Am Fam Physician. 2004 Sep 1;70(5):865-866.
Effect of Exercise Intensity on Osteoarthritis
Does the intensity of therapeutic exercise for osteoarthritis matter?
Although land-based exercise improves physical function, there is no evidence that high-intensity cycling offers benefits over low-intensity cycling for patients with osteoarthritis of the knee.
An earlier Cochrane review1 (last updated in 2001) of 17 studies with 2,562 participants found that group and individual exercise were effective in reducing pain (standardized mean difference [SMD], 0.39; 95 percent confidence interval [CI], 0.30 to 0.47) and improving function (SMD 0.31; 95 percent CI, 0.23 to 0.39).
Brosseau and colleagues reviewed the literature to determine whether the intensity of exercise had an effect on pain reduction. The authors identified only three studies in which adults with osteoarthritis who were assigned to different intensities of exercise were followed. One study did not report statistical data, and one had a dropout rate of more than 20 percent, leaving only a single, randomized, moderate-quality study2 for review.
Adults with osteoarthritis of the knee were assigned to low-intensity (40 percent of heart rate reserve) or high-intensity (70 percent of heart rate reserve) stationary cycling. They had three one-hour sessions per week for 10 weeks. At the end of the study period, improvement in pain and functional capacity was similar between the groups.
Brosseau L, et al. Intensity of exercise for the treatment of osteoarthritis. Cochrane Database Syst Rev. 2003; 3: CD004259.
1. Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee. Cochrane Database Syst Rev. 2003;3:CD004286.
2. Mangione KK, McCully K, Gloviak A, Lefebvre I, Hofmann M, Craik R. The effects of high-intensity and low-intensity cycle ergometry in older adults with knee osteoarthritis. J Gerontol A Biol Sci Med Sci. 1999;54:M184–90.
Intensive Management of Gestational Diabetes
Does intensive management of gestational diabetes improve outcomes?
There is not enough evidence to support dietary or drug treatment in patients with gestational diabetes.
Gestational diabetes and impaired glucose tolerance are associated with macrosomia and may be associated with increased risk for cesarean delivery, shoulder dystocia, and birth trauma. Although preexisting diabetes has been shown to increase the risk of poor perinatal outcomes, it is not clear that data relating to preexisting diabetes can be extrapolated to patients with gestational diabetes.
Tuffnell and colleagues searched the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Central Register of Controlled Trials, and bibliographies of relevant articles. They identified three studies of 223 women with impaired glucose tolerance; none of these studies was a randomized controlled trial comparing management strategies. Treatment of women with impaired glucose tolerance did not offer a statistically significant benefit over nontreatment in terms of abdominal operative delivery rates, neonatal intensive care admissions, or reduction in birth weight. Treatment may be associated with a reduced incidence of neonatal hypoglycemia. The trials had wide confidence intervals and methodologic shortcomings. The small number of patients studied meant that a small but clinically meaningful benefit may have been missed.
In the face of limited and inconsistent research, the American College of Obstetricians and Gynecologists (ACOG) continues to recommend universal screening for gestational diabetes.1 It recommends that insulin therapy be considered in patients for whom nutritional therapy does not result in a fasting glucose level of less than 95 mg per dL (5.3 mmol per L), a one–hour post-prandial glucose level of less than 130 to 140 mg per dL (7.2 to 7.8 mmol per L), or a two-hour postprandial glucose level of less than 120 mg per dL (6.7 mmol per L). ACOG also recommends that physicians consider elective cesarean delivery for women with gestational diabetes and an estimated fetal weight greater than 4,500 g (9 lb, 15 oz). ACOG does not make a recommendation for or against calorie restriction in obese women with gestational diabetes.
Intensive management of gestational diabetes is time-consuming and resource-intensive. Overall, evidence is insufficient to support therapy for gestational diabetes. However, universal screening is the standard of care in most communities. When faced with abnormal results, most family physicians will opt to follow the consensus opinion of our specialist colleagues.
Tuffnell DJ, et al. Treatments for gestational diabetes and impaired glucose tolerance in pregnancy. Cochrane Database Syst Rev. 2003; 3: CD003395.
1. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001 (replaces Technical Bulletin Number 200, December 1994). Gestational diabetes. Obstet Gynecol. 2001;98:525–38.
Copyright © 2004 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact firstname.lastname@example.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions