Authors:

Nuri Cetin, MD Aydan Aytar, PT, MSc Ayce Atalay, MD Mahmut Naz Akman, MD

Knee Osteoarthritis

Afliations:
From the Department of Physical Medicine and Rehabilitation, Baskent University Faculty of Medicine, Ankara, Turkey (NC, A Atalay, MNA); and Department of Physical Therapy and Rehabilitation, Baskent University Faculty of Health Sciences, Ankara, Turkey (A Aytar).

ORIGINAL RESEARCH ARTICLE

Correspondence:
All correspondence and requests for reprints should be addressed to Nuri Cetin, MD, Bahcelievler 5. sok no: 48, 06490, Cankaya, Ankara, Turkey. 0894-9115/08/8706-0443/0 American Journal of Physical Medicine & Rehabilitation Copyright 2008 by Lippincott Williams & Wilkins
DOI: 10.1097/PHM.0b013e318174e467

Comparing Hot Pack, Short-Wave Diathermy, Ultrasound, and TENS on Isokinetic Strength, Pain, and Functional Status of Women with Osteoarthritic Knees
A Single-Blind, Randomized, Controlled Trial
ABSTRACT
Cetin N, Aytar A, Atalay A, Akman MN: Comparing hot pack, short-wave diathermy, ultrasound, and TENS on isokinetic strength, pain, and functional status of women with osteoarthritic knees: a single-blind, randomized, controlled trial. Am J Phys Med Rehabil 2008;87:443 451.

Objective: To investigate the therapeutic effects of physical agents administered before isokinetic exercise in women with knee osteoarthritis. Design: One hundred patients with bilateral knee osteoarthritis were randomized into five groups of 20 patients each: group 1 received shortwave diathermy hot packs and isokinetic exercise; group 2 received transcutaneous electrical nerve stimulation hot packs and isokinetic exercise; group 3 received ultrasound hot packs and isokinetic exercise; group 4 received hot packs and isokinetic exercise; and group 5 served as controls and received only isokinetic exercise. Results: Pain and disability index scores were significantly reduced in each group. Patients in the study groups had significantly greater reductions in their visual analog scale scores and scores on the Lequesne index than did patients in the control group (group 5). They also showed greater increases than did controls in muscular strength at all angular velocities. In most parameters, improvements were greatest in groups 1 and 2 compared with groups 3 and 4. Conclusions: Using physical agents before isokinetic exercises in women with knee osteoarthritis leads to augmented exercise performance, reduced pain, and improved function. Hot pack with a transcutaneous electrical nerve stimulator or short-wave diathermy has the best outcome.
Key Words: Disability Knee Osteoarthritis, Physical Therapy Modalities, Isokinetic Strength,

June 2008

RCT on Physical Therapy Modalities

443

nee osteoarthritis (OA) is the most common form of symptomatic OA. Radiographic evidence of knee OA in men and women older than 65 yrs is reported to be 80%, and approximately one third of these people are symptomatic.1,2 The risk of disability from knee OA alone is comparable with that of cardiac disease and is greater than those for other medical disorders in the elderly.1,3 A recent report by the World Health Organization on the global burden of disease indicates that knee OA is likely to become the fourth-most-important global cause of disability in women and the eighth-mostimportant cause in men.4 The American College of Rheumatology and the European League Against Rheumatism have published clinical guidelines as systematically developed statements to inform practitioners and patients about appropriate health care for specic clinical conditions. The guidelines for managing knee OA recommend a combination of nonpharmacological (i.e., education, exercise, lifestyle changes, and physical therapy) and pharmacologic (i.e., paracetamol, nonsteroidal antiinammatory drugs, and topical agents) treatments. Given these guidelines, conservative management plans for patients with knee OA must be individualized and adjusted according to the responses of the patients.57 Many researchers have demonstrated the benecial effects of exercise programs (e.g., isometric, isokinetic, progressive resistive, aerobic, hydrotherapeutic) in improving muscle strength, decreasing pain, and helping patients with knee OA better perform their activities of daily living.8 12 These recommended exercise therapies are based largely on expert opinion and the results of large, randomized, controlled trials.1319 Several recent longitudinal studies have concluded that carefully controlled exercise programs designed primarily to address knee OA are benecial. The American College of Rheumatology and European League Against Rheumatism have approved regular exercise as a therapeutic approach for knee OA. Exercises that strengthen the quadriceps lead to decreased knee pain and improved function. Although aerobic, proprioceptive, and hydrotherapeutic exercises are used to treat patients with knee OA, strengthening exercises (i.e., isometric, isokinetic, and progressiveresistive) are particularly recommended.57 Ytterberg et al.20 have addressed the importance of appropriate dosing of the exercise to improve joint motion, muscular strength, and cardiovascular tness for patients with OA of the knee. Exercise therapy is important in OA management, but the mode of exercise that would induce maximal functional outcome is not clear. Isotonic exercise is suggested for initial strengthening in patients with knee OA. Isokinetic exercise is suggested for improv-

ing joint stability, walking endurance, and disability in these patients.10,14 Isokinetic exercise seems to strengthen type II fast-twitch bers more than other type of muscle bers in human knee extensor muscles.21 There is growing evidence that increasing isokinetic muscle strength is one of the most common methods whenever muscle strength is thought to be a major factor in sports success and rehabilitation. Many publications during recent years have concerned peak torque (PT) and exor/extensor ratio for the evaluation of knee disorders.2225 The primary goals for OA therapy are to relieve pain, maintain or improve functional status, and minimize deformity and instability. Physical agents like short-wave diathermy (SWD), transcutaneous electrical nerve stimulation (TENS), ultrasound (US), and hot packs (HP) are noninvasive modalities that are commonly used to control both acute and chronic pain arising from several conditions. There is a paucity of information regarding the efcacy of these agents in treating knee OA. Despite the use of different combinations of these modalities in treating knee OA, there is no consensus regarding which of these agents is more effective than the other. A number of trials evaluating the efcacy of these agents in OA have been published. The heterogeneity of the included studies was observed, which might have been attributable to the different study designs and outcomes used. Better-designed studies with a standard protocol and adequate numbers of participants are needed to make conclusions regarding the effectiveness of these physical agents in the treatment of knee OA.57,26 28 Physical treatment modalities are widely prescribed together with exercises; however, there is no agreement about which modality might be better than the other when combined with exercises.5,6 Prescription of different modalities leads to an increase in treatment costs. The optimum combination of treatment modalities has yet to be claried. As a result, questions regarding the effectiveness of a particular modality over others must be addressed. Most previous studies have used exercise or physical agent therapy for knee OA alone. We combined these therapies specically for use in patients with knee OA. To our knowledge, only two previous reports have considered these relationships.29,30 Our aim was to analyze the therapeutic effects of SWD, TENS, US, and HP when applied before isokinetic exercises in women with knee OA.

MATERIALS AND METHODS

One hundred women from the local community (mean age, 59.82 9.05 yrs) with clinical and radiologic diagnoses of knee OA were included. Informed consent was obtained from all patients, and the study protocol was approved by the Am. J. Phys. Med. Rehabil.

444

Cetin et al.

Vol. 87, No. 6

Bas kent University ethics committee for clinical studies (No. KA05/216). American College of Rheumatology classication criteria for OA were used.31 Patients were consecutive outpatients at the department of physical medicine and rehabilitation at Bas kent University in Ankara, Turkey. Patients had no previous history of knee surgery, lower-extremity arthroplasty, or intraarticular injection of hyaluronic acid or steroids in the last 6 mos. Selection criteria were clinical presentation of bilateral knee OA, ability to walk at least 100 m on an even surface, and full or near-full passive range of motion at each knee. All participants were initially examined by the same physician with regard to the selection criteria, and, if found to be appropriate, the participants were included in the study. Demographic data including age, weight, height, and body mass index were obtained. Body mass index was calculated as kilograms per square meter. Body weight was measured with patients dressed in light indoor clothing without shoes, using a SECA electronic stadiometer (Seca Ltd, Medical Scales and Measurement Systems, Birmingham, UK). Anteroposterior and lateral knee joint radiographs were obtained in weight-bearing position. The radiographs were graded by the same physiatrist according to the Kellgren and Lawrence scale, where grade 0 normal and grade 4 severe.32 One hundred patients were randomly assigned to ve groups of 20 patients each. Patients were evaluated at baseline and at the end of the treatment sessions by the physician, who was blinded with regard to the type of treatment the patients would receive. All patients received treatment three times weekly for 8 wks. Patients in group 1 received SWD HP isokinetic exercises; group 2 received TENS HP isokinetic exercises; group 3 received US HP isokinetic exercises; group 4 received HP isokinetic exercises; and group 5 served as the control group and received only isokinetic exercises. After application of physical agents, each patient underwent individual warm-up exercises on a stationary bike set for 20 cycles/min for 5 mins before undergoing muscle-strengthening exercises. The therapeutic effects of these programs were evaluated with regard to pain, disability, ambulation, and muscle strength. Patient compliance also was assessed. Participants were instructed to continue taking any current medications and not to start any new therapies for knee OA during the 8-wk study.

Measurement of Ambulation Activity

Ambulation was evaluated by recording the time (secs) to walk a predetermined distance (50 m) as comfortably and as quickly as possible. Walking time was recorded with a stopwatch by the same physiatrist.

Measurement of Pain
Knee pain severity was evaluated with a visual analog scale (VAS) after a 50-m walk.

Isokinetic Test Protocols

A computerized isokinetic dynamometer (Cybex 770 Norm, Lumex Inc., Ronkonkoma, NY) was used for the testing and training procedures. The same examiner performed isokinetic dynamometric measurements using the same test protocol in all participants. We created a new test protocol and added it to the isokinetic concentric exercise mode menu of the device to standardize the measurements. Subjects were seated on the isokinetic dynamometric bench at 80 degrees of hip exion and 90 degrees of knee exion, with the ankle unrestricted. The trunk and legs were stabilized using straps across the chest, waist, and upper thighs. The range of movement of the knee was measured by the dynamometer from the points of maximum possible exion to maximum possible extension. Five consecutive concentric motions were performed at three preselected velocities (60, 120, and 180 degrees/sec) within the maximum joint range, with a 30-sec rest period between velocities.8,10 The highest torque generated in each movement was recorded from strip chart recording. The effect of gravity was corrected. The maximum PT values in newton-meters for each subject were calculated for each set of repetitions.

Compliance
Although patients were instructed to ll in an exercise diary program, we could not obtain satisfactory data for statistical analysis. Hence, compliance was calculated as the number of patients who had completed the treatment sessions divided by the number of initial patients.34 But the strongest and most consistent predictor of compliance in this study was the behavior of patients.

Treatment Protocols
A TENS MED911 unit (Enraf-NoniusB Delftechpark 39, 2600 AV, Delft, The Netherlands) was used to administer TENS therapy. Sessions lasted 20 mins. The frequency of the TENS unit was set to 60 100 Hz, and the pulse duration was set to 60 msecs. Patients remained in the supine position with both knees at full extension while electrodes were placed around the painful areas. The intensity of the current RCT on Physical Therapy Modalities

Measurement of Disability
Disability of patients with knee OA was evaluated using the index of severity for knee osteoarthritis (ISK),33 which includes questions about knee discomfort, endurance of ambulation, and difculties in activities of daily living. June 2008

445

was increased to the point of seeing no contraction while the patient felt comfortable. A Sonopuls 590 US machine (Enraf-NoniusB Delftechpark 39) was used for continuous US therapy. A 1-MHz US head was used, set to an intensity of 1.5 W/cm2. US was applied around the knee joint with full contact for 10 mins. The patient remained in the supine position with both knees fully extended while US was applied. SWD was applied using a Curapulas 419 (Enraf-NoniusB Delftechpark 39) at a frequency of 27.12 MHz. The condenser eld technique was used for 15 mins as each patient sat on a chair and placed her legs on a table with both knees fully extended during treatment. After applying the physical agents and warming up, the isokinetic muscle-strengthening exercise protocol was performed individually under the supervision of the same physical therapist. The subjects underwent isokinetic strength training of the knee exor and extensor muscle groups, and each subject was encouraged to move her knee joint with maximum effort at each velocity. The isokinetic exercises program was applied three times a week for 8 wks, for a total of 24 sessions. The intensity of isokinetic exercises increased from one to ve sets during the rst through fth sessions and remained at ve sets through the remaining 19 sessions. Each set consisted of ve repetitions of concentric contractions of the knee extensors and exors at angular velocities of 60, 120, and 180 degrees/sec. Patients were allowed to rest for 20 secs between sets and for 60 secs between the right and left knee.

quent post hoc pairwise comparisons. To compare pretreatment and posttreatment values, the Wilcoxon test was used. Also, the 2 test was used to test for differences of Kellgren and Lawrence grades and compliance by treatment groups. Statistical signicance was set at P 0.05.

RESULTS
Table 1 provides the demographic data of the patients. Of the 100 patients enrolled, 15 withdrew. Compliance was lowest in the fth group, although there were no signicant differences between the groups (P 0.694; Table 1). Increased knee pain was the major reason for discontinuing treatment. Fifteen people refused to continue the exercise program because of exercise-induced pain. At baseline, age, body mass index, Kellgren and Lawrence grade, ambulation time, PT values, ISK, and VAS scores in each group were similar (Table 1 6). Changes in mean VAS scores for knee pain in each group are shown in Table 2. VAS scores decreased signicantly in all groups after treatment. Patients in groups 1 through 4 showed the greatest degree of pain reduction, and these scores were signicantly different from those of patients in the control group (P 0.019). A pairwise comparison demonstrated that changes in VAS scores were similar among groups 1 through 4 (P 0.05). Walking time signicantly decreased in all groups, but there were no statistically signicant differences between the groups (P 0.589). Changes in mean Lequesne index scores are shown in Table 2. Average ISK scores decreased signicantly in all groups after treatment. There was a signicant difference in Lequesne index scores among groups (P 0.018). A pairwise comparison demonstrated that groups 1 and 2 were signicantly different from the control group (P 0.022 and 0.001, respectively); however, there was no statistical difference between groups 3 and 4 when compared with the control group (P 0.102 and 0.073, respectively). Regarding isokinetic performance (Table 3 6), changes in mean PT values of knee extension and exion at all angular velocities in groups 1 through

Statistical Analyses
Statistical analyses were performed with SPSS software (Statistical Package for the Social Sciences, version 11.0, SSPS Inc, Chicago, Ill). Because most of the data were not normally distributed, we used nonparametric tests in all statistical analyses. The KruskalWallis test was used to test for differences in outcome measures at baseline by treatment groups, and the MannWhitney U test with a Bonferroni correction was used for subseTABLE 1 Demographic data of the study groups
Group 1 Age, yrs Body mass index, kg/m Compliance (%) Severity on radiograph Grade 1 Grade 2 Grade 3 Grade 4 59.75 11.63 27.94 4.24 90 1 9 8 2 Group 2 61.85 8.64 29.49 4.60 85 1 9 8 2

Group 3 57.60 7.33 29.80 5.71 90 1 7 9 3

Group 4 61.05 8.26 27.71 4.17 85 2 9 7 2

Group 5 58.85 9.08 27.40 4.24 75 0 11 7 2

P 0.549 0.221 0.694 0.976

446

Cetin et al.

Am. J. Phys. Med. Rehabil.

Vol. 87, No. 6

TABLE 2 VAS, WT, and LI scores at baseline and at the end of the study period, and the group differences
Group 1 Baseline VAS Final VAS VAS P Baseline WT Final WT WT P Baseline LI Final LI LI P 5.69 1.55 3.36 1.33 2.33 0.77 0.0001 51.35 6.49 39.90 6.47 11.45 5.78 0.0001 10.95 2.73 6.81 2.69 4.14 1.24 0.0001 Group 2 5.85 1.34 3.52 1.18 2.32 0.60 0.0001 52.95 10.77 42.40 8.40 10.55 4.70 0.0001 11.70 1.93 7.22 2.06 4.47 1.11 0.0001 Group 3 5.90 1.45 3.55 1.41 2.34 0.94 0.0001 53.10 9.84 42.60 11.50 10.50 3.85 0.0001 11.40 2.45 7.67 2.30 3.72 1.08 0.0001 Group 4 5.76 1.48 3.49 1.28 2.27 0.88 0.0001 49.65 6.93 40.60 6.04 9.05 4.48 0.0001 10.77 3.12 6.87 2.58 3.90 1.15 0.0001 Group 5 5.93 1.15 4.10 1.32 1.83 1.32 0.0001 49.70 10.17 39.95 8.89 9.75 3.86 0.0001 10.80 1.56 7.72 2.06 3.07 1.38 0.0001 P 0.888 0.325 0.019* 0.727 0.812 0.589 0.582 0.562 0.018*

VAS, visual analog scale; WT, walking time; LI, Lequesne index. Values are expressed as means standard deviations. Signicant differences in VAS, WT, and LI in each group after treatment (P 0.05). P values are computed using the Wilcoxon test. * Signicant differences in VAS and LI in each group when compared with group 5 (P 0.05). P values are computed using the KruskalWallis test.

4 increased signicantly. Also in the control group, signicant increases in PT values were observed after treatment during right and left knee extension measurements (Tables 3 and 5). Pairwise comparisons reveled that groups 1, 2, and 3 demonstrated signicantly higher PT values compared with the control group at all angular velocities during all four measurements (P 0.05). However, when we compared group 4 with the control group, no signicant difference was found with regard to peak PT values during right knee extension at 180 degrees/sec (P 0.114) and left knee extension at all angular velocities (P 0.142

at 60 degrees/sec, P 0.102 at 120 degrees/sec, and P 0.076 at 180 degrees/sec). Comparisons among groups 1 through 4 revealed that all groups were similar at all angular velocities during right and left knee exion measurements. However, during right knee extension measurements, statistically signicant differences were found between groups 1 and 4 (P 0.037 at 60 degrees/sec, P 0.008 at 180 degrees/sec), 2 and 3 (P 0.01 at 120 degrees/sec), and 2 and 4 (P 0.01 at 180 degrees/sec). Also, during left knee measurements, statistically signicant differences were found between groups 1 and 4 (P 0.005 at

TABLE 3 Mean peak torque levels (Nm) for right knee extension in each group before and after treatment
Angular Velocity 60 degrees Time Group 1 34.80 9.43 54.65 12.35 19.85 9.63 0.0001 27.30 8.30 47.25 11.94 19.94 10.68 0.0001 23.55 8.54 41.45 9.60 17.90 9.52 0.0001 Group 2 37.15 14.84 57.80 17.21 20.65 12.00 0.0001 29.25 10.40 49.85 15.72 20.60 11.21 0.0001 24.70 9.94 41.50 14.19 16.80 8.53 0.0001 Group 3 36.00 8.32 52.35 10.89 16.35 7.86 0.0001 27.65 7.08 41.25 12.99 13.60 10.80 0.0001 23.05 7.88 36.95 11.00 13.90 7.47 0.0001 Group 4 33.80 9.20 47.60 13.80 13.80 8.88 0.0001 27.05 7.65 41.95 12.72 14.90 11.42 0.0001 23.55 9.11 31.85 12.83 8.30 11.29 0.004 Group 5 P

Baseline Final P 120 degrees Baseline Final P 180 degrees Baseline Final P

38.25 9.08 47.60 13.80 3.80 5.55 0.0001* 0.009 27.85 8.20 33.60 8.92 5.75 5.63 0.0001* 0.001 24.30 9.35 29.25 8.58 4.95 5.01 0.0001* 0.001

Signicant differences in mean peak torque values for right knee exion in each group after treatment (P 0.05). P values are computed using the Wilcoxon test. * Signicant differences of change in mean peak torque values for right knee exion between groups (P 0.05). P values are computed using the KruskalWallis test.

June 2008

RCT on Physical Therapy Modalities

447

TABLE 4 Mean peak torque values for right knee flexion in each group before and after treatment (Nm)
Angular Velocity 60 degrees Time Baseline Final P Baseline Final P Baseline Final P Group 1 16.80 3.69 27.30 7.80 10.50 8.56 0.0001 13.70 4.41 23.60 7.42 9.90 6.72 0.0001 11.30 5.03 19.50 8.12 8.20 7.97 0.0001 Group 2 17.35 6.32 25.50 6.43 8.15 6.08 0.0001 13.95 3.85 23.75 4.39 9.80 4.46 0.0001 12.05 5.44 18.45 5.77 6.40 6.73 0.001 Group 3 17.15 7.02 25.75 8.03 8.60 4.90 0.0001 13.50 6.17 21.35 7.09 7.85 4.42 0.0001 11.95 6.03 18.35 5.41 6.40 5.37 0.0001 Group 4 17.00 7.92 27.95 9.28 10.95 6.78 0.0001 14.00 6.75 23.60 9.51 9.60 6.89 0.0001 12.05 4.25 19.75 9.28 7.70 7.42 0.001 Group 5 16.55 4.88 18.80 6.31 2.25 6.85 0.178 12.70 4.74 14.85 6.37 2.15 6.39 0.107 11.40 4.50 13.60 7.07 2.20 5.89 0.097 P

0.001*

120 degrees

0.0001*

180 degrees

0.022*

Signicant differences in mean peak torque values for right knee exion in groups 14 after treatment (P 0.05). P values are computed using the Wilcoxon test. * Signicant differences of change in mean peak torque values for right knee exion between groups (P 0.05). P values are computed using the KruskalWallis test.

60 degrees/sec, P 0.01 at 120 degrees/sec), 2 and 4 (P 0.038 at 60 degrees/sec), and 3 and 4 (P 0.015 at 60 degrees/sec).

DISCUSSION
We conducted a randomized, single-blind, controlled trial to clarify which physical agent(s) used in varying combinations with exercises would increase exercise performance in communitydwelling volunteers with symptomatic knee OA. Signicant improvements were found in patients in all groups with regard to pain, walking time, functioning, and isokinetic performance. Patients in the treatment groups (groups 1 4) demon-

strated signicant improvements compared with patients in the control group (group 5). These improvements were statistically signicant. In our study, pain reduction was similar in all physical agent treatment groups. VAS score decreases in all treatment groups were signicantly greater than those of the control group. Osiri et al.27 performed a recent meta-analysis of literature concerning the use of TENS for knee pain in individuals with knee OA. They conclude that TENS was more effective than placebo when it was used for a duration of 4 wks or more. Cheing et al.35 evaluated the effect of repeated TENS alone and TENS combined with isometric

TABLE 5 Mean peak torque values for left knee extension in each group before and after treatment (Nm)
Angular Velocity 60 degrees Time Group 1 32.50 7.81 53.65 12.95 21.15 11.83 0.0001 26.55 9.49 47.25 12.52 20.70 11.84 0.0001 24.10 9.87 42.25 12.18 18.15 13.27 0.0001 Group 2 35.30 12.11 54.05 14.36 18.75 11.36 0.0001 28.35 9.54 44.85 11.40 16.50 11.50 0.0001 24.85 10.54 38.70 14.25 13.85 11.05 0.0001 Group 3 31.10 11.50 50.60 12.98 19.50 10.63 0.0001 25.60 9.88 42.65 12.04 17.05 9.91 0.0001 22.80 9.30 35.70 11.81 12.90 9.92 0.0001 Group 4 33.25 11.09 44.20 13.97 10.95 10.78 0.0001 26.05 8.12 36.50 12.20 10.45 9.33 0.001 22.75 9.02 32.95 13.04 10.20 10.88 0.002 Group 5 P

Baseline Final P 120 degrees Baseline Final P 180 degrees Baseline Final P

35.65 10.82 44.90 12.65 5.25 5.19 0.0001* 0.001 27.15 11.45 32.65 12.36 5.50 5.79 0.0001* 0.003 23.95 10.21 28.35 9.28 4.40 5.44 0.002* 0.005

Signicant differences in mean peak torque values for left knee extension in each group after treatment (P 0.05). P values are computed using the Wilcoxon test. * Signicant differences of change in mean peak torque values for left knee extension between groups (P 0.05).

448

Cetin et al.

Am. J. Phys. Med. Rehabil.

Vol. 87, No. 6

TABLE 6 Mean peak torque values for left knee flexion in each group before and after treatment (Nm)
Angular Velocity 60 degrees Time Baseline Final P Baseline Final P Baseline Final P Group 1 16.95 8.87 25.90 7.54 8.95 9.07 0.0001 13.30 6.95 22.45 7.25 9.15 5.67 0.0001 11.05 6.70 19.10 9.04 8.05 7.19 0.0001 Group 2 17.20 5.78 25.00 7.91 7.80 5.77 0.0001 13.25 4.14 22.60 7.37 9.35 6.45 0.0001 11.35 3.93 17.80 6.36 6.45 7.19 0.001 Group 3 15.40 5.82 24.70 7.83 9.33 5.54 0.0001 12.20 6.17 20.10 7.46 7.90 5.06 0.0001 10.75 6.05 18.35 6.63 7.60 4.96 0.0001 Group 4 17.20 9.03 24.00 9.09 6.80 5.92 0.0001 12.20 6.17 20.40 7.46 8.25 5.77 0.0001 9.30 6.06 17.55 7.40 8.25 5.54 0.0001 Group 5 16.00 5.14 18.05 6.38 2.05 5.50 0.049 14.25 4.65 13.90 4.88 0.35 5.50 0.628 10.45 5.21 10.90 4.76 0.45 4.51 0.660 P

0.0001*

120 degrees

0.0001*

180 degrees

0.002*

Signicant differences in mean peak torque values for left knee exion in each group after treatment (P 0.05). P values are computed using the Wilcoxon test. * Signicant differences of change in mean peak torque values for left knee exion between groups (P 0.05). P values are computed using the KruskalWallis test.

exercise on OA knee pain during a 4-wk prospective controlled trial. They report that there was no signicant difference between the groups. Welch et al.36 conducted a systematic review on the effectiveness of therapeutic US therapy for treating knee OA. They conclude that US therapy seemed to have no benet over placebo or SWD for patients with knee OA. We also found US to be less effective than SWD and TENS in knee OA. The mechanism of action of physical modalities on alleviation of joint pain is not clear yet. A group of agents called supercial and deep heaters are said to act by elevating the temperature of tissues that induce increases in blood ow. Increased blood ow leads to better tissue perfusion, increased metabolic activity, and muscle relaxation. Another possible mechanism of action is the inhibition of nociceptive transmission by activation of A-alpha and A-beta bers, known as gait control theory.37 Low-frequency electrical currents (i.e., TENS) are also thought to induce endogenous opioid secretion and modulate ascending pain-control pathways.38 Walking time signicantly decreased in all groups after the treatment, but there were no statistically signicant differences between groups. Exercise, both alone and combined with physical agents, improved the patients walking ability. We evaluated the functional status of patients using ISK scores. After treatment protocols in all groups, average ISK scores decreased signicantly. Pairwise comparison tests among groups 1, 2, and the control groups yielded signicant differences. In a similar study, Huang and coworkers10 compared the therapeutic effects of different muscle strengthening (i.e., isotonic, isometric, isokinetic) June 2008

exercise on the functional status of patients with knee OA. Their results show that patients in each treatment group had signicant improvements in pain reduction, function, and walking speed after treatment. When the authors compared the treatment groups, they found that patients in the isotonic exercise group had the greatest reduction in pain, but patients in the isokinetic exercise group showed the greatest increases in walking speed and function and in muscle strength gain at 60 and 180 degrees/sec at angular velocities. Huang et al.10 state that isokinetic strengthening exercise had the greatest therapeutic effects on the functional status of patients with knee OA; it also had the lowest level of compliance with treatment when compared with isotonic or isometric exercise, because of exercise-induced knee pain. When we checked isokinetic performance, we noted a more signicant increase in groups 1, 2, and 3 than in groups 4 and 5. Comparison of group 4 with group 5 revealed no signicant difference regarding the PT values during right knee extension at 180 degrees/sec and left knee extension at all angular velocities. Our results were similar with those of several randomized controlled trials in which it has been reported that signicant progress is achieved in muscle strength after isokinetic training.10,24,29,39 The reliability of the isokinetic measurements was not evaluated in our study. However, quadriceps and hamstring muscle strength measurements on isokinetic devices have been demonstrated to be reliable in recent studies.25,40 We used isokinetic exercise testing and training protocols because they have the advantage of providing objective data and of enhancing motivation with visual and auditory stimuli. Also, RCT on Physical Therapy Modalities

449

the isokinetic programs were carried out in hospital conditions and under supervision. In our study, improvements were more marked after treatment in the four treatment groups, reecting the additional benets of physical agents. A possible explanation for our results involves the specic treatment effects of the physical agents we used acting as local heaters and pain relievers. On the other hand, one could argue that a placebo effect might have been responsible for this condition. Unfortunately, we did not include sham physical therapy groups in this study because it would be technically challenging, and because there would have been too many test groups to compare. In addition, most patients can easily differentiate sham from actual therapy. Our ndings suggest that the physical therapeutic agents investigated offer benets for isokinetic performance as well as physical function. Before our study, one randomized controlled trial had used US to increase the effectiveness of isokinetic exercises for knee OA. Huang and associates29 used a physiotherapy protocol similar to ours; the only differences in their study are that it was conducted with four groups and that they used only US for additional physical therapy. Those authors found that all groups had increased muscle PT and reduced pain and disability scores, but using US to treat knee OA before exercise increased the effectiveness of isokinetic exercise. Similarly, we found additional effects of all physical agents and their combinations used. On the other hand, with regard to most parameters, TENS and SWD combined with HP seemed superior to US with HP or to HP alone. Jan and Lai30 investigated the effect of US and SWD with and without therapeutic exercise on knee OA in 61 women. All patients were assessed by functional scoring and isokinetic testing before and after treatment protocols. All patients had signicant improvements in functional and muscle PT values. The researchers found no signicant differences with regard to treatment effects between US and SWD for knee OA. When the exercise program was combined with SWD, increased treatment effects were seen with regard to function and muscle PT. Patient compliance is another issue, and studies with high patient compliance have shown better results. Patient compliance depends on many factors, including consistent education, encouragement, follow-up, injury, and complications (e.g., knee pain) as a consequence of inappropriate exercise. Therefore, we aimed to eliminate these factors as much as possible. In our study, 15 of 100 patients terminated their participation in the study. Exercise-induced knee pain was the most common reason. The strongest and most consistent predictor of compliance in this study was the behavior of

patients. We believe that using physical agents before isokinetic exercises may increase compliance. We conclude that exercise and physical agents can reduce pain and improve function and health statuses in patients with knee OA. Combined exercise therapy with physical agents increases the effectiveness of exercise. In patients with knee OA, physical treatment applied before isokinetic exercise tends to increase performance and compliance. We found statistically signicant differences with regard to the treatment modalities (i.e., TENS, SWD, US, and HP) for some, but not all, of the parameters (PT values, ISK scores) we tested. TENS and SWD seemed superior to US. Use of physical agents before isokinetic exercises in patients with symptomatic knee OA leads to augmented exercise performance and improved function. Future research also should focus on economic analyses so that clinicians can use the most cost-effective forms of physiotherapy for knee OA treatment.
REFERENCES
1. Cooper C: Epidemiology of osteoarthritis, in Klippel JH, Dieppe PA (eds): Rheumatology, ed 2. London, Mosby, 1998, pp 120 2. Felson DT, Naimark A, Anderson J, Kazis L, Castelli W, Meenan RF: The prevalence of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum 1987;30:9148 3. Guccione AA, Felson DT, Anderson JJ, et al: The effects of specic medical conditions on the functional limitations of elders in the Framingham Study. Am J Public Health 1994; 84:3518 4. Murra CJL, Lopez AD: The Global Burden of Disease, vol 1. Cambridge, Harvard University Press, 1996 5. Jordan KM, Arden NK, Doherty M, et al: Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003;62: 114555 6. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 2000;43:190515 7. Pendleton A, Arden N, Dougados M, et al: EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2000;59:93644 8. Maurer BT, Stern AG, Kinossian B, Cook KD, Schumacher HR Jr: Osteoarthritis of the knee: isokinetic quadriceps exercise versus an educational intervention. Arch Phys Med Rehabil 1999;80:12939 9. Penninx BW, Messier SP, Rejeski WJ, et al: Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis. Arch Intern Med 2001; 161:230916 10. Huang MH, Lin YS, Yang RC, Lee CL: A comparison of various therapeutic exercises on the functional status of patients with knee osteoarthritis. Semin Arthritis Rheum 2003;32:398406 11. van Baar ME, Dekker J, Oostendorp RA, et al: The effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized clinical trial. J Rheumatol 1998;25:24329

450

Cetin et al.

Am. J. Phys. Med. Rehabil.

Vol. 87, No. 6

12. Foley A, Halbert J, Hewitt T, Crotty M: Does hydrotherapy improve strength and physical function in patients with osteoarthritisa randomised controlled trial comparing a gym based and a hydrotherapy based strengthening programme. Ann Rheum Dis 2003;62:11627 13. Wyatt FB, Milam S, Manske RC, Deere R: The effects of aquatic and traditional exercise programs on persons with knee osteoarthritis. J Strength Cond Res 2001;15:33740 14. Bennell K, Hinman R: Exercise as a treatment for osteoarthritis. Curr Opin Rheumatol 2005;17:63440 15. Pelland L, Brosseau L, Wells G, et al: Efcacy of strengthening exercises for osteoarthritis (part I): a meta-analysis. Phys Ther Rev 2004;9:77108 16. Fransen M, McConnell S, Bell M: Exercise for osteoarthritis of the hip or knee. Cochrane Database Syst Rev 2003;(3): CD004286 17. Ettinger WH Jr, Burns R, Messier SP, et al: A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA 1997;277:2531 18. Roddy E, Zhang W, Doherty M, et al: Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or kneethe MOVE consensus. Rheumatology (Oxford) 2005;44:6773 19. Topp R, Woolley S, Hornyak J 3rd, Khuder S, Kahaleh B: The effect of dynamic versus isometric resistance training on pain and functioning among adults with osteoarthritis of the knee. Arch Phys Med Rehabil 2002;83:118795 20. Ytterberg SR, Mahowald ML, Krug HE: Exercise for arthritis. Baillieres Clin Rheumatol 1994;8:16189 21. Thorstensson A, Grimby G, Karlsson J: Force-velocity relations and ber composition in human knee extensor muscles. J Appl Physiol 1976;40:126 22. Grace TG, Sweetser ER, Nelson MA, Ydens LR, Skipper BJ: Isokinetic muscle imbalance and knee-joint injuries. A prospective blind study. J Bone Joint Surg Am 1984;66:73440 23. Greenberger H, Wilkowiski T, Belyea B: Comprasion of quadriceps peak torque using three different isokinetic dynamometers. Isokinet Exerc Sci 1994;4:705 24. Gur H, Cakin N: Muscle mass, isokinetic torque, and functional capacity in women with osteoarthritis of the knee. Arch Phys Med Rehabil 2003;84:153441 25. Giles B, Henke P, Edmonds J, McNeil D: Reproducibility of isokinetic muscle strength measurements in normal and arthritic individuals. Scand J Rehabil Med 1990;22:939 26. Fransen M, Crosbie J, Edmonds J: Physical therapy is effective for patients with osteoarthritis of the knee: a randomized controlled clinical trial. J Rheumatol 2001;28:15664

27. Osiri M, Welch V, Brosseau L, et al: Transcutaneous electrical nerve stimulation for knee osteoarthritis. Cochrane Database Syst Rev 2000;(4):CD002823 28. Laufer Y, Zilberman R, Porat R, Nahir AM: Effect of pulsed short-wave diathermy on pain and function of subjects with osteoarthritis of the knee: a placebo-controlled doubleblind clinical trial. Clin Rehabil 2005;19:25563 29. Huang MH, Lin YS, Lee CL, Yang RC: Use of ultrasound to increase effectiveness of isokinetic exercise for knee osteoarthritis. Arch Phys Med Rehabil 2005;86:154551 30. Jan MH, Lai JS: The effects of physiotherapy on osteoarthritic knees of females. J Formos Med Assoc 1991;90: 100813 31. Altman R, Asch E, Bloch D, et al: Development of criteria for the classication and reporting of osteoarthritis. Classication of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum 1986;29:103949 32. Petersson IF, Boegard T, Saxne T, Silman AJ, Svensson B: Radiographic osteoarthritis of the knee classied by the Ahlback and Kellgren & Lawrence systems for the tibiofemoral joint in people aged 35-54 years with chronic knee pain. Ann Rheum Dis 1997;56:4936 33. Lequesne MG, Samson M: Indices of severity in osteoarthritis for weight bearing joints. J Rheumatol Suppl 1991;27: 168 34. Rejeski WJ, Lawrence RB, Etinger W, et al: Compliance to exercise therapy in older participants with knee osteoarthritis: implication for treating disability. Med Sci Sports Exerc 1997;29:97785 35. Cheing GL, Hui-Chan CW, Chan KM: Does four weeks of TENS and/or isometric exercise produce cumulative reduction of osteoarthritic knee pain? Clin Rehabil 2002;16: 74960 36. Welch V, Brosseau L, Peterson J, Shea B, Tugwell P, Wells G: Therapeutic ultrasound for osteoarthritis of the knee. Cochrane Database Syst Rev 2001;(3):CD003132 37. Melzack R, Stillwell DM, Fox EJ: Trigger points and acupuncture points for pain: correlations and implications. Pain 1977;3:323 38. Basford JR: Physical agents 483505, in Delisa JA, Gans BM (eds): Rehabilitation Medicine Principles and Practice, ed 3. Philadelphia, Lippincott-Raven, 1998 39. Maurer BT, Stern Ag, Kinossian B, Cook KD, Schumacher HR Jr: Osteoarthritis of the knee: isokinetic quadriceps exercise versus an educational intervention. Arch Phys Med Rehabil 1999;80:12939 40. Frontera WR, Hughes VA, Dallal GE, Evans WJ: Reliability of isokinetic muscle strength testing in 45- to 78-year-old men and women. Arch Phys Med Rehabil 1993;74:11815

June 2008

RCT on Physical Therapy Modalities

451