Additional effect of pulsed electromagnetic field therapy on knee osteoarthritis treatment: a randomized, placebo-controlled study

Current Evidence Using Pulsed Electromagnetic Fields in Osteoarthritis: A Systematic Review

(1) Background: Osteoarthritis (OA) significantly impacts patients' quality of life and negatively affects public healthcare costs. The aim of this systematic review is to identify the effectiveness of pulsed electromagnetic fields (PEMFs) in OA treatment across different anatomical districts, determining pain reduction and overall improvement in the patient's quality of life. (2) Methods: In this systematic review following PRISMA guidelines, PubMed and Google Scholar were searched for randomized controlled trials involving patients with osteoarthritis undergoing PEMF therapy. Seventeen studies (1197 patients) were included. (3) Results: PEMF therapy demonstrated positive outcomes across various anatomical districts, primarily in knee osteoarthritis. Pain reduction, assessed through VAS and WOMAC scores, showed significant improvement (60% decrease in VAS, 42% improvement in WOMAC). The treatment duration varied (15 to 90 days), with diverse PEMF devices used. Secondary outcomes included improvements in quality of life, reduced medication usage, and enhanced physical function. (4) Conclusions: Diverse PEMF applications revealed promising results, emphasizing pain reduction and improvement in the quality of life of patients. The variability in the treatment duration and device types calls for further investigation. This review informs future research directions and potential advancements in optimizing PEMF therapies for diverse osteoarthritic manifestations.

Promising application of pulsed electromagnetic fields on tissue repair and regeneration

Tissue repair and regeneration is a vital biological process in organisms, which is influenced by various internal mechanisms and microenvironments. Pulsed electromagnetic fields (PEMFs) are becoming a potential medical technology due to its advantages of effectiveness and non-invasiveness. Numerous studies have demonstrated that PEMFs can stimulate stem cell proliferation and differentiation, regulate inflammatory reactions, accelerate wound healing, which is of great significance for tissue regeneration and repair, providing a solid basis for enlarging its clinical application. However, some important issues such as optimal parameter system and potential deep mechanisms remain to be resolved due to PEMFs window effect and biological complexity. Thus, it is of great importance to comprehensively summarizing and analyzing the literature related to the biological effects of PEMFs in tissue regeneration and repair. This review expounded the biological effects of PEMFs on stem cells, inflammation response, wound healing and musculoskeletal disorders in order to improve the application value of PEMFs in medicine. It is believed that with the continuous exploration of biological effects of PEMFs, it will be applied increasingly widely to tissue repair and other diseases.

Effects of the combination of pulsed electromagnetic field with progressive resistance exercise on knee osteoarthritis: A randomized controlled trial

BACKGROUND

Knee osteoarthritis (OA) is a common and disabling disease among the elderly population. The optimal conservative treatment for knee OA is not well established.

OBJECTIVE

This study aimed to assess the effectiveness of pulsed electromagnetic field (PEMF) combined with progressive resistance exercise (PRE) in improving physical function and pain in patients with knee OA.

METHODS

Thirty-four patients with knee OA (17 in each group) participated in a single-blind randomized control study. Patients were randomly assigned to receive 24 sessions of either combined PEMF and PRE (treatment group) or PRE only (control group). Patients were evaluated at pre-treatment, post-treatment (2 months), and at 3-month and 6-month follow-ups using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Numeric Pain Rating Scale (NPRS); walking speed and 5-times chair stand test. Mixed ANOVA was used for statistical analysis with Bonferroni adjustments.

RESULTS

There was no significant group-by-time interaction for any outcome (P> 0.05). However, both groups scored significantly higher on the NPRS and KOOS at post-treatment, 3-, and 6-month follow-up compared to their baseline. Further, both groups completed the 5-times chair stand test and walking speed test with significantly less time at all post-treatment time points than the pre-treatment. None of the study outcomes (NPRS, KOOS, walking speed, and 5 times chair stand) were significantly different between groups at any of the time points.

CONCLUSION

Both treatment options, PRE only versus PRE with PEMF, were equally effective in decreasing pain and improving physical function in patients with knee OA. This would suggest that the optimal parameters for PEMF that may show beneficial effects for knee OA when added to PRE training need to be determined.

Vector potential dual effect of promoting the proliferation of chondrocytes and inhibiting the calcification process in the articular cartilage

OA commonly affects the articular cartilage of the tibia, and its calcification worsens its advancement and its prevalence has recently increased. Vector potential (VP) represents a novel physical therapy for treating OA. Since the impact of VP on articular cartilage remains unknown, we aimed to assess its effects on articular cartilage and its potential as a new treatment for OA. Here, we divided 24 male Wistar rats, 6-week-old, into control (CO, n = 12) and VP stimulus (n = 12) groups (VP conditions: volt, 67 mV; frequency, 20 kHz; current, 0.12 mA; experimental frequency, 30 min/days, 5 days/week, and 3 weeks). Articular cartilage can be classified into four layers: superficial, medial, deep, and calcified. Moreover, the number of chondrocytes in the articular cartilage was higher in the CO group compared to the VP group, although the calcified layer was thinner in the VP group. Furthermore, MKi67 exhibited higher expression in the VP group than in the CO group, while ectonucleotide pyrophosphatase/phosphodiesterase 1 was downregulated in the VP group. Our findings indicate that VP positively influenced chondrocyte proliferation and inhibited calcification in articular cartilage. Thus, VP stimulation may assist in the development of novel strategies for preventing OA.

Targeting Adenosine Signalling in Knee Chondropathy: The Combined Action of Polydeoxyribonucleotide and Pulsed Electromagnetic Fields: A Current Concept Review

Chondropathy of the knee is one of the most frequent degenerative cartilage pathologies with advancing age. Scientific research has, in recent years, advanced new therapies that target adenosine A2 receptors, which play a significant role in human health against many disease states by activating different protective effects against cell sufferance and damage. Among these, it has been observed that intra-articular injections of polydeoxyribonucleotides (PDRN) and Pulsed Electromagnetic Fields (PEMF) can stimulate the adenosine signal, with significant regenerative and healing effects. This review aims to depict the role and therapeutic modulation of A2A receptors in knee chondropathy. Sixty articles aimed at providing data for our study were included in this review. The present paper highlights how intra-articular injections of PDRN create beneficial effects by reducing pain and improving functional clinical scores, thanks to their anti-inflammatory action and the important healing and regenerating power of the stimulation of cell growth, production of collagen, and the extracellular matrix. PEMF therapy is a valid option in the conservative treatment of different articular pathologies, including early OA, patellofemoral pain syndrome, spontaneous osteonecrosis of the knee (SONK), and in athletes. PEMF could also be used as a supporting therapy after an arthroscopic knee procedure total knee arthroplasty to reduce the post-operative inflammatory state. The proposal of new therapeutic approaches capable of targeting the adenosine signal, such as the intra-articular injection of PDRN and the use of PEMF, has shown excellent beneficial results compared to conventional treatments. These are presented as an extra weapon in the fight against knee chondropathy.

Combined Rehabilitation Protocol in the Treatment of Osteoarthritis of the Knee: Comparative Study of Extremely Low-Frequency Magnetic Fields and Soft Elastic Knee Brace Effect

The investigation of this observational case-control study aimed at determining the effectiveness of a combined treatment of extremely low-frequency electromagnetic fields (ELF) with a soft elastic knee brace versus ELF alone in knee osteoarthritis (KOA) with respect to a reduction in pain and functional recovery. We hypothesized that the combined use of ELF and a soft elastic knee brace may provide better results. Thirty-five patients (N = 35, divided into Group 1 = ELF and Group 2 = ELF with the soft elastic knee brace) were analyzed. The rehabilitative protocol consisted of 10 sessions of antiphlogistic and antiedema programs (first cycle) for 2 weeks, followed by twelve sessions of bone repair and connective tissue repair programs (second cycle) in patients with knee osteoarthritis (KOA) for 4 weeks. Patient evaluations were conducted at baseline (T0) and after 2 (T1) and 4 (T2) weeks of treatment. A follow-up evaluation was conducted 6 weeks after treatment (T3). The LIMFA© Therapy System was used to create multifrequency magnetoelectric fields with an intensity of 100 µT and a low-frequency field. The Incrediwear Cred 40 knee sleeve (Incred) was used for alleviating knee pain. The Visual Analogue Scale (VAS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Lysholm score (Ls) were used as outcome measures. The results showed that pain at rest (Vr), pain in motion (Vm), KOOS, and Ls were significantly affected by ELF over time. In conclusion, Group 2 had a better response in terms of pain resolution at rest (p < 0.05) and a concurrent better response at T3 in terms of functional recovery (p < 0.05).

Effects of Peripheral Electromagnetic Fields on Spasticity: A Systematic Review

Electromagnetic fields are emerging as a therapeutic option for patients with spasticity. They have been applied at brain or peripheral level. The effects of electromagnetic fields applied to the brain have been extensively studied for years in spasticity, but not so at the peripheral level. Therefore, the purpose of our work is to analyze the effects of electromagnetic fields, applied peripherally to spasticity. A systematic review was conducted resulting in 10 clinical trials. The frequency ranged from 1 Hz to 150 Hz, with 25 Hz being the most commonly used and the intensity it was gradually increased but there was low homogeneity in how it was increased. Positive results on spasticity were found in 80% of the studies: improvements in stretch reflex threshold, self questionnaire about difficulties related to spasticity, clinical spasticity score, performance scale, Ashworth scale, spastic tone, Hmax/Mmax Ratio and active and passive dorsal flexion. However, results must be taken with caution due to the large heterogeneity and the small number of articles. In future studies, it would be interesting to agree on the parameters to be used, as well as the way of assessing spasticity, to be more objective in the study of their effectiveness.

The Efficacy of Pulsed Electromagnetic Fields on Pain, Stiffness, and Physical Function in Osteoarthritis: A Systematic Review and Meta-Analysis

Background

Although there are many pharmacological interventions for adults with osteoarthritis (OA) who do not meet the indications for surgery, side effects and adverse effects cannot be ignored. Physical interventions are known for their effectiveness and safety, and pulsed electromagnetic fields (PEMFs) have already been applied to skeletal diseases such as osteoporosis.

Objective

In this systematic review and meta-analysis, we aimed to assess the efficacy of PEMF on the major symptoms of patients with OA compared with efficacy of other interventions.

Methods

Randomized controlled trials (RCTs) investigating OA patients treated with PEMF and with pain, stiffness, and physical function impairment since 2009 were included. The Visual Analog Scale (VAS) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) scores were used for assessment. All extracted data were analyzed using RevMan V.5.3.

Results

Eleven RCTs consisting of 614 patients were enrolled in this meta-analysis, of which 10 trials comprised knee OA and one comprised hand OA. Compared with the control groups, the PEMF treatment yielded a more favorable output. PEMF alleviated pain (standardized mean differences [SMD] = 0.71, 95% confidence interval [CI]: 0.08-1.34, p = 0.03), improved stiffness (SMD = 1.34, 95% CI: 0.45-2.23,p=0.003), and restored physical function (SMD = 1.52, 95% CI: 0.49-2.55,p=0.004).

Conclusions

PEMF therapy ameliorates OA symptoms such as pain, stiffness, and physical function in patients compared to other conservative treatments. There is an urgent need to search for different types of OA in multiple locations.

Impact of Magnetic Stimulation on Periodontal Ligament Stem Cells

The aim of this study was to evaluate the effect of a time-dependent magnetic field on the biological performance of periodontal ligament stem cells (PDLSCs). A Western blot analysis and Alamar Blue assay were performed to investigate the proliferative capacity of magnetically stimulated PDLSCs (PDLSCs MAG) through the study of the MAPK cascade (p-ERK1/2). The observation of ALP levels allowed the evaluation of the effect of the magnetic field on osteogenic differentiation. Metabolomics data, such as oxygen consumption rate (OCR), extracellular acidification rate (ECAR) and ATP production provided an overview of the PDLSCs MAG metabolic state. Moreover, the mitochondrial state was investigated through confocal laser scanning microscopy. Results showed a good viability for PDLSCs MAG. Magnetic stimulation can activate the ERK phosphorylation more than the FGF factor alone by promoting a better cell proliferation. Osteogenic differentiation was more effectively induced by magnetic stimulation. The metabolic panel indicated significant changes in the mitochondrial cellular respiration of PDLSCs MAG. The results suggested that periodontal ligament stem cells (PDLSCs) can respond to biophysical stimuli such as a time-dependent magnetic field, which is able to induce changes in cell proliferation and differentiation. Moreover, the magnetic stimulation also produced an effect on the cell metabolic profile. Therefore, the current study demonstrated that a time-dependent magnetic stimulation may improve the regenerative properties of PDLSCs.

Pain and Functional Scores in Patients Affected by Knee OA after Treatment with Pulsed Electromagnetic and Magnetic Fields: A Meta-Analysis

OBJECTIVE

The purpose of this systematic review and meta-analysis was to evaluate the effect of electromagnetic field treatment on the symptoms of knee osteoarthritis (OA). In addition, the influence of the type of control group and other covariates have been investigated to identify the sources of heterogeneity in the results of the available clinical trials.

METHODS

Randomized controlled trials reporting pulsed electromagnetic field-based therapies for the treatment of knee OA have been included. Main outcomes were self-reported pain and activity scores collected by Visual Analogue Scale (VAS) and/or Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) at short term after treatment.

RESULTS

Thirteen studies comprising 914 unique patients were included in the analysis. Overall reduction in pain score was observed after treatment (standardized mean difference -0.4059, P = 0.0091), while improvement in the activity score was not significant (standardized mean difference -0.4452, P = 0.0859). Type of control (i.e., placebo or alternative therapies) and time of follow-up resulted as the two major elements influencing the outcomes. Indeed, the restriction of the analysis to placebo-controlled trials demonstrated higher standardized mean differences between treatment and control groups, with lower P value for pain, while statistical significance became evident also for the activity score. On the contrary, no differences were observed pooling only studies comparing pulsed electromagnetic or magnetic fields to alternative treatments. In addition, longer follow-up correlated with lower differences between treated and control patients.

CONCLUSIONS

Pulsed electromagnetic field therapy effectively relieves knee OA symptoms at short term, but it is not superior to other conservative therapies such as physiotherapy.

Biophysical Stimulation in Athletes' Joint Degeneration: A Narrative Review

Osteoarthritis (OA) is the most prevalent degenerative joint disease and the main cause of pain and disability in elderly people. OA currently represents a significant social health problem, since it affects 250 million individuals worldwide, mainly adults aged over 65. Although OA is a multifactorial disease, depending on both genetic and environmental factors, it is reported that joint degeneration has a higher prevalence in former athletes. Repetitive impact and loading, joint overuse and recurrent injuries followed by a rapid return to the sport might explain athletes' predisposition to joint articular degeneration. In recent years, however, big efforts have been made to improve the prevention and management of sports injuries and to speed up the athletes' return-to-sport. Biophysics is the study of biological processes and systems using physics-based methods or based on physical principles. Clinical biophysics has recently evolved as a medical branch that investigates the relationship between the human body and non-ionizing physical energy. A physical stimulus triggers a biological response by regulating specific intracellular pathways, thus acting as a drug. Preclinical and clinical trials have shown positive effects of biophysical stimulation on articular cartilage, subchondral bone and synovia. This review aims to assess the role of pulsed electromagnetic fields (PEMFs) and extracorporeal shockwave therapy (ESWT) in the prevention and treatment of joint degeneration in athletes.

The use of an alternating magnetic field in the resorption of postoperative joint effusion following anterior cruciate ligament reconstruction: A randomized double-blind controlled trial

CONTEXT

There are no scientific reports unambiguously describing the efficacy of alternating magnetic field therapy in patients after anterior cruciate ligament (ACL) reconstruction in the early postoperative period.

OBJECTIVE

This study aims to evaluate the efficacy of using an alternating magnetic field in the resorption of postoperative joint effusion in patients after ACL reconstruction.

STUDY DESIGN

A randomized, double-blind placebo-controlled study.

SETTING

Inpatients.

PARTICIPANTS

Forty patients were enrolled in the trial. However, the final study group consisted of 38 patients (28 men and 10 women) after ACL reconstruction who were randomly divided into an experimental group (19 patients) and a control group (19 patients).

INTERVENTION

Each group received magnetic field therapy in the postoperative period, but only 1 apparatus emitted a magnetic field (the experimental group). Patients used the apparatus every day for 30 minutes for the next 11 days. The parameters in both devices were the same-3 mT and 10 Hz.

MAIN OUTCOME MEASURES

The measurement of the knee circumference and range of motion were made. The knee circumference measurement was performed before magnetic field therapy began and for 11 days after magnetic field treatment. The active knee range of motion was evaluated before and after magnetic field therapy was completed.

RESULTS

There were no statistically significant differences between the groups in the reduction of post-operative joint effusion or knee joint function.

CONCLUSION

In patients after ACL reconstruction, in whom an alternating magnetic field was used to treat postoperative joint effusion, there were no beneficial effects on the analyzed variables compared to the control group.

Advancing of titanium medical implants by surface engineering: recent progress and challenges

Introduction:Titanium (Ti) and their alloys are used as main implant materials in orthopedics and dentistry for decades having superior mechanical properties, chemical stability and biocompatibility. Their rejections due lack of biointegration and bacterial infection are concerning with considerable healthcare costs and impacts on patients. To address these limitations, conventional Ti implants need improvements where the use of surface nanoengineering approaches and the development of a new generation of implants are recognized as promising strategies.Areas covered:This review presents an overview of recent progress on the application of surface engineering methods to advance Ti implants enable to address their key limitations. Several promising surface engineering strategies are presented and critically discussed to generate advanced surface properties and nano-topographies (tubular, porous, pillars) able not only to improve their biointegration, antibacterial performances, but also to provide multiple functions such as drug delivery, therapy, sensing, communication and health monitoring underpinning the development of new generation and smart medical implants.Expert opinion:Recent advances in cell biology, materials science, nanotechnology and additive manufacturing has progressively influencing improvements of conventional Ti implants toward the development of the next generation of implants with improved performances and multifunctionality. Current research and development are in early stage, but progressing with promising results and examples of moving into in-vivo studies an translation into real applications.

Effect of dextrose phonophoresis versus pulsed electromagnetic field on temporomandibular dysfunction: A randomized, controlled study

OBJECTIVE

This study investigated and compared the efficacy of dextrose phonophoresis and Pulsed Electromagnetic Field (PEMF) on pain, range of motion (ROM) and function in patients with Temporomandibular Dysfunction (TMD).

METHODS

45 patients with TMD aging from 25 to 45 years, with mean age 29 ± 2.5 years were included in this study, they were assigned randomly into 3 equal groups each contain fifteen TMJ dysfunction patients. Group (A) in which each patient received 50% dextrose phonophoresis for 5 min and therapeutic ultrasound for 5 min, Group (B) in which each patient received Pulsed Electromagnetic Field (PEMF) with frequency of 50 HZ for 50 min, and traditional physiotherapy ultrasound for 5 min, while in the control group (C) the patients received traditional physiotherapy ultrasound for 5 min only, the frequency of treatment session in the three groups was 3 days per week for 4 weeks. The assessment tools were visual analog scale (VAS) for pain evaluation, plastic ruler for TMJ ROM measurements while Fonseca's questionnaire was used for evaluation of TM function at baseline and 4 weeks later.

RESULTS

Paired t-test for comparison between pre and post treatment measurements in each group showed significant decrease pain as well as improvement of ROM and Fonseca's questionnaire in group A and B than placebo group.

CONCLUSIONS

The results found that both dextrose phonophoresis and PEMF have beneficial effects considering pain, ROM and function in patients with (TMD).

Promising application of Pulsed Electromagnetic Fields (PEMFs) in musculoskeletal disorders

Increasing evidence suggests that an exogenous electromagnetic field might be involved in many biologic processes which are of great importance for therapeutic interventions. Pulsed electromagnetic fields (PEMFs) are known to be a noninvasive, safe and effective therapy agent without apparent side effects. Numerous studies have shown that PEMFs possess the potential to become a stand-alone or adjunctive treatment modality for treating musculoskeletal disorders. However, several issues remain unresolved. Prior to their widely clinical application, further researches from well-designed, high-quality studies are still required to standardize the treatment parameters and derive the optimal protocol for health-care decision making. In this review, we aim to provide current evidence on the mechanism of action, clinical applications, and controversies of PEMFs in musculoskeletal disorders.

Effects of Pulsed Electromagnetic Field Therapy on Pain, Stiffness, Physical Function, and Quality of Life in Patients With Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials

OBJECTIVE

Pulsed electromagnetic field (PEMF) therapy is a potentially useful treatment for osteoarthritis (OA), but its effectiveness is still controversial. This study aimed to examine the effects of PEMF therapy and PEMF parameters on symptoms and quality of life (QOL) in patients with OA.

METHODS

Cochrane Central Register of Controlled Trials, PubMed, CINAHL, EMBASE, PEDro, clinical trial registers, and reference lists were searched until April 2019. This study examined randomized, placebo-controlled trials, patients with OA, symptom and/or QOL related outcomes, and articles published in English. Two authors extracted data and completed quality assessment.

RESULTS

Sixteen studies were included in our systematic review, while 15 studies with complete data were included in the meta-analysis. Our primary outcome was the standardized mean difference, which was equal to the treatment effect in the PEMF group minus the treatment effect in the placebo group divided by the pooled standard deviation. For pain, the standardized mean difference was 1.06 (95% CI = 0.61 to 1.51), for stiffness 0.37 (95% CI = 0.07 to 0.67), for function 0.46 (95% CI = 0.14 to 0.78), and for QOL 1.49 (95% CI = -0.06 to 3.04). PEMF parameters did not influence symptoms.

CONCLUSIONS

Compared with placebo, there was a beneficial effect of PEMF therapy on pain, stiffness, and physical function in patients with OA. Duration of treatment may not be a critical factor in pain management. Further studies are required to confirm the effects of PEMF therapy on QOL.

IMPACT

Our study suggests that PEMF therapy has clinically significant effects on pain in patients with OA. The current evidence was limited to the short-term effects of PEMF therapy.

Electromagnetic Field Therapy: A Rehabilitative Perspective in the Management of Musculoskeletal Pain - A Systematic Review

Electromagnetic fields (EMFs) provide a non-invasive, safe, and easy method to treat pain with respect to musculoskeletal diseases. The purpose of this systematic review was to describe the use of electromagnetic therapy in the rehabilitation field by investigating the efficacy in acute and chronic pain in the musculoskeletal disorders. A database search was conducted using the following resources: PubMed, Cochrane, PEDro, SCOPUS, and WoS. The following MESH terms were used: [Electromagnetic field AND/OR Rehabilitation], [Electromagnetic field AND/OR Pain], [Pulsed Magnetic field AND/OR Rehabilitation] and [Pulsed Magnetic field AND/OR Pain], [Pulsed Electromagnetic field AND/OR Rehabilitation] and [Pulsed Electromagnetic field AND/OR Pain], per the guidelines of the PRISMA statement. Articles published between January 1, 2009 and December 31, 2018 were included as assessment of musculoskeletal pain conditions, randomized clinical trial including crossover and prospective design studies, full English text available, population age > 18 years; instead were excluded neurological randomized clinical trials, transcranial magnetic stimulation application, neuropathic pain, animal/in vitro studies, and articles without English abstract or English full text. Three independent investigators (AMC, NG, and LP) retrieved all the information. Twenty-one RTC (N=21) were considered for the inclusion and exclusion criteria. The results showed as pulsed magnetic fields at low intensity and frequency (from 1 Hz up to 100 Hz) are commonly used with efficacy in resolving musculoskeletal pain. EMFs therapy is a well tolerated, effective with no negative side effects, which can be integrated with rehabilitation for the treatment of chronic and acute pain in musculoskeletal diseases, but further studies are needed to examine the use of more standardized protocols.

Translational Insights into Extremely Low Frequency Pulsed Electromagnetic Fields (ELF-PEMFs) for Bone Regeneration after Trauma and Orthopedic Surgery

The finding that alterations in electrical potential play an important role in the mechanical stimulation of the bone provoked hype that noninvasive extremely low frequency pulsed electromagnetic fields (ELF-PEMF) can be used to support healing of bone and osteochondral defects. This resulted in the development of many ELF-PEMF devices for clinical use. Due to the resulting diversity of the ELF-PEMF characteristics regarding treatment regimen, and reported results, exposure to ELF-PEMFs is generally not among the guidelines to treat bone and osteochondral defects. Notwithstanding, here we show that there is strong evidence for ELF-PEMF treatment. We give a short, confined overview of in vitro studies investigating effects of ELF-PEMF treatment on bone cells, highlighting likely mechanisms. Subsequently, we summarize prospective and blinded studies, investigating the effect of ELF-PEMF treatment on acute bone fractures and bone fracture non-unions, osteotomies, spinal fusion, osteoporosis, and osteoarthritis. Although these studies favor the use of ELF-PEMF treatment, they likewise demonstrate the need for more defined and better controlled/monitored treatment modalities. However, to establish indication-oriented treatment regimen, profound knowledge of the underlying mechanisms in the sense of cellular pathways/events triggered is required, highlighting the need for more systematic studies to unravel optimal treatment conditions.

Effects of electromagnetic fields on osteoarthritis

Osteoarthritis (OA), characterized by joint malfunction and chronic disability, is the most common form of arthritis. The pathogenesis of OA is unclear, yet studies have shown that it is due to an imbalance between the synthesis and decomposition of chondrocytes, cell matrices and subchondral bone, which leads to the degeneration of articular cartilage. Currently, there are many therapies that can be used to treat OA, including the use of pulsed electromagnetic fields (PEMFs). PEMFs stimulate proliferation of chondrocytes and exert a protective effect on the catabolic environment. Furthermore, this technique is beneficial for subchondral trabecular bone microarchitecture and the prevention of subchondral bone loss, ultimately blocking the progression of OA. However, it is still unknown whether PEMFs could be used to treat OA in the clinic. Furthermore, the deeper signaling pathways underlying the mechanism by which PEMFs influence OA remain unclear.

Engineered titanium implants for localized drug delivery: recent advances and perspectives of Titania nanotubes arrays

INTRODUCTION

Therapeutics delivery to bones to treat skeletal diseases or prevent postsurgical infections is challenging due to complex and solid bone structure that limits blood supply and diffusion of therapeutics administered by systemic routes to reach effective concentration. Titanium (Ti) and their alloys are employed as mainstream implant materials in orthopedics and dentistry; having superior mechanical/biocompatibility properties which could provide an alternative solution to address this problem.

AREAS COVERED

This review presents an overview of recent development of Ti drug-releasing implants, with emphasis on nanoengineered Titania nanotubes (TNTs) structures, for solving key problems to improve implants osseointegration, overcome inflammation and infection together with providing localized drug delivery (LDD) for bone diseases including cancer. Critical analysis of the advantages/disadvantages of developed concepts is discussed, their drug loading/releasing performances and specific applications.

EXPERT OPINION

LDD to bones can address many disorders and postsurgical conditions such as inflammation, implants rejection and infection. To this end, TNTs-Ti implants represent a potential promise for the development of new generation of multifunctional implants with drug release functions. Even this concept is extensively explored recently, there is a strong need for more preclinical studies using animal models to confirm the long-term safety and stability of TNTs-Ti implants for real-life medical applications.

Clinical results of pulsed signal therapy on patellofemoral syndrome with patellar chondropathy

This study was designed to evaluate the effect of pulsed signal therapy (PST) on patellofemoral pain syndrome associated with patellar chondropathy. A prospective randomized double-blind placebo controlled trial included 25 patients (41 knees) between 20 and 50 years with pain due to isolated patellofemoral syndrome with chondropathy. PST group received nine 60-min daily sessions of PST treatment. Control group received the same protocol of blinded placebo treatment. The main outcome was change from baseline Kujala score at 3 months. After 3 months, patients in the control group received effective treatment (placebo post-treatment). All patients were then followed, for up to 12 months. Seventeen knees (5 males and 12 females, mean age 36.7 ± 7.9) received placebo and 24 knees (8 males and 16 females, mean age 35.5 ± 8.9) received PST. By the third month, PST group exhibited a mean change from baseline of 9.63 ± 7.5 Kujala points, compared to 0.53 ± 1.8 in the placebo group (P < 0.001). A significant progressive improvement was seen in the PST group between the 3rd and 6th and between the 6th and 12th month (P < 0.016). Patients initially allocated in the control group also improved at 3 months (P < 0.001) and 6 months (P = 0.005) post-effective treatment. In conclusion, PST in patellofemoral pain syndrome with chondropathy was effective compared to placebo at 3 months, showing an important improvement of Kujala score. The improvement was progressive and maintained up to 12 months. PST is safe and should be considered as a non-invasive option for management of this condition. Bioelectromagnetics. 40:83-90, 2019. © 2019 Bioelectromagnetics Society.

Efficacy and safety of the pulsed electromagnetic field in osteoarthritis: a meta-analysis

OBJECTIVE

To investigate the efficacy and safety of the pulsed electromagnetic field (PEMF) therapy in treating osteoarthritis (OA).

DESIGN

Meta-analysis.

DATA SOURCES

PubMed, Embase, the Cochrane Library and Web of Science were searched through 13 October 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials compared the efficacy of PEMF therapy with sham control in patients with OA.

DATA EXTRACTION AND SYNTHESIS

Pain, function, adverse effects and characteristics of participants were extracted. RevMan V.5.2 was used to perform statistical analyses.

RESULTS

Twelve trials were included, among which ten trials involved knee OA, two involved cervical OA and one involved hand OA. The PEMF group showed more significant pain alleviation than the sham group in knee OA (standardised mean differences (SMD)=-0.54, 95% CI -1.04 to -0.04, p=0.03) and hand OA (SMD=-2.85, 95% CI -3.65 to -2.04, p<0.00001), but not in cervical OA. Similarly, comparing with the sham-control treatment, significant function improvement was observed in the PEMF group in both knee and hand OA patients (SMD=-0.34, 95% CI -0.53 to -0.14, p=0.0006, and SMD=-1.49, 95% CI -2.12 to -0.86, p<0.00001, respectively), but not in patients with cervical OA. Sensitivity analyses suggested that the exposure duration <=30 min per session exhibited better effects compared with the exposure duration >30 min per session. Three trials reported adverse events, and the combined results showed that there was no significant difference between PEMF and the sham group.

CONCLUSIONS

PEMF could alleviate pain and improve physical function for patients with knee and hand OA, but not for patients with cervical OA. Meanwhile, a short PEMF treatment duration (within 30 min) may achieve more favourable efficacy. However, given the limited number of study available in hand and cervical OA, the implication of this conclusion should be cautious for hand and cervical OA.

No effect of a pulsed magnetic field on induced ischemic muscle pain. A double-blind, randomized, placebo-controlled trial

Empirical evidence supporting the effectiveness of pulsed (electro)magnetic field (PEMF) therapy on chronic and acute pain is equivocal. In the current randomized, double-blind, placebo-controlled experiment, impact of a commercially available whole-body PEMF mat on acute ischemic muscle pain induced in the forearm was studied with the participation of 70 healthy volunteers. The device emitted a pulsed magnetic field with a repetition frequency of 2.05Hz and a maximum flux density of 25.3μT (rms). The highest dB/dt was 48mT/s. No differences between the groups receiving actual and sham PEMF were found in terms of pain threshold, pain tolerance, heart rate, and perceived decrease of pain. However, participants' expectation concerning the effectiveness of the intervention improved pain tolerance and affected perceived change of pain. In conclusion, the used PEMF device had no specific effect on acute ischemic muscle pain, while the contribution of the placebo effect was considerable.

Phisical modalities on the functional performance in knee osteoarthritis: a sytematic review

Abstract Introduction: Despite recent advances in the treatment of osteoarthritis (OA), few studies have evaluated the longitudinal effect of physical modalities in functional capacity in patients with knee OA. Thereby, since the physical components and pain can affect the functional performance of daily activities, the effect of these treatment’s form is still to be established. Objective: Evaluate the effectiveness of therapeutic ultrasound, electrical stimulation and phototherapy in the functional performance, in patients with knee osteoarthritis. Methods: Articles present in the PubMed, Lilacs, SciELO and PEDro’s databases were evaluated. The used keywords were “pulsed ultrasound therapy”, “ultrasound therapy”, “electric stimulation” and “low level laser therapy” in combination with “knee osteoarthritis”. Were included in this presented review, randomized clinical studies using ultrasound, electrical and laser stimulation in subjects with knee osteoarthritis. To evaluate the methodological quality of the selected studies, was used the PEDro’s scale. The dependent variables of the study were: pain, physical function, joint stiffness, life quality and functional performance. Results: 268 studies were found, of these, 41 studies met eligibility criteria and were classified for analysis in full. The used methodology in the studies varied widely, however, in most cases there was improvement in functional performance of individuals with knee OA, with the use of physical modalities, for the pulsed ultrasound, continuous ultrasound, electrical stimulation and laser resourses. Conclusion: The physical modalities used in the studies demonstrated improvement in functional performance of individuals with knee OA.

[Knee joint pain with signs of arthrosis]

Chronic pain in the knee joint is most commonly caused by osteoarthritis, especially in elderly patients but can be due to other causes, such as rheumatoid arthritis. The diagnostics include an exact patient medical history and a clinical examination, which often already provide clear indications of the cause of the knee pain. Subsequently, further diagnostics can then be considered, such as radiological procedures and laboratory diagnostics. The treatment is determined by the cause and the individual patient and aims to reduce pain and to preserve the mobility of the joint. Generally, therapy consists of pain management and physiotherapy as well as alternative therapeutic procedures, mostly in combination. Proximal tibial opening wedge osteotomy can be useful; however, partial or total knee arthroplasty should only be considered when conservative treatment options have been exhausted.

Static or dynamic low-frequency magnetic field? A review of literature

The therapeutic application of magnetic fi elds has experienced signifi cant growth in recent years. A small number of contraindications, as well as the lack of side effects makes both permanent magnets and alternating magnetic fi elds frequently used in physical therapy practice. In a signifi cant number of clinical studies the effi cacy of this physical factor as both an independent method, as well as supporting treatment programs has been confi rmed. In the last few years, a lot of emphasis is put on the fact that all therapeutic methods should have a scientifi c basis and their usage should meet the evidence based medicine criteria (EBM). Therefore, this work will focus on comparison of the use of permanent magnets and alternating low-frequency magnetic fi eld on the basis of the available literature, including mainly, a randomized double-blind trial. Analysis of the available literature on permanent magnet usage has shown clinical effi cacy in many diseases, however, placebo-controlled studies confi rm mainly the analgesic effect in patients after liposuction surgery, with diabetic neuropathy and with chronic pelvic pain. The use of the alternating low-frequency magnetic fi eld also leaves many questions to which scientists have still not found the answer. Randomized double-blind trial proved its therapeutic effi cacy in patients after knee arthroscopy, fractures and delayed bone unions, knee and cervical spine osteoarthritis as well as in case of leg ulceration. Alternating magnetic fi eld application has a wider therapeutic range in comparison to permanent magnets and its effectiveness is much better documented, both in clinical studies as well as randomized double-blind trials. Cite this article as: Głąb G., Dudek J., Klimek K., Skalska-Dulińska B., Chrabota U., Chojak-Fijałka K., Ridan T., Glodzik J. Static or dynamic low-frequency magnetic field? A review of literature. Med Rehabil 2016; 20(2): 31-35.

The use of electric, magnetic, and electromagnetic field for directed cell migration and adhesion in regenerative medicine

Directed cell migration and adhesion is essential to embryonic development, tissue formation and wound healing. For decades it has been reported that electric field (EF), magnetic field (MF) and electromagnetic field (EMF) can play important roles in determining cell differentiation, migration, adhesion, and evenwound healing. Combinations of these techniques have revealed new and exciting explanations for how cells move and adhere to surfaces; how the migration of multiple cells are coordinated and regulated; how cellsinteract with neighboring cells, and also to changes in their microenvironment. In some cells, speed and direction are voltage dependent. Data suggests that the use of EF, MF and EMF could advance techniques in regenerative medicine, tissue engineering and wound healing. © 2016 American Institute of Chemical Engineers Biotechnol. Prog., 33:5-16, 2017.

Titania nanotubes for orchestrating osteogenesis at the bone-implant interface

Titanium implants can fail due to inappropriate biomechanics at the bone-implant interface that leads to suboptimal osseointegration. Titania nanotubes (TNTs) fabricated on Ti implants by the electrochemical process have emerged as a promising modification strategy to facilitate osseointegration. TNTs enable augmentation of bone cell functions at the bone-implant interface and can be tailored to incorporate multiple functionalities including the loading of active biomolecules into the nanotubes to target anabolic processes in bone conditions such as osteoporotic fractures. Advanced functions can be introduced, including biopolymers, nanoparticles and electrical stimulation to release growth factors in a desired manner. This review describes the application of TNTs for enhancing osteogenesis at the bone-implant interface, as an alternative approach to systemic delivery of therapeutic agents.

Pulsed electromagnetic field (PEMF) treatment reduces expression of genes associated with disc degeneration in human intervertebral disc cells

BACKGROUND CONTEXT

Pulsed electromagnetic field (PEMF) therapies have been applied to stimulate bone healing and to reduce the symptoms of arthritis, but the effects of PEMF on intervertebral disc (IVD) biology is unknown.

PURPOSE

The purpose of this study was to determine how PEMF affects gene expression of IVD cells in normal and inflammatory environments.

STUDY DESIGN/SETTING

This was an in vitro human cell culture and microarray gene expression study.

METHODS

Human annulus fibrosus (AF) and nucleus pulposus (NP) cells were separately encapsulated in alginate beads and exposed to interleukin 1α (IL-1α) (10 ng/mL) to stimulate the inflammatory environment associated with IVD degeneration and/or stimulated by PEMF for 4 hours daily for up to 7 days. RNA was isolated from each treatment group and analyzed via microarray to assess IL-1α- and PEMF-induced changes in gene expression.

RESULTS

Although PEMF treatment did not completely inhibit the effects of IL-1α, PEMF treatment lessened the IL-1α-induced upregulation of genes expressed in degenerated IVDs. Consistent with our previous results, after 4 days, PEMF tended to reduce IL-1α-associated gene expression of IL-6 (25%, p=.07) in NP cells and MMP13 (26%, p=.10) in AF cells. Additionally, PEMF treatment significantly diminished IL-1α-induced gene expression of IL-17A (33%, p=.01) and MMP2 (24%, p=.006) in NP cells and NFκB (11%, p=.04) in AF cells.

CONCLUSIONS

These results demonstrate that IVD cells are responsive to PEMF and motivate future studies to determine whether PEMF may be helpful for patients with IVD degeneration.

Effect of pulsed electromagnetic field therapy on experimental pain: A double-blind, randomized study in healthy young adults

Previous studies suggested that pulsed electromagnetic field (PEMF) therapy can decrease pain. To date, however, it remains difficult to determine whether the analgesic effect observed in patients are attributable to a direct effect of PEMF on pain or to an indirect effect of PEMF on inflammation and healing. In the present study, we used an experimental pain paradigm to evaluate the direct effect of PEMF on pain intensity, pain unpleasantness, and temporal summation of pain. Twenty-four healthy subjects (mean age 22 ± 2 years; 9 males) participated in the experiment. Both real and sham PEMF were administered to every participant using a randomized, double-blind, cross-over design. For each visit, PEMF was applied for 10 minutes on the right forearm using a portable device. Experimental pain was evoked before (baseline) and after PEMF with a 9 cm(2) Pelletier-type thermode, applied on the right forearm (120 s stimulation; temperature individually adjusted to produce moderate baseline pain). Pain intensity and unpleasantness were evaluated using a 0-100 numerical pain rating scale. Temporal summation was evaluated by comparing pain intensity ratings obtained at the end of tonic nociceptive stimulation (120 s) with pain intensity ratings obtained after 60 s of stimulation. When compared to baseline, there was no change in pain intensity and unpleasantness following the application of real or sham PEMF. PEMF did not affect temporal summation. The present observations suggest that PEMF does not directly influence heat pain perception in healthy individuals.

Experimentally induced cartilage degeneration treated by pulsed electromagnetic field stimulation; an in vitro study on bovine cartilage

BACKGROUND

Osteoarthritis (OA) is the final result of progressive alterations to articular cartilage structure, composition and cellularity, followed by an increase in the concentration of pro-inflammatory cytokines in joint synovial fluid. Even though the effect of pulsed electromagnetic field (PEMF) stimulation in counteracting OA progression and inflammation is of increasing interest, because of its anabolic and anti-inflammatory properties, the present study aimed to improve the knowledge on cartilage extracellular matrix (ECM) and chondrocyte changes related to the exposure of PEMF, from a histological and histomorphometric point of view.

METHODS

An in vitro OA model was realized, culturing bovine cartilage explants with a high dose of interleukin 1β (IL1β, 50 ng/ml) at different experimental times (24 h, and 7 and 21 days). The effects of PEMFs (75 Hz, 1.5 mT) were evaluated in cartilage explants treated with IL1β or not (control), in terms of cartilage structure, cellularity and proteoglycans, glycosaminoglycans, collagen II and transforming growth factor β1 synthesis by using histology, histomorphometry and immunohistochemistry.

RESULTS

Making a comparison with control cartilage, IL1β-treated explants showed a decrease in cartilage matrix, structure and cellularity parameters. PEMFs were able to counteract the progression of OA acting on both cartilage cellularity and ECM in cartilage previously treated with IL1β. Normal distribution (Kolmogroc-Smirnov test) and homoscedasticity (Levene test) of data were verified, then, the non-parametric Kruskal Wallis test followed by Mann-Whiteny U test for pairwise comparisons were performed. The p-value was adjusted according to the Dunn-Sidak correction.

CONCLUSIONS

These results, obtained by culturing and treating cartilage explants from two different joints, confirmed that PEMF stimulation can be used as adjuvant therapy to preserve cartilage from detrimental effects of high inflammatory cytokine levels during OA.

BEMER Therapy Combined with Physiotherapy in Patients with Musculoskeletal Diseases: A Randomised, Controlled Double Blind Follow-Up Pilot Study

Background. This study evaluates the effect of adjuvant BEMER therapy in patients with knee arthrosis and chronic low back pain in a randomized double blind design. Methods. A total of 50 patients with chronic low back pain and 50 patients with osteoarthritis of knee took part in this study and were randomized into 4 groups. Hospitalized patients received a standardized physiotherapy package for 3 weeks followed by BEMER therapy or placebo. Results. In patients with low back pain, the comparison of the results obtained at the first and second visit showed a significant improvement in resting VAS scores and Fatigue Scale scores. The Oswestry scores and Quality of Life Scale scores showed no change. In patients with knee arthrosis, the comparison of the first and second measurements showed no significant improvement in the abovementioned parameters, while the comparison of the first and third scores revealed a significant improvement in the Fatigue Scale scores and in the vitality test on the Quality of Life Scale. Conclusions. Our study showed that BEMER physical vascular therapy reduced pain and fatigue in the short term in patients with chronic low back pain, while long-term therapy appears to be beneficial in patients with osteoarthritis of knee.

Symptomatic Early Osteoarthritis of the Knee Treated With Pulsed Electromagnetic Fields: Two-Year Follow-up

OBJECTIVE

In vitro and in vivo studies have proven a pro-anabolic and anti-catabolic activity within cartilage with the use of pulsed electromagnetic fields (PEMFs). This has piqued interest of sports physicians for its use in the treatment of early osteoarthritis (OA). The aim was to determine if the use of PEMFs in patients with early OA of the knee would lead to an improved clinical outcome.

STUDY DESIGN

Prospective case series.

METHODS

Twenty-two patients aged between 30 and 60 years who underwent treatment with PEMFs (4-hour treatment per day, duration 45 days) were included. All patients presented with symptomatic early OA with grade 0-2 changes (Kellgren-Lawrence classification) at the pretreatment evaluation. Patients were evaluated before treatment, at 1- and 2-year follow-up using visual analogue scale for pain, International Knee Documentation Committee objective, Tegner, and Knee Injury and Osteoarthritis Outcome Scores.

RESULTS

A significant improvement in all scores was observed at 1-year follow-up (P = 0.008). At 2-year follow-up, results deteriorated but were still superior to pretreatment levels (P = 0.02). No adverse reactions or side effects were seen.

CONCLUSIONS

This study showed that the use of PEMFs in patients with symptomatic early OA of the knee led to significant improvement in symptoms, knee function, and activity at 1-year follow-up. There was a significant decline in all the scores at 2-year follow-up.

The effects of pulsed electromagnetic field on the functions of osteoblasts on implant surfaces with different topographies

The use of pulsed electromagnetic fields (PEMFs) is a promising approach to promote osteogenesis. However, few studies have reported the effects of this technique on the osseointegration of endosseous implants, especially with regard to different implant topographies. We focused on how the initial interaction between cells and the titanium surface is enhanced by a PEMF and the possible regulatory mechanisms in this study. Rat osteoblasts were cultured on three types of titanium surfaces (Flat, Micro and Nano) under PEMF stimulation or control conditions. Protein adsorption was significantly increased by the PEMF. The number of osteoblasts attached to the surfaces in the PEMF group was substantially greater than that in the control group after 1.5h incubation. PEMF stimulation oriented the osteoblasts perpendicular to the electromagnetic field lines and increased the number of microfilaments and pseudopodia formed by the osteoblasts. The cell proliferation on the implant surfaces was significantly promoted by the PEMF. Significantly increased extracellular matrix mineralization nodules were observed under PEMF stimulation. The expression of osteogenesis-related genes, including BMP-2, OCN, Col-1,ALP, Runx2 and OSX, were up-regulated on all the surfaces by PEMF stimulation. Our findings suggest that PEMFs enhance the osteoblast compatibility on titanium surfaces but to different extents with regard to implant surface topographies. The use of PEMFs might be a potential adjuvant treatment for improving the osseointegration process.

Electromagnetic fields for treating osteoarthritis

BACKGROUND

This is an update of a Cochrane review first published in 2002. Osteoarthritis is a disease that affects the synovial joints, causing degeneration and destruction of hyaline cartilage and subchondral bone. Electromagnetic field therapy is currently used by physiotherapists and may promote growth and repair of bone and cartilage. It is based on principles of physics which include Wolff's law, the piezoelectric effect and the concept of streaming potentials.

OBJECTIVES

To assess the benefits and harms of electromagnetic fields for the treatment of osteoarthritis as compared to placebo or sham.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9), PreMEDLINE for trials published before 1966, MEDLINE from 1966 to October 2013, CINAHL and PEDro up to and including October 2013. Electronic searches were complemented by handsearches.

SELECTION CRITERIA

Randomised controlled trials of electromagnetic fields in osteoarthritis, with four or more weeks treatment duration. We included papers in any language.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion in the review and resolved differences by consensus with a third review author. We extracted data using pre-developed data extraction forms. The same review authors assessed the risk of bias of the trials independently using the Cochrane 'Risk of bias' tool. We extracted outcomes for osteoarthritis from the publications according to Outcome Measures in Rheumatology Clinical Trials (OMERACT) guidelines. We expressed results for continuous outcome measures as mean difference (MD) or standardised mean difference (SMD) with 95% confidence interval (CI). We pooled dichotomous outcome measures using risk ratio (RR) and calculated the number needed to treat (NNT).

MAIN RESULTS

Nine studies with a total of 636 participants with osteoarthritis were included, six of which were added in this update of the review. Selective outcome reporting was unclear in all nine included studies due to inadequate reporting of study design and conduct, and there was high risk of bias for incomplete outcome data in three studies. The overall risk of bias across the nine studies was low for the other domains.Participants who were randomised to electromagnetic field treatment rated their pain relief 15.10 points more on a scale of 0 to 100 (MD 15.10, 95% CI 9.08 to 21.13; absolute improvement 15%) after 4 to 26 weeks' treatment compared with placebo. Electromagnetic field treatment had no statistically significant effect on physical function (MD 4.55, 95% CI -2.23 to 11.32; absolute improvement 4.55%) based on the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) scale from 0 to 100 after 12 to 26 weeks' treatment. We also found no statistically significant difference in quality of life on a scale from 0 to 100 (SMD 0.09, 95% CI -0.36 to 0.54; absolute improvement 0.09%) after four to six weeks' treatment, based on the SF-36. No data were available for analysis of radiographic changes. Safety was evaluated in four trials including up to 288 participants: there was no difference in the experience of any adverse event after 4 to 12 weeks of treatment compared with placebo (RR 1.17, 95% CI 0.72 to 1.92). There was no difference in participants who withdrew because of adverse events (measured in one trial) after four weeks of treatment (RR 0.90, 95% CI 0.06 to 13.92). No participants experienced any serious adverse events.

AUTHORS' CONCLUSIONS

Current evidence suggests that electromagnetic field treatment may provide moderate benefit for osteoarthritis sufferers in terms of pain relief. Further studies are required to confirm whether this treatment confers clinically important benefits in terms of physical function and quality of life. Our conclusions are unchanged from the previous review conducted in 2002.

Pulsed electromagnetic field therapy for management of osteoarthritis-related pain, stiffness and physical function: clinical experience in the elderly

BACKGROUND

Pulsed electromagnetic field (PEMF) therapy has shown promising therapeutic effectiveness on bone- and cartilage-related pathologies, being also safe for management of knee osteoarthritis.

AIM

The aim of this study was to investigate the clinical efficacy of a PEMF device for management of knee osteoarthritis in elderly patients.

MATERIALS AND METHODS

A total of 33 patients were screened, and 28 patients, aged between 60 and 83 and affected by bilateral knee osteoarthritis, were enrolled in this study. They received PEMF therapy on the right leg for a total of three 30-minute sessions per week for a period of 6 weeks, while the left leg did not receive any treatment and served as control. An intravenous drip containing ketoprofen, sodium clodronate, glucosamine sulfate, calcitonin, and ascorbic acid, for a total volume of 500 mL, was administered during PEMF therapy. At baseline and 3 months post-PEMF therapy, Visual Analog Scale (VAS) was used to assess knee pain and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) was used to measure knee pain, stiffness and physical function.

RESULTS

Changes in VAS and WOMAC scores were calculated for both knees as baseline minus post-treatment. A two sample Student's t-test, comparing change in knee-related VAS pain for PEMF-treated leg (49.8 ± 2.03) vs control leg (11 ± 1.1), showed a significant difference in favor of PEMF therapy (P < 0.001). A two sample Student's t-test comparing change in knee-related WOMAC pain, stiffness, and physical function for PEMF-treated leg (8.5 ± 0.4, 3.5 ± 0.2, 38.5 ± 2.08, respectively) vs control leg (2.6 ± 0.2; 1.6 ± 0.1; 4.5 ± 0.5 respectively), also showed a significant difference in favor of PEMF therapy (P < 0.001). No adverse reactions to therapy were observed.

CONCLUSION

The present study shows that PEMF therapy improves pain, stiffness and physical function in elderly patients affected by knee osteoarthritis.

Efficacy of low frequency pulsed subsensory threshold electrical stimulation vs placebo on pain and physical function in people with knee osteoarthritis: systematic review with meta-analysis

OBJECTIVE

To determine if low frequency (≤100 Hz) pulsed subsensory threshold electrical stimulation produced either through pulsed electromagnetic field (PEMF) or pulsed electrical stimulation (PES) vs sham PEMF/PES intervention is effective in improving pain and physical function at treatment completion in adults with knee osteoarthritis (OA) blinded to treatment.

METHOD

The relevant studies were identified by searching eight electronic databases and hand search of the past systematic reviews on the same topic till April 5, 2012. We included randomized controlled trials (RCTs) of people with knee OA comparing the outcomes of interest for those receiving PEMF/PES with those receiving sham PEMF/PES. Two reviewers independently selected studies, extracted relevant data and assessed quality. Pooled analyses were conducted using inverse-variance random effects models and standardized mean difference (SMD) for the primary outcomes.

RESULTS

Seven small trials (459 participants/knees) were included. PEMF/PES improves physical function (SMD = 0.22, 95% confidence interval (CI) = 0.04, 0.41, P = 0.02, I(2) = 0%), and does not reduce pain (SMD = 0.08, 95% CI = -0.17, 0.32, P = 0.55, I(2) = 43%). The strength of the body of evidence was low for physical function and very low for pain.

CONCLUSION

Current evidence of low and very low quality suggests that low frequency (≤100 Hz) pulsed subsensory threshold electrical stimulation produced either through PEMF/PES vs sham PEMF/PES is effective in improving physical function but not pain intensity at treatment completion in adults with knee OA blinded to treatment. Methodologically rigorous and adequately powered RCTs are needed to confirm the findings of this review.

Effect of regenerative injection therapy on function and pain in patients with knee osteoarthritis: a randomized crossover study

OBJECTIVE

We assessed the effectiveness of regenerative injection therapy (RIT) to relieve pain and restore function in patients with knee osteoarthritis.

DESIGN

Crossover study where participants were randomly assigned to receive exercise therapy for 32 weeks in combination with RIT on weeks 0, 4, 8, and 12 or RIT on weeks 20, 24, 28, and 32.

PATIENTS

Thirty-six patients with chronic knee osteoarthritis.

INTERVENTIONS

RIT, which is made up of injections of 1 cc of 15% dextrose 0.6% lidocaine in the collateral ligaments and a 5 cc injection of 20% dextrose 0.5% lidocaine inside the knee joint.

OUTCOME MEASURES

The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index of severity of osteoarthrosis symptoms (WOMAC) score (range: 0-96).

RESULTS

Following 16 weeks of follow-up, the participants assigned to RIT presented a significant reduction of their osteoarthritis symptoms (mean ± standard deviation: -21.8 ± 12.5, P < 0.001). WOMAC scores in this group did not change further during the last 16 weeks of follow-up, when the participants received exercise therapy only (-1.2 ± 10.7, P = 0.65). WOMAC scores in the first 16 weeks did not change significantly among the participants receiving exercise therapy only during this period (-6.1±13.9, P=0.11). There was a significant decrease in this groups' WOMAC scores during the last 16 weeks when the participants received RIT (-9.3±11.4, P=0.006). After 36 weeks, WOMAC scores improved in both groups by 47.3% and 36.2%. The improvement attributable to RIT alone corresponds to a 11.9-point (or 29.5%) decrease in WOMAC scores.

CONCLUSIONS

The use of RIT is associated with a marked reduction in symptoms, which was sustained for over 24 weeks.

Physiatric approaches to pain management in osteoarthritis: a review of the evidence of effectiveness

SUMMARY Osteoarthritis (OA), which is highly prevalent in the general population, is one of the leading causes of pain and physical disability. A large number of nonpharmacological interventions are available for the management of pain in patients with OA. These include education and self-management, weight reduction, various forms of exercises, physical agents/modalities, complementary therapies, manual therapy, unloading strategies such as braces and orthoses, and balneotherapy. The aim of this article is to assess the evidence of effectiveness of nonpharmacological interventions pertaining to physiatry to identify best practices for pain management in OA.

Osteoarthritis year 2010 in review: non-pharmacologic therapy

OBJECTIVE

To highlight seminal publications in the past year on the topic of non-pharmacologic management of osteoarthritis (OA).

DESIGN

A systematic search of the PUBMED and Cochrane databases from September 2009 to September 2010 was conducted to identify articles reporting on studies examining the safety or efficacy of non-pharmacologic therapies in the management of OA. Non-pharmacologic therapies were those considered in the 2008 OARSI OA guidelines. Identified articles were reviewed for quality; those of highest quality and deemed to have greatest potential impact on the management of OA were summarized.

RESULTS

The search identified 117 unique articles. Of these, four studies were chosen to highlight. A nested two-stage trial found that traditional Chinese acupuncture (TCA) was not superior to sham acupuncture, but that the providers' style affected both pain reduction and satisfaction with treatment, suggesting that the analgesic benefits of acupuncture may be partially mediated by the acupuncturists' behavior. A systematic review found little evidence of a significant effect for electrostimulation vs sham or no intervention on pain in knee OA. A single-blinded trial of Tai Chi vs attention controls found that 12 weeks of Tai Chi was associated with improvements in symptoms and disability in patients with knee OA. A randomized trial of early ACL reconstructive surgery and rehabilitation vs structured rehabilitation alone in subjects with acute anterior cruciate ligament tears found that, at 24 months following randomization, all study participants had improved, suggesting that a strategy of structured rehabilitation followed acute ACL injury may preclude the need for surgical reconstruction.

CONCLUSIONS

High quality studies of the safety and efficacy of non-pharmacologic agents in the management of OA remain challenging due to difficulties with adequate blinding and appropriate selection of attention controls. High quality studies suggest modest, if any, benefit of many non-pharmacologic therapies over attention control or placebo, but a significant impact of both over no intervention at all.