Dor, sono, exercício e educação na osteoartrite de joelho: uma abordagem integrada com análise transversal, estudo de viabilidade e ensaio clínico randomizado.

Abstract

Objectives: The main aim of this thesis was to investigate whether personalized circuit training promotes effects on pain processing, determined by pressure pain thresholds, temporal summation, and conditioned pain modulation in patients with knee osteoarthritis (KOA), compared to an educational control group. Secondarily, the objective of this study was to investigate whether there is a correlation between quantitative sensory measures and sleep quality, as well as with sleep components, and to evaluate the feasibility and acceptability of this protocol. Format: For this purpose, three studies were conducted. The first one explored the relationship between sleep quality and its components and pain sensitization and was entitled "Pressure pain threshold and temporal summation predict poor sleep quality in knee osteoarthritis". The second one analyzed the feasibility and acceptability of the protocol and was titled "Tailored Circuit Training and an educational program reduce pain sensitivity in patients with knee osteoarthritis: a feasibility study". The third study presents the results of the clinical trial, titled "Remotely-delivered personalized circuit training reduces pain sensitivity in patients with knee osteoarthritis: A randomized controlled clinical trial. "Methods: For all three studies, participants with a primary symptom of pain (≥ 4) and KOA diagnostic criteria were recruited. They were randomly allocated to an experimental group or a control group in a 1:1 ratio for 14 weeks of intervention delivered remotely and a total of 26 weeks of follow-up. The experimental group performed a personalized circuit training program and an educational program, performing exercises three times a week, with individualized progression of exercise duration and intensity. The control group performed only the educational program, which included seven meetings, held every two weeks, in which they received information on the pathophysiology of KOA, treatment recommendations, and topics in pain neuroscience. At baseline, after the 14-week intervention and after the end of follow-up, at week 26, clinical measures such as physical performance, self-administered questionnaires on physical and mental condition, and muscle strength, and quantitative sensory tests were collected. For study 1, only baseline data were used, since it is a cross-sectional study. Open and closed questions were asked for study 2, about feasibility and acceptability. Studies 1 and 2 were analyzed with descriptive statistics, correlation tests and linear regression analysis, with the SPSS 26.0 program and a significance level of 5%. Statistical analyses of the clinical trial were performed using the R programming language. The between-group differences and 95% confidence intervals for post-treatment outcomes were calculated using the linear mixed models through the groups-versus-time interaction analysis. Results: The first study included 80 participants and identified that temporal summation, local pressure pain threshold, and depression and anxiety were associated with poor sleep quality, specifically the components of subjective sleep quality, sleep duration, sleep efficiency, sleep disturbances, and daytime dysfunction. The second study included 30 participants and identified an eligibility rate of 31.6% and a recruitment rate of 2.7 participants per week, considered adequate. Adherence to the exercise protocol was partially adequate (60%), and the educational program was adequate (80%). Differences between groups at different time-points for primary and secondary outcomes were presented. Finally, the clinical trial included 88 participants, 60% of whom were female, and the average age was 59 years. The mean difference between groups in pressure pain threshold in the medial line of the knee was increased (1.3 kg/cm2 [95% CI from 0.8 to 1.7]) in relation to the control group, as well as the other pressure pain thresholds and their CIs. The estimated differences in temporal summation and conditioned pain modulation had reduced means, but wide confidence intervals, and the results were considered inconclusive. Among the clinical parameters, a reduction in pain intensity (-2.3 [95%CI -3.3 to -1.4]) and symptoms of KOA by WOMAC (-14.4 [95% CI -19.8 to -9.0]), increased strength of the knee extensor muscles (4.8 Kgf [95% CI 2.7 to 6.8]) and improved physical performance for climbing and descending stairs (-4.9 s [95%CI -7.6 to -1.9]) were identified in the experimental group compared to the control group. An association between pain intensity and progression in the exercise protocol was identified. Conclusion: The protocol of assessments and interventions with remotely-delivered personalized circuit training and patient education achieved good rates of feasibility and acceptability. Anxiety and depression, and peripheral pain sensitization were associated with poor sleep quality, specifically sleep components, subjective quality, duration, sleep efficiency, sleep disturbances, and daytime dysfunction. Remotely-delivered personalized circuit training constitutes an effective strategy for modulating pain sensitivity and clinical symptoms in individuals with KOA. Higher pain intensity was determinant for slower progression in the exercise protocol.