Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials

Jan M Bjordal, Mark I Johnson, Rodrigo A B Lopes-Martins, Bård Bogen, Roberta Chow, Anne E Ljunggren, Jan M Bjordal, Mark I Johnson, Rodrigo A B Lopes-Martins, Bård Bogen, Roberta Chow, Anne E Ljunggren

Abstract

Background: Treatment efficacy of physical agents in osteoarthritis of the knee (OAK) pain has been largely unknown, and this systematic review was aimed at assessing their short-term efficacies for pain relief.

Methods: Systematic review with meta-analysis of efficacy within 1-4 weeks and at follow up at 1-12 weeks after the end of treatment.

Results: 36 randomised placebo-controlled trials (RCTs) were identified with 2434 patients where 1391 patients received active treatment. 33 trials satisfied three or more out of five methodological criteria (Jadad scale). The patient sample had a mean age of 65.1 years and mean baseline pain of 62.9 mm on a 100 mm visual analogue scale (VAS). Within 4 weeks of the commencement of treatment manual acupuncture, static magnets and ultrasound therapies did not offer statistically significant short-term pain relief over placebo. Pulsed electromagnetic fields offered a small reduction in pain of 6.9 mm [95% CI: 2.2 to 11.6] (n = 487). Transcutaneous electrical nerve stimulation (TENS, including interferential currents), electro-acupuncture (EA) and low level laser therapy (LLLT) offered clinically relevant pain relieving effects of 18.8 mm [95% CI: 9.6 to 28.1] (n = 414), 21.9 mm [95% CI: 17.3 to 26.5] (n = 73) and 17.7 mm [95% CI: 8.1 to 27.3] (n = 343) on VAS respectively versus placebo control. In a subgroup analysis of trials with assumed optimal doses, short-term efficacy increased to 22.2 mm [95% CI: 18.1 to 26.3] for TENS, and 24.2 mm [95% CI: 17.3 to 31.3] for LLLT on VAS. Follow-up data up to 12 weeks were sparse, but positive effects seemed to persist for at least 4 weeks after the course of LLLT, EA and TENS treatment was stopped.

Conclusion: TENS, EA and LLLT administered with optimal doses in an intensive 2-4 week treatment regimen, seem to offer clinically relevant short-term pain relief for OAK.

Figures

Figure 1
Figure 1
Quorum flow chart. Quorum flow chart showing the selection process of the review.
Figure 2
Figure 2
Primary outcome. Efficacy for each intervention measured at the end of treatment. Mean difference over placebo for pain measured on a 100 mm visual analogue scale (VAS) is shown as columns, and error bars indicate 95% confidence limits. The horizontal dotted lines indicate subjective thresholds for mean perceptible improvement (lowest), mean slight improvement (middle) and mean important improvement (top). Abbreviations: LLLT (Low Level Laser Therapy), TENS/IF (Transcutaneous Electrical Nerve Stimulation and Interferential Currents), EA (Electro-acupuncture), PEMF (Pulsed Electro Magnetic Fields), MA (Manual Acupuncture), US (Ultrasound).
Figure 3
Figure 3
Primary outcome – Forest plot for subgroups with optimal treatment. Forest plot over 16 trials with optimal treament procedures and dose. Trials plotted on the right hand side of the middle line (WMD (fixed)) indicates a positive treatment effect. The combined effect size for each intervention is placed below the trials, and combined overall effect of all 16 trials is plotted on the bottom.
Figure 4
Figure 4
Primary outcome – subgroups. Best efficacy for optimal dose and administration of each intervention within 4 weeks after treatment start. Mean difference over placebo for pain measured on a 100 mm visual analogue scale (VAS) is shown as columns, and error bars indicate 95% confidence limits. The horizontal dotted lines indicate subjective thresholds for mean perceptible improvement (lowest), mean slight improvement (middle) and mean important improvement (top). Abbreviations: LLLT (Low Level Laser Therapy), TENS/IF (Transcutaneous Electrical Nerve Stimulation and Interferential Currents), EA (Electro-acupuncture).
Figure 5
Figure 5
Effect size plot TENS/IF trials. Effect/size plot for TENS/IF trials. Open circles indicate trials with non-optimal treatment, and black circles indicate trials with optimal dose and treatment procedure. Effect over placebo is related to the x-axis and sample size is related to the y-axis.
Figure 6
Figure 6
Effect size plot LLLT trials. Effect/size plot for LLLT trials. Open circles indicate trials with non-optimal treatment, and black circles indicate trials with optimal dose and treatment procedure. Effect over placebo is related to the x-axis and sample size is related to the y-axis.
Figure 7
Figure 7
Effect size plot EA trials. Effect/size plot for EA trials. Black circles indicate trials with optimal dose and treatment procedure. Effect over placebo is related to the x-axis and sample size is related to the y-axis.
Figure 8
Figure 8
Publication bias plot. Effect/size plot for trials with TENS/IF, LLLT and EA. Black circles indicate a single trial. Effect over placebo is related to teh x-axis and sample size is related to the y-axis.

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