Effect of A Physiotherapy Rehabilitation Program On Knee Osteoarthritis in Patients With Different Pain Intensities
Effect of A Physiotherapy Rehabilitation Program On Knee Osteoarthritis in Patients With Different Pain Intensities
Effect of A Physiotherapy Rehabilitation Program On Knee Osteoarthritis in Patients With Different Pain Intensities
Original Article
University, Egypt
3) Department of Basic Sciences, Faculty of Physical Therapy, Cairo University, Egypt
Abstract. [Purpose] To examine the effect of physiotherapy rehabilitation program on moderate knee osteoar-
thritis in patients with different pain intensities. [Subjects and Methods] Sixty subjects (37 men and 23 women)
with moderate knee osteoarthritis participated in the current study. Randomization software was used to select the
participating subjects’ numbers from the clinic records. They were classified into three groups according to pain
intensity: mild, moderate, and severe pain groups. All groups underwent a standard set of pulsed electromagnetic
field, ultrasound, stretching exercises, and strengthening exercises. Pain intensity, knee range of motion, knee
function, and isometric quadriceps strength were evaluated using the visual analogue scale, universal goniometer,
Western Ontario and McMaster Universities osteoarthritis index, and Jamar hydraulic dynamometer, respectively.
The evaluation was performed before and after a 4-week rehabilitation program. [Results] All groups showed sig-
nificant differences in pain intensity, knee range of motion, isometric quadriceps strength, and knee function. The
score change in moderate pain group was significantly greater than those in mild and severe pain groups. [Conclu-
sion] Pain intensity is one of the prominent factors that are responsible for the improvement of knee osteoarthritis.
Consequently, pain intensity should be considered during rehabilitation of knee osteoarthritis.
Key words: Knee osteoarthritis, Pain intensity, Quadriceps strength
(This article was submitted Oct. 2, 2017, and was accepted Nov. 28, 2017)
INTRODUCTION
Degenerative joint arthritis is the most common joint disorder that is caused by biomechanical stresses affecting both
the articular cartilage and subchondral bone. Degenerative osteoarthritis (OA) is the most common form of arthritis and is
a major cause of morbidity and functional limitation, especially in elderly patients1). The incidence of knee OA is expected
to increase over the next decades2). Knee OA is directly related to disabilities due to pain, quadriceps dysfunction, and
impaired proprioception. Moreover, knee OA is responsible for the impaired ability of the quadriceps muscle to control force
in patients with OA. Nevertheless, exercise therapy is effective in reducing the pain and improving the function of patients
with knee OA3).
Unlike many other pain conditions in which the underlying injury typically heals or resolves, OA is a disease that does
not resolve. Thus, OA is typically accompanied by chronic pain. Whether, and to what degree, this ongoing chronic pain (i)
plays an important nociceptive role, (ii) represents maladaptive pain, or (iii) reflects other aspects of the pain experience are
not clear4).
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Pain is one of the most commonly reported and prominent factors that are responsible for physical inactivity in patients
with knee OA5). This impairment in physical activity associated with knee OA has important implications for aerobic power
and cardiovascular health. Hence, patients with OA are at a particular risk of poor health outcomes6). Pain pattern and severity
of knee OA as either absent, mild, moderate, severe, or very severe could affect the range of motion (ROM) that involves
daily activities and quality of life7).
Moreover, muscle weakness in knee OA usually results in joint stiffness and decreasing ROM that involves daily activi-
ties8). Quadriceps muscle impairment in knee OA is well documented in the literature. In addition, the differences in the
magnitudes of muscle strength are caused by the differences in the subjects’ characteristics, OA severity, pain severity, and
definition of the control group9–11). Patients with knee OA experience chronic form of pain and show a declining ability to use
their joints, which consequently weakens the muscles. Hence, these destabilise the joints and reduce the physical functions
of patients; further, the motions required for the patients’ daily activities become restricted12).
Although pain is a symptom of OA that is present in almost all classification criteria for OA, there is often a discordance
between reports of pain and radiologic OA13–15). It is suggested that this discordance applies, in particular, to the less severe
grades of knee OA and that pain is more common in more severe grades of OA (1 and 2)13, 14). Moreover, Erden et al.
reported that pain intensity and degrees of inaccuracy of knee joint position sense were positively correlated at 60° and
90° knee flexions. The relationship between pain intensity and knee joint position sense is very important for patients with
OA in the improvement of rehabilitation programs16). Given these findings, only few studies have considered pain severity
during rehabilitation programs for patients with knee OA. Therefore, the aim of this study was to examine the effect of a
physiotherapy treatment program on moderate knee OA with different grades of pain intensity.
Mild pain group (n=20) Moderate pain group (n=20) Severe pain group (n=20) p value
Age (yrs) 55.90 ± 5.01 55.73 ± 5.80 56.10 ± 5.74 0.930
Height (cm) 170.14 ± 5.17 171.91 ± 4.34 170.34 ± 5.17 0.195
Weight(kg) 75.34 ± 5.94 76.17 ± 5.14 77.42 ± 6.53 0.274
Body mass index (kg/m 2) 26.14 ± 3.90 25.10 ± 3.72 26.00 ± 4.53 0.479
Gender (female/male) 8/12 6/14 9/11 0.610
Data are presented as mean ± standard deviation, p<0.05.
Stage Knee pain Radiographic osteophytes Age Morning stiffness Crepitus Bony enlargement in physical examination
I √ √ <40 - - -
II √ √ >40 <30 min √ -
II √ √ >40 >30 min √ -
IV √ √ >40 >30 min √ √
- Findings absent, √ Findings present.
In this study, the treatment program was firstly initiated for treating knee OA based on the Battecha and Soliman pro-
gram26). All groups underwent a standard set of pulsed electromagnetic field (PEMF), ultrasound (US), and stretching and
strengthening exercises. A PEMF device (ASA/Easy terza series, Italy) was used to provide electromagnetic therapy. The
pulse frequencies were 50 Hz for the solenoids and up to 100 Hz for the applicators. The solenoid encircled the target limb
segment at the level of the knee. Each patient was exposed to low-intensity 15 GPMF (Gauss permagnetic field) with a
frequency of 50 Hz for 30 minutes per session. Thereafter, a US device (ITO, US/100, Japan) was used to provide deep
heating therapy. Continuous US waves with a 1-MHz frequency and 1-watt/cm2 power were applied using a 4-cm2-diameter
applicator. The US therapy lasted for 5 minutes per session27). Both PEMF therapy and US therapy were continued for three
sessions weekly for 4 weeks.
Immediately after PEMF and US application, each patient was asked to perform stretching exercises and strengthening
exercises in the following fixed sequence: hamstrings muscle stretching and calf muscle stretching. The physical therapist
repeated the passive stretching exercises thrice per session. Each stretch was sustained for 30 seconds, with 10-second
rest intervals28). After a rest period of 5 minutes, the patients were asked to perform the following: 1) isometric quadriceps
contraction (quadriceps drill) in full knee extension maintained for 5 seconds, followed by a 5-second rest; the exercise was
performed for 20 repetitions per session29); and 2) straight leg raising exercise in a crock lying position (the patients were
asked to tense the quadriceps muscle, elevate the limb to 45° and maintain it for 6 seconds, and lower the limb slowly and
then relax for 6 seconds; the exercise was performed for three sets of 10 repetitions per session)28). Both stretching and
strengthening exercises were performed for three sessions weekly for 4 weeks. The evaluation and treatment procedures
were done for the patients by the same therapist before and after the treatment period. They were instructed to maintain their
activity levels during the study period30).
Data were analysed using the Statistical Package for Social Sciences (IBM Corp.: Armonk, NY USA) version 20.0. A
one-way analysis of variance was used to compare the effect of the physical therapy treatment on the VAS score, knee ROM,
quadriceps strength, and WOMAC score among the three groups with knee OA. Score changes were also calculated. The
level of significance was set at p<0.05.
RESULTS
The descriptive statistics of the VAS score, knee ROM, quadriceps strength, and WOMAC score of the three groups are
presented in Table 3. The pre-intervention VAS score of the mild pain group was lower than those of the moderate and severe
pain groups (p=0.001), and that of the moderate pain group was lower than that of the severe pain group (p=0.001). There was
a significant reduction in pain intensity owing to the interventions in the three groups (p=0.001). The post-intervention VAS
score of the mild pain group was significantly lower than those of the moderate and severe pain groups (p=0.001); further, the
post-intervention VAS score of the moderate pain group was significantly lower than that of the severe pain group (p=0.001).
The pre-intervention ROM of the mild pain group was greater than those of the moderate and severe pain groups (p=0.001),
without a significant difference between the pre-intervention ROMs of the moderate and severe pain groups (p=0.063). There
was a significant improvement in the ROM owing to the interventions in the three groups (p=0.001). The post-intervention
ROM of the mild pain group was significantly greater than those of the moderate and severe pain groups (p=0.008 and 0.001,
respectively); moreover, the post-intervention ROM of the moderate pain group was significantly greater than that of the
309
Table 3. The values of pain intensity, knee ROM, quadriceps strength, and WOMAC of the three groups
Variables Mild pain group (n=20) Moderate pain group (n=20) Severe pain group (n=20)
Pre Post Change Pre Post Change Pre Post Change
score score score
Pain intensity 2.59 ± 1.45 ± −1.14 ± 6.06 ± 4.04 ± −2.02 ± 7.86 ± 6.50 ± −1.36 ±
0.63 0.51 0.44 0.51 0.63 0.36 0.43 0.50 0.28
Knee ROM (°) 111.65 ± 122.50 ± 10.85 ± 101.65 ± 115.40 ± 13.75 ± 96.70 ± 107.20 ± 10.50 ±
8.34 7.96 3.20 7.78 10.30 4.23 7.05 8.28 4.51
Quadriceps 22.15 ± 26.25 ± 4.10 ± 19.23 ± 23.94 ± 4.72 ± 17.38 ± 21.03 ± 3.65 ±
strength (kg) 4.08 4.35 1.78 3.62 4.17 1.46 3.02 3.51 1.25
WOMAC 28.40 ± 21.85 ± −6.55 ± 46.85 ± 33.13 ± −7.73 ± 57.13 ± 51.28 ± −5.85 ±
5.12 4.46 1.70 5.17 5.27 1.48 5.18 4.88 1.26
Data are presented as mean ± standard deviation.
DISCUSSION
To the best of our knowledge, this is the first study to classify patients with moderate knee OA according to their pain
intensity. The results of this study support the hypothesis that a physiotherapy treatment program has different effects in
patients with moderate knee OA with different grades of pain intensity, indicating that the magnitude of pain is one of the
prominent factors that are responsible for the improvement of knee OA. However, these results are not supported by the
findings of Külcü et al. who reported that there is no relationship between VAS scores and regular physical activity habit and
symptom duration in patients with knee OA31).
The patient classification completely depended on the pain intensity, since many previous studies have shown that there
is a discordance in the relationship between pain and radiologic OA. There are patients with a Kellgren/Lawrence grade of
3 or 4 for knee OA without any pain in the knee13–15). For example, 29.9% of patients with Kellgren/Lawrence grade 2 and
64.1% of those with Kellgren/Lawrence grade 3 in the knee in an open population study experienced pain at some points32).
In the pretreatment condition, it was observed that the patients with knee OA with moderate and severe pain showed
significant declines in the knee ROM, isometric quadriceps strength, and level of functional performance, which may be due
to the level of pain that resulted in the weakening of muscle strength, instability of the knee joint, and decreased physical
function33). Moreover, the impairments of muscle activation are magnified in subjects with knee OA ranging from 8 to 25% in
populations of varying disease severities34). Reduced voluntary activation of the muscles and decreased contractile rates are
meaningful as these explain the strength decline and changes in muscle size35), which were experienced by the patients with
knee OA with moderate and severe pain in the current study. However, a recent study discovered that pain did not influence
the thigh muscle electromyogram (EMG) amplitudes or proprioceptive acuity in patients with mild and moderate knee OA
during a stair climbing task36).
The rehabilitation program decreased the pain intensity and improved the knee ROM, isometric quadriceps strength, and
level of functional performance in all knee OA groups. In addition, it was clear that the rehabilitation program had more
drastic effects in the moderate pain group. Thus, the levels of improvement in the moderate pain group were superior to those
Conflict of interest
No conflict of interest is declared by authors.
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