1545
ORIGINAL ARTICLE
Use of Ultrasound to Increase Effectiveness of Isokinetic
Exercise for Knee Osteoarthritis
Mao-Hsiung Huang, MD, PhD, Yueh-Shuang Lin, MS, Chia-Ling Lee, MD, Rei-Cheng Yang, MD, PhD
ABSTRACT. Huang M-H, Lin Y-S, Lee C-L, Yang R-C.
Use of ultrasound to increase effectiveness of isokinetic exer-
cise for knee osteoarthritis. Arch Phys Med Rehabil 2005;86:
1545-51.
Objective: To investigate the effects of ultrasound (US) in
isokinetic muscle strengthening exercises on functional status
of patients with knee osteoarthritis (OA).
Design: Effectiveness of isokinetic muscle strengthening
exercises for treatment of periarticular soft tissue disorders was
compared with and without pulsed and continuous US.
Setting: Outpatient exercise program in a Taiwan medical
university hospital.
Participants: One hundred twenty subjects with bilateral
knee OA (Altman grade II).
Intervention: Subjects were randomized sequentially into
1 of 4 groups. Group I received isokinetic muscular
strengthening exercises, group II received isokinetic exer-
cise and continuous US, group III received isokinetic exer-
cise and pulsed US treatment, and group IV was the control
group.
Main Outcome Measures: Therapeutic effects of isokinetic
exercise were evaluated by changes in ambulation speed and
the Lequesne index. In addition, changes in knee range of
motion (ROM), visual analog scale for pain, and muscle peak
torques during knee flexion and extension were compared.
Compliance in each group was recorded.
Results: Each treated group had increased muscle peak
torques and significantly reduced pain and disability after
treatment and at follow-up. However, only patients in
groups II and III had significant improvement in ROM and
ambulation speed after treatment. Fewer participants in
group III discontinued treatment due to knee pain during
exercise. Patients in group III also showed the greatest
increase in walking speed and decrease in disability after
treatment and at follow-up. Gains in muscular strength in
60°/s angular velocity peak torques were also noted in
groups II and III. However, group III showed the greatest
muscular strength gains with 180°/s angular velocity peak
torques after treatment and follow-up.
Conclusions: US treatment could increase the effectiveness
of isokinetic exercise for functional improvement of knee OA,
and pulsed ultrasound has a greater effect than continuous US.
From the Departments of Physical Medicine and Rehabilitation (Huang, Lee), School
of Sport Medicine (Yang), Kaohsiung Medical University Hospital, Kaohsiung; and
Kun-Shan University of Technology, Tainan (Lin), Taiwan.
Supported by National Science Council of Taiwan (grant no. NSC-92-2314-B-037-
067).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the author(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Mao-Hsiung Huang, MD, PhD, Dept of Physical Medicine and
Rehabilitation, Kaohsiung Medical University Hospital, No.100 Tzyou 1st Rd,
Kaohsiung 807, Taiwan, e-mail: maohuang@ms24.hinet.net.
0003-9993/05/8608-9466$30.00/0
doi:10.1016/j.apmr.2005.02.007
Key Words: Exercise; Osteoarthritis; Rehabilitation; Ultra-
sonics.
© 2005 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
STEOARTHRITIS (OA) is a common disease associated
O with significant morbidity, and its prevalence increases
1
with age. Radiographic abnormalities are present in more than
30% of people older than 65 years; approximately 40% are
symptomatic.2 OA occurs most frequently in the knee joint,
one of the most common sites of major health problems in
older subjects.3 Knee pain and quadriceps weakness are re-
ported determinants of disability in OA of the knee.4,5 Further-
more, restricted joint range of motion (ROM) is associated with
abnormal posture and may result in disability.6
OA is characterized by noninflammatory deterioration of the
articular cartilage with reactive new bone formation at the joint’s
surface and margins. Some studies7-9 have indicated that the
primary lesion of OA is in the articular cartilage, in which the
earliest change is diminution of mucopolysaccharide and chon-
droitin sulphate relative to the collagen in the matrix, thereby
unmasking the collagen. Normally, the matrix dissipates stresses
hydrostatically, but when the collagen is unmasked, its fibers are
subjected to excessive flexural and torsional stresses, leading to
rupture and the lesions characteristic of OA.10
The health of cartilage depends on the mechanical load it
receives. Cartilage is an avascular tissue and the chondrocytes
within it depend on diffusion and convection for nutrition. This
process is enhanced by the cyclic loading induced by everyday
activities that produce deformations, pressure gradients, and
fluid flows within the tissues. Moderate to strenuous articular
loading, such as that associated with regular distance running,
seems to have no adverse affects on the health of normally
congruent joints. However, high impact joint loading, through
either a single traumatic event or repetitive events of less
severity, may lead to joint degeneration.11,12 Normal loads can
also accelerate degeneration in deformed, unconstrained, or
damaged joints because of instability of the arthritic joint and
uneven loading force.12 Therefore, increasing the stability of an
arthritic joint might theoretically prevent further deterioration.
With therapeutic exercise, OA patients may prevent accelerated
degeneration resulting from disuse without causing further degen-
eration and pain as a consequence of joint deformity or incongru-
ence. Several recent longitudinal studies conclude that carefully
controlled exercise programs, designed primarily for OA of the
knee, are indeed beneficial.13,14 Reported benefits include in-
creased joint mobility, increased strength, and enhanced perfor-
mance in sports activities. Our previous report15 showed that
isokinetic muscle strengthening exercise is more effective than
isometric or isotonic exercises for diminishing disability and im-
proving muscular strength and ambulation ability. However, pa-
tient compliance is an issue, and those studies with high compli-
ance rates produced better results. Patient compliance depends on
many elements, including consistent education, encouragement,
and follow-up. Injury and complications as direct consequences of
Arch Phys Med Rehabil Vol 86, August 2005
1546 ULTRASOUND INCREASES EFFECTIVENESS OF EXERCISES FOR OSTEOARTHRITIS, Huang
inappropriate exercise,16 such as knee pain during exercise, weak-
ness of leg muscles, and ROM, are the major reasons for poor
compliance.
Therapeutic ultrasound (US) has been used to treat many
musculoskeletal diseases and is also reputed to reduce
edema,17,18 relieve pain, increase ROM,19 and accelerate tissue
repair.20-22 In a review of the effectiveness of US in treating
musculoskeletal conditions, Falconer et al17 found that most
reports indicate that therapeutic US appears to relieve OA pain.
Some investigations23 have applied US to enhance the flexi-
bility of connective tissues. However, few reports have dis-
cussed the effect of US on therapeutic exercise for OA.
Therefore, in this study we investigated the therapeutic effect of
isokinetic exercise when combined with US treatment in patients
with knee OA, including effect on ROM , knee pain, muscular
peak torque, and status of disability and ambulation speed imme-
diately posttreatment and during the follow-up period.
METHODS
Participants
One hundred twenty patients with bilateral moderate knee OA
(Altman grade II) with periarticular soft tissue pain, as identified
by painful sensations during palpation or passive stretching of the
arthritic knee under orthopedic examination. The locations of soft
tissue pain were confirmed by the findings of musculoskeletal US
images (as shown in US treatment) were selected. After radio-
graphs were taken and patients clinically evaluated by the criteria
of stages of knee OA,24 they were randomly assigned to 4 groups
by a secure system of sequentially numbered I through IV opaque
sealed envelopes. The physician who assigned the patients was
blinded as to the treatment they would receive. Patients in each
group received treatments 3 times weekly for 8 weeks. The 30
patients in group I received isokinetic muscular strengthening
exercises, the 30 in group II received isokinetic exercise and
continuous US, the 30 in group III received isokinetic exercise and
pulsed US, and the 30 in group IV served as controls and received
neither strengthening exercises nor US treatments. All groups
received 20 minutes of hot packs and 5 minutes of passive ROM
exercise on an electric stationary bike (20 cycles/min) of both
knees before undergoing muscle-strengthening exercises. The
therapeutic effects of these exercises were evaluated by changes in
the arthritic knee ROM,25 visual analog scale (VAS),26 Lequesne
index,27 ambulation speed, and muscle peak torques (MPT) of
knee flexion and extension measured with an isokinetic dyna-
mometer (Kin-Coma)28 before treatment, after treatment, and at
follow-up 1 year later. Compliance with the prescribed exercise
program in each group was also analyzed after treatment was
completed. All the participants gave their informed consent for
the study and the Ethical Review Committee of Kaohsiung
Medical University approved the study protocol.
Measurement of Knee ROM
Assisted active ROM was measured with a large plastic
goniometer with 25-cm movable arms, marked in 1° incre-
ments. This device is reportedly reliable if the patient remains
in one position for all measurements.25 Measurements of knee
flexion and extension were taken with subjects lying supine on
an examination couch, at maximum flexion of knee joint with
the hip flexed. Concomitant hip flexion prevented premature
limitation of knee motion from possible rectus femoris short-
ening. The fully extended knee was considered the zero posi-
tion, and the degrees of maximum flexion, maximum exten-
sion, and extension deficit, when present, were recorded. A
negative ROM score for extension indicated that the patient
Arch Phys Med Rehabil Vol 86, August 2005
was unable to reach the zero position. The angle between
maximum flexion and maximum extension was described as
the excursion range.
Measurement of Pain Severity
The severity of knee pain was evaluated by the VAS26 after
patients had remained in a weight-bearing position (walking or
standing) for 5 minutes in the parallel bars. The VAS instru-
ment consisted of horizontal lines 10cm long, with anchor
points of 0 (no pain) and 10 (maximum pain).
Measurement of Disability
We evaluated each patient’s disability with the Lequesne
index.27 The questionnaire included 11 questions about knee
discomfort, endurance of ambulation, and difficulties in daily
life. A maximum score of 26 indicated the greatest degree of
dysfunction. A score of less than 7 points indicated that the patient
had functional status acceptable for isokinetic exercise.15
Measurement of Ambulation Activity
Ambulation activity was evaluated by the patient’s walking
speed. The time it took to complete a predetermined distance of
50m on a treadmill as comfortably and quickly as possible was
recorded. A distance was preset on the treadmill, and an alarm
sounded when the 50m was completed. Walking time was
recorded with a stopwatch by the same physiatrist.
Measurement of Isokinetic Peak Torque of Knee Flexion
and Extension
The maximal voluntary force capacity was evaluated by
measuring the peak torque of the arthritic knee with a modified
form of the method used by Snow and Blacklin28 in the
following positions: (1) extension concentric (ex/con), knee
extension with quadriceps contraction; (2) extension eccentric
(ex/ecc), knee flexion with quadriceps contraction; (3) flexion
concentric (flex/con), knee flexion with biceps femoris contrac-
tion; and (4) flexion eccentric (flex/ecc), knee extension with
biceps femoris contraction. Subjects were seated and leaned
against a backrest inclined at 16° from the vertical and with the
seat inclined 6° from the horizontal. The axis of the knee was
aligned with the axis of the Kin-Com 505 exercise arm; accu-
racy of alignment was checked by allowing the subject to
extend the leg while pushing against the shin pad positioned
over the lower third of the leg. If the pad did not move up or
down the leg over the ROM to be tested, we considered the
knee to be aligned with the axis of the exercise arm. Gravity-
compensated torque values were corrected with the exercise
arm positioned 15° from horizontal.
We use the Kin-Com’s exercise arm to set the test ROM.
The angle at which knee flexor muscle shortening began (start
angle) was set at 20° from horizontal, and the angle at which
muscle lengthening began (return angle) was set at 85° from
horizontal. To calculate torque, we measured the distance be-
tween the point of application of the generated force and the
axis of rotation of the exercise arm, using the scale on the arm
itself and keyed into the computer. Each subject used the same
radius for all tests. Exercise-arm velocity was set to 60°/s and
180°/s, respectively, for the above isokinetic peak torque mea-
surements.
US Treatment
The locations of sonication (US treatment). The regions for
application of US were selected according to locations of
tendinopathy, enthesopathy, Baker’s cyst formation, or bursitis
indicated by the real time 5 to 12MHz high-resolution linear
 ULTRASOUND INCREASES EFFECTIVENESS OF EXERCISES FOR OSTEOARTHRITIS, Huang 1547

Table 1: Average Knee ROM in Each Group Before and After Treatment
Time I II III IV (control)

Before 105⫾15 (60) 106⫾13 (60) 105⫾12 (60) 99⫾15 (60)

After 110⫾17 (50) 115⫾15*† (54) 119⫾15*† (60) 95⫾11 (56)
⌬ROM 5⫾10 9⫾14† 15⫾14†‡ 4⫾13
Follow-up 112⫾14 (42) 118⫾14*† (48) 124⫾18*†‡ (56) 98⫾17 (48)

NOTE. Values are mean degrees ⫾ standard deviation (SD). Values in parentheses are the number of knees in each group at various time
intervals.
*Significant difference in Lequesne index in each group after treatment or follow-up (P⬍.05).
†
Significant difference in Lequesne index in each group compared with control at various time intervals (P⬍.05).
‡
Significant difference compared with other treated groups (P⬍.05).

scanner,b followed by tender point findings on orthopedic ex-
amination. The most common periarticular soft tissue lesions
included anserine bursitis, medial collateral enthesitis, popliteal
tendonitis, Baker’s cyst, and supra- and infrapatellar bursitis.
Continuous sonication. The USc was set at a duty cycle of
100%, with frequency of 1MHz and a spatial and temporal
peak intensity of 1.5W/cm2. The US probe was applied for 5
minutes to each treated region over the medial collateral liga-
ment (MCL), anserine bursa, and the popliteal fossa tender
points—a total treated area of approximately 25cm2. The pa-
tient was kept in a supine position with bilateral knee flexion of
90° for MCL and anserine bursa, and in a prone position with
bilateral knee full extension for treatment of the popliteal fossa
tender points. Sonication was performed 3 times a week for 8
weeks. The intensity of sonication was adjusted to the level at
which the patient felt a warm sensation or a mild sting.
Pulsed sonication. The same US was set at a frequency of
1MHz and a spatial and temporal peak intensity of 2.5W/cm2,
and pulsed at a duty cycle of 25%. The duration of US applied
to each region, and the posture of the patient being treated,
were as described for continuous sonication. Sonication was
performed 3 times a week for 8 weeks. The intensity of
sonication was also adjusted to the level at which the patient
felt a warm sensation or a mild sting.
Isokinetic Exercise
After each arthritic joint pain and ROM were evaluated, and
blood pressure and heart rate were measured, hot packs were
applied and the quadriceps and hamstrings were stretched.The
patient then underwent a 5-minute warm-up exercise on a
stationary bicycle set without resistance. The isokinetic muscle
strengthening exercise program was performed, as described in
our previous study,15 for left and right knees, 3 times a week
for 8 weeks (24 sessions). The isokinetic exercise program
began with 60% of the average peak torque. Intensity of
isokinetic exercise increased from 1 set to 5 sets during the first
through fifth sessions and remained at 6 sets for the remaining
6th through 24th sessions. Each set consisted of 5 repetitions of
concentric contraction in angular velocities of 30°/s and 120°/s
for extensors, and 5 repetitions of eccentric and concentric
contractions in angular velocities of 30°/s and 120°/s for flex-
ors. The start and stop angles for extension exercises were 40°
and 70°, and the start and stop angles for flexion exercises were
70° and 40°. Patients were allowed 5 seconds of rest between
sets, 10 seconds of rest between different modes of training,
and 10 minutes of rest between right and left knee training.
Compliance
Compliance was determined by the number of participants
who completed the treatment course divided by the number of
initial participants. The major causes of noncompliance, and
the times at which the exercise program was discontinued,
were also analyzed.
Home Program Exercise Routine
After the 3 groups completed treatment, the patients were
given a home exercise program consisting of 15 minutes on a
stationary bicycle or on a common bicycle with a device
attached to elevate the rear wheel for subjects who did not have
an exercise bike at home (18 patients).
Statistical Analysis
We used a paired t test to study the changes in VAS,
Lequesne index, ambulation speed values, and peak torques in
each group immediately after treatment and at follow-up 1 year
later. One-way analysis of variance with the Tukey test was
used to compare those differences between 3 treated groups,
and the Dunnett test was used to compare the difference be-
tween treated groups and the control group at zero time, after
treatment, and 1 year later. A statistically significant difference
was defined as P less than .05.
RESULTS
Participants
The 120 patients ranged in age from 42 to 72 years (mean
age, 62.0⫾8.4y), with a female to male ratio of 4.2:1. The
duration of knee pain ranged from 6 months to 11 years.

Table 2: Average VAS Score for Knee Pain in Each Group Before and After Treatment
Time I II III IV (control)

Before 4.9⫾1.5 (60) 5.2⫾1.7 (60) 5.0⫾1.3 (60) 4.8⫾1.8 (60)

After 3.7⫾0.7 (50)*† 3.3⫾0.8 (54)*† 2.6⫾1.7 (60)*†‡ 4.3⫾1.6 (56)
⌬VAS 1.2⫾1.4 1.9⫾1.6 2.4⫾1.8‡ 0.4⫾1.6
Follow-up 3.5⫾1.7 (42)*† 2.6⫾1.4 (48)*† 2.2⫾1.8 (56)*†‡ 6.0⫾1.3 (48)*

NOTE. Values are mean score ⫾ SD. Values in parentheses are the number of knees in each group at various time intervals.
*Significant difference in VAS score in each group after treatment or follow-up (P⬍.05).
†
Significant difference in VAS score compared with control group at various time intervals (P⬍.05).
‡
Significant difference compared with other treated groups (P⬍.05).

Arch Phys Med Rehabil Vol 86, August 2005

1548 ULTRASOUND INCREASES EFFECTIVENESS OF EXERCISES FOR OSTEOARTHRITIS, Huang

Table 3: Average Lequesne Index of Patients in Each Group Before and After Treatment
Time I II III IV (control)

Before 6.7⫾2.1 (30) 7.0⫾1.6 (30) 7.1⫾2.1 (30) 7.0⫾1.1 (30)

After 5.2⫾0.9 (25)*† 4.8⫾1.0 (27)*† 4.1⫾0.6 (30)*†‡ 6.6⫾1.6 (28)
⌬Lequesne index 1.6⫾1.4 2.1⫾1.5 2.9⫾1.8‡ 0.4⫾1.6
Follow-up 5.1⫾1.8 (21)*† 3.9⫾1.5 (24)*† 3.1⫾1.4 (28)*†‡ 7.8⫾1.7* (24)

NOTE. Values are mean score ⫾ SD. Values in parentheses are the number of knees in each group at various time intervals.
*Significant difference in Lequesne index in each group after treatment or follow-up (P⬍.05).
†
Significant difference in Lequesne index compared with control group at various time intervals (P⬍.05).
‡
Significant difference compared with other treated groups (P⬍.05).

Changes in ROM
The changes in average ROM of the arthritic knees for each
group are shown in table 1. Ten subjects stopped the therapeu-
tic exercises because of intolerable pain during exercise (5
subjects in group I, 3 in group II, 2 in group IV). Contact with
13 subjects was lost during the follow-up period (4 subjects in
group I, 3 in group II, 2 in group III, 4 in the control group).
The average ROM of each group was initially similar, but
ROM scores later increased significantly only in groups II and
III after treatment. Patients in group III showed the greatest
increase in ROM, both after treatment and in the follow-up
period.
Changes in Knee Pain
The changes in average scores for knee pain in each group
are shown in table 2. Pain scores for groups I through IV were
initially similar, but pain scores decreased significantly in all
treated groups; pain scores continued to decrease significantly
in groups II and III at follow-up, whereas they were increased
in the controls. Patients in group III showed the greatest degree
of pain reduction, both after treatment and at follow-up.
Changes in Lequesne Index
Initially, the treated and control groups showed no signifi-
cant Lequesne index differences. The changes in mean index
values in each patient group are shown in table 3. The average
scores decreased significantly in all treated groups after treat-
ment, and at the 1-year follow-up. Patients in group I had the
least reduction in Lequesne index scores after treatment, and
patients in group III had the greatest reduction in disability
after treatment and during the follow-up period.
Changes in Ambulation Speed
The mean changes in ambulation speed in each group are
shown in table 4. Initially, the average ambulation speed did
not markedly differ between treated and control groups, but the
average ambulation speed increased significantly only in
groups II and III after treatment. However, the average ambu-
lation speed increased in all treated groups at follow-up when
compared with the controls. Patients in group III showed the
most improvement, and group I showed the least improvement
both, after treatment and at the follow-up.
Changes in Peak Torque
The changes in mean peak torques of knee flexion and
extension in concentric and eccentric contraction in all patient
groups are shown in table 5 (60°/s) and table 6 (180°/s). All the
average peak torque of 60°/s in ex/con, ex/ecc, flex/ecc, and
flex/con increased significantly in group II and group III, both
after treatment and at the follow-up. Patients in group I showed
the least improvement in peak torques, but group I showed
significant improvements in muscle peak torques when com-
pared with the control group at follow-up. Table 6 shows that
patients in group III had the most improvement in peak torque
at 180°/s in all contraction modes (ex/con, ex/ecc, flex/con,
flex/ecc) after treatment and at follow-up, which correlates
closely with joint functional improvement.
Compliance
Compliance was .83 (25/30) in group I, .90 (27/30) in group
II, 1.0 (30/30) in group III, and .93 (28/30) in the control group.
Reasons for withdrawal from the treatment included intolerable
knee pain induced by the prescribed exercises in 6 of 8 patients
(75%) and leg muscle weakness in 2 of 8 (25%). Treatment
compliance was greater in group III, suggesting that therapeu-
tic exercise-induced knee pain was the major reason for dis-
continuing treatment.
DISCUSSION
Physical disability is frequently reported in patients with
knee OA. However, the disability of these patients can only
partly be explained by degeneration of the knee joints. Several
other factors have been proposed as possible explanations for
their disability, including physical factors such as reduced
ROM of the knee joints. In a study of elderly Swedish subjects,
Odding et al29 found correlations between knee and hip joint
ROM and disability. They also found that restricted flexion of
the knees was a strong risk factor for locomotor disability in

Table 4: Average Ambulation Speed of Patients in Each Group Before and After Treatment
Time I II III IV (control)

Before 74.6⫾7.3 (30) 72.6⫾6.5 (30) 73.2⫾6.0 (30) 72.3⫾7.5 (30)

After 81.9⫾5.5 (25)‡ 90.9⫾4.1 (27)*† 92.4⫾3.4 (30)*† 75.6⫾3.5 (28)
⌬ambulation speed 9.2⫾8.6‡ 18.6⫾5.5 19.5⫾7.2 3.4⫾6.8
Follow-up 82.5⫾7.1 (21)*† 90.4⫾7.8 (24)*† 99.7⫾8.7 (28)*†‡ 67.1⫾4.3 (24)

NOTE. Values are mean m/min ⫾ SD. Values in parentheses are the number of knees in each group at various times intervals.
*Significant difference in ambulation speed in each group after treatment or follow-up (P⬍.05).
†
Significant difference in ambulation speed compared with control group at various time intervals (P⬍.05).
‡
Significant difference compared with other treated groups (P⬍.05).

Arch Phys Med Rehabil Vol 86, August 2005

 ULTRASOUND INCREASES EFFECTIVENESS OF EXERCISES FOR OSTEOARTHRITIS, Huang 1549

Table 5: Mean Peak Torque of Knee Flexion and Extension in Concentric and Eccentric Contraction at 60°/s in Each Group
Before and After Treatment
Angular Velocity Time I II III IV (control)

60° (ex/con) Before 233.1 (60) 236.9 (60) 230.3 (60) 237.1 (60)
After 255.7 (50)*‡ 284.5 (54)*† 289.9 (60)*† 233.5 (56)
⌬MPT 21.5‡ 49.4 59.4 ⫺3.6
Follow-up 273.3 (42)*†‡ 321.5 (48)*† 336.1 (56)*† 221.3 (48)
60° (ex/ecc) Before 430.1 (60) 443.3 (60) 438.9 (60) 436.3 (60)
After 476.5 (50)*†‡ 514.3 (54)*† 518.3 (60)*† 444.6 (56)
⌬MPT 38.5‡ 71.2 79.4 7.5
Follow-up 485.1 (42)*†‡ 587.3 (48)*† 587.4 (56)*† 410.4 (48)
60° (flex/con) Before 280.6 (60) 278.5 (60) 270.8 (60) 275.5 (60)
After 299.4 (50)†‡ 319.0 (54)*† 317.9 (60)*† 267.8 (56)
⌬MPT 20.5‡ 41.3 47.9 ⫺8.5
Follow-up 289.8 (42)†‡ 333.2 (48)*† 348.6 (56)*† 237.3 (48)*
60° (flex/ecc) Before 337.3 (60) 344.5 (60) 341.8 (60) 347.1 (60)
After 373.4 (50)†‡ 399.6 (54)*† 401.3 (60)*† 338.1 (56)
⌬MPT 33.3‡ 55.0 60.1 ⫺11.2
Follow-up 379.6 (42)†‡ 416.5 (48)*† 423.6 (56)*† 296.9 (48)*

NOTE. Values in parentheses are the number of knees in each group at various time intervals.
*Significant difference in peak torque in each group after treatment or follow-up (P⬍.05).
†
Significant difference in peak torque compared with control group at various time intervals (P⬍.05).
‡
Significant difference compared with other treated groups (P⬍.05).

activities primarily involving the lower extremities, such as
walking, climbing stairs, and rising from and sitting down in a
chair. Steultjens et al30 reported that restricted joint mobility,
especially in flexion of the knee, appears to be an important
determinant of disability in patients with OA.
The major causes of ROM limitation of the arthritic knee are
joint pain and weakness of the quadriceps,30 which is one of the
key muscles controlling the stability of the arthritic knee. Joint
pain control and muscle strengthening exercise are therefore
important in a rehabilitation program for knee OA.
Pain in the osteoarthritic knee may be caused by several
conditions, including loss of articular cartilage, mechanical
compression of either the medial knee compartment with varus
deformity, mechanical compression of the lateral compartment
with valgus deformity31; stretching of the medial or MCLs;
microfractures and subchondral fracture; capsular distension by
effusion; and patellar and associated syndromes such as an-
serine bursitis or prepatellar bursitis. Furthermore, the interac-
tion of these factors would result in changes of intraarticular
and periarticular connective tissues.
Periarticular connective tissue is composed of collagen
fibers within a proteoglycan matrix. The tissue may become
fibrotic, contracted, or shortened when subjected to immo-
bilization or inactivity due to arthritic joint pain, resulting in
joint capsule contractures and a limited ROM. Adaptive
shortening of the muscles may also occur when a muscle
immobilized in a shortened position demonstrates shorten-
ing within a week. After 3 weeks in this shortened position,

Table 6: Mean Peak Torque of Knee Flexion and Extension in Concentric and Eccentric Contraction at 180°/s in Each Group
Before and After Treatment
Angular Velocity Time I II III IV (control)

180° (ex/con) Before 180.5 (60) 178.1 (60) 184.1 (60) 185.3 (60)
After 203.2 (50)*† 222.3 (54)*† 265.3 (60)*†‡ 181.8 (56)
⌬MPT 23.5 47.1 71.3‡ ⫺3.4
Follow-up 212.3 (42)*† 233.1 (48)*† 279.4 (56)*†‡ 163.2 (48)
180° (ex/ecc) Before 482.6 (60) 483.3 (60) 493.1 (60) 488.3 (60)
After 575.5 (50)*† 604.1 (54)*† 653.3 (60)*†‡ 476.8 (56)
⌬MPT 93.5 123.1 163.7‡ ⫺13.2
Follow-up 592.3 (42)*† 635.3 (48)*† 696.7 (56)*†‡ 432.1* (48)
180° (flex/con) Before 184.7 (60) 187.6 (60) 191.8 (60) 186.1 (60)
After 225.7 (50)*† 246.4 (54)*† 279.8 (60)*†‡ 172.6 (56)
⌬MPT 38.4 61.6 86.3‡ ⫺14.0
Follow-up 235.5 (42)*† 277.2 (48)*† 331.7 (56)*†‡ 160.3 (48)*
180° (flex/ecc) Before 317.4 (60) 315.1 (60) 321.3 (60) 324.1 (60)
After 340.7 (50)† 359.3 (54)*† 395.5 (60)*†‡ 313.4 (56)
⌬MPT 25.3 43.6 75.2‡ ⫺10.7
Follow-up 342.1 (42)† 383.3 (48)*† 426.2 (56)*†‡ 290.1 (48)*

NOTE. Values in parentheses are the number of knees in each group at various time intervals.
*Significant difference in peak torque in each group after treatment or follow-up (P⬍.05).
†
Significant difference in peak torque in each group compared with control group at various time intervals (P⬍.05).
‡
Significant difference compared with other treated groups (P⬍.05).

Arch Phys Med Rehabil Vol 86, August 2005

1550 ULTRASOUND INCREASES EFFECTIVENESS OF EXERCISES FOR OSTEOARTHRITIS, Huang
the loose connective tissue in the muscle becomes dense
connective tissue, and a fixed muscle contracture devel-
ops,32 resulting in the instability of the joint. However,
through an appropriate physical modality such as the US we
used in this study, the patients in groups II and III had more
improvement in muscular peak torques and less disability,
which were correlated closely with an increased ROM after
periarticular soft tissue pain control.
Our previous study15 showed that although isokinetic
strengthening exercise has the greatest therapeutic effect on
the functional status of patients with knee OA, it also had
the lowest level of compliance with treatment when com-
pared with isotonic or isometric exercises because of exer-
cise-induced knee pain. Patients in groups II and III had
better compliance than those in group I, which may have
been due to the decrease in pain in those patients who
received US treatment.17
The literature appears to offer support for neither pulsed US
to treat chronic inflammatory conditions, nor for thermal US to
treat acute inflammatory conditions.33,34 The high rate of com-
pliance was related to the reduction of exercise-induced pain as
in the this study, which showed that knee pain reduction in
group III was greater than that in group II, implying that pulsed
US is more suitable during exercise for patients with OA than
continuous US.
The reduction of soft tissue pain by US could result from
increased blood flow to muscles in spasm, or the rise in
temperature causing relaxation of muscle guarding. Electro-
myographic studies show that US does not change nerve
conduction velocity in small diameter nociceptive affer-
ents.35 Consequently, it is thought that pain relief may occur
as a result of the activation of A alpha- and A beta-mech-
anoreceptors that inhibit nociceptive transmission in A del-
ta- and C-fiber pathways as a proposed pain-gating mecha-
nism.
Isokinetic muscular peak torque at 60°/s and 180°/s were
measured to determine the changes in MPT. Table 5 shows
more MPT (at 60°/s) improvement in both groups II and III.
However, groups II and III show no significant difference in
degree of improvement. Furthermore, table 6 shows that improve-
ment of MPT (at 180°/s) was significantly greater in group III than
in group II. A comparison of the improvement in disability and
ambulation speed implies that the improvement in MPT at 180°/s
is closely correlated with functional status of arthritic knee.
In this study, we administered the sham US treatment for
patients in groups I and IV, however, the absence of a warm
or stinging sensation for the treated patients caused the
failure of the sham US application. Consequently, the pla-
cebo effect of US in groups II and III must be considered
although there were significant differences between groups
II and III and groups I and IV.
CONCLUSIONS
US treatment, especially pulsed US, can enhance the thera-
peutic effects of isokinetic strengthening exercise for treating
periarticular soft tissue pain in patients with knee OA.
References
1. Badley E, Tennant A. Impact of disablement due to rheumatic
disorders in a British population: estimates of severity and prev-
alence from the Calderdale Rheumatic Disablement Survey. Ann
Rheum Dis 1993;52:6-13.
2. Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the
prevalence of arthritis and selected musculoskeletal disorders in
the United States. Arthritis Rheum 1998;41:778-99.
Arch Phys Med Rehabil Vol 86, August 2005
3. Felson DT. The epidemiology of knee osteoarthritis: results from
the Framingham Osteoarthritis Study. Semin Arthritis Rheum
1990;20:42-50.
4. McAlindon TE, Cooper C, Kirwan JR. Knee pain and disability in
the community. Br J Rheumatol 1992;31:189-92.
5. O’Reilly SC, Jones A, Muir KR. Quadriceps weakness in knee
osteoarthritis: the effect of pain and disability. Ann Rheum Dis
1998;57:588-94.
6. McAlindon TE, Cooper C, Kirwan JR. Determinants of disability
in osteoarthritis of the knee. Ann Rheum Dis 1993;52:258-62.
7. Scott JE. Proteoglycan-collagen interactions and subfibrillar struc-
ture in collagen fibrils. Implications in the development and aging
of connective tissue. J Anat 1990;169:223-5.
8. Lark MW, Bayne EK, Lohmander LS. Aggrecan degradation in
osteoarthritis and rheumatoid arthritis. Acta Orthop Scand Suppl
1995;266:92-7.
9. Poole CA, Gilbert RT, Ayad S, Plaas AH. Immunolocalisation of
type VI collagen, decorin, and fibromodulin in articular cartilage
and isolated chondrons. Trans Orthop Res Soc 1993;18:644.
10. Huang CY, Soltz MA, Kopacz M, Mow VC, Ateshian GA.
Experimental verification of the roles of intrinsic matrix viscoelas-
ticity and tension-compression nonlinearity in the biphasic re-
sponse of cartilage. J Biomech Eng 2003;125:84-93.
11. Grodzinsky AJ, Levenston ME, Jin M, Frank EH. Cartilage tissue
remodeling in response to mechanical force. Ann Rev Biomed
Eng 2000;2:691-713.
12. Thompson RC, Oegema TR, Lewis JL, Wallace L. Osteoarthritic
changes after acute transarticular load: an animal model. J Bone
Joint Surg Am 1991;73:990-1001.
13. Fisher NM, Gresham GE, Abrams M. Quantitative effects of
physical therapy on muscular and functional performance in sub-
jects with osteoarthritis of the knees. Arch Phys Med Rehabil
1993;74:840-7.
14. Anderson J, Felson DT. Factors associated with osteoarthritis of
the knee in the first National Health and Nutrition Examination
survey. Am J Epidemiol 1988;128:179-89.
15. 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;32:398-406.
16. Ettinger WH, 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 Fit-
ness Arthritis and Seniors Trial (FAST). JAMA 1997;277:25-31.
17. Falconer J, Hayes KW, Chang RW. Therapeutic ultrasound in the
treatment of musculoskeletal conditions. Arthritis Care Res 1990;
3:85-91.
18. Hogan RD, Burke KM, Franklin TD. The effect of ultrasound on
microvascular hemodynamics in skeletal muscle: effects during
ischemia. Microvasc Res 1982;23:370-9.
19. Stevenson JH, Lindsay WK, Zuker RM. Functional, mechanical,
and biochemical assessment of ultrasound therapy on tendon
healing in the chicken toe. Plast Reconst Surg 1986;77:965-70.
20. Murrell GA, Francis MJ, Bromley L. Modulation of fibroblast
proliferation by oxygen free radicals. Biochem J 1990;265:659-65.
21. Enwemeka CS. The effects of therapeutic ultrasound on tendon
healing: a biomechanical study. Am J Phys Med Rehabil 1989;
68:283-7.
22. Dyson M. Stimulation of tissue repair by ultrasound: a survey of
the mechanisms involved. Physiotherapy 1978;64:105-8.
23. Lizzi FL, Ostromogilsky M. Analytical modelling of ultrasonically
induced tissue healing. Ultrasound Med Biol 1987;13:607-18.
24. Altman RD. Criteria for classification of clinical osteoarthritis.
J Rheumatol Suppl 1991;18:10-2.
25. Rothstein JM, Miller PJ, Roettger RF. Goniometric reliability in a
clinical setting: elbow and knee measurement. Phys Ther 1983;
63:1611-5.
 ULTRASOUND INCREASES EFFECTIVENESS OF EXERCISES FOR OSTEOARTHRITIS, Huang
26. Dalton JA, McNaull F. A call for standardizing the clinical rating
of pain intensity using a 0 to 10 rating scale. Cancer Nurs 1998;
21:46-9.
27. Lequesne M. Clinical features, diagnostic criteria, functional as-
sessments and radiological classifications of osteoarthritis. Rheu-
matology 1982;7:1-10.
28. Snow CJ, Blacklin K. Reliability of knee flexor peak torque
measurement from a standardized test protocol on a Kin/Com
dynamometer. Arch Phys Med Rehabil 1992;73:15-21.
29. Odding E, Valkenburg HA, Algra D, Vandenouweland FA,
Grobbee DE, Hofman A. The association of abnormalities on
physical examination of the hip and knee with locomotor
disability in the Rotterdam study. Br J Rheumatol 1996;35:884-
90.
30. Steultjens MP, Dekker J, Van Baar ME. Range of motion and
disability in patients with osteoarthritis of the knee or hip. Rheu-
matology 2000;39:955-61.
31. Walker CR, Myles C, Nutton R. Movement of the knee in osteo-
arthritis. J Bone Joint Surg Br 2001;83:195-8.
1551
32. Ersoz M, Ergun S. Relationship between knee range of motion and
Kellgren-Lawrence radiographic scores in knee osteoarthritis.
Am J Phys Med Rehabil 2003;82:110-5.
33. Hasson S, Mundorf R, Barnes W. Effect of pulsed ultrasound
versus placebo on muscle soreness perception and muscular per-
formance. Scand J Rehabil Med 1990;22:199-205.
34. Ciccone C, Leggin B, Callamaro J. Effects of ultrasound and
trolamine salicylate phonophoresis on delayed-onset muscle sore-
ness. Phys Ther 1991;71:666-75.
35. Williams A, McHale J, Bowditch M, Miller DL, Reed B. Effect of
1 MHz ultrasound on electrical pain threshold perception in hu-
mans. Ultrasound Med Biol 1987;13:249-58.
Suppliers
a. Kin-Com; Chattecx Group, Chattanooga Corp, 4717 Adams Rd,
Hixson, TN 37343.
b. HDL 1500; ATL Ultrasound, PO Box 3003, Bothell, WA 98041.
c. Sonopulus 590; Enraf Nonius, Röntgenweg 1, PO Box 810 2600
AV Delft, Netherlands.
Arch Phys Med Rehabil Vol 86, August 2005