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However, there was evidence that ultrasound was effective in patients with knee

Huang et al.and Yang et al conducted moderate-strength studies that compared
ultrasound to a control group. Huang et al. found that patients who received isotonic
exercise with ultrasound
had significantly superior ambulation speed, Lequesne Index scores, and VAS pain
scores. Yang
et al. found VAS pain and Lequesne Index scores were significantly superior at 4 weeks
in patients who received ultrasound over those who received a sham treatment.
Due to the overall inconsistent findings for various physical agents and
modalities, we were unable to make a recommendation for or against their use in
patients with
symptomatic osteoarthritis of the knee.
The National Institute for Clinical Excellence (NICE) Inggris mempublikasikan
Osteoarthritis: care and management
Clinical guideline [CG177]
Published date:February 2014
The National Institute for Clinical Excellence (NICE) has not recommended the used of
Pulsed shortwave therapy (PSWT) for OA but the use of TENS as an adjunct only.
There is limited evidence looking at the effect of PSWT on knee conditions specifically,
therefore a search was conducted on the effectiveness of PSWT on oedema and
effusions, a study was identified that looked that the use of cryotherapy versus PSWT on
swelling post calcaneal fractures. There were no differences found in either group and
swelling had significantly improve by day 5 anyway. Cryotherapy was recommended
from this study as this was a cheaper alternative which could be transported anywhere.
The majority of the literature surrounding the used of PSWT in the knee looks at Knee
OA, and due to the lack of evidence found it and guidance from NICE the use of PSWT
cannot be recommended from the literature.
Osteoarthritis Research Society International (OARSI) guideline jntuk OA lutut yang
dipublikasikan Elsevier Ltd.
OARSI guidelines for the non-surgical management of knee
Purpose: To develop concise, patient-focussed, up to date, evidence-based, expert
consensus recommendations for the management of hipand knee osteoarthritis (OA),
which are adaptable and designed to assist physicians and allied health care
professionals in general and
specialist practise throughout the world.
Methods: Sixteen experts from four medical disciplines (primary care, rheumatology,
orthopaedics and evidence-based medicine), two con-tinents and six countries (USA,
UK, France, Netherlands, Sweden and Canada) formed the guidelines development
team. A systematic
review of existing guidelines for the management of hip and knee OA published between
1945 and January 2006 was undertaken usingthe validated appraisal of guidelines
research and evaluation (AGREE) instrument. A core set of management modalities was
generatedbased on the agreement between guidelines. Evidence before 2002 was
based on a systematic review conducted by European League
Against Rheumatism and evidence after 2002 was updated using MEDLINE, EMBASE,
CINAHL, AMED, the Cochrane Library and
HTA reports. The quality of evidence was evaluated, and where possible, effect size
(ES), number needed to treat, relative risk or oddsratio and cost per quality-adjusted life
years gained were estimated. Consensus recommendations were produced following a
exercise and the strength of recommendation (SOR) for propositions relating to each
modality was determined using a visual analogue
Results: Twenty-three treatment guidelines for the management of hip and knee OA
were identified from the literature search, including sixopinion-based, five evidence-
based and 12 based on both expert opinion and research evidence. Twenty out of 51
treatment modalitiesaddressed by these guidelines were universally recommended. ES
for pain relief varied from treatment to treatment. Overall there was
no statistically significant difference between non-pharmacological therapies [0.25, 95%
confidence interval (CI) 0.16, 0.34] and pharmaco-
logical therapies (ES ¼ 0.39, 95% CI 0.31, 0.47). Following feedback from Osteoarthritis
Research International members on the draft
guidelines and six Delphi rounds consensus was reached on 25 carefully worded
recommendations. Optimal management of patients
with OA hip or knee requires a combination of non-pharmacological and
pharmacological modalities of therapy. Recommendations cover
the use of 12 non-pharmacological modalities: education and self-management, regular
telephone contact, referral to a physical therapist,aerobic, muscle strengthening and
water-based exercises, weight reduction, walking aids, knee braces, footwear and
insoles, thermalmodalities, transcutaneous electrical nerve stimulation and acupuncture.
Eight recommendations cover pharmacological modalities of
treatment including acetaminophen, cyclooxygenase-2 (COX-2) non-selective and
selective oral non-steroidal anti-inflammatory drugs(NSAIDs), topical NSAIDs and
capsaicin, intra-articular injections of corticosteroids and hyaluronates, glucosamine
and/or chondroitinsulphate for symptom relief; glucosamine sulphate, chondroitin
sulphate and diacerein for possible structure-modifying effects and theuse of opioid
analgesics for the treatment of refractory pain. There are recommendations covering five
surgical modalities: total joint
replacements, unicompartmental knee replacement, osteotomy and joint preserving
surgical procedures; joint lavage and arthroscopicdebridement in knee OA, and joint
fusion as a salvage procedure when joint replacement had failed. Strengths of
recommendation and95% CIs are provided.
Conclusion: Twenty-five carefully worded recommendations have been generated based
on a critical appraisal of existing guidelines, a
systematic review of research evidence and the consensus opinions of an international,
multidisciplinary group of experts. The recommendations may be adapted for use in
different countries or regions according to the availability of treatment modalities and
SOR for eachmodality of therapy. These recommendations will be revised regularly
following systematic review of new research evidence as thisbecomes available.
Evidence-Based Recommendations for the Management of Knee Osteoarthritis: A
Consensus Report of the Turkish League Against Rheumatism
Physical treatment modalities are widely used and preferred by patients with knee OA.
Superficial and deep heaters along with analgesic currents may be the only treatment
options, especially for elderly patients who are potentially intolerant to drugs. Physical
modalities are recommended by all guidelines for the management of knee OA.[2-5] The
number of RCTs regarding the effects of these agents is not sufficient. In a study
performed in our country, a combination of hot pack, transcutaneous electrical nerve
stimulation (TENS), therapeutic ultrasound, quadriceps strengthening exercises, and
diclofenac was compared with the use of diclofenac alone. After completion of a 10-day
session, painless walking distance and daily living activities showed greater
improvement in the group having a combination of physical agents (LOE Ib).[32] In
another study, the effects of a combination of ultrasound and TENS combined with
exercises was found to be superior to exercise therapy alone on the restoration of
balance (LOE Ib).[33] The 2008 OARSI reccomendations and many other guidelines
have recommended the use of TENS for knee OA. The efficiency of TENS by itself on
pain and joint function in knee OA was evaluated in an SR and was found to be
insignificant.[34] The heterogeneity and inadequate number of patients within the
evaluated trials were the weaknesses of this SR, and the necessity for well-designed
trials was emphasized. According to a recent study, an RCT with a combination of
exercises, hot compresses, and TENS created better results on pain and quality of life
scores than the same combination with sham TENS application (LOE Ib).[35]
Transcutaneous electrical nerve stimulation, diadynamic currents or interferential
currents are thought to produce analgesia. These modalities were investigated in
combination with exercise and/or heat applications in general. Therefore, the pure
efficiency of these currents could not been estimated individually. However, combination
therapy is used in daily practice.
Superficial and deep heating modalities are widely used in the management of knee OA.
According to the 2010 OARSI update, application of any thermal modality in patients
with knee OA is also recommended in the majority of guidelines.[6] Mechanical
vibrations, continous passive motion, and thermal applications in combination with other
treatments were reported to provide significant improvement in pain and functions (LOE
The application of therapeutic ultrasound was found to be effective for providing
symptomatic and functional improvements in knee OA in two MA, but the heterogeneity
of the methods and weaknesses in the level of evidence of evaluated trials created
difficulty in predicting the effect size of this modality (LOE Ia).[37,38] In a study
performed in our country, the authors showed that an exercise program combined either
with ultrasound or short-wave diathermy had significant beneficial effects on pain and
function. However, the low number of subjects and lack of a control group were
limitations of this study (LOE III).[39] The application of a 10-session therapeutic
ultrasound was compared with sham in another RCT, and a significant reduction in pain
scores (48%) together with significant improvements in the total WOMAC score and 50-
meter walking time were found (LOE Ib).[40]
Pulsed electromagnetic field treatment for knee OA was evaluated in a small trial, and a
significant improvement in WOMAC scores was reported (LOE Ib).[41] Based on nine
trials with 483 patients, the authors concluded that pulsed electromagnetic field therapy
improved pain and stiffness scores in patients with knee OA, but not significantly. In
contrast, the daily living activities and functional scores improved significantly (LOE
Ia).[42] It was shown that pulsed electromagnetic field therapy was not superior to
conventional physical therapy (LOE Ib).[43] Pulsed electromagnetic field treatment did
not exist in guidelines published before the 2010 update of the OARSI
recommendations.[6] In summary, the beneficial effect of pulsed electromagnetic field
therapy is evident with respect to function functions, but it is not as clear considering on
Dari Physiopedia
Clinical Practice Guidelines for Knee Osteoarthritis and Exercise
The medical literature describes over 50 modalities for the treatment of symptoms that
accompany OA. Over 40 clinical practice guidelines (CPG) have been published since
the 1980’s for knee
OA and all guidelines recommend exercise. Clinical practice
guidelines provide a critical review
of clinical trials of exercise and therapeutic
interventions. The American College of Rheumatology guidelines for hip and knee OA 4
state that physical therapy plays a central role in the management of patients with
functional limitations. The following is a list of the most recent and best clinical practice
guidelines that support physical activity/exercise for the treatment of OA of the knee:
· Philadelphia Panel (2001)
· EULAR (2003)
· MOVE Consensus (2004)
· Ottawa Panel (2005)
· OARSI (2008, 2010) 

The next section is a brief summary of the conclusions from each of the guidelines that
relate specifically to exercise and physical activity recommendations. 

a) Philadelphia Panel (2001)5 
This was a panel of physical therapists and these CPG’s
included 6 studies. In summary for OA, it found that traditional therapeutic exercise
benefits pain and global patient satisfaction. Strengthening exercises improve gait and
pain in the performance of activities of daily living. 

b) EULAR (European League Against Rheumatism) (2003)2 
These CPG’s were based
on 9 studies. In the summary, it emphasized the importance of addressing knee OA risk
factors such as obesity, adverse mechanical factors and decreased physical activity.
Non-pharmacological treatment should include regular exercise, aids (canes, insoles,
bracing) and weight reduction. 

c) MOVE Consensus (2004)6 
This set of guidelines was based on 25 studies and
found there were few, if any, contra-indications to the prescription of strengthening or
aerobic exercise in patients with knee OA. It also recommends both general (aerobic)
exercise and site specific strengthening exercises as essential core aspects of managing
patients with knee OA. 

d) Ottawa Panel (2005)7 
This was another panel of physical therapists and the CPG’s
are based on 26 studies. These guidelines stressed the importance of finding effective
strategies to help patients adopt and maintain regular physical activity habits and to
prevent the development of secondary consequences of being sedentary. It found that
therapeutic exercise (strengthening, aerobic, range of motion) is beneficial for pain,
range of motion, strength, gait, function, aerobic capacity and quality of life. It is the only
study to specifically include a note on predisposing intra-personal and inter-personal
factors or characteristics (i.e., including readiness to change) that will determine the
success of physical activity interventions.
e) OARSI (2008, 2010)8,9The OARSI guidelines were originally published in 2008 and
underwent an update in 2010, but the essential elements of the original guidelines have
not changed with the revision. These guidelines emphasize the importance of patient
education in self-management and weight control to achieve and maintain a healthy
weight. As with the previous CPGs, regular therapeutic exercise comprised of
strengthening, aerobic and range of motion exercises are beneficial. Interestingly,
regular phone contact improves clinical outcomes.
Two recent systematic reviews have been published on land-based10 and aquatic-
based11 exercises for knee OA. The review of 32 studies on land-based exercises
found that therapeutic exercise benefits both pain and disability. Additionally, there were
similar benefits from individual treatment, classes, and monitored home programs
provided by a physiotherapist or trained health professional. The review of aquatic-
based exercises was limited by a small number of studies available on this topic (6
studies met the inclusion criteria) and low methodological quality of the included studies.
The findings of the review stated aquatic-based exercise provided small to moderate
beneficial treatment effects on function and quality of life and small effects for pain
reduction in the short-term directly after the completion of an exercise program. Long-
term benefits could not be evaluated due to lack of studies on this particular outcome
and therefore merits further research.
Beberapa evidence:
Effectiveness of thermal and athermal short-wave diathermy for the management of
knee osteoarthritis: a systematic review and meta-analysis.
Review article
Laufer Y, et al. Osteoarthritis Cartilage. 2012.
OBJECTIVE: To assess the effectiveness of short-wave diathermy (SWD) treatment in
the management of knee osteoarthritis (KOA) and to assess whether the effects are
related to the induction of a thermal effect.
METHODS: A systematic literature search was conducted in PubMed, CINAHL, PEDro,
EMBASE, SPORTdiscus and Scholar Google. Included were trials that compared the
use of SWD treatment in patients diagnosed with KOA with a control group (placebo
SWD treatment or no intervention) and studies that used high-frequency electromagnetic
energy (i.e., 27.12 MHz) with sufficient information regarding treatment dosage.
Methodological quality of the included studies was assessed in accordance with the
PEDro classification scale. A minimum of a 6/10 score was required for inclusion.
RESULTS: Seven studies were included in the final analysis. Treatment protocols
(dosage, duration, number of treatments) varied extensively between studies. The meta-
analysis of the studies with low mean power did not favour SWD treatment for pain
reduction, while the results of studies employing some thermal effect were significant.
No treatment effect on functional performance measures was determined.
CONCLUSION: This meta-analysis found small, significant effects on pain and muscle
performance only when SWD evoked a local thermal sensation. However, the variability
in the treatment protocols makes it difficult to draw definitive conclusions about the
factors determining the effectiveness of SWD treatment. More research (using
comparable protocols and outcome measurements) is needed to evaluate possible long-
term effects of thermal SWD treatment and its cost effectiveness in patients with KOA.
Copyright © 2012 Osteoarthritis Research Society International. Published by Elsevier
Ltd. All rights reserved.
Comparative effects of pulsed and continuous short wave diathermy on pain and
selected physiological parameters among subjects with chronic knee osteoarthritis.
Randomized controlled trial
Teslim OA, et al. Technol Health Care. 2013.
PURPOSE: The purposes of this study were to compare the effects of pulsed and
continuous short wave diathermy on pain, range of motion, pulse rate and skin
temperature in subjects with chronic knee osteoarthritis.
METHODS: 24 Participants with grade 111 OA of the knee were randomly selected into
CSWD and PSWD groups. Pre and post treatment parameters were recorded at onset
and the end of 4th week. ANO VA, independent, paired t-test and chi-square were used
to analyze the data.
RESULTS: The pain experienced by participants in the CSWD group was significantly
lower than that of the PSWD groups (P < 0.03) after 4 weeks. Also, both active and
passive knee range of motions significantly increased in the CSWD group compared to
that of PSWD group (p < 0.01 and 0.002). Across the groups, there was no significant
difference in the initial pulse rate at onset of treatments and at the end of 4 weeks. There
was an increase in skin temperature within a range of 0.61 to 0.63°C and 0.31 to 0.35°C
of participants within both the CSWD and PSWD group respectively. The skin
temperature of participants who had continuous SWD was significantly higher after 4
weeks (F=8.38, p < 0.001) but the difference was insignificant within the pulse group.
However, there was no significant difference in body temperatures of the 2 groups.
CONCLUSION: This study concluded that CSWD was more effective than PSWD in
alleviating pain and in increasing knee flexion range of motion among subjects with
chronic knee OA. Also, a mild elevation of skin temperature was able to elicit
physiological effects that could exert therapeutic effects
Instrumen yang digunakan dalam penelitian ini adalah visual analog scale

(VAS) yang bertujuan untuk meniliai seberapa besar tingkat derajat nyeri yang

dirasakan oleh pasien. Prosedur yaitu dengan diberikan penjelasan tentang pe-

ngukuran nyeri dengan VAS, kemuadian pasien dianjurkan untuk melakukan tes

provokasi ( jongkok- berdiri). Selajutnya diinstruksikan kepada pasien untuk

menandai pada garis skala VAS yang dapat menggambarkan rasa nyeri yang di

keluhkannya, di mulai dari 0 (tidak nyeri) sampai 100 (nyeri hebat).