Short-term effectiveness of ultrasound therapy in knee osteoarthritis

Jingle Cell Rock: Steering Cellular Activity With Low-Intensity Pulsed Ultrasound (LIPUS) to Engineer Functional Tissues in Regenerative Medicine

Acoustic manipulation or perturbation of biological soft matter has emerged as a promising clinical treatment for a number of applications within regenerative medicine, ranging from bone fracture repair to neuromodulation. The potential of ultrasound (US) endures in imparting mechanical stimuli that are able to trigger a cascade of molecular signals within unscathed cells. Particularly, low-intensity pulsed ultrasound (LIPUS) has been associated with bio-effects such as activation of specific cellular pathways and alteration of cell morphology and gene expression, the extent of which can be modulated by fine tuning of LIPUS parameters including intensity, frequency and exposure time. Although the molecular mechanisms underlying LIPUS are not yet fully elucidated, a number of studies clearly define the modulation of specific ultrasonic parameters as a means to guide the differentiation of a specific set of stem cells towards adult and fully differentiated cell types. Herein, we outline the applications of LIPUS in regenerative medicine and the in vivo and in vitro studies that have confirmed the unbounded clinical potential of this platform. We highlight the latest developments aimed at investigating the physical and biological mechanisms of action of LIPUS, outlining the most recent efforts in using this technology to aid tissue engineering strategies for repairing tissue or modelling specific diseases. Ultimately, we detail tissue-specific applications harnessing LIPUS stimuli, offering insights over the engineering of new constructs and therapeutic modalities. Overall, we aim to lay the foundation for a deeper understanding of the mechanisms governing LIPUS-based therapy, to inform the development of safer and more effective tissue regeneration strategies in the field of regenerative medicine.

Ultrasound therapy for pain reduction in musculoskeletal disorders: a systematic review and meta-analysis

Background

Ultrasound therapy is a non-invasive technique used to address a variety of health issues.

Objectives

This systematic review and meta-analysis aim to assess the effectiveness of ultrasound therapy in alleviating pain associated with musculoskeletal diseases.

Design

This study was conducted following PRISMA guidelines, with relevant articles identified through comprehensive searches in electronic databases.

Data sources and methods

We conducted searches across multiple databases, including Scopus, PubMed, MEDLINE, ProQuest, Science Direct, CINAHL, AIM, and ELDIS. Two independent reviewers screened the titles and abstracts of the retrieved articles. We included randomized controlled trials (RCTs) and observational cohort studies published between 2010 and 2023 that evaluated ultrasound therapy for knee and shoulder skeletal disorders. The selected data were analyzed qualitatively and synthesized, with the risk of bias assessed using the RoB2 tool.

Results

Initially, 117 articles were reviewed using the search strategy, and 10 trials that met the inclusion criteria were identified. In seven of these studies, the primary musculoskeletal disorder was osteoarthritis, while three studies focused on shoulder pain and impingement. Most studies indicated that ultrasound therapy significantly reduced pain. The meta-analysis showed that ultrasound therapy was significantly more effective than other interventions for knee disorders (I 2 = 51%, Z = 2.65, p = 0.008). However, for shoulder disorders, both ultrasound and other intervention methods were found to be ineffective (I 2 = 93%, Z = 0.73, p = 0.46).

Conclusion

The current evidence supports the effectiveness of ultrasound therapy in reducing pain and aiding rehabilitation for knee conditions. However, there are mixed results regarding its efficacy for shoulder conditions, highlighting the need for further research in this area.

Evaluation of the effect of low-intensity pulsed ultrasound in pain and dysfunction for knee osteoarthritis: a double-blind, randomised controlled trial protocol

INTRODUCTION

Osteoarthritis (OA) is the most common joint disorder among musculoskeletal conditions. Non-surgical treatment is the standard therapy for knee OA (KOA). Ultrasound therapy is recommended for alleviating pain and dysfunction from OA, but high-quality scientific evidence for its effectiveness in OA treatment is still lacking.Therefore, we want to analyse whether combining conventional physical therapy with low-intensity pulsed ultrasound (LIPUS) can enhance the efficacy of conventional therapy, thus improving symptoms in patients with KOA.

METHODS AND ANALYSIS

This randomised controlled trial aims to recruit 200 patients diagnosed with KOA, aged 38 years or above, who meet the clinical diagnostic criteria for KOA. Patients will be randomly assigned in a 1:1 ratio to either a LIPUS treatment group or a sham ultrasound treatment control group. The 2-week treatment will consist of five sessions per week and evaluations will take place at baseline, on the day of the last intervention and 1 month post intervention. The main outcome measures will be the Western Ontario and McMaster Universities' scores. Secondary outcome indicators will be the Numerical Pain Rating Scale, the Lequesne scale, the time up and go test and the range of motion of the knee. An intention-to-treat analysis will be performed for dropouts and missing data.

ETHICS AND DISSEMINATION

The study was approved by the ethics committee of Shengjing Hospital of China Medical University (2023PS592K). Findings will be disseminated to participants and made available to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

The trial was registered on the Chinese Clinical Trial Registry platform (chictr.org.cn) on 22 March 2023, with the registration ID ChiCTR2300069643.

Effects of therapeutic ultrasound in patients with knee osteoarthritis: A systematic review and meta-analysis

Background

Therapeutic ultrasound (US) is a treatment for knee osteoarthritis (KOA), but its efficacy and safety are unclear. The objective of this study is to quantify the effect of US on pain relief and function recovery in KOA, and to analyze the US treatment duration and parameters on treatment outcome.

Methods

We searched PubMed, MEDLINE, EMBASE, Google Scholar, Cochrane databases and ClinicalTrials.gov databases up to April 7, 2023. RCTs that compared the efficacy of therapeutic US with the control in KOA were included in the study, and the methodological quality of the trials was assessed using the Cochrane Risk of Bias tool.

Results

Twenty-one RCTs (1315 patients) were included. US had a positive effect on visual analog scale (VAS) (SMD = -0.64, 95 % CI [-0.88, -0.40], I2 = 71 %) and Western Ontario and McMaster Universities (WOMAC) total scale (SMD = -0.45, 95 % CI [-0.69, -0.20]; I2 = 67 %). Pulsed US with an intensity ≤2.5 W/cm2 reduced visual analog scale (VAS), and differed in sessions (24 sessions (SMD = -0.80, 95 % CI [-1.07, -0.53], I2 = 0 %) vs 10 sessions (SMD = -0.71, 95 % CI [-1.09, -0.33], I2 = 68 %)). For pulsed US, a duration of treatment of 4-8 weeks (SMD = -0.69, 95 % CI [-1.13, -0.25], I2 = 73 %) appeared to be superior to ≤4 weeks (SMD = -0.77, 95 % CI [-1.04, -0.49], I2 = 0 %) for reducing visual analog scale (VAS). No US treatment-related adverse events were reported.

Conclusion

Therapeutic US may be a safe and effective treatment for patients with KOA. The mode, intensity, frequency, and duration of US may affect the effectiveness of pain relief. Pulsed US with an intensity ≤2.5 W/cm2, 24 sessions, and a treatment duration of ≤4 weeks appears to have better pain relief.

Effectiveness of Rehabilitation for Osteoarthritis of the Knee: A Scoping Review of Network Meta-Analyses

BACKGROUND

 Although an increasing number of network meta-analyses have been conducted on the effectiveness of conservative therapy for knee osteoarthritis, these may have been poorly planned and executed.We aimed to review the qualities of a comprehensive set of network meta-analyses on rehabilitation therapies for knee osteoarthritis and provide an overview of the effectiveness of each therapy.

METHODS

The eligibility criteria were as follows: (i) conservative rehabilitation was the primary treatment in the intervention group, (ii) included patients were diagnosed with knee osteoarthritis, and (iii) patient groups were aged ≤75 years, and rehabilitation interventions comprised exercise, orthotic, or physical therapies or patient education. Two independent reviewers screened the titles and abstracts of the identified records and selected the eligible reviews; their full texts were further assessed for eligibility. Then, a checklist derived from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension statement for the reporting of systematic reviews incorporating network meta-analyses of healthcare Interventions was used to validate the completeness of the reporting of each network meta-analysis. Furthermore, the statistical and outcome data regarding the quality of life, knee joint function and pain, adverse events, and physical functions were extracted using a customized spreadsheet.

RESULTS

Overall, 2701 titles and abstracts were screened, and eight network meta-analyses were ultimately selected. Nearly all reviews adequately addressed the PRISMA extension checklist, and the completeness of reporting was adequate; therefore, all expected information could be extracted. However, the methodology used to confirm the transitivity assumption was insufficient in many reviews. The following interventions were effective in reducing pain and improving physical function: (i) strengthening, flexibility, aerobic, and mind-body exercises, (ii) pulsed ultrasound, (iii) focused and radial extracorporeal shockwave therapy, and (iv) continuous ultrasound. The following interventions were effective in improving the quality of life: (i) strengthening, (ii) mixed, and (iii) mind-body exercises.

CONCLUSIONS

Our results suggested that exercise therapies, including muscle-strengthening, aerobic, flexibility, and mind-body exercises, are likely to be effective for pain relief and functional improvement in knee osteoarthritis. This may be the first review to provide a comprehensive perspective for considering priorities for future rehabilitation interventions for knee osteoarthritis.

Minimal clinically important change of knee flexion in people with knee osteoarthritis after non-surgical interventions using a meta-analytical approach

BACKGROUND

Minimal clinically important change (MCIC) represents the minimum patient-perceived improvement in an outcome after treatment, in an individual or within a group over time. This study aimed to determine MCIC of knee flexion in people with knee OA after non-surgical interventions using a meta-analytical approach.

METHODS

Four databases (MEDLINE, Cochrane, Web of Science and CINAHL) were searched for studies of randomised clinical trials of non-surgical interventions with intervention duration of ≤ 3 months that reported change in (Δ) (mean change between baseline and immediately after the intervention) knee flexion with Δ pain or Δ function measured using tools that have established MCIC values. The risk of bias in the included studies was assessed using version 2 of the Cochrane risk-of-bias tool for randomised trials (RoB 2). Bayesian meta-analytic models were used to determine relationships between Δ flexion with Δ pain and Δ function after non-surgical interventions and MCIC of knee flexion.

RESULTS

Seventy-two studies (k = 72, n = 5174) were eligible. Meta-analyses included 140 intervention arms (k = 61, n = 4516) that reported Δ flexion with Δ pain using the visual analog scale (pain-VAS) and Δ function using the Western Ontario and McMaster Universities Osteoarthritis Index function subscale (function-WOMAC). Linear relationships between Δ pain at rest-VAS (0-100 mm) with Δ flexion were - 0.29 (- 0.44; - 0.15) (β: posterior median (CrI: credible interval)). Relationships between Δ pain during activity VAS and Δ flexion were - 0.29 (- 0.41, - 0.18), and Δ pain-general VAS and Δ flexion were - 0.33 (- 0.42, - 0.23). The relationship between Δ function-WOMAC (out of 100) and Δ flexion was - 0.15 (- 0.25, - 0.07). Increased Δ flexion was associated with decreased Δ pain-VAS and increased Δ function-WOMAC. The point estimates for MCIC of knee flexion ranged from 3.8 to 6.4°.

CONCLUSIONS

The estimated knee flexion MCIC values from this study are the first to be reported using a novel meta-analytical method. The novel meta-analytical method may be useful to estimate MCIC for other measures where anchor questions are problematic.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022323927.

Therapeutic ultrasound ameliorates hyperalgesia and edema on CFA-induced persistent inflammatory response in mice

BACKGROUND

The present study investigated the effects of pulsed and continuous ultrasound (USP and USC) in edema and hyperalgesia after chronic inflammatory process induced by Complete Freund's Adjuvant-CFA and analyzing the relationship of the application frequency of ultrasound, in pro- and anti-inflammatory cytokine production.

METHODS

Forty-five animals were divided into 9 groups; all animals from groups 2 to 9 were subjected to a persistent inflammation model induced by CFA in mice. We report the effects and the underlying action mechanisms of USP and USC in the animals which were irradiated two, three or five times a week on the left hind paw. The analyses performed in this study were: evaluation of hind paw edema through the plethysmometer, evaluation of thermal hyperalgesia through withdrawal test using a water container at 44.5°C (± 0.5°C), and the plantar region of the left paw which was removed for analysis of cytokines.

RESULTS

Our results showed that USP and USC consistently reduced paw edema, and pulsed ultrasound showed a higher significant effect than the continuous mode. Moreover, groups with irradiation frequency of five times a week presented an inhibition of the edema, and groups with frequency of three or two times a week reduced mainly hyperalgesia, in comparison with the control group. The beneficial effects of the US then seem to be associated with upregulation of anti- and pro-inflammatory mediators, such as IL-10 and IL-6, respectively.

CONCLUSION

This study provided evidence that ultrasound constitutes an important non-pharmacological intervention for the management of inflammatory and pain states.

Effects of low-intensity pulsed ultrasound on knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To systemically review the effects of low-intensity pulsed ultrasound (LIPUS) on pain relief and functional recovery in patients with knee osteoarthritis (KOA).

DATA SOURCES

PubMed, Web of Science, Cochrane Library, Physiotherapy Evidence Database (PEDro), and China National Knowledge Infrastructure (CNKI) were used from inception to 18 March 2022.

REVIEW METHODS

Meta-analysis was performed to evaluate pain and function recovery between control and LIPUS groups. Standardized mean difference (SMD) or mean difference (MD) and 95% confidence interval (CI) were calculated, and data were combined using the fixed or random-effect model.

RESULTS

Thirteen studies involving 807 patients with KOA were included. Patients' outcomes treated by LIPUS were improved significantly, including Visual analog scale (VAS) score (MD = -0.95, 95% CI: -1.43 to -0.48，P < 0.001), Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) score (MD = -4.35, 95% CI: -8.30 to -0.40, P = 0.0309), Lysholm score (SMD = 1.59, 95% CI: 1.29 to 1.90, P < 0.001), Lequesne index (MD = -1.33, 95% CI: -1.69 to -0.96, P < 0.001), Range of motion (ROM) (MD = 2.43, 95% CI: 0.39 to 4.46, P = 0.0197) and 50 meter walking time (SMD = 1.48, 95% CI: 0.46 to 2.49, P = 0.0044). Subgroup analyses showed monotherapy of LIPUS produced a better effect on reducing VAS score (P = 0.0213), and the shorter therapeutic period (≤4 weeks) produced a more significant effect on raising the WOMAC score (P = 0.0083).

CONCLUSION

LIPUS was beneficial for pain relief and functional knee recovery and maybe as an alternative therapy in KOA rehabilitation.

Mechanical-based therapies may reduce pain and disability in some patients with knee osteoarthritis: A systematic review with meta-analysis

BACKGROUND

Mechanical-based therapies are not yet recommended to manage osteoarthritis (OA). This systematic review and meta-analysis aim to assess the effects of passive mechanical-based therapies (isolated or combined with other therapies) on patients with knee OA compared to placebo, other isolated or combined interventions.

METHODS

Pubmed, Cochrane, Web of Science and EMBASE were searched up to December 2020. We included randomized and non-randomized trials using therapeutic ultrasound, phonophoresis, extracorporeal shockwave therapy (ESWT) and vibration (single or combined with other therapies) compared to placebo, and/or other physical therapies groups. Biochemical, patient-reported, physical and imaging outcome measures were retrieved. We judged risk of bias using the RoB2 tool for randomized studies, the ROBINS-I tool for non-randomized studies, and the GRADE to interpret certainty of results.

RESULTS

We included 77 clinical studies. Ultrasound and ESWT statistically improved pain and disability comparing to placebo (combined or not with other therapies), and when added to other therapies versus other therapies alone. Ultrasound was statistically inferior to phonophoresis (combined or not with other therapies) in reducing pain and disability for specific therapeutic gels and/or combined therapies. Vibration plus exercise statistically improved pain relief and function versus exercise alone. All meta-analyses showed very-low certainty of evidence, with 15 of 42 (38%) pooled comparisons being statistically significant (weak to large effect).

CONCLUSIONS

Despite the inconsistent evidence with very-low certainty, the potential benefits of passive mechanical-based therapies should not be disregard and cautiously recommended that clinicians might use them in some patients with knee OA.

A Meta-Analysis of Analgesic Effect of Ultrasound Therapy for Patients With Knee Osteoarthritis

To compare the efficacy of therapeutic ultrasound in pain relief and functional recovery in knee osteoarthritis. A comprehensive search of five databases including EMBASE, PubMed, CBM, the Cochrane Library, and Google scholar was conducted to identify relevant studies published between January 1, 2005 and December 31, 2020. Eligible randomized trials were screened for inclusion in this study. Data about the mean change of visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and range of motion (ROM) were collected. Fourteen randomized trials covering 1080 patients with treatment durations of 2 to 24 weeks were included. Both pulsed (SMD [CI] = 1.11 [0.86, 1.36], P for heterogeneity < .00001, I²  = 18%) and continuous ultrasound (SMD [CI] = 1.18 [0.78, 1.57], P for heterogeneity < .00001, I²  = 72%) therapy had obvious pain relief effects, and high-intensity (>1.5 W/cm² ) ultrasound seemed more effective (SMD [CI] = 1.34 [0.94, 1.73], P for heterogeneity < .00001, I²  = 35%). In addition, therapeutic ultrasound was also effective in increasing joint function by WOMAC (SMD [CI] = 8.18 [5.88, 10.48], P for heterogeneity < .00001, I²  = 59%). There was a certain degree of heterogeneity due to the differences between the subjects in the study and the ultrasound parameter settings. Our analysis confirmed that both pulsed and continuous ultrasound are effective and safe for pain relief and functional recovery of knee osteoarthritis, especially in high intensity (> 1.5 W/cm² ). However, more high-quality randomized controlled trials will be necessary.

Knee Pain from Osteoarthritis: Pathogenesis, Risk Factors, and Recent Evidence on Physical Therapy Interventions

For patients presenting knee pain coming from osteoarthritis (OA), non-pharmacological conservative treatments (e.g., physical therapy interventions) are among the first methods in orthopedics and rehabilitation to prevent OA progression and avoid knee surgery. However, the best strategy for each patient is difficult to establish, because knee OA's exact causes of progression are not entirely understood. This narrative review presents (i) the most recent update on the pathogenesis of knee OA with the risk factors for developing OA and (ii) the most recent evidence for reducing knee pain with physical therapy intervention such as Diathermy, Exercise therapy, Ultrasounds, Knee Brace, and Electrical stimulation. In addition, we calculated the relative risk reduction in pain perception for each intervention. Our results show that only Brace interventions always reached the minimum for clinical efficiency, making the intervention significant and valuable for the patients regarding their Quality of Life. In addition, more than half of the Exercise and Diathermy interventions reached the minimum for clinical efficiency regarding pain level. This literature review helps clinicians to make evidence-based decisions for reducing knee pain and treating people living with knee OA to prevent knee replacement.

Study on the effects of the use of therapeutic ultrasound in the treatment of osteoarticular diseases

Introduction. The use of therapeutic ultrasounds is a method that proved its efficiency in articu-lar and periarticular pathology, in the subacute and chronic stages. The biological effects of the ultrasound use are determined by their interaction with the cellular structures whereas the re-sults depend on the used parameters. The purpose of the survey is to evaluate / identify the ef-fects of using ultrasounds in the treatment of musculoskeletal conditions (lumbar discopathy), knee osteoarthritis). Material and method. The survey was conducted on an outpatient basis in a period of 7 months and it is of the longitudinal type. It included 151 patients diagnosed with low back pain and knee osteoarthritis. The evaluated parameters were: pain, functional skills, articu-lar rigidity and the quality of life. Results. The effects of the use of ultrasounds is found in the decrease of pain, the stiffness of the joints and the contracture of the muscles, as shown by the re-sults of several surveys. Our survey proves that the use of ultrasounds decreases pain and in-creases the functional skills, it influences the physical function more obviously in patients with knee osteoarthritis, which is an aspect found in others surveys. Discussion. The use of a complex ultrasound treatment (in the pulsed way to avoid thermal effects) and kinesiotherapy enabled in our research the decrease of the pain and of the rigidity in the joints, the increase of the function-al skills and the quality of life, whereas these obtained results are in accordance with those of others surveys. Conclusions. The use of the therapeutic ultrasounds can have the following ef-fects: the decrease of the pain and of the joint rigidity, the improvement of the physical capacity for daily activities and the improvement of the quality of life. The use of low intensity ultra-sounds can determine biological effects with actions for a short period or for an average one. Keywords: therapeutic ultrasound, treatment, osteoarticular diseases, quality of life

Effect of Ultrasonic Penetration with Volatile Oil of Olibanum and Chuanxiong Rhizoma on Acute Knee Synovitis Induced by Sports Training: An Open-Label Randomized Controlled Study

Background

Knee synovitis is a common sports injury. We proposed the use of UTV_OR, which is a combination of the use of volatile oil of Olibanum (VOO) and volatile oil of Chuanxiong Rhizoma (VOCR) and conventional ultrasound (US) therapy, to treat knee synovitis. Design, Setting, Participants, and Interventions. Participants were randomly assigned into a control group (conventional US therapy group) and a test group (UTV_OR group). The control group received conventional US therapy with a coupling agent as the medium. The test group received a revised US therapy with VOO and VOCR as media. Both groups were treated once per day for three consecutive days. Main Outcome Measures. The subjects' Visual Analogue Scale (VAS) pain score, Lysholm knee score, knee swelling degree, circumference, and range of motion of the knee joint were evaluated before the first treatment and 24 h after the third treatment. The VAS pain score was considered the primary outcome, while the three other measurements were regarded as the secondary outcomes. An adverse event was reported subjectively and recorded.

Results

A total of 116 participants were included in the analysis (test group: n = 64; control group: n = 52). The evaluation results showed that the VAS pain scores of the male and female participants in both groups decreased after treatment (P < 0.001), but only the difference among the male sub-group had significant between-group difference (P < 0.001). After treatment, the Lysholm scores in both groups increased significantly (all P < 0.001), the range of motion and the circumference of the injured knee decreased significantly (P < 0.001), while no between-group difference was observed in general or in the gender sub-groups (all P > 0.025). No side effect or complication was reported during the treatment.

Conclusion

UTV_OR had a superior analgesic effect to conventional US therapy in the male population, but its effects on alleviating joint function, swelling, and range of motion were comparable to that of conventional US therapy. Our study found that UTV_OR can be an effective method to reduce pain and treat knee synovitis, and it is subjectively safe. Trial registration. This study was registered under the Chinese Clinical Trial Registry (Trial Registration Number: ChiCTR2000035671).

A Review of Laser Therapy and Low-Intensity Ultrasound for Chronic Pain States

PURPOSE OF REVIEW

Chronic pain management therapies have expanded quickly over the past decade. In particular, the use of laser therapy and ultrasound in the management of chronic pain has risen in recent years. Understanding the uses of these types of therapies can better equip chronic pain specialists for managing complicated chronic pain syndromes. The purpose of this review was to summarize the current literature regarding laser radiation and ultrasound therapy used for managing chronic pain syndromes.

RECENT FINDINGS

In summary, there is stronger evidence supporting the usage of laser therapy for managing chronic pain states compared to low-intensity ultrasound therapies. As a monotherapy, laser therapy has proven to be beneficial in managing chronic pain in patients with a variety of pain syndromes. On the other hand, LIUS has less clear benefits as a monotherapy with an uncertain, optimal delivery method established. Both laser therapy and low-intensity ultrasound have proven beneficial in managing various pain syndromes and can be effective interventions, in particular, when utilized in combination therapy.

Therapeutic ultrasound for knee osteoarthritis: A systematic review and meta-analysis with grade quality assessment

BACKGROUND

Therapeutic ultrasound (US) is a widely used intervention in physical therapy to manage pain and to aid in the healing of soft tissue.

OBJECTIVE

This systematic review aimed to determine the effects of therapeutic US on knee osteoarthritis (KOA) symptoms.

METHODS

PubMed, MEDLINE, EMBASE, Google Scholar, and the Cochrane databases were searched from inception to April 2019. Randomized controlled trials (RCTs) involving adults with symptomatic KOA that compared therapeutic US with a sham or other control were included. The methodological quality of the trials was assessed at the study level using the Cochrane Risk of Bias tool. The quality of evidence at the outcome level- and overall- was assessed using GRADE methodology. Meta-analyses were conducted using random effects models, and heterogeneity was assessed using the I2 statistic.

RESULTS

Four studies (N = 234 participants) were eligible for inclusion in our primary analyses assessing therapeutic US versus sham. The methodological quality of the included RCTs ranged from moderate to very low. Treatment with therapeutic US resulted in small, statistically significant benefits for pain (approximate 9.6% improvement on a 0-100 visual analog scale [95% confidence interval: 2, 17.4%]) and self-reported measures of function (approximate 12.8% improvement on a 0-100 visual analog scale [0.4, 25.2%]). The overall quality of the evidence was very low. No adverse events were reported in any of the included studies.

CONCLUSIONS

The use of therapeutic US may provide additional benefits to physical therapy regimens in terms of symptom relief in individuals with KOA. However, it is not possible to make any meaningful recommendations for clinical practice due to the small number of applicable RCTs and the low methodological quality of the RCTs deemed eligible for this study.

The effect of transcranial direct stimulation as an add-on treatment to conventional physical therapy on pain intensity and functional ability in individuals with knee osteoarthritis: A randomized controlled trial

OBJECTIVE

To investigate the effect of adding transcranial direct current stimulation (tDCS) to conventional physiotherapy treatment (PT) on pain and performance of individuals with knee osteoarthritis (KOA).

METHODS

Eighty people suffering from chronic KOA participated in this study. They were randomly divided into four treatment groups, including PT combined with tDCS over the primary motor cortex (M1), PT combined with tDCS over the primary sensory cortex (S1), PT combined with tDCS over the dorsolateral prefrontal cortex (DLPFC), and PT combined with sham tDCS. A visual analog scale (VAS) for pain intensity, the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire for knee-related disability, and several performance tests (stepping 15 s, chair stand test in 30 s, and walking 4 × 10 m) were used for assessment following 10 sessions of tDCS (T1), and one month after the last session of tDCS (T2).

RESULTS

Differential effects on pain intensity, knee-related disability, and performance were found between groups. Compared to sham tDCS: (i) tDCS over M1 improved VAS pain score, KOOS disability score, and performance tests at T1 and T2; (ii) tDCS over S1 improved VAS pain score at T1 and T2 and KOOS disability score and performance tests at T2; (iii) tDCS over the DLPFC improved VAS pain score at T1 and performance tests at T1 and T2.

CONCLUSION

tDCS could be a beneficial add-on treatment to conventional PT for pain relief, disability reduction and functional improvement in patients with KOA.

Low-Intensity Continuous Ultrasound Therapies—A Systematic Review of Current State-of-the-Art and Future Perspectives

Therapeutic ultrasound has been studied for over seven decades for different medical applications. The versatility of ultrasound applications are highly dependent on the frequency, intensity, duration, duty cycle, power, wavelength, and form. In this review article, we will focus on low-intensity continuous ultrasound (LICUS). LICUS has been well-studied for numerous clinical disorders, including tissue regeneration, pain management, neuromodulation, thrombosis, and cancer treatment. PubMed and Google Scholar databases were used to conduct a comprehensive review of all research studying the application of LICUS in pre-clinical and clinical studies. The review includes articles that specify intensity and duty cycle (continuous). Any studies that did not identify these parameters or used high-intensity and pulsed ultrasound were not included in the review. The literature review shows the vast implication of LICUS in many medical fields at the pre-clinical and clinical levels. Its applications depend on variables such as frequency, intensity, duration, and type of medical disorder. Overall, these studies show that LICUS has significant promise, but conflicting data remain regarding the parameters used, and further studies are required to fully realize the potential benefits of LICUS.

Therapeutic Ultrasound for Chronic Pain Management in Joints: A Systematic Review

BACKGROUND

Treatments for joint pain and dysfunction focus on restoration of joint motion, improvement in pain and a return to the previous level of the patient's daily activity. Therapeutic ultrasound is a noninvasive modality widely utilized in the management of musculoskeletal disorders. The objective of this systematic review was to evaluate the effectiveness of therapeutic ultrasound in the management of patients with knee, shoulder and hip pain.

METHODS

Using PRISMA guidelines, a search of the PubMed, CENTRAL (The Cochrane Library), Web of Science and Scopus databases was performed to retrieve randomized controlled trials (RCTs) that evaluated therapeutic ultrasound (continuous and pulsed) in patients with chronic knee, shoulder and hip pain.

RESULTS

The search strategy identified 8 trials for knee, 7 trials for shoulder and 0 trials for hip that met the criteria for inclusion. All 8 trials showed improvement in knee pain, and of these studies 3 showed statistical significance improvement for therapeutic ultrasound versus the comparator. For shoulder pain, all 7 trials showed reduction in pain, but should be noted that 4 of studies demonstrated that therapeutic ultrasound is inferior to the comparator modality.

CONCLUSION

Therapeutic ultrasound is frequently used in the treatment of knee, shoulder and hip pain and is often combined with other physiotherapeutic modalities. The literature on knee arthritis is most robust, with some evidence supporting therapeutic ultrasound, though the delivery method of ultrasound (pulsed vs continuous) is controversial. As a monotherapy, ultrasound treatment may not have a significant impact on functional improvement but can be a reasonable adjunct to consider with other common modalities. In all three pain syndromes, especially for hip pain, further trials are needed to define the true effect of low-intensity ultrasound therapy knee, shoulder and hip pain. No conclusive recommendations may be made for optimal settings or session duration.

Effects of various types of ultrasound therapy in hip osteoarthritis - a double-blind, randomized, controlled, follow-up study

Purpose: To compare the effects of various types of ultrasound therapy (UST) on pain, function, and quality of life in patients with hip osteoarthritis.Methods: Seventy-one patients receiving conventional physiotherapy (exercise, massage, and balneotherapy), were randomly allocated into four treatment groups: (1) continuous UST, (2) pulsed UST, (3) UST combined with transcutaneous electrical nerve stimulation (TENS), (4) placebo UST. We evaluated the hip pain (Visual Analog Scale), medication use, functional impairment (Western Ontario and McMaster Universities Arthritis Index; 6-minute walking test) and quality of life (SF-36) before, right after the treatments, and at 3 months follow-up.Results: Resting pain improved significantly in all treatment groups at the follow-up visit compared to baseline (p (group1-4) ≤0.002). The proportion of patients achieving Minimal Clinically Important Improvement (MCII) in function at month 3 was the highest in group 3 (73%). The 6-minute walking test significantly improved in each group during the follow-up period (p (group1-4) ≤ 0.025). Pain (p (group1-4) ≤ 0.014) and general health domains of the SF-36 showed the greatest improvement (p (group 2-4) ≤ 0.018).Conclusions: There was no difference among the effects of various types of UST on pain, function, and quality of life in the treatment of hip osteoarthritis. Additional ultrasound treatment is not likely to increase the effect of the conventional therapy on pain and function in hip osteoarthritis.

The effectiveness of pulsed ultrasound treatment on pain, function, synovial sac thickness and femoral cartilage thickness in patients with knee osteoarthritis: a randomized, double-blind clinical, controlled study

OBJECTIVE

This study aims to investigate the efficacy of therapeutic pulsed ultrasound on pain, function, synovial sac and femoral cartilage in knee osteoarthritis.

DESIGN

Randomized, double-blind, controlled study.

SETTING

Dokuz Eylul University, Department of Physical Medicine and Rehabilitation.

SUBJECTS

A total of 96 patients with knee osteoarthritis.

INTERVENTIONS

Participants were randomized into two groups; Group I (n = 48, pulsed ultrasound) and Group II (n = 48, sham ultrasound). The sessions were held three times a week for 8 weeks. The study continued for 12 weeks (with 4 weeks follow-up). All participants performed exercises at home for 12 weeks.

MAIN MEASURES

Knee pain (at rest and ADLs) was assessed using the visual analog scale (VAS). Functionality was assessed using the Timed Up and Go test and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) questionnaire. Femoral cartilage and synovial sac thickness was measured using ultrasonography. All evaluations were performed at the baseline, at the 8 and 12 weeks after baseline.

RESULTS

The study was completed with a total of 75 patients (n = 39 in group I and n = 36 in group II). The mean (SD) pain at ADLs score at baseline and week 12 was 7.2 (2.1), with 3.6 (2.9) in the group I, and 6.7 (2.0) and 4.3 (2.2) in the group II, respectively. Both groups presented significant improvements in terms of pain and function (P < 0.001). There was no difference between groups for any parameters.

CONCLUSION

Treatment of pulsed ultrasound has no positive effect on knee pain, function, femoral cartilage and synovial sac thickness in knee osteoarthritis.

A clinical practice guideline for physical therapy in patients with hip or knee osteoarthritis

OBJECTIVE

The purpose of this paper is to revise the 2010 Dutch guideline for physical therapy (PT) in patients with hip or knee osteoarthritis (OA), issued by the Royal Dutch Society for Physical Therapy (KNGF).

METHOD

This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation (AGREE) and Guidelines International Network (G-I-N) standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers to current care. A narrative or systematic literature review was undertaken in response to each clinical question. The panel formulated recommendations based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence-to-Decision framework.

RESULTS

A comprehensive assessment should be based on the International Classification of Functioning Disability and Health (ICF) core set for OA, including the identification of OA-related red flags. Based on the assessment, four treatment profiles were distinguished: (1) education and instructions for unsupervised exercises, (2) education and short-term supervised exercise therapy, (3) education and longer term supervised exercise therapy, and (4) education and exercise therapy before and/or after total hip or knee surgery. Education included individualized information, advice, instructions, and self-management support. Exercise programs were tailored to individual OA-related issues, were adequately dosed, and were in line with public health recommendations for physical activity. Recommended measurement instruments included the Patient-Specific Complaints Instrument, the Numeric Pain Rating Scale, the Hip Disability and Osteoarthritis Outcome Score/the Knee Injury Osteoarthritis Outcome Score, and the Six Minute Walk Test.

CONCLUSION

An evidence-based PT guideline for the management of patients with hip or knee OA was developed. To improve quality of care for these patients, an extensive implementation strategy is necessary.

The effect of physical therapy and rehabilitation modalities on sleep quality in patients with primary knee osteoarthritis: A single-blind, prospective, randomized-controlled study

Objectives

In this study, we aimed to evaluate the effect of physical therapy modalities on pain, sleep, mental status, and quality of life of patients with osteoarthritis (OA).

Patients and methods

Between January 2017 and June 2017, a total of 40 patients (9 males, 31 females; mean age 56.6±8.9 years; range, 40 to 70 years) who were diagnosed with knee OA according to the American College of Rheumatology (ACR) criteria and were in Kellgren- Lawrence Grade 2-3 were included in the study. The patients were divided into two groups equally. Both groups received 15 sessions of exercise therapy, whereas the intervention group also received 10 consecutive physical therapy sessions in the form of hot pack, therapeutic ultrasound (US), and transcutaneous electrical nerve stimulation (TENS) by a single physiotherapist. Isometric and isotonic exercises were planned as 10 reps for three times a day as a home-based program. Clinical assessments were performed using the visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Beck Depression Inventory (BDI), Pittsburg Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and Short Form 36 (SF-36) before and after treatment.

Results

Pre-treatment VAS, ESS, PQSI, BDI, WOMAC, and SF-36 scores showed no significant difference between the groups, whereas post-treatment scores showed a significant difference in the intervention group (p<0.05). The difference between the pre- and post-treatment VAS, ESS, PQSI, BDI, WOMAC, and SF-36 scores were significantly higher in the intervention group, compared to the controls (p<0.05).

Conclusion

Our study results show positive effects of exercise and physical therapy modalities on pain, disease activity, sleep quality, depression, and quality of life in knee OA patients.

Efficacy of continuous and pulsed therapeutic ultrasound combined with exercises for knee osteoarthritis: a randomized controlled trial

OBJECTIVES

To compare the effects of continuous and pulsed therapeutic ultrasound combined with strengthening exercises.

DESIGN

This is a double-blind randomized controlled trial.

SETTING

Pontifical Catholic University.

SUBJECTS

One hundred participants with Grade 2-4 knee osteoarthritis and both genders were involved.

INTERVENTION

Participants were randomized into five groups: Group I (n = 20; in the first month, continuous ultrasound was applied), Group II (n = 20; in the first month, pulsed ultrasound was applied), Group III (n = 20; in the first and second months, continuous ultrasound was applied), Group IV (n = 20; in the first and second months, pulsed ultrasound was applied) and Group V (n = 20; patients received only exercise sessions for eight weeks). All patients in the groups that received ultrasound application performed exercises in the second month of treatment. The sessions occurred three times a week.

MAIN MEASURES

Pain was assessed using the visual analogical scale, functionality was assessed using the Lequesne questionnaire, range of motion was assessed using a universal goniometer, muscular strength was assessed using a dynamometer, mobility was assessed using the Timed Up and Go test and 8-meter walk test and the activity level was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire.

RESULTS

Statistically significant differences (P < 0.05) were presented by Group III in the variables pain during activities of daily living (ADLs) 5.89 (2.18), mobility assessed by 8-meter test 2.68 (2.56), in pain 10.65 (4.40), function 25.50 (10.87) and total 38.65 (15.29) of WOMAC and functionality 9.10 (5.15).

CONCLUSION

Prolonged applications of continuous ultrasound combined with exercises are effective in providing pain, mobility, functionality and activity in subjects with knee osteoarthritis.

Squatting versus squatting with hip adduction in management of patellofemoral osteoarthritis: A randomized controlled trial

BACKGROUND

Patellofemoral osteoarthritis is a common presentation in the outpatients' physical therapy clinics. The muscle imbalance between the vastus medialis oblique and vastus lateralis muscles is one of the main factors that lead to the development of this condition.

OBJECTIVE

To compare the effect of a squatting versus squatting with hip adduction in management of patellofemoral osteoarthritis.

METHODS

Patients in group A received a traditional physical therapy program in addition to squatting exercise and those in group B received a traditional physical therapy program in addition to squatting with hip adduction exercise for four weeks. The primary outcome measures were pain on the numerical rating scale (NRS) and performance of functional activities by Kujala scale, while the secondary outcomes were vastus medialis oblique (VMO) and vastus lateralis (VL) amplitudes as well as the VMO:VL ratio by surface electromyography were considered before and after intervention.

RESULTS

Thirty patients (group A n= 15; group B n= 15) were randomized and analyzed. Comparing both groups post-program revealed that there was no significant difference between both groups regarding the vastus medialis oblique activity, VMO:VL ratio, pain intensity and performance of functional activities.

CONCLUSION

Both a traditional physical therapy program in addition to squatting exercise and a traditional physical therapy program in addition to squatting exercise with hip adduction are effective in reduction of pain intensity increases performance of functional activities, and vastus medialis oblique amplitude. However, there is no superiority of one program over the other.

Effects of therapeutic ultrasound for knee osteoarthritis: a systematic review and meta-analysis

Objective:

To assess the effectiveness and safety of therapeutic ultrasound with sham ultrasound on pain relief and functional improvement in knee osteoarthritis patients. As phonophoresis is a unique therapeutic ultrasound, we also compared the effects of phonophoresis with conventional non-drug ultrasound.

Data sources:

PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized controlled trials from inception up to June 2019.

Review methods:

Randomized controlled trials comparing therapeutic ultrasound with sham ultrasound in knee osteoarthritis patients were included. Phonophoresis in the experimental and control groups were compared through conventional ultrasound, and corresponding trials were also included. Two reviewers independently identified eligible studies and extracted data. Risk of bias assessments and therapeutic ultrasound safety assessments were also performed.

Results:

Fifteen studies including three phonophoresis-related studies with 1074 patients were included. Meta-analyses demonstrated that therapeutic ultrasound significantly relieved pain ( P < 0.00001) and reduced the Western Ontario and McMaster Universities (WOMAC) physical function score ( P = 0.03). In addition, therapeutic ultrasound increased the active range of motion ( P < 0.00001) and reduced the Lequesne index ( P < 0.00001). Subgroup analysis of phonophoresis ultrasound illustrated significant differences on the visual analogue scale ( P = 0.009), but no significant differences on WOMAC pain subscales ( P = 0.10), and total WOMAC scores were observed ( P = 0.30). There was no evidence to suggest that ultrasound was unsafe treatment.

Conclusions:

Therapeutic ultrasound is a safe treatment to relieve pain and improve physical function in patients with knee osteoarthritis. However, phonophoresis does not produce additional benefits to functional improvement, but may relieve pain compared to conventional non-drug ultrasound.

Effects of ultrasound therapy on the synovial fluid proteome in a rabbit surgery-induced model of knee osteoarthritis

Background

Ultrasound (US) therapy may improve osteoarthritis symptoms. We investigated the effects of US on the synovial fluid (SF) proteome in a rabbit knee osteoarthritis (KOA) model to explore its therapeutic mechanisms.

Methods

Sixteen healthy 6-month-old New Zealand white rabbits (eight male, eight female), weighing 2.5–3.0 kg, were randomly divided into groups A and B with eight rabbits per group. Both groups were subjected to right anterior cruciate ligament transaction. Six weeks after surgery, we treated the operated knee joint of group A rabbits with US and of group B rabbits with sham US for 2 weeks. The proteomes of knee joint SF from groups A and B rabbits were then analyzed using a label-free mass spectrometry (MS) quantification method.

Results

We identified 19 protein sequences annotated by 361 Gene Ontology (GO) items. According to the Kyoto Encyclopedia of Genes and Genomes (KEGG) database of rabbit protein sequences, we then annotated the KO numbers of homologous/similar proteins to 32 relevant KEGG pathways. We extracted 10 significantly differentially expressed proteins among the 32 relevant KEGG messages/metabolism pathways. The proteins whose levels were decreased were apolipoprotein A-I (AopA-1), transferrin (TF), carboxypeptidase B2 (CBP2), arylesterase/paraoxonase (PON), fibrinogen alpha chain, and alpha-2-macroglobulin (A2M). The proteins whose levels were increased were molecular chaperone HtpG/heat shock proteins (htpG, HSP90A), decorin (DCN), pyruvate kinase (PK, pyk), and fatty acid-binding protein 4/adipocyte (FABP4, aP2).

Conclusions

US therapy can alter protein levels in SF, which can decrease AopA-1, TF, CBP2, PON, fibrinogen alpha chain and A2M protein levels, and increase HtpG/HSP90A, DCN, PK/PKY, and FABP4/aP2 protein levels in SF of KOA, suggesting that the therapeutic mechanisms of US therapy on KOA may occur through changes in the SF proteome.

Multifunctional Scaffolds with Improved Antimicrobial Properties and Osteogenicity Based on Piezoelectric Electrospun Fibers Decorated with Bioactive Composite Microcapsules

The incorporation of bioactive compounds onto polymer fibrous scaffolds with further control of drug release kinetics is essential to improve the functionality of scaffolds for personalized drug therapy and regenerative medicine. In this study, polymer and hybrid microcapsules were prepared and used as drug carriers, which are further deposited onto polymer microfiber scaffolds [polycaprolactone (PCL), poly(3-hydroxybutyrate) (PHB), and PHB doping with the conductive polyaniline (PANi) of 2 wt % (PHB-PANi)]. The number of immobilized microcapsules decreased with increase in their ζ-potential due to electrostatic repulsion with the negatively charged fiber surface, depending on the polymer used for the scaffold's fabrication. Additionally, the immobilization of the capsules in dynamic mechanical conditions at a frequency of 10 Hz resulted in an increase in the number of the capsules on the fibers with increase in the scaffold piezoelectric response in the order PCL < PHB < PHB-PANi, depending on the chemical composition of the capsules. The immobilization of microcapsules loaded with different bioactive molecules onto the scaffold surface enabled multimodal triggering by physical (ultrasound, laser radiation) and biological (enzymatic treatment) stimuli, providing controllable release of the cargo from scaffolds. Importantly, the microcapsules immobilized onto the surface of the scaffolds did not influence the cell growth, viability, and cell proliferation on the scaffolds. Moreover, the attachment of human mesenchymal stem cells (hMSCs) on the scaffolds revealed that the PHB and PHB-PANi scaffolds promoted adhesion of hMSCs compared to that of the PCL scaffolds. Two bioactive compounds, antibiotic ceftriaxone sodium (CS) and osteogenic factor dexamethasone (DEXA), were chosen to load the microcapsules and demonstrate the antimicrobial properties and osteogenesis of the scaffolds. The modified scaffolds had prolonged release of CS or DEXA, which provided an improved antimicrobial effect, as well as enhanced osteogenic differentiation and mineralization of the scaffolds modified with capsules compared to that of individual scaffolds soaked in CS solution or incubated in an osteogenic medium. Thus, the immobilization of microcapsules provides a simple, convenient way to incorporate bioactive compounds onto polymer scaffolds, which makes these multimodal materials suitable for personalized drug therapy and bone tissue engineering.

Effectiveness of home-based physiotherapy on pain and disability in participants with osteoarthritis of knee: an observational study

[Purpose] The objective of this observational study was to examine the effect of home physiotherapy on pain and disability in participants with knee osteoarthritis. [Participants and Methods] From January 2017 to December 2017, 139 participants who were recipients of HealthCare atHome physiotherapy services across various locations were included in the main analysis. The mean treatment cycle duration was 31.5 days (mean number of sessions delivered, 19.7). Physiotherapy was performed for approximately 45–50 min in the form of electrotherapy, exercise therapy, and manual therapy. Visual analog scale (VAS) scores were documented after each visit, whereas The Western Ontario and Mcmaster Universities Osteoarthritis Index (WOMAC) as an outcome were recorded weekly. [Results] Statistically significant improvement in the visual analog scale and Western Ontario and Mcmaster Universities Osteoarthritis Index scores were observed, with overall % improvement of 52% and 43%, respectively. [Conclusion] The average scores in pain and disability were reduced after home based physiotherapy.

Effects of Low-Intensity Pulsed Ultrasound on Knee Osteoarthritis: A Meta-Analysis of Randomized Clinical Trials

Background

Osteoarthritis (OA) is a common degeneration disease characterized with joint pain. The aim of the present study was to systemically review the effects of LIPUS on pain relief and functional recovery in patients with knee osteoarthritis (OA).

Methods

PubMed, Embase, and Cochrane Library were searched manually for researches on LIPUS treatment in patients with knee OA from 1945 to July 2017. Two investigators independently selected the studies according to the inclusion and exclusion criteria, extracted the concerned data, and assessed the included studies. Meta-analysis was performed to evaluate VAS, WOMAC, and ambulation speed between control and LIPUS groups.

Results

Five studies were selected in this study. Compared with control group, LIPUS group received a decrease of pain intensity with moderate heterogeneity (-0.79, 95% CI, -1.57 to 0.00; I² = 65%, P = 0.04) by VAS and improvement in knee function by WOMAC (-5.30, 95% CI, -2.88 to -7.71; I² = 44%, P = 0.17). No significant improvement was found in ambulation speed (0.08 m/s, 95% CI, -0.02 to 0.18 m/s; I² = 68%, P = 0.03).

Conclusion

The present study includes 5 high quality randomized controlled trials. The result indicated that LIPUS, used to treat knee OA without any adverse effect, had a beneficial effect on pain relief and knee functional recovery. More evidence is needed to prove whether LIPUS is effective in improving walking ability.

Ultrasound plus low-level laser therapy for knee osteoarthritis rehabilitation: a randomized, placebo-controlled trial

This study evaluated the synergistic effects of ultrasound (US) and low-level laser therapy (LLLT) with or without therapeutic exercises (TE) in women with knee osteoarthritis. Forty-two Caucasian women with knee osteoarthritis were allocated into three groups: (1) the placebo group who did not perform TE, but the prototype without emitting light or ultrasonic waves was applied, (2) the US + LLLT group in which only the prototype was applied and (3) the TE + US + LLLT group that performed TE before the prototype was applied. However, 35 women completed the full clinical trial. Pressure pain thresholds (PPT) using an algometer and functional performance during the sit-to-stand test were carried out. The average PPT levels increased for US + LLLT (41 ± 9 to 54 ± 15 N, p < 0.01) and TE + US + LLLT (32 ± 8 to 45 ± 9 N, p < 0.01) groups. The number of sit-to-stands was significantly higher for all groups. However, the change between pre-treatment and post-treatment (delta value) was greater for the US + LLLT (4 ± 1) and TE + US + LLLT groups (5 ± 1) than for the placebo group (2 ± 1) with a significant intergroup difference (p < 0.05). This study showed reduced pain and increased physical functionality after 3 months of US + LLLT with and without TE.

Effects of pulsed therapeutic ultrasound on the treatment of people with knee osteoarthritis

[Purpose] The aim was to evaluate the effect of therapeutic ultrasound on the pain, joint mobility, muscle strength, physical function, and quality of life of people with knee OA. [Subjects and Methods] One-site, one-arm, before-after study that included people with Grade II or III tibiofemoral osteoarthritis. Ten therapeutic ultrasound sessions (duty cycle=20%, ERA=10 cm², BNR=6:1, SATP=2.2 W/cm², SATA=0.44 W/cm², frequency=1 MHz, time=4 minutes) were applied. Assessments of primary outcome variables: pain intensity and function, and secondary variables: joint mobility, muscle strength and quality of life, were performed at onset and end of therapy; an additional intermediate evaluation was included for the primary variables. [Results] Means of repeated measurements of pain intensity (pain at rest, pain on palpation and pain after functional activities) and function showed significant differences. There was a significant reduction in pain intensity at the end of functional activities as well as a significant increase in function and in quadriceps muscle strength. [Conclusion] Therapeutic ultrasound applied in accordance with the parameters used, could be recommended during the treatment of individuals with knee osteoarthritis, because it significantly decreased the intensity of pain after the 5th session, and this reduction was maintained until the end of the intervention.

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.

Efficacy of focused low-intensity pulsed ultrasound therapy for the management of knee osteoarthritis: a randomized, double blind, placebo-controlled trial

The aim of this study was to investigate the effects of focused low-intensity pulsed ultrasound (FLIPUS) therapy on the functional and health status of patients with knee osteoarthritis (KOA). A total of 106 subjects with bilateral KOA were randomized sequentially into two groups. Group I received FLIPUS + diclofenac sodium, and group II received sham FLIPUS + diclofenac sodium. The therapeutic effects of the interventions were evaluated by measuring changes in VAS pain, the WOMAC scores, and the LI scores after 10 days of treatment as well as changes in LI and VAS at follow-up, 4 and 12 weeks later. In addition, changes in the range of motion, ambulation speed, and the SF-36 in each group were recorded after 10 days of treatment. Compared with those in group II, patients in group Ishowed significant improvements in VAS, WOMAC, LI, ambulation speed, and most items in the SF-36 after 10 days of treatment. In addition, patients in group I showed significant improvements in LI and VAS at follow-up. There were no FLIPUS-related adverse events during and after the interventions. In conclusion, FLIPUS is a safe and effective treatment modality for relieving pain and improving the functions and quality of life of patients with KOA.

A study to evaluate the effect of ultrasound treatment on nodules in multiple sclerosis patients

Purpose/aim: Ultrasound has demonstrated anti-inflammatory and pain-relief benefits in several conditions such as cellulite or trauma events. We assessed the efficacy of ultrasound therapy on nodules associated with first-line treatments in multiple sclerosis patients.

MATERIALS AND METHODS

Twenty-two multiple sclerosis patients were enrolled during 2013 and randomized to two groups: in the control group patients were treated only with a conventional gel prescribed for cellulite and nodules, while in the experimental group the gel was combined with ultrasound therapy. Patients were treated during 10 weeks and followed up for 10 additional weeks. Three nodules were assessed for each patient, measuring size, pain and redness at 0, 10 and 20 weeks.

RESULTS

We found a significant decrease in both groups in size, pain and redness across the three visits (p < 0.0001 for size, p = 0.01 and p < 0.0001 for pain, and p = 0.0002 and p < 0.0001 for redness, respectively for the difference at visit 2 and 3 with respect to visit 1). More interestingly, we observed a greater reduction in pain and redness in the ultrasound-treated group, but the difference was only statistically significant at 10 weeks (p = 0.01 for both pain and redness). On the third visit, no differences between control and experimental groups were detected, both achieving the same levels in measured variables.

CONCLUSIONS

Both treatments are useful to improve skin reaction after first-line treatments, but ultrasound in combination with gel achieves a faster reduction in pain and redness, suggesting that ultrasound treatment might be a good analgesic for nodule management in multiple sclerosis patients.

The effects of ultrasound and alternating current on the laser penetration in the tissue

The visible (VIS) and near-infrared (NIR) lasers are now widely used in therapeutic and other medical applications. Some of these applications require to deliver the laser energy deep toward the desired tissue target or organ. The aim of this in vitro study is to investigate practically whether the modulation of laser energy by employing the therapeutic ultrasound or electrical energies can increase the penetration depth of the laser light inside the tissue. Such modulation was implemented in this study by coupling the (c.w.) diode and Nd:YAG laser energies with the ultrasound or AC current simultaneously as they pass through preprepared ex vivo bovine muscular tissue strips. Two wavelengths of diode lasers were used, 637 and 808 nm beside the 1064-nm Nd:YAG laser. The results showed a noticeable decrease of these laser attenuation factors as they pass through the tissue strips in the presence of the ultrasound or AC energies. By using this coupling modulation, the capability of increasing the laser penetration depths inside the tissue was confirmed without having to increase their applied power.

Comparison of therapeutic duration of therapeutic ultrasound in patients with knee osteoarthritis

[Purpose] The aim of study was to compare different durations of ultrasound in patients with knee osteoarthritis. [Subjects and Methods] One hundred patients diagnosed with bilateral knee osteoarthritis (OA) were enrolled in this study. Patients were divided into two groups. The first group (G1) received 4 minutes of ultrasound. The second group (G2) received the exact same treatment, but the duration of ultrasound was longer at 8 minutes. Patients in both groups underwent a total of 10 ultrasound over 2 weeks. Following treatment, all patients provided self-evaluations of pain via the Visual Analog Scale (VAS), overall physical function with WOMAC, disability via the Lequesne index (Leq), and depressive symptoms with the Beck Depression Index (BDI). [Results] There were no significant differences in VAS, WOMAC Leq, and BDI values between groups 1 and 2. After treatment, VAS, WOMAC, Leq, and BDI values improved for both treatment groups. However, following treatment, G2 had significantly greater values for WOMAC functional and total scores than G1. No statistically significant differences were observed for VAS scores while inactive, WOMAC pain and stiffness scores, and BDI values after treatment between both groups. VAS pain scores while active and Leq index values were significantly lower in G1 than G2. [Conclusion] Patients in both groups demonstrated improved functionality, pain and psychological status following a consistent, 2-week regimen of 4-minute or 8-minute treatments with ultrasound. Yet, patients that experienced longer treatment durations of 8 minutes demonstrated better outcomes in pain and the ability to carry out activities of daily living.

Effects of therapeutic ultrasound on pain, physical functions and safety outcomes in patients with knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To explore the effects of therapeutic ultrasound with sham or no intervention on pain, physical function and safety outcomes in patients with knee osteoarthritis.

DATA SOURCES

This systematic review was searched on CENTRAL, EMBASE, MEDLINE, CINAHL, Physiotherapy Evidence Database, Open Gray on 4 September 2015. Trials included randomized controlled trials that compared therapeutic ultrasound with a sham or no intervention in patients with osteoarthritis of the knee.

REVIEW METHODS

Eligible trials and extracted data were identified by two independent investigators. Standardized mean differences (SMDs) and 95% confidence interval (CI) were calculated for pain and physical function outcomes. Heterogeneity was assessed by the I² test and inverse-variance random-effects analysis was applied to all trials.

RESULTS

Ten randomized controlled trials (645 patients) met the inclusion criteria. Therapeutic ultrasound showed a positive effect on pain (SMD = -0.93, 95%, CI = -1.22 to -0.64, p < 0.01, p for heterogeneity = 0.12, I² = 42%). For physical function, therapeutic ultrasound was advantageous for reducingWestern Ontario and McMaster Universities physical function score (SMD = -0.37, 95% CI = -0.73 to -0.01, p = 0.04, p for heterogeneity = 0.94, I² = 0%). In terms of safety, no occurrence of adverse events caused by therapeutic ultrasound was reported in any trial.

CONCLUSION

The authors suggested that therapeutic ultrasound is beneficial for reducing knee pain and improving physical functions in patients with knee osteoarthritis and could be a safe treatment.

Synergic effects of ultrasound and laser on the pain relief in women with hand osteoarthritis

Patients with pain avoid movements, leading to a gradual impairment of their physical condition and functionality. In this context, the use of ultrasound (US) and low-level laser therapy (LLLT) show promising results for nonpharmacological and noninvasive treatment. The aim of this study was evaluated the synergistic effects of the US and the LLLT (new prototype) with or without therapeutic exercises (TE) on pain and grip strength in women with hand osteoarthritis. Forty-five women with hand osteoarthritis, aged 60 to 80 years, were randomly assigned to one of three groups, but 43 women successfully completed the full study. The three groups were as follows: (i) the placebo group which did not perform TE, but the prototype without emitting electromagnetic or mechanical waves was applied (n = 11); (ii) the US + LLLT group which carried out only the prototype (n = 13); and (iii) the TE + US + LLLT group which performed TE before the prototype is applied (n = 13). The parameters of US were frequency 1 MHz; 1.0 W/cm(2) intensity, pulsed mode 1:1 (duty cycle 50%). Regarding laser, the output power of the each laser was fixed at 100 mW leading to an energy value of 18 J per laser. Five points were irradiated per hand, during 3 min per point and 15 min per session. The prototype was applied after therapeutic exercises. The treatments are done once a week for 3 months. Grip strength and pressure pain thresholds (PPT) were measured. Grip strength did not differ significantly for any of the groups (p ≥ 0.05). The average PPT between baseline and 3 months shows significant decrease of the pain sensitivity for both the US + LLLT group (∆ = 30 ± 19 N, p˂0.001) and the TE + US + LLLT group (∆ = 32 ± 13 N, p < 0.001). However, there were no significant differences in average PPT for placebo group (∆ = -0.3 ± 9 N). There was no placebo effect. The new prototype that combines US and LLLT reduced pain in women with hand osteoarthritis.

Efficacy of therapeutic ultrasound vs sham ultrasound on pain and physical function in people with knee osteoarthritis: A meta-analysis of randomized controlled trials

AIM: To determine the efficacy of therapeutic ultrasound vs sham for improving pain and physical function immediately post-intervention in people with knee osteoarthritis (OA).

METHODS: We hand searched meta-analyses on the topic published in 2010 and updated the search in three electronic databases (MEDLINE, EMBASE, CINAHL) January 1, 2009 to September 5, 2013 to identify relevant studies. The inclusion criteria were human randomized controlled trials published in the English language in which active therapeutic ultrasound was compared to sham ultrasound, data for people with knee OA were reported separately, participants were blinded to treatment allocation and outcomes assessed before and after treatment included pain, self-reported physical function and performance-based physical function. Two reviewers independently screened titles and abstracts retrieved in the search to identify trials suitable for full text review. Data extraction and risk of bias assessment of the identified trials were completed independently by two reviewers. Pooled analyses were conducted using inverse-variance random effects models.

RESULTS: We screened 1013 titles and abstracts. Meta-analysis of pain outcomes from 5 small trials (281 participants/OA knees) showed that, compared to sham ultrasound, therapeutic ultrasound improves pain [standardized mean difference (SMD) (95%CI) = -0.39 (-0.70, -0.08); P = 0.01] but not physical function [self-reported in 3 trials (130 participants/OA knees): SMD (95%CI) = -0.21 (-0.55, 0.14), P = 0.24; walking performance in 4 trials (130 participants/OA knees): SMD (95%CI) = -0.11 (-0.59, 0.37), P = 0.65). For the walking performance outcome, the dispersion of the estimated effects exceeded that expected due to sampling error (χ² = 8.37, P = 0.04, I² = 64%). Subgroup analyses of three trials that administered high dose ultrasound improved the consistency (I² = 28%) but the treatment effect remained insignificant.

CONCLUSION: Meta-analyzed double-blind placebo-controlled randomized trials provide low-strength evidence that therapeutic ultrasound decreases knee OA pain and very low-strength evidence that it does not improve physical function.

[Evidence-based physiotherapy]

This article on physiotherapy presents some current evidence stating the strengths and weaknesses of the physiotherapeutic procedures. In the area of physiotherapy empirical data obtained during decades were overtaken by evidence from current studies. The author points out the great problem of physiotherapy, namely the heterogeneity of the applied parameters. Knowledge of current evidence may be very important and helpful for the physicians, but the author proposes, from the practical point of view, that physiotherapeutical procedures based on exprience and used for many years should not be entirely neglected. Nowadays physiotherapy plays an important role in the treament of locomotor diseases but its use is increasing in other fields of medicine, as well.

Comparison of the efficacy of ketoprofen phonophoresis, ultrasound, and short-wave diathermy in knee osteoarthritis

The present study aimed to compare the efficacy of three different deep heating modalities: phonophoresis (PH), short-wave diathermy (SWD), and ultrasound (US), in knee osteoarthritis. Patients who consented to participate in the study were randomly divided into the following three groups. Group 1 (n = 33) received PH, Group 2 (n = 33) received US, and Group 3 (n = 35) received SWD. These deep heating therapies were applied by the same therapist. Each therapy began with 20-min hot pack application. Each of the three physical therapy modalities was applied 5 days a week for 2 weeks (a total of 10 sessions). The patients were evaluated using visual analogue scale (VAS) at rest, 15-m walking time, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) both before and after the treatment. Moreover, at the end of the treatment, both the physician and the patient made an overall evaluation, by rating the treatment efficacy. The results of the study showed that VAS, 15-m walking time, and WOMAC parameters were improved with all three deep heating modalities, and all the three modalities were effective. However, there was no significant difference between the three modalities in terms of efficacy. There was also no significant difference between the three groups in terms of post-treatment general evaluation of the physician and the patient. The present study is the first to suggest that choosing one of PH/US/SWD therapy options would provide effective results and none of them are superior to the others, and we believe that these findings will be a basis for further studies.

Physical therapy management of knee osteoarthritis in the middle-aged athlete

Osteoarthritis (OA) is prevalent in today's population, including the athletic and recreationally active "middle-aged" population. OA is a degenerative condition of the articular/hyaline cartilage of synovial joints and commonly affects the knee joint. In general, athletic participation does not specifically influence a higher incidence of knee OA in this population; however, traumatic injury to the knee joint poses a definitive risk in developing early-onset OA. The purpose of this article is to review evidence-based nonpharmacological interventions for the conservative management of knee OA. Manual therapy, therapeutic exercise, patient education, and weight management are strongly supported in the literature for conservative treatment of knee OA. Modalities [thermal, electrical stimulation (ES), and low-level laser therapy (LLLT)] and orthotic intervention are moderately supported in the literature as indicated management strategies for knee OA. While many strongly supported conservative interventions have been published, additional research is needed to determine the most effective approach in treating knee OA.

[Pharmacological cost impact of the osteoarthritis of the knee in a primary care health centre]

OBJECTIVE

To establish the pharmacological cost incurred by an urban Primary Health Care centre for treating osteoarthritis (OA) of the knee, including the main drugs used in its treatment and its contribution to the total cost of each group studied.

PATIENTS AND METHODS

A cross-sectional, descriptive study of 188 patients diagnosed with OA of the knee. After counting the total number of pre-packaged pharmaceutical products assigned to each patient over one year, the average cost of each product was calculated. The ratio between the total cost and the total number of patients was then calculated, which gave the cost per patient per year.

RESULTS

NSAIDs (non-steroids anti-inflammatory drugs) were the most frequently prescribed. SYSADOAs (symptomatic slow-acting drugs for osteoarthritis) rated second in both frequency and cost. Acetaminophen rated third. Topical treatments, "other analgesics" and proton pump inhibitors (PPIs), cost much less. The total pharmacological cost per patient per year thus amounted to 151.6 € (SD:±101,9).

CONCLUSIONS

The pharmacological cost for treatment of osteoarthritis of the knee incurs an increase in cost of health resources in Primary Care. The total pharmacological cost per patient per year was 151.60 €. In our centre, NSAIDs account for most of the pharmacological costs in the treatment of osteoarthritis of the knee.

Effects of phonophoresis of piroxicam and ultrasound on symptomatic knee osteoarthritis

OBJECTIVE

To compare the effects of phonophoresis of piroxicam (PhP) and ultrasound therapy (UT) in patients with mild to moderate, symptomatic knee osteoarthritis (OA).

DESIGN

A randomized, double-blind, controlled trial.

SETTING

Department of rehabilitation medicine, university hospital.

PARTICIPANTS

Patients with knee OA (N=46; mean age ± SD, 58.91±10.50y) who had visual analog scale (VAS) scores of 50 to 92mm (mean, 71.5mm) for knee pain intensity and Kellgren-Lawrence grades of I to III were randomly allocated into 2 groups: PhP and UT (23 in each group).

INTERVENTIONS

Both the PhP and UT groups were treated with an ultrasound program using the stroking technique, continuous mode, 1.0W/cm(2), 10 minutes per session, and 5 times per week for 2 weeks. Four grams of 0.5% piroxicam gel (20mg of piroxicam drug) was used in the PhP group, while the nondrug coupling gel was used in the UT group.

MAIN OUTCOME MEASURES

A 100-mm VAS for usual pain and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were evaluated before and after treatment in both groups using a double-blinded procedure.

RESULTS

The VAS and total WOMAC scores were significantly improved after treatment in both groups (P<.001). The PhP group showed more significant effects than the UT group, both in reducing the VAS pain score (P=.009) and in improving the WOMAC score, although it did not reach the level of significance (P=.143).

CONCLUSIONS

Our results indicated that PhP was significantly more effective than UT in reducing pain and tended to improve knee functioning in Kellgren-Lawrence grades I to III knee OA. PhP is suggested as a new, effective method for treatment of symptomatic knee OA.

Effects of kinesiotherapy, ultrasound and electrotherapy in management of bilateral knee osteoarthritis: prospective clinical trial

BACKGROUND

Although recent advances in knee osteoarthritis (OA) treatment and evaluation were achieved, to the best of our knowledge, few studies have evaluated the longitudinal effect of therapeutic modalities on the functional exercise capacity of patients with knee OA. The purpose was to investigate the effects of kinesiotherapy and electrotherapy on functional exercise capacity, evaluated using the six-minute walk test (6-MWT) in patients with bilateral knee OA. Secondary measurements included range of motion (ROM), severity of knee pain (VAS), and a measure of perceived health and physical function, evaluated using the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index.

METHODS

A total of 40 women with bilateral knee OA were assigned to three groups: kinesiotherapy (KIN, n = 16), transcutaneous electrical nerve stimulation (TENS, n = 12), or ultrasound (US, n = 10). The groups underwent 12 weeks of intervention twice per week. The participants were subjected to the 6-MWT, ROM, VAS and WOMAC index. These tests were performed before and after the intervention. The study was focused on outpatients and was carried out at Universidade Estadual de Campinas, Brazil.

RESULTS

At follow-up, the KIN and US groups had significantly higher 6-MWT distances (19.8 ± 21.7 and 14.1 ± 22.5%, respectively) compared with their respective pre-intervention values. All treatments were effective for reducing pain and improving the WOMAC index.

CONCLUSIONS

We demonstrated that the 6-MWT is a tool that can be used to evaluate improvements in the functional exercise capacity of patients submitted to a clinical intervention.

Efeito do ultrassom pulsado e do ultrassom contínuo associado a exercícios em pacientes com osteoartrite de joelho: estudo piloto

A osteoartrite (OA) é uma doença crônica associada à morbidade significante. O objetivo deste estudo foi comparar o exercício isolado ao ultrassom pulsado (USP) e contínuo (USC) associados a exercício na redução da dor, melhora da amplitude de movimento (ADM), força muscular (FM), qualidade de vida (QV) e funcionalidade de pacientes com OA de joelhos. Trinta indivíduos, 50 a 75 anos, OA grau 2-4, foram randomizados: Grupo USC (USC + exercícios), Grupo USP (USP + exercícios) e Grupo EXE (exercícios). Os grupos foram avaliados antes e após o tratamento. A intervenção foi realizada três vezes por semana durante oito semanas: nas quatro primeiras foi aplicado USC ou USP e, nas demais foram realizados os exercícios. O Grupo EXE realizou exercícios durante oito semanas. Para análises intragrupos, utilizou-se o teste de Wilcoxon e, intergrupos, o teste de Kruskall-Walis. Na comparação intragrupos, o Grupo USC apresentou melhora significativa (p<0,05) nas variáveis da Western Ontario and McMaster Universities Osteoarthritis (WOMAC) dor, função e escore total; o Grupo USP na dor repouso, ADM, FM e nas variáveis da WOMAC dor, função e escore total; já, o Grupo EXE na mobilidade e ADM. Na comparação intergrupos, o Grupo USC apresentou melhora significativa (p<0,05) quando comparado aos demais grupos na dor repouso, ADM, escores função e total da WOMAC e o Grupo EXE na dor da WOMAC. A associação do USC a exercícios foi mais efetiva na melhora da dor, ADM, função e QV em pacientes com OA de joelho.