeutic ultrasound did not demonstrate a clinically important benefit for osteoarthritis of the knee or for patellofemoral pain syndrome. (5,24) No studies were found for postsurgery or acute conditions. Other research work is obviously needed for knee pain at different stages and for different conditions. The BMJ (21) and ACR (23) guidelines did not evaluate therapeutic ultrasound for knee pain. One trial to used continuous therapeutic ultrasound, which generates vasodilatation, (85) combined with a 2-minute ice application, which induces vasoconstriction. (86) Other confounding variables such as randomization method, characteristics of the device, size of the applicator, and study duration might have contributed to the lack of effect of therapeutic ultrasound for patellofemoral pain syndrome found by this trial. (46,49) These results concur with those of previous reviews. (46,78,87) Puett and Griffin (78) also conclude that no support exists in the literature for therapeutic ultrasound treatment prior to therapeutic exercise in management of knee osteoarthritis. TENS Clinical benefit was demonstrated in our meta-analysis of TENS for knee osteoarthritis (9,28,30,31,35,88) In contrast, our meta-analysis of TENS after knee surgery showed no benefit (level I, grade C). Other reviews of TENS have not found evidence of benefit. (78,89) One of these reviews78 did not use Cochrane Collaboration methodology and considered only 3 of the 6 studies included in our meta-analysis. (28,31,35) The other review did not specifically study the effectiveness of TENS for knee osteoarthritis; the investigators included various conditions involving pain. (89) Transcutaneous electrical nerve stimulation is thought to generate neuroregulatory peripheral and central effects (90-93) and modulate pain transmission. (94-96) The Philadelphia Panel EBCPGs (level I, grade A) cannot be compared with BMJ (21) and ACR (23) guidelines because these guidelines did not evaluate TENS for pain relief. Therapeutic Massage There were insufficient data for the Philadelphia Panel to make a recommendation regarding therapeutic massage (Cyriax's deep transverse frictions) as an intervention alone for knee tendinitis. There are no other systematic reviews on massage for knee pain. The Philadelphia Panel recommendation cannot be compared with the BMJ, (21) ACR, (23) or Manal and Snyder-Mackler (70) guidelines because they did not evaluate massage as an intervention for knee pain. There are a number of confounding variables related to the therapeutic application of massage. For example, the effectiveness of massage is influenced by the types of maneuvers used, the massage approach adopted, years of experience of the therapist, number and size of the muscles involved, patient position, pressure, rhythm and progression, and frequency and duration of the treatment sessions. (97) Thermotherapy The Philadelphia Panel concluded that there was poor evidence to include or exclude thermotherapy for postsurgery knee pain. This recommendation is based on only one RCT of cryotherapy (with cold gel packs) in which both groups received therapeutic stretching and isometric strengthening exercises. (8) We also found poor evidence to include or exclude ice massage for knee osteoarthritis; however, this finding was based on a trial that used ice massage applied to acupoints. (23) There was insufficient evidence to make a recommendation regarding thermotherapy for patellofemoral pain syndrome. These results are in agreement with a recent systematic Review (78) for osteoarthritis of the knee. The BMJ, (21) ACR, (23) and Manal and Snyder-Mackler (70) guidelines did not evaluate thermotherapy for knee pain. Physiological studies have shown significant effects of cryotherapy on circulatory and temperature responses, muscle spasm, and inflammation, (86,87) but its mechanism of action has not yet been fully elucidated. (86) It is unknown whether these physiological effects translate to important effects on clinical outcomes (such as pain and functional status). EMG Biofeedback, Electrical Stimulation, and Combined Rehabilitation Interventions Despite the positive physiological effect of these interventions,(98) either there are no clinical data or there is insufficient clinical information on the effectiveness of EMG biofeedback, electrical stimulation, and combined rehabilitation interventions for acute and chronic knee pain. The Philadelphia Panel was unable to make clinical recommendations regarding these specific interventions. Similarly, the BMJ (21) and ACR (23) guidelines did not evaluate these modalities. Overall The main difficulty in determining the effectiveness of rehabilitation interventions is the lack of well-designed prospective RCTs. An enormous research effort is needed to conduct RCTs for almost every rehabilitation intervention for knee pain. This situation is critical compared with the growing knee research area. There is a pressing need for further work on other rehabilitation interventions for knee pain, particularly considering the increased use of physical therapists in North America. Furthermore, these trials need to use standardized and validated outcomes, describe fully the intervention and its characteristics, and consider evaluating subgroups of particular interest. CONCLUSION We have used structured methodology and a transdisciplinary expert panel and practitioner feedback to develop rigorous EBCPGs for the use of selected rehabilitation interventions for managing knee conditions. This process has resulted in 2 clear recommendations of clinical benefit of TENS and exercise for knee osteoarthritis. There is a lack of evidence at present regarding whether to include or exclude the use of thermotherapy, therapeutic massage, EMG biofeedback, therapeutic ultrasound, electrical stimulation, and combined rehabilitation interventions in the daily practice of physical rehabilitation for knee pain.
Appendix I.
Strength of Published Evidence and Clinical Recommendations of
Previous Evidence-Based Clinical Practice Guidelines (EBCPGs) for Knee
Pain (a)
Rehabilitation The Philadelphia Panel
Intervention (2001)
Previous EBCPGs for Postsurgery of the Knee
Therapeutic Strength of published Good scientific evidence
exercises evidence in comparison Level I for preoperative
with other guidelines exercises
Clinical recommendations Poor evidence to include
compared with other or exclude (grade C
guidelines for pain and function)
preoperative
strengthening exercises
alone as an
intervention prior to
unilateral knee
replacement surgery
Therapeutic Strength of published N/A
ultrasound evidence in comparison
with other guidelines
Clinical recommendations No data found
compared with other
guidelines
TENS Strength of published Good scientific evidence
evidence in comparison Level I for TENS
with other guidelines
Clinical recommendations Poor evidence to include
compared with other or exclude (grade C for
guidelines pain) TENS alone as an
intervention for
postsurgery
rehabilitation
EMG Strength of published Insufficient scientific
biofeedback evidence in comparison evidence (grade ID) for
with other guidelines EMG biofeedback
Clinical recommendations Insufficient evidence to
compared with other include or exclude
guidelines (grade ID) EMG
biofeedback alone as an
intervention for
postsurgery knee pain
Therapeutic Strength of published N/A
massage evidence in comparison
with other guidelines
Clinical recommendations No data found
compared with other
guidelines
Thermotherapy Strength of published Good scientific evidence
evidence in comparison (level I) for
with other guidelines cryotherapy
Clinical recommendations Poor evidence to include
compared with other or exclude (grade C for
guidelines pain) cryotherapy alone
as an intervention for
postsurgery knee pain
Electrical Strength of published Insufficient scientific
stimulation evidence in comparison evidence (grade ID) for
with other guidelines electrical stimulation
Clinical recommendations Insufficient evidence to
compared with other include or exclude
guidelines (grade ID) electrical
stimulation alone as an
intervention for
postsurgery knee pain
Combined Strength of published Insufficient scientific
rehabilitation evidence in comparison evidence (grade ID) for
interventions with other guidelines combined rehabilitation
interventions
Clinical recommendations Insufficient evidence to
compared with other include or exclude
guidelines (grade ID) for combined
rehabilitation
interventions for
postsurgery knee pain
Rehabilitation Manal and Snyder-
Intervention Mackler (70)
(1996)
Previous EBCPGs for Postsurgery of the Knee
Therapeutic Strength of published Common practice, but no
exercises evidence in comparison scientific evidence for
with other guidelines ACL postsurgery
Clinical recommendations Preoperative and
compared with other postsurgery exercises
guidelines are listed as option to
increase strength, ROM,
and endurance
Therapeutic Strength of published N/C
ultrasound evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
TENS Strength of published N/C
evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
EMG Strength of published N/C
biofeedback evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Therapeutic Strength of published N/C
massage evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Thermotherapy Strength of published N/C
evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Electrical Strength of published N/C
stimulation evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Combined Strength of published N/C
rehabilitation evidence in comparison
interventions with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Note: No previous EBCPGs for RA, for patellotemoral pain syndrome, and
for tendinitis of the knee.
Rehabilitation The Philadelphia Panel
Intervention (2001)
Previous EBCPGs for Osteoarthritis of the Knee
Therapeutic Strength of published Good scientific evidence
exercises evidence in comparison Level I for therapeutic
with other guidelines exercises
Clinical recommendations Good evidence (grade A
compared with other for pain, patient
guidelines global assessment,
grade C+ for function)
to include
strengthening and
stretching exercises
alone as an
intervention for knee
OA
Therapeutic Strength of published Good scientific evidence
ultrasound evidence in comparison Level I for therapeutic
with other guidelines ultrasound
Clinical recommendations Poor evidence to include
compared with other or exclude (grade C
guidelines for pain) therapeutic
ultrasound alone as an
intervention for knee
OA
TENS Strength of published Good scientific evidence
evidence in comparison Level I for TENS
with other guidelines
Clinical recommendations Good evidence (grade A
compared with other for pain and patient
guidelines global assessment) to
include TENS alone as
an intervention for
knee OA
EMG biofeedback Strength of published N/A
evidence in comparison
with other guidelines
Clinical recommendations No data found
compared with other
guidelines
Therapeutic Strength of published N/A
massage evidence in comparison
with other guidelines
Clinical recommendations No data found
compared with other
guidelines
Thermotherapy Strength of published Good scientific evidence
evidence in comparison (level 1, RCT) for ice
with other guidelines massage
Clinical recommendations Poor evidence to include
compared with other or exclude (grade C
guidelines for pain)
thermotherapy alone as
an intervention for
knee OA
Electrical Strength of published Good scientific evidence
stimulation evidence in comparison Level I for electrical
with other guidelines stimulation
Clinical recommendations Poor evidence to include
compared with other or exclude (grade C
guidelines for function)
electrical stimulation
alone as an
intervention for knee
OA
Combined Strength of published N/A
rehabilitation evidence in comparison
interventions with other guidelines
Clinical recommendations No data found
compared with other
guidelines
Rehabilitation ACR Knee OA (22)
Intervention (1995)
Previous EBCPGs for Osteoarthritis of the Knee
Therapeutic Strength of published Not reported (N/R)
exercises evidence in comparison
with other guidelines
Clinical recommendations Recommend ROM,
compared with other quadriceps
guidelines femoris muscle
strengthening, and
aerobic exercise
programs
Therapeutic Strength of published N/C
ultrasound evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
TENS Strength of published N/C
evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
EMG biofeedback Strength of published N/C
evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Therapeutic Strength of published N/C
massage evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Thermotherapy Strength of published N/C
evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Electrical Strength of published N/C
stimulation evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Combined Strength of published N/C
rehabilitation evidence in comparison
interventions with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Rehabilitation
Intervention BMJ (21) (2000)
Previous EBCPGs for Osteoarthritis of the Knee
Therapeutic Strength of published Likely to be beneficial
exercises evidence in comparison
with other guidelines
Clinical recommendations Likely to be beneficial
compared with other (pain relief and
guidelines improved function)
Therapeutic Strength of published N/C
ultrasound evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
TENS Strength of published N/C
evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
EMG biofeedback Strength of published N/C
evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Therapeutic Strength of published N/C
massage evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Thermotherapy Strength of published N/C
evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Electrical Strength of published N/C
stimulation evidence in comparison
with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Combined Strength of published N/C
rehabilitation evidence in comparison
interventions with other guidelines
Clinical recommendations N/C
compared with other
guidelines
Note: No previous EBCPGs lot patellofemoral pain syndrome or
tendinitis of the knee. (a) ACL=anterior cruciate ligament, ROM=range
of motion, N/A=not applicable, N/C=no comparison, N/R=not reported,
TENS=transcutaneous electrical nerve stimulation,
EMG=electromyographic, OA=osteoarthritis, CPG=clinical practice
guideline, ID=insufficient data, ACR=American College of Rheumatology,
BMJ=British Medial Journal.
Appendix 2.
Characteristics of Included Trials (a)
Type of
Author/Year Sample Size Surgery
Antich, (5) 1986 86 knees, 64 Tenderness on
patients extension
Bautch et al, (10) 17/17
1997
Beard et al, (42) 25/25 ACL reconstruction
1994
Borjesson et al, (11) 34/34
1996
Callaghan et al, (18) Control (n=9)
1995 Home (n=10)
Exercise (n=8)
D'Lima et al, (6) 10/10 Unilateral knee
1996 replacement
Draper et al, (44) 15/15 ACL reconstruction
1991
Falconer et al, (24) 37/37
1992
Fargas-Babjak, (35) 56
1992
Grimmer, (27) 1992 60
Harrison et al, (40) Home (n=42) Patellofemoral
1999 Supervised pain syndrome
(n=34) (no surgery)
Feedback
(n=36)
Jan and Lai, (15) 21/20
1991
Jensen et al, (9) 30/30 Arthroscopic
1985 partial
meniscectcomy
Jensen et al, (88) 20
1991
Lessard et al, (8) Ice+exercise Arthroscopic
1997 (n=23) surgery for
Ice alone meniscectomy,
(n=22) chondromalacia,
OA, plica or
loose bodies
Levitt et al, (45) 26/25 Minor
1995 arthroscopic
surgeries for
meniscal tears,
loose bodies,
patellar
chondromalacia
Lewis et al, (28) 36
1994
Lewis et al, (29) 30
1984
Oldham et al, (36) 30 On waiting list for
1995 knee
replacement
surgery
O'Reilly et al, (13) Exercise
1999 (n=13)
Control
(n=78)
Rogind et al, (12) Exercise
1998 (n=12)
Control
(n=13)
Schilke et al, (17) Exercise
1996 (n=10)
Control
(n=10)
Schwellnus et 10/10 Iliotibial band
al, (37) 1992 syndrome
Smith et al, (30) 15/15
1983
Svarcova et al, (25) 60/60
1988
Taylor et al, (31) 12
1981
van Baar et al, (20) Exercise
1998 (n=99)
Control
(n=102)
Yurkuran and TENS (n=25)
Kocagil, (23) Electroacupuncture
1999 (n=25)
Ice massage
(n=25)
Placebo
(n=25)
Zatterstrom et Specific QF Chronic ACL
al, (43) 1992 (n=9) insufficiency
Function at
trunk and
leg training
(n=17)
Symptom
Duration
Prior to
Author/Year Sample Size Surgery Mean Age
Antich, (5) 1986 86 knees, 64 Not reported Not reported
patients
Bautch et al, (10) 17/17 Not reported 69 y
1997
Beard et al, (42) 25/25 13 mo 25 y
1994
Borjesson et al, (11) 34/34 7.5 y 64 y
1996
Callaghan et al, (18) Control (n=9) 4 y 52 y
1995 Home (n=10)
Exercise (n=8)
D'Lima et al, (6) 10/10 NA 69 y
1996
Draper et al, (44) 15/15 Not reported 25 y
1991
Falconer et al, (24) 37/37 >6 mo 67.5 y
1992
Fargas-Babjak, (35) 56 >6 mo 29-81 y
1992
Grimmer, (27) 1992 60 Mean=7.8 y 66 y
Harrison et al, (40) Home (n=42) Acute 25% 21.8 y
1999 Supervised Insidious
(n=34) 63%
Feedback Traumatic
(n=36) 10%
Jan and Lai, (15) 21/20 27 mo 62 y
1991
Jensen et al, (9) 30/30 Not reported Not reported
1985
Jensen et al, (88) 20 >6 mo 75 y
1991 exercise-
induced
pain
Lessard et al, (8) Ice+exercise Not reported 42 y
1997 (n=23)
Ice alone
(n=22)
Levitt et al, (45) 26/25 Not reported 45 y
1995
Lewis et al, (28) 36 >6 mo NA
1994
Lewis et al, (29) 30 >12 mo 61 y
1984
Oldham et al, (36) 30 NR 69 y
1995
O'Reilly et al, (13) Exercise Not reported 62 y
1999 (n=13)
Control
(n=78)
Rogind et al, (12) Exercise Not reported 69.3 y
1998 (n=12)
Control
(n=13)
Schilke et al, (17) Exercise <10 y 64 y
1996 (n=10)
Control
(n=10)
Schwellnus et 10/10 >4 wk 25 y
al, (37) 1992 Chronic Not reported
Smith et al, (30) 15/15 NR 65 years
1983
Svarcova et al, (25) 60/60 6.6 y 64 y
1988
Taylor et al, (31) 12 NA 71.5 y
1981
van Baar et al, (20) Exercise 48% <1 y 68.3 y
1998 (n=99)
Control
(n=102)
Yurkuran and TENS (n=25) >6 mo 58.1 y
Kocagil, (23) Electroacupuncture
1999 (n=25)
Ice massage
(n=25)
Placebo
(n=25)
Zatterstrom et Specific QF 1-96 mo 27 y
al, (43) 1992 (n=9)
Function at
trunk and
leg training
(n=17)
Author/Year Sample Size Treatment
Antich, (5) 1986 86 knees, 64 Continuous US/ice massage
patients contrast 3 sets of US
for 3 min, ice massage
for 2 min
Bautch et al, (10) 17/17 Strengthening and
1997 stretching
Beard et al, (42) 25/25 Proprioceptive: closed
1994 kinetic chain,
functional exercises,
progressed by
decreasing stability of
starting position and
increasing repetitions
and removing feedback
Borjesson et al, (11) 34/34 Group exercise:
1996 strengthening and
stretching
Callaghan et al, (18) Control (n=9) Strengthening
1995 Home (n=10)
Exercise (n=8)
D'Lima et al, (6) 10/10 Strengthening
1996
Draper et al, (44) 15/15 Visual, sound portable EMG
1991 feedback on QF during
exercises
Falconer et al, (24) 37/37 Continuous US, 1 MHz, 10-
1992 [cm.sup.2] soundhead, 3
min per 100 [cm.sup.2]
area, up to 2.5
W/[cm.sup.2], as
tolerated
Fargas-Babjak, (35) 56 TENS, 2x/day for 30 min,
1992 4 Hz, electrodes placed
on 13 acupuncture and
tender points
Grimmer, (27) 1992 60 1. High-rate TENS, 80 Hz
for 30 min
2. Strong-burst TENS 3-Hz
trains of 80-Hz pulses
for 30 min
Harrison et al, (40) Home (n=42) Exercise, patellar taping
1999 Supervised by the patient +
(n=34) biofeedback on vastus
Feedback medialis muscle,
(n=36) progressive increase in
difficulty of exercises
(more functional) and
weights
Jan and Lai, (15) 21/20 SLR, 200/d
1991
Jensen et al, (9) 30/30 TENS, asymmetrical,
1985 bipolar, modified
rectangular wave with
negatively decaying
spike, pulse width=180
ms, pulse duration=300
ms, pulse rate=70 Hz
Jensen et al, (88) 20 TENS, high-frequency, 80
1991 Hz, pulse width=150
[micro]s for 30 min/d
Lessard et al, (8) Ice+exercise Cryotherapy (2 cold gel
1997 (n=23) packs for 20 min prior
Ice alone to exercise)
(n=22)
Levitt et al, (45) 26/25 Portable visual and sound
1995 biofeedback on QF
during isokinetic and
isometric contractions
performed at home, 3
X/d (adherence=54%)
Lewis et al, (28) 36 TENS, pulse frequency=70
1994 Hz, placed on 4
acupuncture points
Lewis et al, (29) 30 TENS, self-administered,
1984 70 Hz to classical
Chinese acupuncture
points for 30-60 min
Oldham et al, (36) 30 Patterned electrical
1995 stimulation of QF, pulse
width=300 [micro]s, duty
cycle=200%, self-
administered
O'Reilly et al, (13) Exercise Strengthening
1999 (n=13)
Control
(n=78)
Rogind et al, (12) Exercise Strengthening, stretching
1998 (n=12)
Control
(n=13)
Schilke et al, (17) Exercise Strengthening
1996 (n=10)
Control
(n=10)
Schwellnus et 10/10 Deep transverse friction
al, (37) 1992 over most tender area,
2 min lightly, 8 min
hard such that
discomfort but not pain
experienced
Smith et al, (30) 15/15 TENS, 32-50 Hz on most
1983 tender areas around knee
Svarcova et al, (25) 60/60 Continuous US
1988
Taylor et al, (31) 12 TENS, electrodes on
1981 anterior, posterior,
lateral, and medical
sides of knee
van Baar et al, (20) Exercise Strengthening stretching,
1998 (n=99) and functional exercises
Control
(n=102)
Yurkuran and TENS (n=25) 1. TENS, 0.4-2.5 V
Kocagil, (23) Electroacupuncture intermittent waveform at
1999 (n=25) 4 Hz, pulse
Ice massage width=1,000 [micro]s
(n=25) applied to 4 acupoints
Placebo 2. Electroacupuncture,
(n=25) acupuncture needles
3. Ice massage,frozen wood
used to massage 4
ocupoints
Zatterstrom et Specific QF Specific QF training, with
al, (43) 1992 (n=9) static and dynamic
Function at contractions (10
trunk and repetitions)
leg training
(n=17)
Comparison
Author/Year Sample Size Group
Antich, (5) 1986 86 knees, 64 Ice bag for 10 min
patients
Bautch et al, (10) 17/17 Untreated
1997
Beard et al, (42) 25/25 Open kinetic, traditional
1994 exercises, graduated
weight-resisted with
emphasis on
hamstring muscles
Borjesson et al, (11) 34/34 Control
1996
Callaghan et al, (18) Control (n=9) 1. Sham electrical
1995 Home (n=10) stimulation
Exercise (n=8) 2. Home exercises
D'Lima et al, (6) 10/10 Usual care
1996
Draper et al, (44) 15/15 Electrical stimulation
1991 during QF exercises
Falconer et al, (24) 37/37 Sham US
1992
Fargas-Babjak, (35) 56 Placebo TENS (0.2 Hz)
1992
Grimmer, (27) 1992 60 Placebo TENS
Harrison et al, (40) Home (n=42) 1. Home exercises for 4
1999 Supervised wk
(n=34) 2. Supervised stretching
Feedback and strengthening
(n=36) exercises, 3 sets of
10 repetitions,
progressive increase
in weights
Jan and Lai, (15) 21/20 None
1991
Jensen et al, (9) 30/30 Placebo TENS unit
1985 Untreated group
Jensen et al, (88) 20 TENS, low frequency, 2
1991 high pulse trains for
30 min/d
Lessard et al, (8) Ice+exercise No ice packs
1997 (n=23)
Ice alone
(n=22)
Levitt et al, (45) 26/25 Isokinetic and isometric
1995 contractions
performed at home, 3
X/d
(adherence=54%)
without biofeedback
Lewis et al, (28) 36 Placebo TENS
1994
Lewis et al, (29) 30 Placebo TENS (no
1984 battery)
Oldham et al, (36) 30 Sham stimulation of 300
1995 [micro]s impulse every 3
min
O'Reilly et al, (13) Exercise None
1999 (n=13)
Control
(n=78)
Rogind et al, (12) Exercise Untreated
1998 (n=12)
Control
(n=13)
Schilke et al, (17) Exercise Usual care
1996 (n=10)
Control
(n=10)
Schwellnus et 10/10 Untreated
al, (37) 1992
Smith et al, (30) 15/15 Placebo
1983
Svarcova et al, (25) 60/60 Galvanic current
1988
Taylor et al, (31) 12 Placebo TENS
1981
van Baar et al, (20) Exercise GP therapy
1998 (n=99)
Control
(n=102)
Yurkuran and TENS (n=25) Placebo TENS
Kocagil, (23) Electroacupuncture
1999 (n=25)
Ice massage
(n=25)
Placebo
(n=25)
Zatterstrom et Specific QF Functional synergic
al, (43) 1992 (n=9) training of trunk and
Function at leg muscles,
trunk and progressing to more
leg training difficult, less stable
(n=17) positions
Concurrent
Author/Year Sample Size Therapy
Antich, (5) 1986 86 knees, 64 Isometric hip adduction
patients QF setting, modified
SLR, resisted short-
arc QF exercise (2
sets of 10
repetitions)
Bautch et al, (10) 17/17 Education
1997
Beard et al, (42) 25/25 None
1994
Borjesson et al, (11) 34/34 None
1996
Callaghan et al, (18) Control (n=9) None
1995 Home (n=10)
Exercise (n=8)
D'Lima et al, (6) 10/10 Usual care both
1996 preoperation and
postoperation
Draper et al, (44) 15/15 Progressive strength
1991 and stretch
Falconer et al, (24) 37/37 Stretching and
1992 strengthening
exercises
Fargas-Babjak, (35) 56 None
1992
Grimmer, (27) 1992 60 Voluntary withholding
analgesics, muscle
relaxants, and anti-
inflammatories for
48 h prior to test
Harrison et al, (40) Home (n=42) Education session
1999 Supervised
(n=34)
Feedback
(n=36)
Jan and Lai, (15) 21/20 US, continuous mode,
1991 10 min
Jensen et al, (9) 30/30 None
1985
Jensen et al, (88) 20 Analgesics and
1991 NSAIDs allowed
Lessard et al, (8) Ice+exercise Home exercises: knee,
1997 (n=23) ankle ROM; QF,
Ice alone hamstring muscle
(n=22) stretches, static QF
exercise; Tylenol (b) as
needed
Levitt et al, (45) 26/25 Verbal instructions on
1995 home exercises for
QF
Lewis et al, (28) 36 None
1994
Lewis et al, (29) 30 Analgesics
1984
Oldham et al, (36) 30
1995
O'Reilly et al, (13) Exercise Verbal advice on
1999 (n=13) shoes, weight, fitness
Control
(n=78)
Rogind et al, (12) Exercise Medication hold
1998 (n=12) constant except for
Control acetaminophen
(n=13)
Schilke et al, (17) Exercise None
1996 (n=10)
Control
(n=10)
Schwellnus et 10/10 Rest from running
al, (37) 1992 Ice, 20 min, twice
daily
Iliotibial band stretch
daily
US 1 MHz, 0.5 W/
cm/cm, 5-7 min, 6
d/wk
Smith et al, (30) 15/15 Some analgesics or
1983 NSAIDs
Svarcova et al, (25) 60/60 None
1988
Taylor et al, (31) 12 None
1981
van Baar et al, (20) Exercise Education brochure,
1998 (n=99) paracetamol to be
Control used as little as
(n=102) possible
Yurkuran and TENS (n=25) None
Kocagil, (23) Electroacupuncture
1999 (n=25)
Ice massage
(n=25)
Placebo
(n=25)
Zatterstrom et Specific QF None
al, (43) 1992 (n=9)
Function at
trunk and
leg training
(n=17)
Treatment
Duration,
Sessions/
Author/Year Sample Size Week
Antich, (5) 1986 86 knees, 64 10 d, total
patients sessions=4
Bautch et al, (10) 17/17 12 wk, 3X/
1997 wk
Beard et al, (42) 25/25 7 wk, 2X/
1994 wk
supervised
+ daily
home
exercises
Borjesson et al, (11) 34/34 5 wk, 3X/
1996 wk
Callaghan et al, (18) Control (n=9) 4 wk, 2 X/
1995 Home (n=10) wk
Exercise (n=8)
D'Lima et al, (6) 10/10 6 wk prior to
1996 surgery, 3
X/wk
Draper et al, (44) 15/15 6 wk, 3 X/d
1991 in first 4
wk, 2 X/
wk in last
2 wk
Falconer et al, (24) 37/37 4-6 wk, 2-
1992 3 X/wk
Fargas-Babjak, (35) 56 6 wk, 2 X/d
1992
Grimmer, (27) 1992 60 30-min
sessions,
once
(immediate
pain relief)
Harrison et al, (40) Home (n=42) 4 wk, 3 X/2
1999 Supervised wk
(n=34)
Feedback
(n=36)
Jan and Lai, (15) 21/20 10 wk, 4 X/
1991 wk
Jensen et al, (9) 30/30 3-4 d
1985
Jensen et al, (88) 20 1 wk, daily
1991 for 5 d
Lessard et al, (8) Ice+exercise 1 wk, daily
1997 (n=23)
Ice alone
(n=22)
Levitt et al, (45) 26/25 2 wk, daily 3
1995 x/d
Lewis et al, (28) 36 3 wk, 3
1994 sessions
daily
Lewis et al, (29) 30 3 wk, 3
1984 sessions
daily
Oldham et al, (36) 30 3 h/d for 6
1995 wk
O'Reilly et al, (13) Exercise 12 wk, 3 in
1999 (n=13) 12 wk
Control
(n=78)
Rogind et al, (12) Exercise 12 wk, 2
1998 (n=12) supervised
Control + 5 X/wk
(n=13) at home
Schilke et al, (17) Exercise 8 wk, 3 X/
1996 (n=10) wk
Control
(n=10)
Schwellnus et 10/10 10 d
al, (37) 1992
Smith et al, (30) 15/15 20 min/
1983 session, 2
X/wk for
8 wk
Svarcova et al, (25) 60/60 3 wk, 3-4
1988 X2 wk
Taylor et al, (31) 12 2 wk, daily
1981 for 30 min
van Baar et al, (20) Exercise 12 wk, 1-3
1998 (n=99) X/wk
Control
(n=102)
Yurkuran and TENS (n=25) 20 min, 5
Kocagil, (23) Electroacupuncture X/wk for
1999 (n=25) 2 wk
Ice massage
(n=25)
Placebo
(n=25)
Zatterstrom et Specific QF 12 wk, 2 X/
al, (43) 1992 (n=9) wk
Function at
trunk and
leg training
(n=17)
Author/Year Sample Size Follow-up
Antich, (5) 1986 86 knees, 64 1.5 wk
patients
Bautch et al, (10) 17/17 None
1997
Beard et al, (42) 25/25 None
1994
Borjesson et al, (11) 34/34 24 wk
1996
Callaghan et al, (18) Control (n=9) None
1995 Home (n=10)
Exercise (n=8)
D'Lima et al, (6) 10/10 48 wk
1996 postsurgery
Draper et al, (44) 15/15 None
1991
Falconer et al, (24) 37/37 None
1992
Fargas-Babjak, (35) 56 24 wk
1992
Grimmer, (27) 1992 60 None
Harrison et al, (40) Home (n=42) 52 wk
1999 Supervised
(n=34)
Feedback
(n=36)
Jan and Lai, (15) 21/20 None
1991
Jensen et al, (9) 30/30 7 wk
1985
Jensen et al, (88) 20 None
1991
Lessard et al, (8) Ice+exercise None
1997 (n=23)
Ice alone
(n=22)
Levitt et al, (45) 26/25 None
1995
Lewis et al, (28) 36 9 wk
1994
Lewis et al, (29) 30 1 wk
1984 washout
Oldham et al, (36) 30 6 wk, 12
1995 wk
O'Reilly et al, (13) Exercise 24 wk
1999 (n=13)
Control
(n=78)
Rogind et al, (12) Exercise 52 wk
1998 (n=12)
Control
(n=13)
Schilke et al, (17) Exercise None
1996 (n=10)
Control
(n=10)
Schwellnus et 10/10 2 wk
al, (37) 1992
Smith et al, (30) 15/15 4 wk
1983
Svarcova et al, (25) 60/60 None
1988
Taylor et al, (31) 12 52 wk
1981
van Baar et al, (20) Exercise 24 wk
1998 (n=99)
Control
(n=102)
Yurkuran and TENS (n=25) None
Kocagil, (23) Electroacupuncture
1999 (n=25)
Ice massage
(n=25)
Placebo
(n=25)
Zatterstrom et Specific QF None
al, (43) 1992 (n=9)
Function at
trunk and
leg training
(n=17)
Quality (3,4)
Author/Year Sample Size (R, B, W)
Antich, (5) 1986 86 knees, 64 1, 0, 0
patients
Bautch et al, (10) 17/17 1, 0, 0
1997
Beard et al, (42) 25/25 2, 1, 1
1994
Borjesson et al, (11) 34/34 1, 0, 1
1996
Callaghan et al, (18) Control (n=9) 1, 0, 0
1995 Home (n=10)
Exercise (n=8)
D'Lima et al, (6) 10/10 2, 0, 0
1996
Draper et al, (44) 15/15 1, 0, 1
1991
Falconer et al, (24) 37/37 1, 2, 1
1992
Fargas-Babjak, (35) 56 1, 1, 1
1992
Grimmer, (27) 1992 60 2, 1, 1
Harrison et al, (40) Home (n=42) 2, 0, 0
1999 Supervised
(n=34)
Feedback
(n=36)
Jan and Lai, (15) 21/20 1, 0, 0
1991
Jensen et al, (9) 30/30 1, 2, 0
1985
Jensen et al, (88) 20 1, 0, 1
1991
Lessard et al, (8) Ice+exercise 1, 1, 0
1997 (n=23)
Ice alone
(n=22)
Levitt et al, (45) 26/25 0, 0, 0
1995
Lewis et al, (28) 36 1, 1, 0
1994
Lewis et al, (29) 30 0, 1, 1
1984
Oldham et al, (36) 30 1, 1, 0
1995
O'Reilly et al, (13) Exercise 2, 0, 1
1999 (n=13)
Control
(n=78)
Rogind et al, (12) Exercise 2, 0, 1
1998 (n=12)
Control
(n=13)
Schilke et al, (17) Exercise 2, 0, 0
1996 (n=10)
Control
(n=10)
Schwellnus et 10/10 1, 0, 1
al, (37) 1992
Smith et al, (30) 15/15 1, 1, 1
1983
Svarcova et al, (25) 60/60 0, 0, 0
1988
Taylor et al, (31) 12 1, 2, 1
1981
van Baar et al, (20) Exercise 2, 0, 1
1998 (n=99)
Control
(n=102)
Yurkuran and TENS (n=25) 1, 2, 0
Kocagil, (23) Electroacupuncture
1999 (n=25)
Ice massage
(n=25)
Placebo
(n=25)
Zatterstrom et Specific QF 0, 0, 1
al, (43) 1992 (n=9)
Function at
trunk and
leg training
(n=17)
(a) R: randomization, B=blinding, W=withdrawals, NA=not available,
ACL=anterior cruciate ligament, QF=quadriceps femoris muscle,
SLR=straight leg raise, US=therapeutic ultrasound,
EMG=electromyographic, TENS=transcutaneous electrical nerve
stimulation, NSAID=nonsteroidal anti-inflammatory drug,
OA=osteoarthritis, ROM=range of motion, GP=general practitioner.
(b) McNeil Consumer Healthcare, Div of McNeil-PPC Inc, Camp Hill Rd,
Fort Washington, PA 19034.
Table 1.
Details of Philadelphia Panel Classification System
Clinical Statistical
Importance Significance
Grade A >15% P <.05
Grade B >15% P <.05
Grade C+ >15% Not significant
Grade C <15% Unimportant (b)
Grade D <0% (favors control)
Study Design (a)
Grade A RCT (single or meta-analysis)
Grade B CCT or observational (single or meta-analysis), with a
quality score of 3 or more on the 5-point Jadad
methodologic quality checklist
Grade C+ RCT or CCT or observational (single or meta-analysis)
Grade C Any study design
Grade D Well-designed RCT with > 100 patients
(a) RCT=randomized controlled trial, CCT=controlled clinical trial.
(b) For grade C, statistical significance is unimportant (ie, clinical
importance is not met; therefore, statistical significance is
irrelevant).
Table 2.
Master Grid of Knee Pain Guidelines (a)
Patello-
femoral
Pain Post-
Syndrome surgery Osteoarthritis
Exercise ID [check] C [check] A
Massage nd nd nd
Thermotherapy nd [check] C [check] C
Therapeutic ultrasound [check] C nd [check] C
Transcutaneous nd [check] C [check] A
electrical nerve
stimulation
Electrical stimulation nd ID [check] C
Electromyographic nd ID nd
biofeedback
Combined rehabilitation nd ID nd
modalities
interventions
Knee
Tendinitis
Exercise ID
Massage [check] C
Thermotherapy nd
Therapeutic ultrasound nd
Transcutaneous nd
electrical nerve
stimulation
Electrical stimulation nd
Electromyographic nd
biofeedback
Combined rehabilitation nd
modalities
interventions
(a) [check] =evidence-based recommendation formulated, A=based on
randomized controlled trial (RCT) showing >15% benefit and
statistically significant, B=based on controlled clinical trial (CCT)
showing >15% benefit and statistically significant, C=based on RCT or
CCT and showing no evidence of benefit, C+=based on RCT or CCT and
showing >15% benefit but not statistically significant,
ID=insufficient data due to lack of placebo, lack of relevant
outcomes, nd=no data.
Table 3.
Grade A Rehabilitation Interventions: Clinically Important Benefit
Demonstrated (a)
Relative
Guideline Recommendation Outcomes Difference
Therapeutic exercises for
knee osteoarthritis Grade A Pain 16%-78%
Grade C+ Function 7%-26%
Grade A Patient global 21%
assessment
TENS for knee Grade A Pain 40%
osteoarthritis Grade A Patient global
assessment 18%-22%
Study
Guideline Recommendation Outcomes Design
(No. of
Patients)
Therapeutic exercises for
knee osteoarthritis Grade A Pain 3 RCTs
Grade C+ Function (N=293)
Grade A Patient global
assessment 4 RCTs
TENS for knee Grade A Pain
osteoarthritis Grade A Patient global (N=184)
assessment
(a) TENS=transcutaneous electrical nerve stimulation, RCT=randomixed
controlled trial.
Table 4.
Grade C Rehabilitation Interventions: No Evidence of Clinically
Important Benefit (a)
Relative
Guideline Recommendation Outcomes Difference
Therapeutic ultrasound Grade C Patient None
for patellofemoral global
pain syndrome assessment
Preoperative exercises Grade C Pain None
for postsurgery Grade C Function
knee conditions
Thermotherapy for Grade C Pain None
postsurgery knee
conditions
TENS for postsurgery Grade C Pain None
rehabilitation
Grade C Function
Therapeutic ultrasound Grade C Pain None
for knee
osteoarthritis
Electrical stimulation Grade C Function Less than 15%
for knee
osteoarthritis
Massage for knee Grade C Pain None
tendinitis
Study Design
Guideline Recommendation Outcomes (No. of
Patients)
Therapeutic ultrasound Grade C Patient 1 RCT (N=64)
for patellofemoral global
pain syndrome assessment
Preoperative exercises Grade C Pain 1 RCT (N-20)
for postsurgery Grade C Function
knee conditions
Thermotherapy for Grade C Pain 1 RCT (N=45)
postsurgery knee
conditions
TENS for postsurgery Grade C Pain 1 RCT (N=60)
rehabilitation
Grade C Function
Therapeutic ultrasound Grade C Pain 1 RCT (N=74)
for knee
osteoarthritis
Electrical stimulation Grade C Function 1 RCT (N=30)
for knee
osteoarthritis
Massage for knee Grade C Pain 1 RCT (N=20)
tendinitis
(a) TENS=transcutaneous electrical nerve stimulation, RCT=randomized
controlled trial.
Table 5.
Rehabilitation Interventions With Insufficient Data
Intervention and
Indication Details
Combined rehabilitation Due to different interventions
interventions for postsurgery and poorly defined
knee pain interventions, the panel
decided that it was
impossible to draw
conclusions
Therapeutic exercises for knee No relevant outcomes
tendinitis
Electrical stimulation for knee Insufficient sample size (n=5
postsurgery per group) (39)
Therapeutic exercises for Head-to-head trials
patellofemoral pain
Therapeutic exercises for Head-to-head trials
postsurgery knee
rehabilitation
Electromyographic Head-to-head trials
biofeedback for knee
postsurgery
Table 6.
Pain After 1 Month of Exercise Therapy for Knee Osteoarthritis (a)
Treatment No. of
Study Group Outcome Patients
Bautch et al, (10) E: strength and Pain, 0-10 VAS 15
1997 stretch
C: untreated 15
O'Reilly et al, (13) E: strength Pain: WOMAC, 108
1999 0-20 VAS
C: untreated 72
Rogind et al, (12) E: strength and Pain, 0-10 VAS 11
1998 stretch
C: untreated 12
van Baar et al, (20) E: strength, stretch, Pain, 0-100 93
1998 stretch,
functional
C: usual care 98
Treatment Baseline
Study Group Outcome Mean
Bautch et al, (l0) E: strength and Pain, 0-10 VAS 3.49
1997 stretch
C: untreated 1.46
O'Reilly et al, (13) E: strength Pain: WOMAC, 6.45
1999 0-20 VAS
C: untreated 6.75
Rogind et al, (12) E: strength and Pain, 0-10 VAS 5
1998 stretch VAS
C: untreated 4.5
van Baar et al, (20) E: strength, stretch, Pain, 0-100 46.9
1998 stretch, VAS
functional
C: usual care 43.1
End of
Treatment Study
Study Group Outcome Mean
Bautch et al, (l0) E: strength and Pain, 0-10 VAS 2.19
1997 stretch
C: untreated 2.08
O'Reilly et al, (13) E: strength Pain: WOMAC, 5.00
1999 0-20 VAS
C: untreated 6.33
Rogind et al, (12) E: strength and Pain, 0-10 VAS 2
1998 stretch
C: untreated 3.5
van Baar et al, (20) E: strength, Pain, 0-100 24.1
1998 stretch, VAS
functional
C: usual care 37.4
Treatment
Study Group Outcome Absolute
Benefit
Bautch et al, (10) E: strength and Pain, 0-10 VAS -1.92 (I)
1997 stretch on
10-cm
VAS
C: untreated
O'Reilly et al, (13) E: strength Pain: WOMAC, -1.03 (I)
1999 0-20 VAS on
20-cm
VAS
C: untreated
Rogind et al, (12) E: strength and Pain, 0-10 VAS -2.00 (I)
1998 stretch on
10-cm
VAS
C: untreated
van Baar et al, (20) E: strength, Pain, 0-100 -17.10 (I)
1998 stretch, VAS on
functional 100-mm
VAS
C: usual care
Relative
Difference
in Change
Treatment From
Study Group Outcome Baseline
Bautch et al, (l0) E: strength and Pain, 0-10 VAS -78% (I)
1997 stretch (b)
C: untreated
O'Reilly et al, (13) E: strength Pain: WOMAC, -16% (I)
1999 0-20 VAS
C: untreated
Rogind et al, (12) E: strength and Pain, 0-10 VAS -42% (I)
1998 stretch
C: untreated
van Baar et al, (20) E: strength, Pain, 0-100 -38% (I)
1998 stretch, VAS
functional
C: usual care
(a) E=experimental group, C=control group, VAS=visual analog scale.
(b) This study shows a large relative difference in change from
baseline due to baseline differences.
Table 7.
Patient Global Assessment and Function After 1 Month of Exercise
Therapy for Knee Osteoarthritis
No.
Study Treatment Group (a) Outcome Improved
Borjesson et al, E: strength and stretch Patient global 20
(11) 1996 assessment
C: control 1
van Baar et al, E: strength, stretch, Patient global 44
(20) 1998 functional assessment
C: control 18
No. of
Study Treatment Group (a) Outcome Patients
Borjesson et al, E: strength and stretch Patient global 34
(11) 1996 assessment
C: control 34
van Baar et al, E: strength, stretch, Patient global 98
(20) 1998 functional assessment
C: control 102
Risk (%
Study Treatment Group (a) Outcome Occurrence)
Borjesson et al, E: strength and stretch Patient global 59%
(11) 1996 assessment 3%
C: control 45%
van Baar et al, E: strength, stretch, Patient global
(20) 1998 functional assessment 18%
C: control
Study Treatment Group (a) Outcome Risk
Difference
Borjesson et al, E: strength and stretch Patient global 56%
(11) 1996 assessment
C: control
van Baar et al, E: strength, stretch, Patient global 27%
(20) 1998 functional assessment
C: control
(a) E=experimental group, C=control group.
Table 8.
Ice Massage for Knee Osteoarthritis: Pain Relief (a)
Treatment No. of
Study Group Outcome Patients
Yurtkuran and Ice massage Pain, 1-5 25
Kocagil, (23) PPI
1999 1=mild
2=moderate
3=severe
4=very severe
5=excruciating
Placebo TENS 25
Treatment Baseline
Study Group Outcome Mean
Yurtkuran and Ice massage Pain, 1-5 0.7
Kocagil, (23) PPI
1999 1=mild
2=moderate
3=severe
4=very severe
5=excruciating
Placebo TENS 0.7
End-of-
Treatment Study
Study Group Outcome Mean
Yurtkuran and Ice massage Pain, 1-5 0.4
Kocagil, (23) PPI
1999 1=mild
2=moderate
3=severe
4=very severe
5=excruciating
Placebo TENS 0.5
Treatment
Study Group Outcome Absolute Benefit
Yurtkuran and Ice massage Pain, 1-5 -0.10 (I) on 5-point
Kocagil, (23) PPI Likert scale
1999 1=mild
2=moderate
3=severe
4=very severe
5=excruciating
Placebo TENS
Relative
Difference in
Change
Treatment From
Study Group Outcome Baseline
Yurtkuran and Ice massage Pain, 1-5 -14% (I)
Kocagil, (23) PPI
1999 1=mild
2=moderate
3=severe
4=very severe
5=excruciating
Placebo TENS
(a) TENS=transcutaneous electrical nerve stimulation, PPI=present
pain intensity.
Table 9.
Pain at 1 to 3 Months After Transcutaneous Electrical Nerve
Stimulation (TENS) for Knee Osteoarthritis (a)
No.
Study Treatment Group Outcome Improved
Fargas-Babjak et E: TENS, 4 Hz LF, Pain, 6 wk 14
al, (35) 1992 acupoints
C: placebo 5
Smith et al, (30) E: TENS, 32-50 Hz on Pain, 8 wk 7
1983 tender points
(usually acupoints)
C: placebo 4
Taylor et al, (31) E: TENS, frequency Pain, 4 wk 8
1981 NR, 4 points
around knee
C: placebo 4
No. of
Study Treatment Group Outcome Patients
Fargas-Babjak et E: TENS, 4 Hz LF, Pain, 6 wk 19
al, (35) 1992 acupoints
C: placebo 18
Smith et al, (30) E: TENS, 32-50 Hz on Pain, 8 wk 15
1983 tender points
(usually acupoints)
C: placebo 15
Taylor et al, (31) E: TENS, frequency Pain, 4 wk 10
1981 NR, 4 points
around knee
C: placebo 10
Risk (%
Study Treatment Group Outcome Occurrence)
Fargas-Babjak et E: TENS, 4 Hz LF, Pain, 6 wk 74%
al, (35) 1992 acupoints
C: placebo 28%
Smith et al, (30) E: TENS, 32-50 Hz on Pain, 8 wk 47%
1983 tender points
(usually acupoints)
C: placebo 27%
Taylor et al, (31) E: TENS, frequency Pain, 4 wk 80%
1981 NR, 4 points
around knee
C: placebo 40%
Risk
Study Treatment Group Outcome Difference
Fargas-Babjak et E: TENS, 4 Hz LF, Pain, 6 wk 46%
al, (35) 1992 acupoints
C: placebo
Smith et al, (30) E: TENS, 32-50 Hz on Pain, 8 wk 20%
1983 tender points
(usually acupoints)
C: placebo
Taylor et al, (31) E: TENS, frequency Pain, 4 wk 40%
1981 NR, 4 points
around knee
C: placebo
(a) HF=high frequency, LF=low frequency, NR=not reported.
Table 10.
Transcutaneous Electrical Nerve Stimulation (TENS) for Knee
Osteoarthritis: Pain Relief on Continuous Scales (a)
No. of
Study Treatment Group Outcome Patients
Lewis et al, (29) E: TENS, 70-Hz Pain, VAS 10 cm, 31
1984 HF, 4 acupoints 0=no pain
relief,
10=complete
pain relief
C: placebo 28
Lewis et al, (28) E: TENS, 70-Hz Pain, VAS 100 29
1994 HF, 4 acupoints mm, 0=no
relief,
100=complete
pain relief
C: placebo 29
Fargas-Babjak E: TENS, 4-Hz Pain, VAS 100 18
et al, (35) LF, 7 acupoints mm 0=no
1992 relief,
100=complete
pain relief
C: placebo 19
Taylor et al, (31) E: TENS, frequency Pain, VAS 10 cm 10
1981 NR, 4 points 0=no pain,
around knee 10=extreme
pain
C: placebo 10
Yurtkuran and TENS Pain, 1-5 25
Kocagil, (23) PPI
1999 1=mild
2=moderate
3=severe
4=very severe
5=excruciating
Placebo TENS 25
Baseline
Study Treatment Group Outcome Mean
Lewis et al, (29) E: TENS, 70-Hz Pain, VAS 10 cm, 3.5
1984 HF, 4 acupoints 0=no pain
relief,
10=complete
pain relief
C: placebo 3.5
Lewis et al, (28) E: TENS, 70-Hz Pain, VAS 100 NA
1994 HF, 4 acupoints mm, 0=no
relief,
100=complete
pain relief
C: placebo NA
Fargas-Babjak E: TENS, 4-Hz Pain, VAS 100 NA
et al, (35) LF, 7 acupoints mm 0=no
1992 relief,
100=complete
pain relief
C: placebo NA
Taylor et al, (31) E: TENS, frequency Pain, VAS 10 cm NA
1981 NR, 4 points O=no pain,
around knee 10=extreme
pain
C: placebo NA
Yurtkuran and TENS Pain, 1-5 1.2
Kocagil, (23) PPI
1999 1=mild
2=moderate
3=severe
4=very severe
5=excruciating
Placebo TENS 0.7
End-of-
Study
Study Treatment Group Outcome Mean
Lewis et al, (29) E: TENS, 70-Hz Pain, VAS 10 cm, 5.5
1984 HF, 4 acupoints 0=no pain
relief,
10=complete
pain relief
C: placebo 4.8
Lewis et al, (28) E: TENS, 70-Hz Pain, VAS 100 48.1
1994 HF, 4 acupoints mm, 0=no
relief,
100=complete
pain relief
C: placebo 43.2
Fargas-Babjak E: TENS, 4-Hz Pain, VAS 100 56.05
et al, (35) LF, 7 acupoints mm 0=no
1992 relief,
100=complete
pain relief
C: placebo 10.72
Taylor et al, (31) E: TENS, frequency Pain, VAS 10 cm 0.9
1981 NR, 4 points O=no pain,
around knee 10=extreme
pain
C: placebo 0.8
Yurtkuran and TENS Pain, 1-5 0.2
Kocagil, (23) PPI
1999 1=mild
2=moderate
3=severe
4=very severe
5=excruciating
Placebo TENS 0.5
Absolute
Study Treatment Group Outcome Benefit
Lewis et al, (29) E: TENS, 70-Hz Pain, VAS 10 cm, 0.7 (I) on
1984 HF, 4 acupoints 0=no pain 10-cm VAS
relief,
10=complete
pain relief
C: placebo
Lewis et al, (28) E: TENS, 70-Hz Pain, VAS 100 5.1 (I) on
1994 HF, 4 acupoints mm, 0=no 100-mm VAS
relief,
100=complete
pain relief
C: placebo
Fargas-Babjak E: TENS, 4-Hz Pain, VAS 100 45.33 (I) on
et al, (35) LF, 7 acupoints mm 0=no 100-mm VAS
1992 relief,
100=complete
pain relief
C: placebo
Taylor et al, (31) E: TENS, frequency Pain, VAS 10 cm 0.1 on 10-cm
1981 NR, 4 points O=no pain, VAS (I)
around knee 10=extreme
pain
C: placebo
Yurtkuran and TENS Pain, 1-5 -0.80 (I) on
Kocagil, (23) PPI 5-point
1999 1=mild Likert
2=moderate scale
3=severe
4=very severe
5=excruciating
Placebo TENS
Relative
Difference
in Change
From
Study Treatment Group Outcome Baseline
Lewis et al, (29) E: TENS, 70-Hz Pain, VAS 10 cm, 20% (I) (b)
1984 HF, 4 acupoints 0=no pain
relief,
10=complete
pain relief
C: placebo
Lewis et al, (28) E: TENS, 70-Hz Pain, VAS 100 10.6% (I) (b)
1994 HF, 4 acupoints mm, 0=no
relief,
100=complete
pain relief
C: placebo
Fargas-Babjak E: TENS, 4-Hz Pain, VAS 100 NA (b)
et al, (35) LF, 7 acupoints mm 0=no
1992 relief,
100=complete
pain relief
C: placebo
Taylor et al, (31) E: TENS, frequency Pain, VAS 10 cm NA
1981 NR, 4 points O=no pain,
around knee 10=extreme
pain
C: placebo
Yurtkuran and TENS Pain, 1-5 -84% (I)
Kocagil, (23) PPI
1999 1=mild
2=moderate
3=severe
4=very severe
5=excruciating
Placebo TENS
(a) E=experimental group, C=control group, HF=high frequency, LF=low
frequency, NR=not reported, VAS=visual analog scale, NA=not
applicable, PPI=present pain intensity.
(b) Study had pain scale where a higher score indicates greater pain
relief.
Table 11.
Patient Global Assessment at 1 and 3 Months After Transcutaneous
Electrical Nerve Stimulation (TENS) for Knee Osteoarthritis (a)
Treatment No.
Study Group Outcome Improved
Lewis et al, (29) E: TENS, 70-Hz HF, Patient global 12
1984 4 acupoints assessment, 3 wk
C: placebo 4
Lewis et al, (28) E: TENS, 70-Hz HF, Patient global 7
1994 4 acupoints assessment, 3 wk
C: placebo 2
Fargas-Babjak et E: TENS, 4 Hz LF, Patient global 9
al, (35) 1992 7 acupoints assessment, 12 wk
C: placebo 2
Treatment No. of
Study Group Outcome Patients
Lewis et al, (29) E: TENS, 70-Hz HF, Patient global 28
1984 4 acupoints assessment, 3 wk
C: placebo 28
Lewis et al, (28) E: TENS, 70-Hz HF, Patient global 29
1994 4 acupoints assessment, 3 wk
C: placebo 29
Fargas-Babjak et E: TENS, 4 Hz LF, Patient global 15
al, (35) 1992 7 acupoints assessment, 12 wk
C: placebo 17
Treatment Risk (%
Study Group Outcome Occurrence)
Lewis et al, (29) E: TENS, 70-Hz HF, Patient global 43%
1984 4 acupoints assessment, 3 wk
C: placebo 14%
Lewis et al, (28) E: TENS, 70-Hz HF, Patient global 24%
1994 4 acupoints assessment, 3 wk
C: placebo 7%
Fargas-Babjak et E: TENS, 4 Hz LF, Patient global 60%
al, (35) 1992 7 acupoints assessment, 12 wk
C: placebo 12%
Treatment Risk
Study Group Outcome Difference
Lewis et al, (29) E: TENS, 70-Hz HF, Patient global 29%
1984 4 acupoints assessment, 3 wk
C: placebo
Lewis et al, (28) E: TENS, 70-Hz HF, Patient global 17%
1994 4 acupoints assessment, 3 wk
C: placebo
Fargas-Babjak et E: TENS, 4 Hz LF, Patient global 48%
al, (35) 1992 7 acupoints assessment, 12 wk
C: placebo
(a) E=experimental group, C=control group, HF=high frequency,
LF=low frequency.
Acknowledgments: Summer students: Sarah Milne, Michael Saginur, Marie-Josee Noel, Melanie Brophy, Anne Mailhot Philadelphia Panel Members: Clinical Specialty Experts: John Albright, MD, (Orthopaedic Surgeon), American Academy of Orthopaedic Surgeons, USA Richard Allman, MD (Internist, Rheumatologist), American College of Physicians, USA Richard Paul Bonfiglio, MD (Physiatrist) Alicia Conill, MD (Internist), University of Pennsylvania, Philadelphia. USA Bruce Dobkin, MD (Neurologist), American Academy of Neurology, USA Andrew A Guccione, PT, PhD, (Physical Therapist), American Physical Therapy Association, USA Scott Hasson, PT, PhD, (Physical Therapist), American College of Rheumatology, Association of Health Professionals, USA Randolph Russo, MD (Physiatrist), American Academy of Physical Medicine and Rehabilitation, USA Paul Shekelle, MD, PhD (Internist), Cochrane Back Group, USA Jeffrey L Susman, MD (Family Practice), American Academy of Family Physicians, USA Ottawa Methods Group: Lucie Brosseau, PhD (Public Health, specialization in epidemiology); Career Scientist, Ministry of Ontario Health (Canada), and Assistant Professor, Physiotherapy Program, School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada Peter Tugwell, MD, MSc (Epidemiology), Chair, Centre for Global Health, Institute of Population Health, Ottawa, Ontario, Canada George A Wells, PhD (Epidemiology and Biostatistics), Professor and Chairman, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada Vivian A Robinson, MSc (Kinesiology), Research Associate, Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada Ian D Graham, PhD (Medical Sociology), Medical Research Council Scholar, Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada Beverley J Shea, RN, MSc (Epidemiology), Research Associate, Department of Medicine, University of Ottawa and Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada Manathip Osiri, MD, Research Fellow, Ottawa Hospital, General Campus, Ottawa, Ontario, Canada Jessie McGowan, Director of the Medical Library, Ottawa Hospital, Ottawa, Ontario, Canada Joan Peterson, Research Associate, Department of Medicine, Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada Helene Corriveau, PhD; Lucie Pelland, PhD; Michelle Morin, BSc; Lucie Poulin, MSc; Michel Tousignant, PhD; Lucie Laferriere, MHA; Lynn Casimiro; Louis E Tremblay; Program of Physiotherapy, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada * Oxford, England: The Cochrane Collaboration, 2000. 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Address all correspondence and requests for reprints to: Peter Tugwell, MD, MSc, Chair, Centre for Global Health, Institute of Population Health, 1 Stewart St, Rm 312, Ottawa, Ontario, Canada K1N 6N5 (ptugwell@uottawa.ca). This study was financially supported by an unrestricted educational grant from the Cigna Foundation, Philadelphia, Pa, USA; the Ministry of Human Resources and Development, Government of Canada (Summer Students Program); and the Ontario Ministry of Health and Long-term Care (Canada). Dr Ian Graham is a Medical Research Council Scholar, Canadian Institutes of Health Research (Canada). |
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