Accepted Manuscript Therapeutic effects of whole body vibration training in knee osteoarthritis: a systematic review and meta-analysis Hamayun Zafar, PhD, PT, Assistant Professor, Ahmad Alghadir, MS, PhD, PT, Associate Professor and Consultant of Rehabilitation and Physical Therapy, Shahnawaz Anwer, MPT, Researcher, Einas Al-Eisa, PhD, PT, Associate Professor PII:
S0003-9993(15)00259-2
DOI:
10.1016/j.apmr.2015.03.010
Reference:
YAPMR 56147
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 15 January 2015 Revised Date:
25 February 2015
Accepted Date: 20 March 2015
Please cite this article as: Zafar H, Alghadir A, Anwer S, Al-Eisa E, Therapeutic effects of whole body vibration training in knee osteoarthritis: a systematic review and meta-analysis, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2015), doi: 10.1016/j.apmr.2015.03.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title page Running head: WBV in knee osteoarthritis Title: Therapeutic effects of whole body vibration training in knee osteoarthritis: a
Hamayun Zafar, PhD, PT2 Assistant Professor Ahmad Alghadir, MS, PhD, PT1
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Authors:
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systematic review and meta-analysis
Shahnawaz Anwer, MPT 1,3 Researcher, Einas Al-Eisa, PhD, PT 1 Associate Professor
Rehabilitation Research Chair, Department of Rehabilitation Sciences, College of
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Associate Professor and Consultant of Rehabilitation and Physical Therapy,
Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia 2
Department of Rehabilitation Sciences, College of Applied Medical Sciences
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King Saud University, Riyadh, KSA
Padmashree Dr. D. Y. Patil College of Physiotherapy
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Dr. D. Y. Patil Vidyapeeth, Pune, India Corresponding author:
Shahnawaz Anwer, MPT Researcher Rehabilitation Research Chair, CAMS, King Saud University,
ACCEPTED MANUSCRIPT Riyadh, Saudi Arabia. Mobile:+966-595668288; email: [email protected] Funding: Rehabilitation Research Chair, King Saud University
Deanship of Research Chairs, Rehabilitation Research Chair
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Conflict of interest: None declared
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Acknowledgment: The project was financially supported by King Saud University, Vice
ACCEPTED MANUSCRIPT Therapeutic effects of whole body vibration training in knee osteoarthritis: A
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systematic review and meta-analysis
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Abstract:
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Objectives
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This systematic review was conducted to examine the current evidence regarding the
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effects of whole body vibration (WBV) training in individuals with knee osteoarthritis
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(OA).
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Data Sources
We searched Pubmed, CINAHL, Embase, Scopus, PEDro, and Science citation index for
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research articles published prior to January 2015 using the keywords whole body
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vibration, vibration training, and vibratory exercise in combination with Medical Subject
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Headings “Osteoarthritis knee”.
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Study Selection
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This meta-analysis was restricted to randomized controlled trials published in English
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language. The quality of the selected studies was assessed by the PEDro Scale. The risk
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of bias was assessed using the Cochrane collaboration’s tool in the domain based
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evaluation. We also evaluated the quality of each study based on the criteria given by the
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International Society of Musculoskeletal and Neuronal Interactions (ISMNI) for reporting
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WBV intervention studies, consisting of 13 factors.
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Data Extraction
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Descriptive data regarding subjects, design, intervention, WBV parameters, outcomes,
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and conclusions were collected from each study by two independent evaluators. The
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mean and standard deviation of the baseline and final end point scores for pain, stiffness,
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and function were extracted from included studies.
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Data synthesis
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A total of 83 studies were found in the search. Of these, 5 studies met the inclusion
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criteria and were further analyzed. Four of these 5 studies reached high methodological
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quality on the PEDro scale. Overall, studies demonstrated mixed results in favor of 1
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additive effects of WBV for reducing pain and improving function in knee OA. There
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was considerable variation in the parameters of the WBV included in this systematic
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review.
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Conclusions
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Whole body vibration training reduces pain and improves function in individuals with
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knee OA.
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Key words
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Osteoarthritis; Whole body vibration; Squat; Pain; Strength; Function
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List of abbreviations
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WBV, Whole-body vibration; OA, Osteoarthritis; RCTs, Randomized clinical trials;
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ISMNI, International Society of Musculoskeletal and Neuronal Interactions; WOMAC,
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Western Ontario and McMaster Universities Osteoarthritis Index; JKOM, Japanese Knee
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Osteoarthritis Measure; KWOMAC, Korean Western Ontario and McMaster Universities
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Osteoarthritis Index
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ACCEPTED MANUSCRIPT Knee osteoarthritis (OA) is the commonest form of degenerative joint disease affecting
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both men and women.1,2 In addition to pain, knee OA causes joint stiffness and decreased
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quadriceps strength resulting in physical disability.3 The target of any treatment approach
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in the management of knee OA includes reduction of pain, disability and improvement in
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quadriceps muscle strength. Currently accepted non-pharmacological treatment options
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for OA recommended by the Osteoarthritis Research Society International (OARSI)
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include patient education, weight loss, physical rehabilitation, exercise, change in
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activities of daily living and coping strategies.4
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Recently, the use of whole body vibration (WBV) has been recommended as an
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efficient and alternative option for improving muscle strength in individuals with knee
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OA.5-8 Other studies demonstrated improvement in the function and the self-reported
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disease status in individuals with knee OA after a 12-week training program of squatting
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exercise combined with WBV.9,10 However, Trans et al. reported no improvement in self-
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reported knee pain and function, which shows that there is no consistent finding on this
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issue.6
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WBV training is the exercise program performed with the body on a platform that
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generates vibrations.11 These vibrations are transmitted to the body and stimulate the
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primary endings of the muscle spindles, thereby activate ɑ-motor neuron which causes
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muscle contractions, similar to the tonic vibration reflex.6 WBV training can be given via
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two types of machine, the rotational vibration (RV) and the vertical vibration (VV)
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machine.12 RV machines can vibrate in two dimensions (right and left), whereas, VV
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machines can vibrate in all three spatial dimensions. The study suggests that it is easier to
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maintain the correct training posture on VV machine as compared to RV machine.12
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Recently, Wang et al. published a systematic review and meta-analysis to
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investigate the effects of WBV on pain, stiffness and physical functions in individuals 3
ACCEPTED MANUSCRIPT with knee OA.13 They reported that the WBV training program significantly improves
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physical functions, but there is no evidence that WBV can reduce pain and stiffness in
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individuals with knee OA. However, because this review compared post test data, there is
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a possibility that the group variations in the baseline data can affect the results. Therefore
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the comparison of mean differences between groups would give more reliable results. In
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addition, the use of the International Society of Musculoskeletal and Neuronal
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Interactions (ISMNI) recommended criteria would improve the quality of reports about
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WBV treatment studies.
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Therefore, the objective of this systematic review is to provide an overview of
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current available evidence regarding the therapeutic effects of WBV training in
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individuals with knee OA.
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Methods
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Data sources
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The search for published studies was conducted using Pubmed, CINAHL, Embase,
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Scopus, PEDro and Science citation index using a combination of these keywords whole
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body vibration, vibration therapy, and vibratory exercise with “Osteoarthritis knee” and
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the Medical Subject Headings “osteoarthritis, knee” combined with “whole body
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vibration” or “vibration”. The bibliographical search was restricted to randomized
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controlled trials published in English language prior to January, 2015. Hand searching of
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the identified studies was used to find other appropriate studies. Two independent
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evaluators (SA and HZ) selected the studies based on titles and abstract, excluding those
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articles not related to the objectives of this review.
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Study selection 4
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English language prior to January, 2015. Trials were required to compare exercise with
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and without WBV, or comparing exercise with WBV and control. Studies that did not
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include WBV therapy in their interventions were excluded. The outcome measures of
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interest were pain, stiffness, and function in individuals with knee OA. RCTs were
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excluded if the publication was in abstract form only.
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Assessment of methodological quality
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Two independent reviewers (SA and HZ) assessed the quality of the included studies
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using the PEDro Scale.14 It consists of 11 questions to assess the quality of RCTs on two
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aspects including internal validity (criteria 2-9) and sufficient statistical information to
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make it interpretable (criteria10-11). Each question is scored according to its presence or
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absence in the assessed study. The sum of all positive responses gives the final score.
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The studies with a score equal to or greater than 5 (50%) were considered high
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quality, as reported by Moseley et al.15 So, in the present review, all randomized studies
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with scores greater than or equal to 5 (5/10) were considered to be of high
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methodological quality. Two evaluators independently assessed methodological quality
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using the PEDro Scale.
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The risk of bias was assessed using the Cochrane collaboration’s tool in the
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domain based evaluation. The assessed domains were the sequence generation, allocation
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concealment, blinding, completeness of outcome data, and absence of selective outcome
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reporting. Risk of bias was classified as low, unclear and high in each domain.16
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In addition, we also evaluated the quality of each study based on the criteria given
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by the International Society of Musculoskeletal and Neuronal Interactions (ISMNI) for
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reporting WBV intervention studies, consisting of 13 factors.17 We evaluated whether 5
ACCEPTED MANUSCRIPT each article adequately described the 13 questions inquiring about the WBV parameters
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(e.g. frequency, amplitude, and acceleration) and participants’ position (e.g. holding on to
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a railing, exercise position, and foot wear condition). Based on the description of each of
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the above was scored with ‘yes’, ‘no’, or ‘unclear’. If the displacement was not described
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as peak-to-peak, the vibration amplitude was scored as ‘unclear’. If figures shows holding
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on to a railing and foot-wear condition, we scored these with ‘yes’
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Data Analysis
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The selected studies were screened by 2 independent evaluators (SA and HZ). The
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analysis of included studies was performed according to a structured script using the
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following parameters: author/year, subjects, design, intervention, WBV parameters,
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outcomes and conclusions. Disagreements between the evaluators were resolved by
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discussion to reach consensus. The unweighted kappa (k) was used to determine the
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agreement between the two evaluators.
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The outcome measures of interest were pain, stiffness, and function. The mean
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and standard deviation of the baseline and final end point scores for pain, stiffness, and
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function were extracted from included studies. The mean change score (final score minus
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baseline score) for each outcome measure was calculated for each intervention. The
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standardized mean difference (SMD) for the outcomes (pain, stiffness, and function) was
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computed using Hedges’ (adjusted) g [g = M1-M2/ Spooled; where, M1 and M2 are the
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mean change score of groups 1 and 2. Spooled is the estimate of the population standard
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deviation].18
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The magnitude of the effect size was categorized using Cohen’s categories, with g
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0.8, large effect
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size. The random effects meta-analysis was conducted to determine the overall effect size 6
ACCEPTED MANUSCRIPT of WBV. Ninety-five percent confidence intervals were calculated for effect sizes based
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on a generic inverse variance outcome model. The significance of the overall effect was
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tested using the z statistic. The Cochran’s Q statistic and the Higgins’ I2 statistic were
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used to determine statistical heterogeneity between studies.18 A low P value (≤.10) for the
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Q statistic was considered evidence of heterogeneity of treatment effects. All statistics
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were computed using Comprehensive Meta-Analysis software.19
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Results
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Identified studies
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The initial search resulted in 83 research studies. A total of 65 studies that appeared in
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more than one database or did not meet predetermined inclusion criteria were excluded.
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A total of 18 studies were assessed for eligibility. Thirteen studies were eliminated
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because they did not match the inclusion criteria or were not available in full text (Figure
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1). The final selection, made by consensus, resulted in the inclusion of 5 studies in the
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quality assessment phase.
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Quality assessment of study
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The 5 included studies had an average PEDro score of 5.6/10, as illustrated in Table 1.
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These scores represent multiple sources of bias that may skew the results. The most
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common shortcomings were lack of blinding (patient, therapist, or assessor),6-10 follow-
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up,6-8 intention to treat analysis,8-10 and concealed allocation.7,8,10 The most adhered to
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items on Pedro scale were random allocation, baseline comparability, measurements of
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variability, and between group comparison, which were evident in almost all of the trials.
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The majority of studies seemed to suggest a favorable additive benefit following WBV
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with exercise for pain and function, compared to control.
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Agreement between evaluators was excellent (unweighted k=0.88) in assessing
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risk of bias across studies. Table 2 details the risk of bias assessment of the included
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studies. The overall risk of bias assessment indicated that the risk of bias was low in 1
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study,9 high in 3 studies,7,8,10 and unclear in 1 study.6 The quality score of each study followed by the ISMNI recommendation is shown
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in Table 3. The overall mean score were 6.8±0.84 (range: 6 to 8) of 13 points. All
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included studies have given the brand name and type of the vibration device used. None
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of the included studies has clearly described that the given amplitude was peak-to-peak.
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Characteristics of study populations
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The participant characteristics are given in Table 4. The sample size ranged from 23 to 47
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with the mean age varying from 60 to 75 years. Most of the studies included only women
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participants with knee OA.6-8 Most of the studies used clinical and radiographic criteria of
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ACR to diagnose knee OA.6,8-10 One study used Kellgren and Lawrence scale to assess
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severity of knee OA.7
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Training protocol
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The training protocols are summarized in Table 4. Three studies6,8,9
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vibration while others7,10 did not specify the type of vibration used. Four studies had
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frequency of 3 sessions per week7-10, while 1 study had 2 sessions per week.6 Three
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studies had 8 weeks duration of treatment6-8, while 2 studies had 12 weeks of
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treatment.9,10 The frequency and amplitude of the vibration signals used varied from 12 to
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40 Hz, and 2 mm to 5 mm, respectively. The frequency of vibration was increased from
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35 to 40 Hz in 2 studies,9,10 30 to 40 Hz in 1 study,7 25 to 30 Hz in 1 study,6 and 12 to 14
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Hz in 1 study8 during treatment duration. One study did not specify the amplitude used.6
used vertical
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lasted for 20 s to 10 min for each. Two studies had vibration bouts of 6 to 8 repetitions
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for 20 to 40 sec for each.9,10 One study had vibration bouts of 1-2 repetitions for 30 to 60
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sec for each,7 1 study had 6 to 9 repetitions for 30 to 70 sec,6 and 1 study had 2
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repetitions for 10 min for each.8
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Outcome Measures
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The outcome measures of interest were pain, stiffness, and function in individuals with
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knee OA. Three studies used Western Ontario and McMaster Universities Osteoarthritis
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Index (WOMAC) pain score,6,9,10 1 study used numerical rating scale (NRS),8 and 1
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study used Japanese Knee Osteoarthritis Measure (JKOM) pain score,7 for measuring
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pain. One study used Japanese Knee Osteoarthritis Measure (JKOM),7 1 study used
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Korean Western Ontario and McMaster Universities Osteoarthritis Index (KWOMAC),8
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while others used WOMAC for measuring stiffness and function.
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Effect of WBV on pain
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Meta-analysis of 5 trials showed that most studies displayed an insignificant effect size
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point estimate to favor WBV compared with control; however, the test for an overall
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effect across the 5 included studies were significant (P =0.016), with an overall small
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effect size point estimate of 0.40 (95% CI, 0.076 - 0.726) based on a fixed-effects model
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that favored the WBV compared with control, WBV was effective in reducing pain
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(Figure 2). No significant heterogeneity was found (I2 0.0%, P = 0.558).
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Effect of WBV on stiffness
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point estimate to favor WBV compared with control; the test for an overall effect across
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the 5 included studies were insignificant (P =0.193), with an overall small effect size
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point estimate of 0.21 (95% CI, -0.108 - 0.537) based on a fixed-effects model, WBV
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compared to control was not effective at reducing stiffness (Figure 3). No significant
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heterogeneity was found (I2 0.0%, P = 0.809).
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Effect of WBV on Function
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Meta-analysis of 5 trials showed that most studies displayed an insignificant effect size
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point estimate to favor WBV compared with control; however, the test for an overall
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effect across the 5 included studies was significant (P =0.024), with an overall small
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effect size point estimate of 0.37 (95% CI, 0.050 - 0.704) based on a fixed-effects model,
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WBV compared to control was effective at improving function (Figure 4). No significant
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heterogeneity was found (I2 52.22%, P = 0.079).
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Discussion
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The present review evaluated 5 RCTs included a total of 165 participants to examine
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evidence regarding the therapeutic effect of WBV in the management of knee OA.
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Among the 5 studies evaluated using the PEDro scale,14 4 were considered of high
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methodological quality. Of the 5 included studies, 3 studies would be regarded as “high
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risk of bias” because they failed to fulfill the required criteria.7,8,10 Our evaluation showed
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that more than half of the studies performed adequate random sequence generation,
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whereas blinding of outcome assessment was unclear (Table 2).
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As per the guidelines given by the ISMNI recommendations,17 some factors
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related to the acceleration were not sufficiently documented in the included studies. Only 10
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2 studies measured the actual acceleration of the WBV platform and described the
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method used to ensure consistent targeting amplitude of WBV.9,10 The acceleration
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generated by the WBV platform is one of the most salient factors in WBV studies;
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therefore future studies should strictly adhere to these guidelines.33 The methodology and procedures of the intervention of the evaluated studies were
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properly prepared and described, allowing clinical reproducibility. The use of the
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International
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recommended criteria and the Cochrane collaboration’s tool to assess risk of bias give
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additional strength and improve the quality of this review about WBV treatment studies.
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On the basis of the present review, the WBV along with exercises compared to
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control has shown a greater reduction of pain and improvement in function. However,
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present review did not find any additional effect of WBV on stiffness as compared to
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control. Similarly, Yoon et al. reported significant improvement of function after WBV
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training in middle-aged and older Japanese women with knee OA and knee pain.31
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Another study reported WBV training yields similar results as traditional strength
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training for reduction of pain in individuals with knee OA.30
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Recently in a systematic review and meta-analysis, Wang et al. reported that the
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WBV training program significantly improves physical functions, but in contrast to the
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present study, there was no evidence that WBV can reduce pain in individuals with knee
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OA.13 These differences in the results may be due to the methodological differences we
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adopted in this review. In the present review, the mean change score (final score minus
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baseline score) for each outcome measure was compared, however, Wang et al.,
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compared post test data, there is a possibility that the group variations in the baseline data
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can affect the results. In addition, the present review included one more trial which can
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cause this result.7
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number of subjects necessary for each group for adequate power. Although there was
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some variation in the methods and interventions used in these studies, overall, the studies
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demonstrated mixed results in favor of additive effects of WBV for reducing pain, and
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improving function in knee OA. There was variation in the content and duration of the
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exercise programs included in our systematic review. Length of intervention ranged from
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8 to 12 weeks, with a frequency of intervention range from 2 to 3 per weeks. There was
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considerable variation in the parameters of the WBV included in our systematic review.
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Variations among the 5 studies included: duration of intervention, type of control groups,
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and vibration parameters including frequency, amplitude and acceleration.
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Study limitations
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There are several limitations in the present review. Three out of the 5 studies included
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only female participants. Additionally, in this review, no study assessed the isolated
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effect of WBV on outcome. For example, it is undetermined whether isolated WBV
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would yield similar or better effects than when utilizing in combination with other
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intervention. This would be an important area of research to determine the clinical
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effectiveness of WBV. Moreover, different vibration platforms have different technical
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characteristics and may induce different therapeutic effects. None of the selected studies
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attempted to compare the effects of different vibration platforms. Furthermore, none of
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the selected studies evaluated long term follow-up effects of WBV on outcome. In
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addition, the present study did not suggest the optimal vibration parameters due to the
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variations in methodologies.
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knee OA. WBV training reduces pain and improves function in individuals with knee
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OA. In the present review, there is a variation in the vibration protocol, training dose and
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reported results. Therefore, more robust, well-designed studies are required for
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conclusive evidence of the beneficial therapeutic effects of WBV training in individuals
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with knee OA.
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20. Kitay GS, Koren MJ, Helfet DL, Parides MK, Markenson JA. Efficacy of
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combined local mechanical vibrations, continuous passive motion and
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thermotherapy in the management of osteoarthritis of the knee. Osteoarthritis and
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Cartilage 2009;17(10):1269-1274.
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21. Osugi T, Iwamoto J, Yamazaki M, Takakuwa M. Effect of a combination of
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whole body vibration exercise and squat training on body balance, muscle power,
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and walking ability in the elderly. Ther Clin Risk Manag 2014 Feb 20;10:131-8.
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doi: 10.2147/TCRM.S57806. eCollection 2014.
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22. Blackburn JT, Pamukoff DN, Sakr M, Vaughan AJ, Berkoff DJ. Whole body and
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local muscle vibration reduce artificially induced quadriceps arthrogenic
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inhibition. Arch Phys Med Rehabil 2014;95(11):2021-8.
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23. Mikhael M, Orr R, Amsen F, Greene D, Singh MA. Effect of standing posture during whole body vibration training on muscle morphology and function in older adults: a randomised controlled trial. BMC Geriatr 2010 Oct 15;10:74.
24. Sitjà-Rabert M, Martínez-Zapata MJ, Fort-Vanmeerhaeghe A, Rey-Abella F,
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Romero-Rodríguez D, Bonfill X. Whole body vibration for older persons: an open
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randomized, multicentre, parallel, clinical trial. BMC Geriatr 2011 Dec 22;11:89. 16
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25. Bogaerts AC, Delecluse C, Claessens AL, Troosters T, Boonen S, Verschueren
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SM. Effects of whole body vibration training on cardiorespiratory fitness and
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muscle strength in older individuals (a 1-year randomised controlled trial). Age
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Ageing. 2009 Jul;38(4):448-54. 26. Bogaerts A, Delecluse C, Claessens AL, Coudyzer W, Boonen S, Verschueren
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SM. Impact of whole-body vibration training versus fitness training on muscle
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strength and muscle mass in older men: a 1-year randomized controlled trial. J
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Gerontol A Biol Sci Med Sci 2007;62(6):630-5.
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27. Salmon JR, Roper JA, Tillman MD. Does acute whole-body vibration training improve the physical performance of people with knee osteoarthritis? J Strength
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Cond Res 2012;26(11):2983-9.
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28. Stein G, Knoell P, Faymonville C, et al. Whole body vibration compared to
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conventional physiotherapy in patients with gonarthrosis: a protocol for a
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randomized, controlled study. BMC Musculoskelet Disord 2010 Jun 21;11:128.
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29. Tossige-Gomes R, Avelar NC, Simão AP, et al. Whole-body vibration decreases
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the proliferativeb response of TCD4(+) cells in elderly individuals with knee
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osteoarthritis. Braz J Med Biol Res 2012;45(12):1262-8.
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30. Rapp W, Boeer J, Albrich C, Heitkamp HC. Auswirkung eines vibrations und
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kraft trainings auf die beinmuskulatur bei gonarthrosepatienten (Efficiency of
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vibration or strength training for knee stability in osteoarthritis of the knee) [German]. Aktuelle Rheumatologie 2009;34(4):240-245.
31. Yoon J, Tsuji T, Kanamori A, Tanaka K, Okura T. The effects of whole-body
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vibration training on knee function and physical performance of middle-aged and
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elderly woman with knee osteoarthritis and chronic knee pain [Japanese].
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Japanese Journal of Physical Fitness and Sports Medicine 2014;63(4):371-382. 17
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potential might be. Eur J Appl Physiol 2010;108(5):877-904.
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33. Rittweger J. Vibration as an exercise modality: how it may work, and what its
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Child 2005;90(8):845-8.
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32. Akobeng AK. Understanding systematic reviews and meta-analysis. Arch Dis
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ACCEPTED MANUSCRIPT Lists of figure legends Figure 1: Flow Diagram of the study procedure Figure 2: Effect of whole body vibration training on pain
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Figure 4: Effect of whole body vibration training on function
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Figure 3: Effect of whole body vibration training on knee stiffness
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ACCEPTED MANUSCRIPT Lists of table legends Table 1: Methodological classification assessed by PEDro scale Table 2: Risk of bias of included studies (Yes, Low risk of bias; No, High risk of bias)
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Table 3: Methodological assessment by the recommendations of the ISMNI
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Table 4: Overview of selected Whole-Body Vibration studies in Knee OA
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ACCEPTED MANUSCRIPT Table 1: Methodological classification assessed by PEDro scale Simao AP9
Trans T6
Avelar NCP10
Tsuji T7
Park YG8
Random allocation? Concealed allocation? Baseline comparability? Blind participants? Blind therapists Blind assessors? Follow-up? Intention-totreat analysis? Group comparisons? Point and variability measures? Cumulative score
Yes
Yes
Yes
No
Yes
Cumulative score (Maximum=10) 4/5
Yes
Yes
No
No
No
2/5
Yes
Yes
Yes
Yes
Yes
5/5
No
No
No
Yes
No
1/5
No
No
No
No
No
Yes
Yes
No
No
Yes No
No Yes
Yes No
No Yes
Yes
Yes
Yes
Yes
Yes
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0/5 2/5
No No
2/5 2/5
Yes
Yes
5/5
Yes
Yes
Yes
5/5
5
5
4
5.6
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Criteria
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Blinding?
Simao AP9 Trans T6 Avelar NCP10 Tsuji T7 Park YG8
Yes Yes No No Yes
Yes Yes No No No
Yes Unclear Unclear Unclear No
Incomplete outcome data addressed? Yes Yes Yes Yes Yes
Free of selective reporting?
Conclusions
Yes Yes Yes Yes Yes
Low risk of bias Unclear risk of bias High risk of bias High risk of bias High risk of bias
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Adequate sequence generation?
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Citations
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Table 3: Methodological assessment by the recommendations of the ISMNI Q3
Q4
Q5
Q6
Q7
yes
yes
yes
unclear yes
yes
unclear unclear yes
yes
yes
yes
no
unclear unclear unclear no
yes
unclear yes
unclear yes
yes
yes
unclear yes
unclear no
yes
yes
unclear yes
unclear no
unclear unclear unclear unclear yes
Q9
Q12
Q13
unclear no
yes
yes
Quality score 8
unclear yes
yes
yes
6
unclear unclear yes
unclear no
yes
yes
7
unclear no
unclear yes
yes
yes
7
yes
yes
6
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no
Q8
Q10
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Simao AP9 Trans T6 Avelar NCP10 Tsuji T7 Park YG8
Q1
yes
Q11
yes
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Q1, Brand name of vibration platform; Q2, Type of vibration; Q3, Vibration frequency; Q4, Vibration amplitude; Q5, Peak acceleration; Q6, Accuracy of vibration parameter; Q7, Evaluation of skidding of the feet; Q8, Changes of vibration parameters; Q9, Rationale for choosing vibration parameters; Q10, Support devices during vibration exposure; Q11, Type of footwear; Q12, Body position; Q13, Description of exercise.
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Table 4: Overview of selected Whole-Body Vibration studies in Knee OA Group
WBV parameters
Duration
Outcomes
Conclusions
RCT
1: Squat-WBV (n=12) 2: Control (n=12)
Frequency (Hz): 35, 40 Amplitude (mm): 4 Acceleration (g):2 – 2.61
3/week, 12 weeks
WOMAC index
Group 1:61.5 (0/100) Group 2: 61.1 (0/100)
RCT
1: WBVexercise on stable platform (n=17) 2: Control (n=18)
Frequency (Hz): 25, 30 Amplitude (mm):? Acceleration (g):? Time/repetition: 30 s/6 – 70 s/9
2/week, 8 weeks
The addition of vibration training to squat exercise reduces the selfperception of pain. No significant differences between groups were observed on functional scores. No significant differences between groups were observed on pain and functional scores.
Knee OA based on clinical and radiographic criteria of ACR
Avelar NCP10
Knee OA based on clinical and radiographic criteria of ACR
Group 1:75 (18/82) Group 2: 71 (10/90)
RCT
1: Squat-WBV (n=12) 2: Squat (n=11)
3/week, 12 weeks
WOMAC index
The addition of vibration training to squat exercise does not reduce pain and improve function beyond that of squat exercise without WBV.
Tsuji T7
Post-menopausal women with knee pain in the age group of 50 – 75 years. Knee OA based on KL scale (0 – 4)
Group 1:62.1 (0/100) Group 2: 60.9 (0/100)
RCT
1: Accelerated training-WBV (n=32) 2: Controlhome exercise (n=15)
Frequency (Hz): 35, 40 Amplitude (mm): 4 Acceleration (g):2.78 – 3.26 Frequency (Hz): 30, 40 Amplitude (mm): 2.5 Acceleration (g):?
3/week, 8 weeks
JKOM
The accelerated training program consisting of strength and flexibility training with WBV reported improvement in function. No significant differences between groups were observed on pain score.
Park YG8
Knee OA based on clinical and radiographic criteria of ACR
Group 1:62.5 (0/100) Group 2: 60 (0/100)
RCT
1: WBV and Home exercise (n=17) 2: Controlhome exercise (n=19)
Frequency (Hz): 12, 14 Amplitude (mm): 2.5- 5 Acceleration (g):?
3/week, 8 weeks
NRS KWOMAC Index
The WBV with home exercise group reported significant reduction in pain as compared to home exercise alone. No significant differences between groups were observed on function.
WOMAC index
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Knee OA based on clinical and radiographic criteria of ACR
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Design
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Simao AP9
Mean age, Years (male/female, %) Group1: 75 (18/82) Group 2: 71 (9/91)
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Subjects
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Study
ACR, American College of Rheumatology ; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; JKOM, Japanese Knee Osteoarthritis Measure; WBV, Whole-body vibration; NRS, Numerical rating scale; KWOMAC, Korean Western Ontario and McMaster Universities Osteoarthritis Index; RCT, Randomized controlled trial; KL scale, Kellgren and Lawrence scale; ?, not reported
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Studies excluded (n = 07)17-23
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Studies screened (n = 18)
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Screening
Studies after duplicates removed (n = 18)
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Studies identified through hand searching (n = 27)
Identification
Studies identified through electronic database searching (n = 56)
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Full-text studies assessed for eligibility (n = 11)
No control group (n=01) Only protocol (n=01) Objective not related to the review (n=02) Article not in English language (n=02)
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Studies included in qualitative synthesis (n = 05)
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Included
Eligibility
Full-text studies excluded (n = 06)5,24-28
Studies included in meta-analysis (n = 05)
Figure 1: Flow Diagram of the study procedure
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Figure 2: Effect of whole body vibration training on pain
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Study name
Statistics for each study
Hedges's g and 95% CI
0.013 0.294 0.511 0.016 0.401 0.214
-0.644 -0.533 -0.230 -0.623 -0.396 -0.108
0.669 1.121 1.252 0.656 1.198 0.537
0.038 0.697 1.351 0.051 0.985 1.302
0.970 0.486 0.177 0.960 0.324 0.193 -1.00
-0.50
Favours Control
0.50
Favours WBV
1.00
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Heterogeneity: Q- value, 1.598 (p=0.809); I-squared, 0%
0.00
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Trans T et al. 2009 Avelar NCP et al. 2011 Tsuji T et al. 2014 Park YG et al. 2013 Simao AP et al. 2012
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Hedges's Lower Upper g limit limit Z-Value p-Value
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Figure 3: Effect of whole body vibration training on knee stiffness
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Figure 4: Effect of whole body vibration training on function
ACCEPTED MANUSCRIPT Highlights •
Whole body vibration can reduce pain and improve function in individuals with knee OA. Whole body vibration does not relieve knee stiffness in individuals with knee OA.
•
The long term follow-up effects of Whole body vibration were not investigated.
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•
S0003-9993(15)00259-2
DOI:
10.1016/j.apmr.2015.03.010
Reference:
YAPMR 56147
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 15 January 2015 Revised Date:
25 February 2015
Accepted Date: 20 March 2015
Please cite this article as: Zafar H, Alghadir A, Anwer S, Al-Eisa E, Therapeutic effects of whole body vibration training in knee osteoarthritis: a systematic review and meta-analysis, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2015), doi: 10.1016/j.apmr.2015.03.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title page Running head: WBV in knee osteoarthritis Title: Therapeutic effects of whole body vibration training in knee osteoarthritis: a
Hamayun Zafar, PhD, PT2 Assistant Professor Ahmad Alghadir, MS, PhD, PT1
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Authors:
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systematic review and meta-analysis
Shahnawaz Anwer, MPT 1,3 Researcher, Einas Al-Eisa, PhD, PT 1 Associate Professor
Rehabilitation Research Chair, Department of Rehabilitation Sciences, College of
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Associate Professor and Consultant of Rehabilitation and Physical Therapy,
Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia 2
Department of Rehabilitation Sciences, College of Applied Medical Sciences
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King Saud University, Riyadh, KSA
Padmashree Dr. D. Y. Patil College of Physiotherapy
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Dr. D. Y. Patil Vidyapeeth, Pune, India Corresponding author:
Shahnawaz Anwer, MPT Researcher Rehabilitation Research Chair, CAMS, King Saud University,
ACCEPTED MANUSCRIPT Riyadh, Saudi Arabia. Mobile:+966-595668288; email: [email protected] Funding: Rehabilitation Research Chair, King Saud University
Deanship of Research Chairs, Rehabilitation Research Chair
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Conflict of interest: None declared
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Acknowledgment: The project was financially supported by King Saud University, Vice
ACCEPTED MANUSCRIPT Therapeutic effects of whole body vibration training in knee osteoarthritis: A
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systematic review and meta-analysis
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Abstract:
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Objectives
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This systematic review was conducted to examine the current evidence regarding the
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effects of whole body vibration (WBV) training in individuals with knee osteoarthritis
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(OA).
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Data Sources
We searched Pubmed, CINAHL, Embase, Scopus, PEDro, and Science citation index for
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research articles published prior to January 2015 using the keywords whole body
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vibration, vibration training, and vibratory exercise in combination with Medical Subject
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Headings “Osteoarthritis knee”.
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Study Selection
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This meta-analysis was restricted to randomized controlled trials published in English
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language. The quality of the selected studies was assessed by the PEDro Scale. The risk
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of bias was assessed using the Cochrane collaboration’s tool in the domain based
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evaluation. We also evaluated the quality of each study based on the criteria given by the
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International Society of Musculoskeletal and Neuronal Interactions (ISMNI) for reporting
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WBV intervention studies, consisting of 13 factors.
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Data Extraction
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Descriptive data regarding subjects, design, intervention, WBV parameters, outcomes,
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and conclusions were collected from each study by two independent evaluators. The
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mean and standard deviation of the baseline and final end point scores for pain, stiffness,
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and function were extracted from included studies.
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Data synthesis
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A total of 83 studies were found in the search. Of these, 5 studies met the inclusion
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criteria and were further analyzed. Four of these 5 studies reached high methodological
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quality on the PEDro scale. Overall, studies demonstrated mixed results in favor of 1
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additive effects of WBV for reducing pain and improving function in knee OA. There
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was considerable variation in the parameters of the WBV included in this systematic
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review.
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Conclusions
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Whole body vibration training reduces pain and improves function in individuals with
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knee OA.
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Key words
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Osteoarthritis; Whole body vibration; Squat; Pain; Strength; Function
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List of abbreviations
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WBV, Whole-body vibration; OA, Osteoarthritis; RCTs, Randomized clinical trials;
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ISMNI, International Society of Musculoskeletal and Neuronal Interactions; WOMAC,
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Western Ontario and McMaster Universities Osteoarthritis Index; JKOM, Japanese Knee
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Osteoarthritis Measure; KWOMAC, Korean Western Ontario and McMaster Universities
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Osteoarthritis Index
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2
ACCEPTED MANUSCRIPT Knee osteoarthritis (OA) is the commonest form of degenerative joint disease affecting
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both men and women.1,2 In addition to pain, knee OA causes joint stiffness and decreased
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quadriceps strength resulting in physical disability.3 The target of any treatment approach
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in the management of knee OA includes reduction of pain, disability and improvement in
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quadriceps muscle strength. Currently accepted non-pharmacological treatment options
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for OA recommended by the Osteoarthritis Research Society International (OARSI)
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include patient education, weight loss, physical rehabilitation, exercise, change in
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activities of daily living and coping strategies.4
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Recently, the use of whole body vibration (WBV) has been recommended as an
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efficient and alternative option for improving muscle strength in individuals with knee
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OA.5-8 Other studies demonstrated improvement in the function and the self-reported
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disease status in individuals with knee OA after a 12-week training program of squatting
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exercise combined with WBV.9,10 However, Trans et al. reported no improvement in self-
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reported knee pain and function, which shows that there is no consistent finding on this
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issue.6
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WBV training is the exercise program performed with the body on a platform that
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generates vibrations.11 These vibrations are transmitted to the body and stimulate the
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primary endings of the muscle spindles, thereby activate ɑ-motor neuron which causes
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muscle contractions, similar to the tonic vibration reflex.6 WBV training can be given via
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two types of machine, the rotational vibration (RV) and the vertical vibration (VV)
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machine.12 RV machines can vibrate in two dimensions (right and left), whereas, VV
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machines can vibrate in all three spatial dimensions. The study suggests that it is easier to
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maintain the correct training posture on VV machine as compared to RV machine.12
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Recently, Wang et al. published a systematic review and meta-analysis to
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investigate the effects of WBV on pain, stiffness and physical functions in individuals 3
ACCEPTED MANUSCRIPT with knee OA.13 They reported that the WBV training program significantly improves
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physical functions, but there is no evidence that WBV can reduce pain and stiffness in
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individuals with knee OA. However, because this review compared post test data, there is
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a possibility that the group variations in the baseline data can affect the results. Therefore
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the comparison of mean differences between groups would give more reliable results. In
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addition, the use of the International Society of Musculoskeletal and Neuronal
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Interactions (ISMNI) recommended criteria would improve the quality of reports about
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WBV treatment studies.
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Therefore, the objective of this systematic review is to provide an overview of
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current available evidence regarding the therapeutic effects of WBV training in
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individuals with knee OA.
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Methods
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Data sources
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The search for published studies was conducted using Pubmed, CINAHL, Embase,
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Scopus, PEDro and Science citation index using a combination of these keywords whole
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body vibration, vibration therapy, and vibratory exercise with “Osteoarthritis knee” and
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the Medical Subject Headings “osteoarthritis, knee” combined with “whole body
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vibration” or “vibration”. The bibliographical search was restricted to randomized
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controlled trials published in English language prior to January, 2015. Hand searching of
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the identified studies was used to find other appropriate studies. Two independent
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evaluators (SA and HZ) selected the studies based on titles and abstract, excluding those
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articles not related to the objectives of this review.
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Study selection 4
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English language prior to January, 2015. Trials were required to compare exercise with
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and without WBV, or comparing exercise with WBV and control. Studies that did not
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include WBV therapy in their interventions were excluded. The outcome measures of
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interest were pain, stiffness, and function in individuals with knee OA. RCTs were
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excluded if the publication was in abstract form only.
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Assessment of methodological quality
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Two independent reviewers (SA and HZ) assessed the quality of the included studies
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using the PEDro Scale.14 It consists of 11 questions to assess the quality of RCTs on two
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aspects including internal validity (criteria 2-9) and sufficient statistical information to
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make it interpretable (criteria10-11). Each question is scored according to its presence or
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absence in the assessed study. The sum of all positive responses gives the final score.
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The studies with a score equal to or greater than 5 (50%) were considered high
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quality, as reported by Moseley et al.15 So, in the present review, all randomized studies
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with scores greater than or equal to 5 (5/10) were considered to be of high
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methodological quality. Two evaluators independently assessed methodological quality
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using the PEDro Scale.
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The risk of bias was assessed using the Cochrane collaboration’s tool in the
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domain based evaluation. The assessed domains were the sequence generation, allocation
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concealment, blinding, completeness of outcome data, and absence of selective outcome
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reporting. Risk of bias was classified as low, unclear and high in each domain.16
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In addition, we also evaluated the quality of each study based on the criteria given
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by the International Society of Musculoskeletal and Neuronal Interactions (ISMNI) for
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reporting WBV intervention studies, consisting of 13 factors.17 We evaluated whether 5
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(e.g. frequency, amplitude, and acceleration) and participants’ position (e.g. holding on to
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a railing, exercise position, and foot wear condition). Based on the description of each of
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the above was scored with ‘yes’, ‘no’, or ‘unclear’. If the displacement was not described
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as peak-to-peak, the vibration amplitude was scored as ‘unclear’. If figures shows holding
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on to a railing and foot-wear condition, we scored these with ‘yes’
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Data Analysis
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The selected studies were screened by 2 independent evaluators (SA and HZ). The
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analysis of included studies was performed according to a structured script using the
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following parameters: author/year, subjects, design, intervention, WBV parameters,
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outcomes and conclusions. Disagreements between the evaluators were resolved by
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discussion to reach consensus. The unweighted kappa (k) was used to determine the
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agreement between the two evaluators.
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The outcome measures of interest were pain, stiffness, and function. The mean
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and standard deviation of the baseline and final end point scores for pain, stiffness, and
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function were extracted from included studies. The mean change score (final score minus
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baseline score) for each outcome measure was calculated for each intervention. The
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standardized mean difference (SMD) for the outcomes (pain, stiffness, and function) was
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computed using Hedges’ (adjusted) g [g = M1-M2/ Spooled; where, M1 and M2 are the
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mean change score of groups 1 and 2. Spooled is the estimate of the population standard
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deviation].18
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The magnitude of the effect size was categorized using Cohen’s categories, with g
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0.8, large effect
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size. The random effects meta-analysis was conducted to determine the overall effect size 6
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on a generic inverse variance outcome model. The significance of the overall effect was
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tested using the z statistic. The Cochran’s Q statistic and the Higgins’ I2 statistic were
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used to determine statistical heterogeneity between studies.18 A low P value (≤.10) for the
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Q statistic was considered evidence of heterogeneity of treatment effects. All statistics
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were computed using Comprehensive Meta-Analysis software.19
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Results
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Identified studies
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The initial search resulted in 83 research studies. A total of 65 studies that appeared in
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more than one database or did not meet predetermined inclusion criteria were excluded.
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A total of 18 studies were assessed for eligibility. Thirteen studies were eliminated
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because they did not match the inclusion criteria or were not available in full text (Figure
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1). The final selection, made by consensus, resulted in the inclusion of 5 studies in the
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quality assessment phase.
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Quality assessment of study
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The 5 included studies had an average PEDro score of 5.6/10, as illustrated in Table 1.
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These scores represent multiple sources of bias that may skew the results. The most
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common shortcomings were lack of blinding (patient, therapist, or assessor),6-10 follow-
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up,6-8 intention to treat analysis,8-10 and concealed allocation.7,8,10 The most adhered to
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items on Pedro scale were random allocation, baseline comparability, measurements of
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variability, and between group comparison, which were evident in almost all of the trials.
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The majority of studies seemed to suggest a favorable additive benefit following WBV
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with exercise for pain and function, compared to control.
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Agreement between evaluators was excellent (unweighted k=0.88) in assessing
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risk of bias across studies. Table 2 details the risk of bias assessment of the included
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studies. The overall risk of bias assessment indicated that the risk of bias was low in 1
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study,9 high in 3 studies,7,8,10 and unclear in 1 study.6 The quality score of each study followed by the ISMNI recommendation is shown
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in Table 3. The overall mean score were 6.8±0.84 (range: 6 to 8) of 13 points. All
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included studies have given the brand name and type of the vibration device used. None
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of the included studies has clearly described that the given amplitude was peak-to-peak.
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Characteristics of study populations
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The participant characteristics are given in Table 4. The sample size ranged from 23 to 47
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with the mean age varying from 60 to 75 years. Most of the studies included only women
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participants with knee OA.6-8 Most of the studies used clinical and radiographic criteria of
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ACR to diagnose knee OA.6,8-10 One study used Kellgren and Lawrence scale to assess
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severity of knee OA.7
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Training protocol
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The training protocols are summarized in Table 4. Three studies6,8,9
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vibration while others7,10 did not specify the type of vibration used. Four studies had
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frequency of 3 sessions per week7-10, while 1 study had 2 sessions per week.6 Three
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studies had 8 weeks duration of treatment6-8, while 2 studies had 12 weeks of
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treatment.9,10 The frequency and amplitude of the vibration signals used varied from 12 to
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40 Hz, and 2 mm to 5 mm, respectively. The frequency of vibration was increased from
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35 to 40 Hz in 2 studies,9,10 30 to 40 Hz in 1 study,7 25 to 30 Hz in 1 study,6 and 12 to 14
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Hz in 1 study8 during treatment duration. One study did not specify the amplitude used.6
used vertical
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lasted for 20 s to 10 min for each. Two studies had vibration bouts of 6 to 8 repetitions
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for 20 to 40 sec for each.9,10 One study had vibration bouts of 1-2 repetitions for 30 to 60
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sec for each,7 1 study had 6 to 9 repetitions for 30 to 70 sec,6 and 1 study had 2
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repetitions for 10 min for each.8
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Outcome Measures
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The outcome measures of interest were pain, stiffness, and function in individuals with
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knee OA. Three studies used Western Ontario and McMaster Universities Osteoarthritis
209
Index (WOMAC) pain score,6,9,10 1 study used numerical rating scale (NRS),8 and 1
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study used Japanese Knee Osteoarthritis Measure (JKOM) pain score,7 for measuring
211
pain. One study used Japanese Knee Osteoarthritis Measure (JKOM),7 1 study used
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Korean Western Ontario and McMaster Universities Osteoarthritis Index (KWOMAC),8
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while others used WOMAC for measuring stiffness and function.
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Effect of WBV on pain
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Meta-analysis of 5 trials showed that most studies displayed an insignificant effect size
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point estimate to favor WBV compared with control; however, the test for an overall
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effect across the 5 included studies were significant (P =0.016), with an overall small
219
effect size point estimate of 0.40 (95% CI, 0.076 - 0.726) based on a fixed-effects model
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that favored the WBV compared with control, WBV was effective in reducing pain
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(Figure 2). No significant heterogeneity was found (I2 0.0%, P = 0.558).
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Effect of WBV on stiffness
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point estimate to favor WBV compared with control; the test for an overall effect across
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the 5 included studies were insignificant (P =0.193), with an overall small effect size
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point estimate of 0.21 (95% CI, -0.108 - 0.537) based on a fixed-effects model, WBV
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compared to control was not effective at reducing stiffness (Figure 3). No significant
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heterogeneity was found (I2 0.0%, P = 0.809).
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Effect of WBV on Function
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Meta-analysis of 5 trials showed that most studies displayed an insignificant effect size
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point estimate to favor WBV compared with control; however, the test for an overall
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effect across the 5 included studies was significant (P =0.024), with an overall small
235
effect size point estimate of 0.37 (95% CI, 0.050 - 0.704) based on a fixed-effects model,
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WBV compared to control was effective at improving function (Figure 4). No significant
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heterogeneity was found (I2 52.22%, P = 0.079).
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Discussion
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The present review evaluated 5 RCTs included a total of 165 participants to examine
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evidence regarding the therapeutic effect of WBV in the management of knee OA.
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Among the 5 studies evaluated using the PEDro scale,14 4 were considered of high
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methodological quality. Of the 5 included studies, 3 studies would be regarded as “high
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risk of bias” because they failed to fulfill the required criteria.7,8,10 Our evaluation showed
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that more than half of the studies performed adequate random sequence generation,
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whereas blinding of outcome assessment was unclear (Table 2).
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As per the guidelines given by the ISMNI recommendations,17 some factors
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related to the acceleration were not sufficiently documented in the included studies. Only 10
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2 studies measured the actual acceleration of the WBV platform and described the
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method used to ensure consistent targeting amplitude of WBV.9,10 The acceleration
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generated by the WBV platform is one of the most salient factors in WBV studies;
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therefore future studies should strictly adhere to these guidelines.33 The methodology and procedures of the intervention of the evaluated studies were
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properly prepared and described, allowing clinical reproducibility. The use of the
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International
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recommended criteria and the Cochrane collaboration’s tool to assess risk of bias give
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additional strength and improve the quality of this review about WBV treatment studies.
of
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Interactions
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On the basis of the present review, the WBV along with exercises compared to
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control has shown a greater reduction of pain and improvement in function. However,
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present review did not find any additional effect of WBV on stiffness as compared to
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control. Similarly, Yoon et al. reported significant improvement of function after WBV
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training in middle-aged and older Japanese women with knee OA and knee pain.31
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Another study reported WBV training yields similar results as traditional strength
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training for reduction of pain in individuals with knee OA.30
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Recently in a systematic review and meta-analysis, Wang et al. reported that the
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WBV training program significantly improves physical functions, but in contrast to the
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present study, there was no evidence that WBV can reduce pain in individuals with knee
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OA.13 These differences in the results may be due to the methodological differences we
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adopted in this review. In the present review, the mean change score (final score minus
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baseline score) for each outcome measure was compared, however, Wang et al.,
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compared post test data, there is a possibility that the group variations in the baseline data
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can affect the results. In addition, the present review included one more trial which can
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cause this result.7
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number of subjects necessary for each group for adequate power. Although there was
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some variation in the methods and interventions used in these studies, overall, the studies
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demonstrated mixed results in favor of additive effects of WBV for reducing pain, and
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improving function in knee OA. There was variation in the content and duration of the
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exercise programs included in our systematic review. Length of intervention ranged from
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8 to 12 weeks, with a frequency of intervention range from 2 to 3 per weeks. There was
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considerable variation in the parameters of the WBV included in our systematic review.
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Variations among the 5 studies included: duration of intervention, type of control groups,
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and vibration parameters including frequency, amplitude and acceleration.
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Study limitations
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There are several limitations in the present review. Three out of the 5 studies included
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only female participants. Additionally, in this review, no study assessed the isolated
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effect of WBV on outcome. For example, it is undetermined whether isolated WBV
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would yield similar or better effects than when utilizing in combination with other
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intervention. This would be an important area of research to determine the clinical
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effectiveness of WBV. Moreover, different vibration platforms have different technical
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characteristics and may induce different therapeutic effects. None of the selected studies
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attempted to compare the effects of different vibration platforms. Furthermore, none of
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the selected studies evaluated long term follow-up effects of WBV on outcome. In
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addition, the present study did not suggest the optimal vibration parameters due to the
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variations in methodologies.
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knee OA. WBV training reduces pain and improves function in individuals with knee
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OA. In the present review, there is a variation in the vibration protocol, training dose and
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reported results. Therefore, more robust, well-designed studies are required for
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conclusive evidence of the beneficial therapeutic effects of WBV training in individuals
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with knee OA.
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9. Simão AP, Avelar NC, Tossige-Gomes R, et al. Functional performance and
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inflammatory cytokines after squat exercises and whole-body vibration in elderly
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individuals with knee osteoarthritis. Arch Phys Med Rehabil 2012;93(10):1692-
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700. 10. Avelar NC, Simão AP, Tossige-Gomes R, et al. The effect of adding whole-body
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12. Merriman H, Jackson K. The effects of whole-body vibration training in aging adults: a systematic review. J Geriatr Phys Ther 2009;32(3):134-45. 13. Wang P, Yang X, Yang Y, et al. Effects of whole body vibration on pain, stiffness
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15. Moseley AM, Herbert RD, Sherrington C, Maher CG. Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). Aust J Physiother 2002;48(1):43-9.
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16. Higgins JPT, Altman DG. Assessing risk of bias in included studies. In: Higgins
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version 5.0.1. Oxford: The Cochrane Collaboration; 2008. 15
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17. Rauch F, Sievanen H, Boonen S, et al. Reporting whole body vibration
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intervention
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Musculoskeletal and Neuronal Interactions. J Musculoskelet Neuronal Interact
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20. Kitay GS, Koren MJ, Helfet DL, Parides MK, Markenson JA. Efficacy of
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combined local mechanical vibrations, continuous passive motion and
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21. Osugi T, Iwamoto J, Yamazaki M, Takakuwa M. Effect of a combination of
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and walking ability in the elderly. Ther Clin Risk Manag 2014 Feb 20;10:131-8.
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doi: 10.2147/TCRM.S57806. eCollection 2014.
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22. Blackburn JT, Pamukoff DN, Sakr M, Vaughan AJ, Berkoff DJ. Whole body and
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local muscle vibration reduce artificially induced quadriceps arthrogenic
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inhibition. Arch Phys Med Rehabil 2014;95(11):2021-8.
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23. Mikhael M, Orr R, Amsen F, Greene D, Singh MA. Effect of standing posture during whole body vibration training on muscle morphology and function in older adults: a randomised controlled trial. BMC Geriatr 2010 Oct 15;10:74.
24. Sitjà-Rabert M, Martínez-Zapata MJ, Fort-Vanmeerhaeghe A, Rey-Abella F,
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Romero-Rodríguez D, Bonfill X. Whole body vibration for older persons: an open
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randomized, multicentre, parallel, clinical trial. BMC Geriatr 2011 Dec 22;11:89. 16
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25. Bogaerts AC, Delecluse C, Claessens AL, Troosters T, Boonen S, Verschueren
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SM. Effects of whole body vibration training on cardiorespiratory fitness and
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muscle strength in older individuals (a 1-year randomised controlled trial). Age
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Ageing. 2009 Jul;38(4):448-54. 26. Bogaerts A, Delecluse C, Claessens AL, Coudyzer W, Boonen S, Verschueren
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SM. Impact of whole-body vibration training versus fitness training on muscle
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strength and muscle mass in older men: a 1-year randomized controlled trial. J
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27. Salmon JR, Roper JA, Tillman MD. Does acute whole-body vibration training improve the physical performance of people with knee osteoarthritis? J Strength
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Cond Res 2012;26(11):2983-9.
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28. Stein G, Knoell P, Faymonville C, et al. Whole body vibration compared to
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conventional physiotherapy in patients with gonarthrosis: a protocol for a
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randomized, controlled study. BMC Musculoskelet Disord 2010 Jun 21;11:128.
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29. Tossige-Gomes R, Avelar NC, Simão AP, et al. Whole-body vibration decreases
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the proliferativeb response of TCD4(+) cells in elderly individuals with knee
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osteoarthritis. Braz J Med Biol Res 2012;45(12):1262-8.
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30. Rapp W, Boeer J, Albrich C, Heitkamp HC. Auswirkung eines vibrations und
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kraft trainings auf die beinmuskulatur bei gonarthrosepatienten (Efficiency of
399 400 401
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vibration or strength training for knee stability in osteoarthritis of the knee) [German]. Aktuelle Rheumatologie 2009;34(4):240-245.
31. Yoon J, Tsuji T, Kanamori A, Tanaka K, Okura T. The effects of whole-body
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vibration training on knee function and physical performance of middle-aged and
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elderly woman with knee osteoarthritis and chronic knee pain [Japanese].
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potential might be. Eur J Appl Physiol 2010;108(5):877-904.
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33. Rittweger J. Vibration as an exercise modality: how it may work, and what its
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Child 2005;90(8):845-8.
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32. Akobeng AK. Understanding systematic reviews and meta-analysis. Arch Dis
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ACCEPTED MANUSCRIPT Lists of figure legends Figure 1: Flow Diagram of the study procedure Figure 2: Effect of whole body vibration training on pain
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Figure 4: Effect of whole body vibration training on function
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Figure 3: Effect of whole body vibration training on knee stiffness
19
ACCEPTED MANUSCRIPT Lists of table legends Table 1: Methodological classification assessed by PEDro scale Table 2: Risk of bias of included studies (Yes, Low risk of bias; No, High risk of bias)
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Table 3: Methodological assessment by the recommendations of the ISMNI
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Table 4: Overview of selected Whole-Body Vibration studies in Knee OA
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Trans T6
Avelar NCP10
Tsuji T7
Park YG8
Random allocation? Concealed allocation? Baseline comparability? Blind participants? Blind therapists Blind assessors? Follow-up? Intention-totreat analysis? Group comparisons? Point and variability measures? Cumulative score
Yes
Yes
Yes
No
Yes
Cumulative score (Maximum=10) 4/5
Yes
Yes
No
No
No
2/5
Yes
Yes
Yes
Yes
Yes
5/5
No
No
No
Yes
No
1/5
No
No
No
No
No
Yes
Yes
No
No
Yes No
No Yes
Yes No
No Yes
Yes
Yes
Yes
Yes
Yes
7
7
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0/5 2/5
No No
2/5 2/5
Yes
Yes
5/5
Yes
Yes
Yes
5/5
5
5
4
5.6
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Criteria
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Blinding?
Simao AP9 Trans T6 Avelar NCP10 Tsuji T7 Park YG8
Yes Yes No No Yes
Yes Yes No No No
Yes Unclear Unclear Unclear No
Incomplete outcome data addressed? Yes Yes Yes Yes Yes
Free of selective reporting?
Conclusions
Yes Yes Yes Yes Yes
Low risk of bias Unclear risk of bias High risk of bias High risk of bias High risk of bias
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Table 3: Methodological assessment by the recommendations of the ISMNI Q3
Q4
Q5
Q6
Q7
yes
yes
yes
unclear yes
yes
unclear unclear yes
yes
yes
yes
no
unclear unclear unclear no
yes
unclear yes
unclear yes
yes
yes
unclear yes
unclear no
yes
yes
unclear yes
unclear no
unclear unclear unclear unclear yes
Q9
Q12
Q13
unclear no
yes
yes
Quality score 8
unclear yes
yes
yes
6
unclear unclear yes
unclear no
yes
yes
7
unclear no
unclear yes
yes
yes
7
yes
yes
6
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no
Q8
Q10
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yes
Q11
yes
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Q1, Brand name of vibration platform; Q2, Type of vibration; Q3, Vibration frequency; Q4, Vibration amplitude; Q5, Peak acceleration; Q6, Accuracy of vibration parameter; Q7, Evaluation of skidding of the feet; Q8, Changes of vibration parameters; Q9, Rationale for choosing vibration parameters; Q10, Support devices during vibration exposure; Q11, Type of footwear; Q12, Body position; Q13, Description of exercise.
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Table 4: Overview of selected Whole-Body Vibration studies in Knee OA Group
WBV parameters
Duration
Outcomes
Conclusions
RCT
1: Squat-WBV (n=12) 2: Control (n=12)
Frequency (Hz): 35, 40 Amplitude (mm): 4 Acceleration (g):2 – 2.61
3/week, 12 weeks
WOMAC index
Group 1:61.5 (0/100) Group 2: 61.1 (0/100)
RCT
1: WBVexercise on stable platform (n=17) 2: Control (n=18)
Frequency (Hz): 25, 30 Amplitude (mm):? Acceleration (g):? Time/repetition: 30 s/6 – 70 s/9
2/week, 8 weeks
The addition of vibration training to squat exercise reduces the selfperception of pain. No significant differences between groups were observed on functional scores. No significant differences between groups were observed on pain and functional scores.
Knee OA based on clinical and radiographic criteria of ACR
Avelar NCP10
Knee OA based on clinical and radiographic criteria of ACR
Group 1:75 (18/82) Group 2: 71 (10/90)
RCT
1: Squat-WBV (n=12) 2: Squat (n=11)
3/week, 12 weeks
WOMAC index
The addition of vibration training to squat exercise does not reduce pain and improve function beyond that of squat exercise without WBV.
Tsuji T7
Post-menopausal women with knee pain in the age group of 50 – 75 years. Knee OA based on KL scale (0 – 4)
Group 1:62.1 (0/100) Group 2: 60.9 (0/100)
RCT
1: Accelerated training-WBV (n=32) 2: Controlhome exercise (n=15)
Frequency (Hz): 35, 40 Amplitude (mm): 4 Acceleration (g):2.78 – 3.26 Frequency (Hz): 30, 40 Amplitude (mm): 2.5 Acceleration (g):?
3/week, 8 weeks
JKOM
The accelerated training program consisting of strength and flexibility training with WBV reported improvement in function. No significant differences between groups were observed on pain score.
Park YG8
Knee OA based on clinical and radiographic criteria of ACR
Group 1:62.5 (0/100) Group 2: 60 (0/100)
RCT
1: WBV and Home exercise (n=17) 2: Controlhome exercise (n=19)
Frequency (Hz): 12, 14 Amplitude (mm): 2.5- 5 Acceleration (g):?
3/week, 8 weeks
NRS KWOMAC Index
The WBV with home exercise group reported significant reduction in pain as compared to home exercise alone. No significant differences between groups were observed on function.
WOMAC index
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Knee OA based on clinical and radiographic criteria of ACR
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Simao AP9
Mean age, Years (male/female, %) Group1: 75 (18/82) Group 2: 71 (9/91)
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Study
ACR, American College of Rheumatology ; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; JKOM, Japanese Knee Osteoarthritis Measure; WBV, Whole-body vibration; NRS, Numerical rating scale; KWOMAC, Korean Western Ontario and McMaster Universities Osteoarthritis Index; RCT, Randomized controlled trial; KL scale, Kellgren and Lawrence scale; ?, not reported
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Studies excluded (n = 07)17-23
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Studies screened (n = 18)
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Screening
Studies after duplicates removed (n = 18)
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Studies identified through hand searching (n = 27)
Identification
Studies identified through electronic database searching (n = 56)
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No control group (n=01) Only protocol (n=01) Objective not related to the review (n=02) Article not in English language (n=02)
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Studies included in qualitative synthesis (n = 05)
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Eligibility
Full-text studies excluded (n = 06)5,24-28
Studies included in meta-analysis (n = 05)
Figure 1: Flow Diagram of the study procedure
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Figure 2: Effect of whole body vibration training on pain
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Study name
Statistics for each study
Hedges's g and 95% CI
0.013 0.294 0.511 0.016 0.401 0.214
-0.644 -0.533 -0.230 -0.623 -0.396 -0.108
0.669 1.121 1.252 0.656 1.198 0.537
0.038 0.697 1.351 0.051 0.985 1.302
0.970 0.486 0.177 0.960 0.324 0.193 -1.00
-0.50
Favours Control
0.50
Favours WBV
1.00
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Heterogeneity: Q- value, 1.598 (p=0.809); I-squared, 0%
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Hedges's Lower Upper g limit limit Z-Value p-Value
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Figure 3: Effect of whole body vibration training on knee stiffness
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Figure 4: Effect of whole body vibration training on function
ACCEPTED MANUSCRIPT Highlights •
Whole body vibration can reduce pain and improve function in individuals with knee OA. Whole body vibration does not relieve knee stiffness in individuals with knee OA.
•
The long term follow-up effects of Whole body vibration were not investigated.
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•
