Purpose Despite the high incidence of falls in patients with OA, few studies have explored whether falls risk is affected after patients undergo total knee arthroplasty (TKA). Therefore, the aim of this systematic review was to identify the extent of the effects of TKA on balance and incidence of falls by critically reviewing the available literature. Methods A systematic review of published literature sources was conducted up to March 2014. All studies assessing balance and incidence of falls after TKA (without physiotherapeutic intervention) were included. The methodological quality of each study was reviewed using the Critical Appraisal Skill Programme tool. Results Thirteen studies were included, comprising of ten cohort studies (Level II) and three studies with Level of evidence III. Conclusions Findings provide evidence that TKA improves significantly single-limb standing balance (~60%) and dynamic balance up to 1-year following surgery (Level of evidence II). Moreover, TKA influences positively fear of falling and incidence of falls by switching 54.2 % of pre-operative fallers to post-operative non-fallers (Level of evidence II–III). It is highlighted that knee extension strength, proprioception and symmetrization of postural strategies have not fully recovered post-TKA and influence balance performance. Clinically, these persistent deficits need to be mitigated by physiotherapy even before TKA takes place.

Purpose: Aim of this study is to assess the psychometric properties of the developed Greek version of the Knee Injury and Osteoarthritis Outcome Score (KOOS) in total knee replacement (TKR) patients. Methods: Psychometric properties of the Greek version of KOOS were evaluated according to the Consensus-based Standards Measurements Instruments (COSMIN) checklist. Patients’ pre-operative clinical status and post-operative outcomes at two occasions (at discharge and 10–12 days post-operatively) were evaluated using the KOOS, KOS-ADL and SF-12 Health Survey. Results: A comprehensive Greek KOOS was piloted and well accepted by patients and therefore administered to 60 consecutive TKR patients (mean age 72.2 ± 7.2 years, 39 women). Excellent Internal consistency, good test–retest reliability of KOOS and KOOS 5 subdomains, respectively [ICC(2-1) 0.76, 95% CI = 0.235–0.902 and 0.89, 95% CI = 0.843–0.927] was yielded. A priori hypotheses for construct validity were confirmed with KOOS score and subdomains for pain, symptoms and Everyday Living function (ADL) correlating moderately with KOS-ADL. Responsiveness for KOOS subdomains of Pain and Symptoms yielded moderate effect size (ES = 0.4). Conclusion: The Greek KOOS was found to be a practical and comprehensible self-reported measure for TKR patients with acceptable psychometric properties. It is therefore, recommendable for usage in future clinical trials and clinical practice.

The purpose of this study was to investigate the effects of a manual mobilization technique on indirect measures of sympathetic nervous system activity. Forty-five healthy volunteers participated in this randomized, single-blinded, parallel-group 3-arm design (experimental, sham [placebo], and control group), comprising 15 subjects each. For the experimental group, lumbar mobilization involving an active movement, the Mulligan sustained natural apophyseal glide (SNAG), was applied on L4 spinous process by an experienced manual therapist. Sustained natural apophyseal glides were performed in sitting with active flexion (6 times × 3 sets). The sham technique simulated the SNAG without applying any force. In the control group, participants were placed in a static sitting position throughout the experiment. Measures of skin conductance in the lower limbs (L4 dermatome) were recorded to reflect sympathetic nervous system activity in the preintervention, periintervention, and postintervention periods. Differences in percentage change of skin conductance were analyzed with analysis of variance and post hoc tests. Lumbar SNAG produced sympathoexcitation compared with the control group in the intervention period (P = .04). No significant difference was found between SNAG and sham groups, and no statistically significant difference was found between groups in the final rest period. The results of this study showed that, in asymptomatic participants, both lumbar SNAG and sham techniques performed on L4/5 intervertebral joint with active flexion induced a sympathoexcitatory response in lower limbs compared with the control group.

Background: Mulligan's mobilisation techniques are thought to increase the range of movement (ROM) in patients with low back pain. The primary aim of this study was to investigate the application of the Mulligan's Sustained Natural Apophyseal Glide (SNAG) technique on lumbar flexion ROM. The secondary aim was to measure the intra- and inter-day reliability of lumbar ROM employing the same procedure.Methods: 49 asymptomatic volunteers participated in this double-blinded study. Subjects were randomly assigned to receive either SNAG mobilisation (n = 25), or a sham mobilisation (n = 24). The SNAG technique was applied at the L₃and L₄spinal levels with active flexion in sitting by an experienced manual therapist. Three sets of 10 repetitions at each of the two spinal levels were performed. The sham mobilisation was similar to the SNAG but did not apply the appropriate direction or force. Lumbar ROM was measured by a three dimensional electronic goniometer (Zebris CMS20), before and after each technique. For the reliability, five measurements in two different days (one week apart) were performed in 20 healthy subjects.Results: When both interventions were compared, independentttests yielded no statistically significant results in ROM between groups (p = 0.673). Furthermore no significant within group differences were observed: SNAG (p = 0.842), sham (p = 0.169). Intra- and inter-day reliability of flexion measurements was high (ICC_1,1> 0.82, SEM < 4.0°, SDD<16.3%) indicating acceptable clinical applicability.Conclusion: While the Zebris proved to be a reliable device for measuring lumbar flexion ROM, SNAG mobilisation did not demonstrate significant differences in flexion ROM when compared to sham mobilisation.Trial registration: Current Controlled Trials NCT00678093.

Low-intensity exercise with blood flow restriction (LIE-BFR) has been proposed as an effective intervention to induce hypoalgesia in both healthy individuals and patients with knee pain. Nevertheless, there is no systematic review reporting the effect of this method on pain threshold. We aimed to evaluate the following: (i) the effect of LIE-BFR on pain threshold compared to other interventions in patients or healthy individuals; and (ii) how different types of applications may influence hypoalgesic response. We included randomized controlled trials assessing the effectiveness of LIE-BFR alone or as an additive intervention compared with controls or other interventions. Pain threshold was the outcome measure. Methodological quality was assessed using the PEDro score. Six studies with 189 healthy adults were included. Five studies were rated with ‘moderate’ and ‘high’ methodological quality. Due to substantial clinical heterogeneity, quantitative synthesis could not be performed. All studies used pressure pain thresholds (PPTs) to assess pain sensitivity. LIE-BFR resulted in significant increases in PPTs compared to conventional exercise at local and remote sites 5 min post-intervention. Higher-pressure BFR results in greater exercise-induced hypoalgesia compared to lower pressure, while exercise to failure produces a similar reduction in pain sensitivity with or without BFR. Based on our findings, LIE-BFR can be an effective intervention to increase pain threshold; however, the effect depends on the exercise methodology. Further research is necessary to investigate the effectiveness of this method in reducing pain sensitivity in patients with pain symptomatology.