Physical Therapy Versus No Treatment
Three studies comparing physical therapy with no treatment were found (2,7,14). Two out of the three advocate the need for physical therapy after partial meniscectomy surgery. In a study of 31 men, patients who received physical therapy recovered their preoperative isokinetic knee extensor strength in 3 wk, compared with 7–12 wk for patients who received no treatment (7). In a matched subgroup of the original sample (N = 16), strength differences between groups were as large as 26%, and the residual deficits of the untreated patients were 2 to 3 times greater than those of the treated patients (7). In the second study in this category, 10 subjects in a pilot study received nine physical therapy treatments compared with 10 subjects who received no treatment. A statistically significant improvement in return to sports activity (P = 0.04) and vertical and horizontal hop tests (P = 0.04 and 0.02, respectively) was reported for those who received physical therapy 4 wk after surgery (14). The third study in this category included three arms: physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and a no-treatment group. No benefits were found from physical therapy or NSAIDs compared with no treatment in terms of subjective knee function, the only outcome recorded (2). In total, this study included 120 subjects, of which 68 had meniscal tears, 14 were classed as normal, and 38 had cartilage degeneration, loose bodies, or ligamentous lesions. Despite group classification, all the pathologies were included in the final analysis. This was the only study not to adhere to strict exclusion criteria, examining only uncomplicated partial meniscectomies. This and the use of only one outcome measure leave the results of this study of little use to the question of necessity of physical therapy after partial meniscectomy.
Some studies advocating the need for physical therapy after partial meniscectomy surgery (7,14) have done so without supportive evidence from both objective and subjective outcome measures. Statistically significant improvements in knee extensor strength at 30°·s−1 (P = 0.005) and 180°·s−1 (P = 0.008) were reported for subjects who received physical therapy compared with those who received no treatment. No statistically significant differences were found in terms of knee function measured using the Lysholm and Gillquist questionnaire (ANCOVA;P = 0.56) (7). When a relationship between function and strength deficit was investigated, correlations were found between knee function and strength deficits at both velocities of 30°·s−1 (r = −0.51) and 180°·s−1 (r = 0.40) 3 wk after surgery. The authors suggest, however, that the strength of this relationship is questionable. The weak relationship may be due to the insensitivity of the functional measure used or to the small sample size of the study (N = 31) (7). It could be argued that the recommendation for physical therapy after surgery based on quadriceps femoris strength deficits alone is inappropriate. Supportive evidence should also be gained using tests such as objective knee function, patient satisfaction with their knee condition, and changes in quality of life.
Only one study reviewed found that subjects’ function improved as a result of physical therapy after arthroscopic partial meniscectomy (14). Vervest et al. (14) included horizontal and vertical hop tests as objective measures of outcome when the effectiveness of physical therapy was compared with no treatment. Statistically significant differences were found between groups in terms of improvement over a 4-wk period (physical therapy group = 11.4 cm, no treatment group = 1.5 cm) (P = 0.04). However, subjects differed in baseline measurements for the vertical hop tests (physical therapy group = 11.1 cm, no treatment group = 18.6 cm) (P = 0.05). In addition, although the physical therapy group made a greater improvement between week 1 and 4, no statistically significant difference between the two groups existed 4 wk after surgery (physical therapy group = 22.5 cm, no treatment group = 20.1 cm) (P = 0.47). No statistically significant differences were found between groups for any of the other outcome measures reported by Vervest et al. (14), including Tegner score, Lysholm score, satisfaction with treatment, and satisfaction with function or pain.
From the three studies in this category, two show results in favor of receiving physical therapy after arthroscopic partial meniscectomy. However, low subject numbers, a lack of double blinding, and inequities of group characteristics at baseline reduce the strength of this evidence. The reporting of only one outcome measure and the failure to analyze pathologies individually in one study reduces the overall meaningful findings in this category.
Physical Therapy Versus Physical Therapy Plus an Extra Modality
The efficacy of three modalities used as adjuncts to physical therapy has been assessed in the treatment of patients after arthroscopic partial meniscectomy. Electrical stimulation used for pain management, stress inoculation training (SIT), and ES used for muscle strengthening combined with physical therapy have all been found to be more effective when compared with physical therapy alone (4,11,15). In the study that used ES for pain control, 90 subjects were divided into three equal groups, each of which received physical therapy. Preoperatively, the first group was instructed on the use of a “live” ES machine, the second group was instructed on the use of a non-live or “placebo” ES machine, and the final group was not given an ES machine. Outcomes were measured 1, 3, and 7 wk postoperatively. Ninety-three percent of subjects who used live ES reported strength improvements and decreased postoperative pain, causing the greatest reduction in medication required when compared with placebo and control groups (4). The study that combined SIT with physical therapy consisted of athletes. Stress inoculation training consisted of conceptualization, skill acquisition, and application in two 1-h sessions 3 d postsurgery. The athletes who received SIT and physical therapy experienced a reduction in self-reported postsurgical pain (VAS) and anxiety (STAI) compared with those who received only physical therapy (11). In the study that combined ES for muscle strengthening with physical therapy, ES was found to have had a significant effect in strengthening the quadriceps femoris muscles (15).
Isokinetic knee strength was measured in all three of these studies. Electrical stimulation provided symptomatic relief to patients who combined it with physical therapy, allowing isokinetic knee extensor strength (velocities of 60 and 180°·s−1) to return to preoperative values 3 wk after surgery, 1 month sooner than those who received placebo or no treatment (4). In the study that combined ES for strengthening with physical therapy, quadriceps strength improved at four isokinetic speeds (120, 180, 240 and 300°·s−1) for subjects who received ES and a strengthening program. Subjects who only received the strengthening program improved their quadriceps strength at the two lowest isokinetic speeds (120 and 180°·s−1) only, suggesting that ES may be valuable in strengthening at higher speeds of contraction (15).
Those subjects who received SIT combined with physical therapy reported fewer days taken to return to a defined physical function level when compared with those that received only physical therapy (23 vs 29 d, respectively). The defined physical function level was when the strength of the injured knee reached 80% of the noninjured knee for two consecutive isokinetic measurements (11). Isokinetic testing or reexamination procedures were not described in this study, limiting its repeatability and comparison with other studies. As well as isokinetic strength, Ross and Berger (11) measured current anxiety and general anxiety using the State-Trait Anxiety Inventory in the study assessing the efficacy of SIT. The measuring scale was not described and, without explanation, only the results of current anxiety were reported. Those who received SIT combined with physical therapy experienced less anxiety compared with those who received no SIT. The authors listed the sports in which the athletes participated, but did not state whether improved function and less pain and anxiety were clinically relevant, allowing earlier return to training or competition, and bringing into question the usefulness of these results.
Of the studies described, the study combining ES for pain with physical therapy suffered from low subject numbers at follow-up (3). Seven wk postoperatively, only 34% (N = 28) of the original subjects were tested. This was due firstly to the noncompliance of patients and secondly to the reluctance of the clinicians to retest a “normalized” knee. The remaining two studies retested all of their subjects (Williams et al. (15), N = 21; Ross and Berger (11), N = 60); however, none indicated any predetermination of the number of subjects required to increase statistical power.
Modalities such as ES and SIT involve extra costs in addition to physical therapy in terms of equipment (ES) and training (SIT). The improvement gained from the use of these adjuncts compared with physical therapy alone has not been assessed in relation to the extra costs involved. The extra costs involved in the treatment of these subjects may far outweigh the benefits they receive.
To conclude, ES and SIT have been shown to be effective adjuncts to physical therapy in improvement of recovery after arthroscopic partial meniscectomy. Results have not, however, indicated their cost-effectiveness and have relied on few and partially reported outcome measures with low subject numbers at the retest.
Immediate Versus Delayed Treatment
The minimally invasive nature of arthroscopic partial meniscectomy results in less knee trauma and, therefore, quicker recovery time than more invasive procedures such as anterior cruciate ligament reconstruction. In an uncomplicated partial meniscectomy, postsurgical physical therapy, theoretically, should therefore be initiated in the early period when healing is rapid, rather than at a later period when the healing is slower or completed. Although not specifically attempting to answer the question of whether physical therapy is more efficacious in the early period after surgery rather than a later period, examples can be drawn from two of the studies reviewed.
A study from the category of physical therapy versus no treatment advocated physical therapy in the early period after surgery (7). Patients who received physical therapy began treatment approximately 3 h after surgery. Three wk after surgery, they experienced less pain and better knee extensor strength recovery than those patients receiving no treatment (7). Unfortunately, despite finding physical therapy beneficial in the early period, no comparisons were made with an alternative treatment period.
As previously reported, Williams et al. (15) recruited subjects between 16 and 88 d after surgery (mean = 31 and 44 d, respectively, for the physical therapy/ES and physical therapy alone groups). Typically, at this stage of between 4 and 6 wk after surgery, healing is well under way. In the study, they compared the effects of ES for strengthening and physical therapy with physical therapy alone. Statistically significant improvements in quadriceps femoris strength and thigh girth were reported in this period after surgery. Again, although combined ES and exercise was reported as effective, it was not compared with an alternative treatment period.
St. Pierre et al. (12) was the only study found that specifically compared the effects of early or delayed rehabilitation (2 or 6 wk) postoperatively. No statistically significant differences in isokinetic knee strength were found between the two groups 10 wk after surgery. In fact, both groups had returned to their preoperative values by week 6. Differences between groups may not have been detected in this study because significant recovery may have already been made 2 wk after surgery. Acknowledged in this study was the absence of a control group. It is difficult to infer how effective the early or delayed rehabilitation is without comparing it with the recovery seen in subjects who received no treatment. The lack of differences between groups at 10 wk may be due to the ineffectiveness of the rehabilitation, unrecorded activities undertaken in addition to the rehabilitation, or the small numbers involved resulting in a type 2 error, i.e., finding no differences when differences really exist.
Physical Therapy Versus Alternative Treatment
One study was found in the category of physical therapy compared with alternative treatments. Formal physical therapy was compared with a structured home exercise program involving progressive weights, advice, and encouragement on sports participation. No statistically significant differences were found between the two programs, which left the authors recommending a well-formulated home program over physical therapy for routine patients (5). In this study, although physical therapy began on day 5, and exercises for the home exercise group began on day 1 postoperatively, baseline outcome measures were recorded 2 wk after surgery. Thus, any improvements in the early period after surgery possibly resulting from the different treatments would not have been detected.
Previous studies have not included cost-effectiveness analyses of physical therapy treatment after surgery compared with alternatives. A figure of $850 for supervised physical therapy and $40 for a home program has been quoted (5), but falls short of a comprehensive economic analysis, although it does illustrate the potential economic differences between the two interventions.
It could be argued that a well-defined home exercise program prescribed by a physical therapist could be described as “physical therapy.” Here, the difference between physical therapy and the alternative is not only where the rehabilitation takes place and the equipment used, but also that it is unsupervised.
The value of guidance intended for clinicians on the effectiveness of physical therapy after knee partial meniscectomy relies on clear descriptions of the treatment program applied. Generally, the studies that have evaluated the effectiveness of physical therapy for this patient group have poorly described the treatment program used. Criteria for the progression or regression of specific exercises, equipment used, and frequency and duration of the treatment are commonly unexplained, and decisions to end physical therapy have been arbitrary (5). The lack of treatment standardization reduces the external validity of studies and therefore their usefulness.
The longest subject follow-up reported in these studies was 10 wk. The exception was a study that also sent postal questionnaires on knee function to subjects at 3 and 6 months postsurgery (7). Thomson et al. (13) consider follow-up too short in clinical trials where, potentially, improvements in muscle strength over time could translate into improved long-term function. This, however, is unlikely, as a relationship between strength and functional recovery has not been found in studies that have included these measures together (7). Physical therapy has enabled more subjects to return to sporting activity (11), but rather than an improvement in strength, it is possibly due to the lack of advice received by those not in contact with clinicians and not receiving treatment.
It is difficult to achieve double blinding in clinical trials because it is difficult to blind a patient into a treatment or an alternative group if the patient has given informed consent and the information given is that the patient will receive treatment or not. Prerandomization or group allocation before patients give informed consent is an alternative to patient blinding. A disadvantage of this method is that an unequal number in each group can result if too many patients in one group drop out after being prerandomized. It is much easier to blind the examiner, although this was not always done in the studies reviewed (3,4,8,12). This factor, along with the lack of intention-to-treat analysis, results in smaller samples, which affects the external validity of the available results.
Researchers may advocate physical therapy, but it is not clear whether patients’ share the same view, shown from the lack of subjective evidence regarding knee function, pain, patient satisfaction (14), or changes in quality of life. Without both parties agreeing on the need for physical therapy, recommendations for treatment will be met with low motivation, patient nonattendance, and wasted valuable resources.
From the eight studies included in this review, three found individual modalities, such as ES and SIT, used alongside physical therapy to be effective in the treatment of patients after arthroscopic partial meniscectomy. Their cost-effectiveness in these studies, however, has not been evaluated. Physical therapy after partial meniscectomy may or may not include these modalities, and generally, due to poor treatment descriptions in the reviewed studies, it is impossible to tell whether they have or have not been included. From the five remaining studies, one found physical therapy beneficial in decreasing knee strength deficits, one identified greater recovery during hop tests and quicker return to sport, and three studies found no benefit from receiving physical therapy compared with their alternatives. Studies suffered from methodological problems, low subject numbers, and ineffective outcome measures, all of which limited their usefulness. We therefore conclude that for those patients who have undergone an uncomplicated arthroscopic partial meniscectomy, physical therapy is not necessary, as it will have little or no effect on their return to activities of daily living.
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Keywords:©2003 The American College of Sports Medicine
knee surgery; arthroscopy; randomized-controlled trial; rehabilitation; review article