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Journal of Bodywork & Movement Therapies (2012) 16, 456e463

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

COMPARATIVE PILOT STUDY

Medical exercise therapy, and not arthroscopic


surgery, resulted in decreased depression and
anxiety in patients with degenerative meniscus
injury
s, MSc, PT a,*, Berit stera
vard stera
Ha s, MSc a,
Tom Arild Torstensen, MSc (Hons) PT b

a
Sr-Trndelag University College, Faculty of Health Education and Social Work, Department of Physical Therapy,
N-7004 Trondheim, Norway
b
Holten Institute, Lidingo, Sweden

Received 1 February 2012; received in revised form 19 March 2012; accepted 30 March 2012

KEYWORDS Summary The purpose of this pilot study was to compare the effectiveness of conservative
Degenerative therapy involving medical exercise therapy (MET) versus arthroscopic surgery in patients with
meniscus injury; knee pain, with MRI-verified degenerative meniscus. The patients were randomly assigned
Knee pain; either to MET (n Z 9) or to arthroscopic surgery (n Z 8). Patients receiving MET had 3 treat-
Medical exercise ments a week for 3 months, a total of 36 treatments. The arthroscopy consisted of meniscect-
therapy; omy with no structured conservative therapy after surgery. Assessment of pain, function,
Arthroscopic surgery anxiety and depression were performed at inclusion and after 3 months. At the end of treat-
ment, which was 3 months after inclusion, there were no statistical differences between the
two groups regarding pain and function. However, anxiety and depression were significantly
reduced in the MET group compared with the patients receiving arthroscopic surgery. Bearing
in mind the low number of included patients in this pilot study, arthroscopy was found to be no
better than MET regarding knee pain and overall daily function. The results from this pilot
study are similar to other clinical studies, thereby demonstrating that conservative therapy
is just as effective as surgery.
2012 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: 47 73 55 93 05; fax: 47 73 55 93 51.


E-mail address: havard.osteras@hist.no (H. stera
s).

1360-8592/$ - see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2012.04.003
Medical exercise therapy resulting in decreased depression 457

Background by Herrlin et al. (2007), an exercise program was found to


be just as effective as an exercise program plus arthro-
Knee pain is one of the most common symptoms in middle scopic surgery. The exercises used in the study were well
age, and a degenerative meniscus is a normal finding in this described regarding the type of exercises and their grading.
patient category (Murphy et al., 2008). Affected individuals In Herrlin et al. (2007), exercise therapy was carried out
clinically present with knee pain, stiffness, swelling and only two times a week for 8 weeks, while the exercises
impaired function (Ericsson et al., 2006). These symptoms were performed with a low number of repetitions in sets.
can be part of early osteoarthritis (Englund et al., 2009), as Over the 8 weeks of physical therapy, each treatment las-
meniscal tears are common and a frequent incidental ted from 20 to 40 min.
finding on knee MR imaging of middle-aged people. The We postulate that clinical outcomes are related to the
surgical resection of non-obstructive degenerative exercise dosage given and to a decrease in pain and
meniscus lesions may only remove evidence of the disorder swelling, thereby resulting in an improved neuromuscular
while the osteoarthritis and associated symptoms proceed. function. Moreover, a high number of repetitions in sets (3
Using MRI imaging, Englund et al. (2009) and Bhattacharyya sets each of 30 repetitions) are more beneficial than
et al. (2003) demonstrated that an injury of the medial or a fewer number of repetitions in sets (2 sets each of 10
lateral meniscus is a common finding in elderly people, both repetitions), which was shown by stera s et al. (2009),
with or without symptoms of knee osteoarthritis. In comparing two different exercise dosages in patients with
patients with symptoms, the investigators found that 91% of long-term subacromial pain. In this randomized trial, high-
the participants had an abnormal meniscus defined as repetition, high-dosage medical exercise therapy (MET) was
meniscus damage, and as many as 76% of the clinically superior to a low-repetition, low-dosage exercise
asymptomatic-matched participants also had a damaged program. In stera s et al. (2009), the MET treatment con-
meniscus as shown by MRI imaging. An injured meniscus can sisted of 11 exercises, in which 8 of the exercises consisted
lead to impaired knee function and knee instability, which of a high number of repetitions involving 3 sets of 30
again can result in an increased risk of cartilage injury repetitions, whereas the last remaining 3 exercises were
(Muellner et al., 1999). endurance type exercises using a stationary bike at the
Clinical studies on the effectiveness of arthroscopic start of the treatment (20 min), in the middle (5 min) and at
surgery for patients with osteoarthritis of the knee have the end (10 min). Each MET treatment lasted for
shown that active surgery is no better than placebo surgery 50e70 min, with all of the patients in the study in both
(Moseley et al., 2002), while two clinical studies (Kirkley intervention groups receiving 3 treatments a week for 12
et al., 2008; Herrlin et al., 2007) failed to show any weeks, a total of 36 treatments.
benefit from arthroscopic surgery. Where patients were MET was first presented in 1967 by the Norwegian
assigned to arthroscopic treatment in addition to physical physiotherapist and manual therapist, Oddvar Holten, who
therapy, there was no greater improvement when defined an exercise approach with its own specific criteria
compared with those who received only physical therapy. (Torstensen, 1997):
Despite the increasing evidence that arthroscopic
surgery is no better than conservative therapy, such as 1) The physiotherapist is present in the exercise room
different forms of physical therapy, including exercise while the patient is treated/exercising;
therapy, partial arthroscopic meniscectomy remains 2) Specific exercise equipment is used to meet the need of
a common surgical procedure in patients with meniscus the patient in order to grade exercises according to
injury, both with or without osteoarthritis. Postoperatively, their dysfunction, while starting exercising as early as
many patients report less pain, better function and a better possible (using a pulley apparatus with the smallest
quality of life (Burks et al., 1997). Despite reduced knee weight being 0.5 kg and the highest 50 kg, while also
pain and improved knee function, Roos et al. (2000) found using an angle bench, a mobilizing bench, a multi-
that as many as 38% had reduced their level of physical purpose bench, a pulley and other pieces of
activity 3 months after knee surgery compared with only 9% equipment);
of the patients before surgery. Physical activity is a well- 3) The assessment of the patient is the basis for designing
documented form of treatment that reduces pain and the exercise program; the exercise therapy lasts for at
improves the function and quality of life for patients with least 60 min;
subacute and long-term knee pain with osteoarthritis of the 4) The exercise program/treatment is reassessed at least
knee (Bo rjesson et al., 1996; Matthews and St-Pierre, every third to fourth treatment;
1996). 5) Four to five patients are exercising at the same time,
The goal of exercise therapy is primarily to decrease the making a form of group therapy. However, every
pain experience and swelling of the knee since both pain patient has his/her individually designed exercise
and swelling are two important factors leading to changes program (Torstensen, 1997). Treating patients with
in muscle function, such as decreased muscle strength and knee pain, the treatment consists of 11 exercises that
coordination. When pain and swelling decrease, a second combine global, semi-global and local exercises. Global
goal is to regain knee control, as well as increasing range of exercises involve dynamically working the whole
motion and muscle strength, while also improving activities organism. Semi-global exercising involves working the
of daily functioning. Many different exercise protocols exist entire lower limb in a closed chain activity such as
for treating knee pain, although there is no consensus as to squatting. A local exercise might only involve working
what type of exercise program is most effective. In a study the knee locally, as in a seated, open-chain knee
458 H. stera
s et al.

extension exercise. To optimize the dosage, global,


Table 1 Baseline characteristics of the study population,
semi-global and local exercises are combined, thus
given in mean values and standard deviation (SD) unless
making the treatment close to pain free. The goal of
otherwise noted.
the highly repetitive, high-dosage exercise therapy is to
modulate the patients pain experience, modifying Train group Surg group Total (n Z 17)
homeostasis in the different tissues in the knee joint. (n Z 9) (n Z 8) participants
To avoid or decrease the level of sensitization of the Age 47.0 (10.4) 52.7 (7.2) 49.7 (9.3)
nervous system, we believe it is very important to grade Body weight 79.8 (7.5) 82.3.8 (10.9) 80.9 (9.0)
the exercises as close to pain free as possible. Patients Duration of 1.6 (1.2) 2.1 (1.7) 1.8 (1.4)
with knee pain who experience that an exercise session symptoms
lasting from 50 to 70 min can be performed close to Stage of 0.6 (0.7) 0.9 (1.0) 0.7 (0.8)
pain free often have a positive cognitive effect, giving arthritis
the patient control over the painful knee. Hence, Gender 8 (88.9) 5 (62.5) 13 (76.4)
medical exercise therapy is a biopsychosocial treat- (% male)
ment approach, meeting the patient where the patient Number of 29.4 (6.2)
is, thereby increasing their level of self-efficacy. In this treatments
present study, our hypothesis is that the outcome for
exercise therapy in patients with knee pain due to VAS 3.5 (1.7) 3.7 (0.9) 3.6 (1.4)
a ruptured degenerative meniscus would be signifi- FiveRM 12.4 (6.1) 8.6 (5.4) 10.6 (5.9)
cantly improved if a higher exercise dosage were KOOS 51.4 (24.4) 48.4 (25.6) 50.0 (24.2)
applied, and significantly better when compared with HAD Anxiety 4.5 (3.1) 4.0 (2.6) 5.3 (3.2)
arthroscopic meniscus resection. Depression 5.0 (2.9) 5.0 (2.5) 4.9 (2.2)

Methods The exclusion criteria were ACL rupture for individuals


requiring acute trauma surgeries, including high-energy
Design traumas with ligament injuries, osteoarthritis grade 3e4
(KellgreneLawrence classification, Scott et al., 1993),
Ethical approval was acquired from the Human Subject haemarthroses and acute cases of locking knee and symp-
Review Committee (Trondheim, Norway), and all partici- tomatic pain in contrary extremities, as well as other
pants gave their written consent to participate in the study musculoskeletal comorbidities severely affecting lower
after receiving written information about the study. The extremity muscle function that override the symptoms from
tester was not blinded to which intervention the patient the knee, and comorbidities excluding physical activities
received. The subjects were informed about the length of and exercise that are not able to speak or read the
the study, test procedures and treatment procedures, and language of interest.
were told that they could withdraw from the study at any Patients were recruited from orthopedic surgeons in two
time. Baseline data for all of the included subjects is pre- hospitals in Norway over a period of one year. The inter-
sented in Table 1. The included subjects were randomly vention was formulated not to worsen the injury, and was
assigned to either a medical exercise therapy group or implemented in accordance with the known medical exer-
arthroscopic surgery, and the randomization procedure was cise therapy principles used by physical therapists. All
concealed from the experimenters and treating physio- participation was based on informed consent, voluntariness
therapist. The medical exercise group was tested at base- and the right to withdraw from the study without further
line and after the 3-month intervention period, while the consequences. Three physiotherapists at three different
arthroscopy group was tested at baseline and 3 months locations were involved in the study, and the same phys-
after surgery. At these visits, all patients answered the iotherapist always dealt with the same subjects.
questionnaires and complete the functional- and muscle
tests. The present research project could not afford to hire
Sample size
an additional assessor, thus one of the authors had to serve
as the assessor.
Sample size calculation based on a predetermined differ-
ence between treatment groups of 20% change in pain on
Subjects
a 10 cm visual analog scale and a standard deviation of
1.5 cm, showed that 10 participants were required in each
The inclusion criteria were subjects with knee pain for group to have 80% power to detect the 20% difference as
more than 3 months, who were 35e60 years old and eligible statistically significant at the level of p < 0.05.
for an arthroscopic partial meniscectomy and MRI showing
a degenerative meniscus tear. The magnetic resonance
imaging (MRI) included coronal T1-weighted turbo spin echo Outcome measures
(TSE) and T2-weighted fat saturated TSE, transversal T2-
weighted gradient echo and oblique sagittal T2-weighted The primary outcome was pain in the last week, with
fat saturated imaging sequences performed on a Siemens a subjective score measured with a visual analog scale
1.5 Tesla Magnet (Symphony) before starting treatment. (VAS) at rest recorded on a 0e10 cm line. The extreme
Medical exercise therapy resulting in decreased depression 459

limits were marked by perpendicular lines using the verbal and the program was a combination of the global aerobic
descriptors of no pain and the worst pain I can imagine, exercises using a stationary ergometer cycle, a treadmill or
the higher the score, the more the pain. The subjects were a step machine, whereas semi-global and local exercises to
not shown their previous markings at follow-ups, as the VAS modulate pain and increase range of motion were per-
has been shown to be a reliable tool for measuring pain formed using specially designed exercise equipment. This
(Huskisson, 1974). The secondary outcome was a self- included wall pulleys and quadriceps and hamstrings
reported composite measure known as a: Knee Injury muscle strength training apparatus, including squats to 90
and Osteoarthritis Outcome Score (KOOS), which is of flexion, leg extension and leg flexion.
comprised of five different subscales: a) Pain, b) Other Each treatment in the exercise group started with
symptoms, c) Activities in daily living, d) Functioning in 15e20 min of aerobic work on a stationary ergometer cycle.
sport and recreation, and e) Knee-related quality of life After 4 exercises each of 3 sets of 30 repetitions halfway
(Roos et al., 1998; Roos and Lohmander, 2003). The KOOS is through the exercise program, the subjects cycled for
a valid and reliable patient-relevant questionnaire for 10 min and again after the last 4 exercises, the subjects did
patients with knee injury and knee osteoarthritis (Roos another 10 min on a stationary ergometer cycle. The
et al., 1998) that was registered at baseline and with all intensity during cycle exercises was moderate to high, i.e.
tests during this study. a heart rate frequency of 70e80% of the maximal heart
Anxiety and depression are often seen in this group of rate. The hypothesis was that the global exercises are
patients, which may affect treatment. Anxiety and important to stimulate the bodys own pain modulating
depression were measured with the Hospital Anxiety and system through the gate control mechanism in the posterior
Depression Scale (HAD) (Bjelland et al., 2002), which is horn of the spinal cord and the release of endogenous
a self-screening questionnaire for depression and anxiety. neuropeptides in the central nervous system.
The patients were instructed not to take too long with their
replies since their immediate reaction to each item would Statistical analyses
probably be more accurate than a long, thought-out
response. It consisted of 14 questions, 7 for anxiety and 7 All data were analyzed with the Statistical Package for the
for depression. Each item was answered by the patient on Social Sciences (PASW) 19.0, and descriptive statistics were
a 4-point (0e3) response category, so the possible scores used to determine participant characteristics. Prior to
ranged from 0 to 21 for anxiety and 0 to 21 for depression. statistical analysis, the KolmogoroveSmirnov test was per-
In both the KOOS and HAD questionnaires, a lower score formed to assess the normality of the continuous data. A
indicates a better clinical status. comparison of treatment groups at baseline with respect to
Dynamic quadriceps muscle strength was measured with demographic and possible prognostic factors was per-
a leg extension bench (Holm et al., 1995), and a protocol in formed with the use of appropriate nonparametric tests.
which the patients lifted a weight with a maximum external Main comparative analyses, both within and between
load using 5 repetitions (5RM). The test started at a 90 groups, were performed by using the general linear model
flexion and was accepted only when the leg reached full in which the pretest values of the outcome measures were
extension. The amount of weight was determined with 3e5 applied as covariates.
sets, in which the patients received an increasing external
load until they were not able to reach 5 repetitions in a set
according to the full extension criterion.
Results

All of the allocated patients completed the study, with the


Intervention flow of the subjects throughout the study presented in
Fig. 1. There were no participants lost to the follow-up
A standard arthroscopic partial meniscectomy NGD 11 was assessments, and the baseline characteristics of the study
applied as a surgical intervention, which was carried out at population are outlined in Table 1.
two hospitals in Trondheim, Norway and performed on All possible efforts were made to enhance compliance
patients who were fulfilling inclusion criteria and random- and adherence with the program. On average, the subjects
ized to surgical treatment. Normal procedures for this in the MET group completed 84% (range 77e92%) of the
surgery at the respective hospitals were followed, the rehabilitation program.
protocols did not differ between the hospitals, and there
were two surgeons involved. Primary outcome parameters and main comparison
An exercise program was developed for this particular analyses
study, with a focus on coordination and muscle function
training, along with pain modification exercise therapy. The The KolmogoroveSmirnov test revealed normal test distri-
program was pragmatically adjusted for individual differ- butions for the continuous outcome data. Table 2 shows the
ences due to performance and progression. Based on clin- primary outcome measurements at baseline and at follow-
ical experience, the intervention period was 3 months, and up (at approximately 3 months), change scores within
the subjects performed the exercise program 3 times per groups and adjusted differences between groups with
week. Symptoms and clinical findings were the basis for respect to the outcome parameters. Both the training group
choosing individual starting positions, range of motion and and the surgery group exhibited improvements at follow-up
weight resistance for each exercise. The treatment goal in compared to baseline, and there were no statistical
the exercise group was to perform 3 sets of 30 repetitions, differences between groups at follow-up with respect to
460 H. stera
s et al.

Figure 1 Subject flow diagram.

VAS, FiveRM and KOOS. However, there were significant patients with a non-traumatic meniscus tear. At the end
differences (p < 0.05) between groups with respect to of treatment 3 months after inclusion, there were no
scores on HAD at follow-up in favor of the MET group. The differences between the two groups regarding pain and
final scores of the outcome parameters were all adjusted function. However, there was a significant difference
for baseline values. between groups with less depression and anxiety in the MET
group.
This is an important finding because anxiety and
Discussion depression is a major factor for persistent pain, decreased
function, social isolation and early death (Turvey et al.,
The purpose of the present pilot study was to compare the 2009; Bogner et al., 2011). Today, there is good evidence
clinical effects of high-repetition, high-dosage medical that the symptoms of depression decrease with an appro-
exercise therapy (MET) versus surgery for middle-aged priate dosage of endurance exercise therapy (Brown et al.,

Table 2 (n Z 17) Mean (SD) of groups, mean (SD) difference within groups, and adjusted mean (95% CI) difference between
groups.
Outcome Groups Difference within groups Adjusted difference
Baseline Follow-up (change scores) between groups
(final scores adjusted
Training Surgery Training Surgery Train Surgery for baseline values)
(n Z 9) (n Z 8) (n Z 9) (n Z 8)
VAS 3.5 (1.7) 3.7 (0.9) 2.0 (1.4) 2.6 (1.1) 1.5 (0.8) 1.1 (0.6) 0.5 (1.2 to 0.2)
KOOS 51.4 (24.4) 48.4 (25.6) 39.7 (25.9) 40.9 (23.1) 11.8 (13.3) 7.5 (8.2) 3.9 (15.6 to 7.8)
HAD Anxiety 4.5 (3.1) 4.0 (2.6) 3.5 (1.8) 3.9 (2.5) 1.0 (0.6) 0.1 (0.2) 0.6* (1.5 to 0.2)
Depression 5.0 (2.9) 5.0 (2.5) 3.6 (1.8) 4.2 (2.6) 1.4 (0.5) 0.8 (0.3) 1.0* (1.4 to 0.3)
FiveRM 12.4 (6.1) 8.6 (5.4) 16.7 (7.6) 11.0 (6.1) 4.3 (2.6) 2.4 (2.3) 1.4 (1.2 to 4.0)
*p < 0.05.
Medical exercise therapy resulting in decreased depression 461

2005; Galper et al., 2006), as well as in patients with of 16 treatments. Most of the exercises, eight in all, were
a chronic disease (Matthew et al., 2012). There is a dose performed doing 3 sets of 10 repetitions each. Other
response effect, with higher exercise dosages being more exercises, such as using a stationary bike, were performed
effective in decreasing depression (Dunn et al., 2002, from 7 to 15 min, whereas stair walking and balancing on
2005). Arthroscopic surgery did not result in a decrease in wobble board were performed for 3 min and jogging, jumps
depression and anxiety, though MET did, thus suggesting and landing on a rebounder were performed for 5 min. The
that MET, and not arthroscopic surgery, should be the entire program lasted for approximately 30e45 min, with
preferred treatment for non-traumatic meniscus tears in the goal of the exercise program being to reduce pain,
middle-aged patients. restore a full range of motion and improve knee function.
In two clinical studies (Kirkley et al., 2008; Herrlin et al., Patients also performed a home program consisting of one-
2007), conservative therapy, including physiotherapy, was leg standing for 1 min and a step down exercise, comprising
compared versus arthroscopic surgery. There is clear 3 sets of 10 repetitions.
evidence from both studies that surgery is no better than In our study using high-repetition, high-dosage MET, the
conservative therapy (Kirkley et al., 2008), and that exer- total exercise dosage was considerably higher compared to
cise therapy plus arthroscopic surgery are no better than the dosage given in both Kirkley et al. (2008) and Herrlin
exercise therapy alone (Herrlin et al., 2007). These findings et al. (2007). We used a high number of repetitions in
confirm the findings from Moseley et al. (2002) in relation to sets, such as 3 sets of 30 repetitions combined with
classic RCT, in which active arthroscopic surgery was no stationary bicycling at the start (20 min), in the middle
better than placebo surgery. (5e10 min) and at the end of the treatment (10 min). The
Kirkley et al. (2008) included 188 patients with moderate other exercises were either performed doing 3 sets of 30
to severe osteoarthritis of the knee, although those with repetitions or changed to 5 min of continuous repetitions.
large meniscal tears, malalignment, previous arthroscopic This type of exercise treatment is endurance training that
surgery or severe biocompartmental arthritis were acts on the pain modulating systems in the central nervous
excluded. One intervention group received arthroscopic system. In future research, it is important to make
surgery (including a debridement of articular cartilage and a distinction between strength training, consisting of per-
menisci, an excision of osteophytes and the removal of forming 2e3 sets of 10 repetitions, and pain modulating
loose bodies and medical and physiotherapy). The exercise therapy, consisting of performing 3 sets of 30
comparison group received physiotherapy consisting of 1 h repetitions. Because pain has such an inhibiting effect on
of physiotherapy a week and twice daily exercises in motor drive on both the spinal- and cortical levels, this is an
combination with NSAIDs and intra articular hyaluronic acid argument that supports the use of a high number of repe-
injections. At the 2-year follow-up, there were no differ- titions type of exercise program such as in medical exercise
ences between the groups regarding pain, function and therapy, which has been proven to be able to decrease the
quality of life, nor did surgery provide any benefit to the experience of pain, thereby resulting in an increased
subgroup of patients with mechanical symptoms. muscle strength and range of motion in patients with long-
Herrlin et al. (2007) included 99 middle-aged patients term subacromial pain (stera s et al., 2009). Both anxiety
after a non-traumatic medial meniscal tear that were and depression changes could indicate that limbic system
diagnosed with a radiological examination and magnetic changes had occurred which show higher center changes in
resonance imaging. In this randomized trial, patients in one addition to those of spinal origin. It might be wrong to focus
group received a partial meniscectomy followed by on strength training for subjects with pain since pain
a supervised exercise program, while the other group subjects do not tolerate high-resistance exercises with
received supervised exercise only. Both intervention groups a low number of repetitions. To be able to perform
improved significantly within groups, but there was no strength training exercises, e.g. 3  10 repetitions in
difference between groups regarding pain, function and subjects with degenerative knee pain, there will be
level of physical activity. Based on these results, the a compromise decreasing the resistance, hence resulting in
authors recommend supervised exercise alone as the first a low total dosage with a less positive outcome.
choice of treatment. Training to strengthen the quadriceps muscle has been
From Kirkley et al. (2008), we can assume that the considered as an essential component in the rehabilitation
exercise dosage is very low, with only 1 h of supervised of persons with knee injuries (Thomee ` et al., 1995). Results
treatment a week for 12 weeks, thus comprising a total of from previous clinical trials in this patient group are mixed,
12 treatments. The patients also performed a home exer- as previous studies may not have taken into sufficient
cise program during both the intervention period, as well as account the fact that pain inhibits force development, thus
after this period had ended. Unfortunately, there is no limiting the effects of strength training (stera s et al.,
information in their publication on the type of exercises 2009). Where training principles and dosing are provided,
and dosage. Herrlin et al. (2007) have described the entire it turns out that there are few exercises used, including
exercise program and the home exercise program in detail, high stress and relatively few repetitions (Witvrouw et al.,
which is very helpful for further research in relation to 2000). It is only when pain is reduced that an increase in
believing that clinical differences depend on the dosage strength, improved coordination and a normalization of
applied such as the number of exercises, the number of sets function can be expected (Butler and Gifford, 1997). Future
and the number of repetitions of each set in combining studies could investigate whether the pain improvements of
global aerobic exercises with more local exercises for the the exercise group was as much to do with improvements in
knee. Moreover, Herrlin et al. (2007) stated that the exer- mood as it was to do with physiological improvements in
cises were performed twice a week for 8 weeks, for a total musculoskeletal system.
462 H. stera
s et al.

Several studies point out that patients with knee pain be a blinding to group allocation, even though we do
develop compensatory movement strategies in functional acknowledge the lack of blinding as a limitation.
tasks, probably as a result of pain, fear of pain or muscle From this pilot study, we are not able to indicate further
failure (Thomee ` et al., 1999; Salsich et al., 2001). It details regarding a possible doseeresponse effect in ther-
appears that these compensatory strategies are perma- apeutic rehabilitation, and another therapeutic regimen
nent, even when the relevant functional tasks no longer may have provided other clinical results. Hence, there is
trigger pain, therefore involving selective muscle wake and a strong need for further research in the field of dos-
dysfunction. In order not to provoke any inflammation, eeresponse effects in therapeutic rehabilitation, and an
exercises should be as painless as possible (Dye, 2001), with emphasis should be put on clinical trials comparing differ-
one way of accomplishing this being to utilize pain free, ences in rehabilitation protocols. Further trials should be
repetitive movements that are deemed beneficial to the adequately powered and address a blinding of the outcome
healing of local tissue damage (Kjr, 2003). assessor, along with follow-up data for at least one year.
Other studies show positive effects using exercise
therapy (Herrlin et al., 2007), although the focus here is on Conclusion
strength training that only uses a few number of repetitions
per set.
With the low number of participants in mind for patients
The overall anxiety and depression level (HAD) has
with non-traumatic meniscal injury, arthroscopy was not
changed significantly in favor of the MET group in this study.
superior to medical exercise therapy alone in terms of knee
The MET is pain treatment, in which the exercise dosage
pain and overall daily function. This study therefore indi-
is varied in different ways in order to modulate the pain
cates a need for further studies to elaborate the effect of
experience. The hypothesised gate control mechanism in
medical exercise therapy compared to arthroscopy surgery
the posterior horn of the spinal canal is possibly more highly
for patients with chronic knee pain and verified degenera-
activated using the exercise program, while another
tive meniscus. Further research should also be completed
possible mechanism being the release of endogenous
as randomized controlled trials that include postoperative
neuropeptides such as b-endorphin and enkephalins in the
treatment and osteoarthritis.
pituitary gland and other parts of the central nervous
system. The release of neuropeptides influences the
descending pain inhibitory system. These neuropeptides Conflicts of interest
have strong analgesic effects, and high-intensity exercise
for 45 min has been revealed to have the same analgesic None.
effect as 10 mg of morphine administered intravenously
(Janal et al., 1984). More research is needed in order to be Acknowledgments
able to make any conclusions regarding the possible phys-
iological mechanisms of pain management in the exercising
participants in this study. The authors wish to thank physiotherapists, Lasse Haugerud
There are difficulties in reliably predicting whether and Eivind Selven, for their contribution in interventions for
meniscal tears and no other structures on the knee are the patients.
related to a patients problems since many meniscal tears
without reported knee problems are found through MRIs References
(Bhattacharyya et al., 2003), as the correlation between
osteoarthritis and knee pain verified after radiological Bhattacharyya, T., Gale, D., Dewire, P., Totterman, S., 2003. The
examination has been reported to be low. Therefore, it clinical importance of meniscal tears demonstrated by
would be logical to not rush too early into a surgical magnetic resonance imaging in osteoarthritis of the knee. J.
intervention, which is supported by several reports that Bone Jt. Surg. Am. 85, 4e9.
suggest that degenerative menisci could be a part of an Bjelland, I., Dahl, A.A., Haug, T.T., Neckelmann, D., 2002, Feb.
osteoarthritis process in the knee (e.g. Marx, 2008). On the The validity of the hospital anxiety and depression scale. An
updated literature review. J. Psychosom. Res. 52 (2), 69e77.
other hand, it would be of great importance in further
Bogner, H.R., Morales, K.H., Reynalds, C.F., Cary, M.S.,
studies to see whether a delay in surgery could possibly Bruce, M.L., 2011. Course of depression and mortality among
increase the patients problems, including an increase in older primary care patients. Am. J. Geriatr. Psychiatry 19, 1e9.
the development of osteoarthritis. If a wait-and-see- Brown, W.J., Ford, J.H., Burton, N.W., Marshall, A.L.,
attitude is chosen, however, it is suggested from the Dobson, A.J., 2005. Prospective study of physical activity and
results of this study that the patient should undergo an depressive symptoms in middle-aged women. Am. J. Prev. Med.
exercise and rehabilitation program. 29, 265e272.
A limitation of this study is that the measurements were Burks, R.T., Metcalf, M.H., Metcalf, R.W., 1997. Fifteen-year
undertaken by the treating physiotherapists and not by follow-up of arthroscopic partial meniscectomy. J. Arthroscopic
another person, though this was a multicenter study with Rel. Surg. 13, 673e679.
Butler, D.S., Gifford, L.S., 1997. The integration of pain science
four physiotherapists. The outcome measurements were
into clinical practice. J. Hand Ther. 10, 86e95.
also not obtained by a blinded assessor, which is a major Bo
rjesson, M., Robertson, E., Weidenhielm, L., Mattsson, E.,
limitation, as a blinded assessment is considered essential Olsson, E., 1996. Physiotherapy in knee osteoarthrosis: effect
to help prevent bias and assure internal validity in a clinical on pain and walking. Physiother. Res. Int. 1, 89e97.
trial. Two outcome measures were self-reports (VAS, the Dunn, A.L., Trivedi, M.H., Kampert, J.B., Clark, C.G.,
KOOS questionnaire), which were used so there would not Chambliss, H.O., 2002. The DOSE study: a clinical trial to
Medical exercise therapy resulting in decreased depression 463

examine efficacy and dose response of exercise as treatment Ashton, C.M., Wray, N.P., 2002. A controlled trial of arthro-
for depression. Control. Clin. Trial. 23, 584e603. scopic surgery for osteoarthritis of the knee. N. Engl. J. Med.
Dunn, A.L., Trivedi, M.H., Kampert, J.B., Clark, C.G., 347, 81e88.
Chambliss, H.O., 2005. Exercise treatment for depression: Muellner, T., Nikolic, A., Vecsei, V., 1999, May. Recommendations
efficacy and dose response. Am. J. Prev. Med. 28, 1e8. for the diagnosis of traumatic meniscal injuries in athletes.
Dye, S.F., 2001. Therapeutic implications of a tissue homeostasis Sports Med. 27 (5), 337e345.
approach to patellofemoralt pain. Sports Med. Arthrosc. Rev. 9, Murphy, L., Schwartz, T.A., Helmick, C.G., et al., 2008. Lifetime
306e311. risk of symptomatic knee osteoarthrosis. Arthritis. Rheum. 59,
Englund, M., Guermazi, A., Lohmander, S.L., 2009. The role of the 1207e1213.
meniscus in knee osteoarthritis: a cause or consequence? steras, H., Torstensen, T.A., Haugerud, L., steras, B., Jan, 2009.
Radiol. Clin. North Am. 47 (4), 703e712. The dose-response effect of graded therapeutic exercises in
Ericsson, Y.B., Roos, E.M., Dahlberg, L., 2006. Muscle strength, patients with unilateral chronic subacromial pain. A randomized
functional performance, and self-reported outcomes four years clinical trial. Adv. Physiother. 11 (4), 199e209.
after arthroscopic partial meniscectomy in middle-aged Roos, E., Lohmander, L.S., 2003, Nov. The knee injury and osteo-
patients. Arthritis. Rheum. 15 (55), 946e952. arthritis outcome score (KOOS): from joint injury to osteoar-
Galper, D.I., Trivedi, M.H., Barlow, C.E., Dunn, A.L., thritis. Health Qual. Life Outcomes 3 (1), 64.
Kampert, J.B., 2006. Inverse association between physical Roos, E.M., Roos, H.P., Lohmander, L.S., Ekdahl, C., Beynnon, B.D.,
inactivity and mental health in men and women. Med. Sci. 1998, Aug. Knee injury and osteoarthritis outcome score
Sports Exerc. 38, 173e178. (KOOS)-development of a self-administered outcome measure.
Herrlin, S., Hallander, M., Wange, P., Weidenhielm, L., Werner, S., J. Orthop. Sports Phys. Ther. 28 (2), 88e96.
2007, Apr. Arthroscopic or conservative treatment of degener- Roos, E.M., Roos, H.P., Ryd, L., Lohmander, L.S., 2000. Substantial
ative medial meniscal tears: a prospective randomized trial. disability 3 months after arthroscopic partial meniscectomy:
Knee Surg. Sports Traumatol. Arthrosc. 15 (4), 393e401. a prospective study of patient relevant outcomes. J. Arthrosc.
Holm, I., Hammer, S., Larsen, S., Nordsletten, L., Steen, H., 1995. Rel. Surg. 16 (6), 619e626.
Can a regular leg extension bench be used in testing deficits of Salsich, G.B., Brechter, J., Powers, C.M., 2001. Lower extremity
the quadriceps muscle during rehabilitation? Acnd. J. Med. Sci. kinetics during stair ambulation in patients with and without
Sports 5, 29e35. patellofemoralt pain. Clin. Biomech. 16, 906e912.
Huskisson, E.L., 1974. Measurement of pain. Lancet 9, 1127e1131. Scott, W.W., Lethbridge-Cejku, M., Reichle, R., Wigley, F.M.,
Janal, M.N., Colt, E.W., Clark, W.C., Glusman, M., 1984. Pain Tobin, J.D., Hochberg, M.C., 1993. Reliability of grading scales
sensitivity, mood and plasma endocrine levels in man following for individual radiographic features of osteoarthritis of the
long-distance running: effects of naloxone. Pain 19, 13e25. knee: the Baltimore longitudinal study of aging atlas of knee
Kirkley, A., Birmingham, T.B., Litchfield, R.B., Giffin, J.R., osteoarthritis. Invest. Radiol. 28, 497e501.
Willits, K.R., Wong, C.J., Feagan, B.G., Donner, A., Thomee `, R., Augustsson, J., Karlsson, J., 1999, Oct. Patellofemoral
Griffin, S.H., DAscanio, L.M., Pope, J.E., Fowler, P.J., 2008. pain syndrome: a review of current issues. Sports Med. 28 (4),
Arthroscopic surgery provides no additional benefit over phys- 245e262.
iotherapy and medication for the treatment of knee osteoar- Thomee `, R., Renstrom, P., Karlsson, J., Grimby, G., 1995. Patel-
thritis. N. Engl. J. Med. 359, 1097e1107. lofemoral pain syndrome in young women, II: muscle function in
Kjr, P., 2003. Role of extracellular matrix in adaptation of tendon and patients and healthy controls. Scan. J. Med. Sci. .Sports 5,
skeletal muscle to mechanical loading. Physiol. Rev. 83, 649e698. 245e251.
Marx, R.G., 2008, Sep. Arthroscopic surgery for osteoarthritis of the Torstensen, T.A., 1997. Medical Exercise Therapy for Hip, Knee and
knee? N. Engl. J. Med. 11 (V359(11)), 1169. Ankle Pain e Dysfunction of the Lower Extremity e Exercise
Matthews, P., St-Pierre, D.M., 1996, Jan. Recovery of muscle strength Manual. Holten Institute, Oslo, ISBN 82-92018-02-6.
following arthroscopic meniscectomy. J. Orthop. 23 (1), 18e26. Turvey, C.L., Schultz, S.K., Beglinger, L., Klein, D.M., 2009. A
Matthew, P., Herring, M.P., Puetz, P.W., OConnor, P.J., longitudinal community based study of chronic illness, cognitive
Dishman, R.K., 2012. Effect of exercise training on depressive and physical function, and depression. Am. J. Geriatr. Psychi-
symptoms among patients with a chronic illness. A systematic atry 17, 632e641.
review and meta-analysis of randomized controlled trials. Arch. Witvrouw, E., Lysens, R., Bellemans, J., Peers, K.,
Intern. Med. 172, 101e111. Vanderstraeten, G., 2000. Open versus closed kinetic chain
Moseley, J.B., OMalley, K., Petersen, N.J., Menke, T.J., exercises for patellofemoralt pain. Am. J. Sports Med. 28 (5),
Brody, B.A., Kuykendall, D.H., Hollingsworth, J.C., 687e694.