International Journal of Health Sciences and Research

www.ijhsr.org ISSN: 2249-9571

Original Research Article

Comparison of Effectiveness of Ultrasound plus

Strengthening Exercises and Transcutaneous
Electric Nerve Stimulation in Managing Functional
Activity and Pain in Patients with Acute Knee
Osteoarthritis
Monica Preet Kour1, Shyamal Koley2
1
Post-Graduate Student, 2Professor and Head,
Department of Physiotherapy, Guru Nanak Dev University, Amritsar - 143005, Punjab, India
Corresponding Author: Shyamal Koley

ABSTRACT

Introduction: In elderly population, osteoarthritis is very common, affecting mostly knees, hands,
hips, spine, and feet. Knee osteoarthritis can be commonly classified into acute or chronic stage. In
the present study, four weeks interventions with ultrasound plus strengthening exercises and
transcutaneous electric nerve stimulation were given to patients with acute knee osteoarthritis to
observe the efficacy of these modalities.
Method: A total of purposively selected 50 confirmed cases of acute knee osteoarthritis aged 31-65
years were considered for the present study and were collected from the Government Medical
College, Jammu, Jammu & Kashmir, India. The subjects were divided into two groups for
intervention. Group A consisted of 25 subjects who were treated with ultrasound plus strengthening
exercises for four weeks. Group B consisted of 25 subjects who were treated with transcutaneous
electric nerve stimulation (TENS) for 4 weeks.
Results: Statistically significant differences (p<0.022-0.002) were found in functional activity score
(before and after treatment) and pain (after treatment) between the two sets of data. When male and
female acute knee osteoarthritis patients treated with ultrasound plus strengthening exercises were
compared, statistically no significant differences (p>0.05) were found in any case between them.
Similarly, when male and female acute knee osteoarthritis patients treated with TENS were compared,
statistically significant differences (p<0.035-0.017) were found in weight and BMI only between
them.
Conclusion: It might be concluded that ultrasound plus strengthening exercises were more effective
than transcutaneous electric nerve stimulation for increment of functional activity and reduction of
pain in patients with acute knee osteoarthritis.

Key Words: Acute knee osteoarthritis patient. Ultrasound plus strengthening exercises.
Transcutaneous electric nerve stimulation.

INTRODUCTION radiographic evidence of Osteoarthritis is

Osteoarthritis (OA) is one of the approximately 85%, [3] affecting mostly
most common musculoskeletal disorders knees, hands, hips, spine, and feet. [4-6]
resulting in chronic degenerative joint Patients with knee OA present mostly with
disease. [1,2] In elderly population pain, articular stiffness, crepitation, articular

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Vol.9; Issue: 5; May 2019
Monica Preet Kour et.al. Comparison of Effectiveness of Ultrasound plus Strengthening Exercises and
Transcutaneous Electric Nerve Stimulation in Managing Functional Activity and Pain in Patients with Acute
Knee Osteoarthritis
edema, joint deformities, articular plus strengthening exercises and
instability, decrease in range of motion transcutaneous electric nerve stimulation in
(ROM), physical activity limitations and patients with acute knee osteoarthritis.
muscle weakness. [6,7] Hence pain relief with
pharmacologic [8,9] and non-pharmacologic MATERIALS AND METHODS
strategies [10-13] have been studied widely. Subjects
Knee joint being major weight The present cross-sectional study
bearing joint consists of: Tibiofemoral joint was based on purposively selected 50
and Patellofemoral joint. Osteoarthritis is a confirmed cases of acute knee osteoarthritis
chronic degenerative disorder primarily aged 31-65 years. The samples were
affecting the articular cartilage of synovial collected from the Government Medical
joint, with eventual bony remodelling and College, Jammu, Jammu & Kashmir, India.
overgrowth at margins of the joints. [14] The subjects were divided into two groups
Knee Osteoarthritis can be commonly for intervention. Group A consisted of 25
classified into acute or chronic stage. Some subjects (21 females and 04 males) who
peculiar features of Knee Osteoarthritis are were treated with ultrasound plus
– pain initially on weight bearing later strengthening exercises for four weeks.
becomes continuous even at rest, swollen Group B consisted of 25 subjects (21
joints due to synovitis, stiffness sets in females and 04 males) who were treated
which gradually results in deformity. [15] with transcutaneous electric nerve
Signs and symptoms of end stage OA stimulation for 4 weeks. The study was
include- severe pain, loss of joint motion approved by the Institutional Ethics
and movements of involved joints, joint Committee.
effusion, and abnormal gait mechanics. [16] Anthropometric Measurements
Osteoarthritis is steadily becoming the most Three anthropometric variables, such
common cause for middle age and for those as, height, weight and BMI were taken on
above the age of 65 years. [17] each subject using the techniques provided
Physiotherapy provides very by Lohman et al. [23] and were measured in
effective non-pharmacological interventions triplicate with the median value used as the
knee osteoarthritis [18] and procedures criterion.
prescribed by physiotherapists are The height was recorded during
considered important and play a inspiration using a stadiometer (Holtain
fundamental role in patients’ treatment. In Ltd., Crymych, Dyfed, UK) to the nearest
this context, kinesiotherapy (KIN) 0.1 cm. Weight was measured by digital
comprising of different types of therapeutic standing scales (Model DS-410, Seiko,
exercises, such as stretching, strengthening Tokyo, Japan) to the nearest 0.1 kg. BMI
(isotonic, isokinetic, and isometric) and was then calculated using the formula
aerobic exercise, [19] and electrotherapy are weight (kg)/height 2 (m) 2. Functional
frequently used for the treatment of different activity and pain score of the patients were
[20-22]
musculoskeletal disorders. measured by Samual-Greenguard
Electrotherapy includes ultrasound (US), a Questionnaire (SGQ) and Visual Analog
modality of treatment that uses sound waves Scale (VAS).
to generate heat within a body part, and Ultrasound with Knee Strengthening
transcutaneous electrical nerve stimulation Exercises
(TENS), a method of pain relief in which a In this group, patients of acute knee
special device transmits low-voltage osteoarthritis were treated with ultrasound
electrical impulses through electrodes on the along with knee strengthening exercises for
skin to an area of the body that is in pain. [8] four weeks. Session started with patients of
In the present study an attempt has been this group to perform the exercises, such as,
made to observe the efficacy of ultrasound Isometric Quadriceps Exercise, Patellar

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Vol.9; Issue: 5; May 2019
Monica Preet Kour et.al. Comparison of Effectiveness of Ultrasound plus Strengthening Exercises and
Transcutaneous Electric Nerve Stimulation in Managing Functional Activity and Pain in Patients with Acute
Knee Osteoarthritis
Mobility Exercise, End Range Extension undergoing treatment was slightly flexed
and Active Knee Flexion-extension. One set and supported with pillow. The area of the
consisted of 10 repetitions; one repetition skin was cleansed with alcohol to improve
was held for 10 seconds followed by 10 skin conductivity. Four rubber electrodes
seconds rest between each successive with acoustic gel spreaded evenly over them
repetition and the rest period of 2 minutes to improve conductivity were applied to
between the 2 successive sets. Patients were either side of the affected knee joint aligned
asked to perform 2 sets per session per day. longitudinally along the length of the limb.
After the completion of exercises, patients The electrodes were secured using Velcro
were given continuous Ultrasound therapy straps. Stimulation frequency was 80 Hz
with 1.5 Watt/cm2 for 10 minutes with continuous, phase duration was 200 ms, and
frequency of 1 MHz. For this, subjects were the current intensity will be strong but
made to sit with knee partially flexed with a comfortable. Each TENS treatment session
pillow underneath the knee. Acoustic gel lasted 30 minutes. The patients of this group
was applied to the treatment head as well as were treated in the same way 5 times /week
to the skin over the knee joint to allow for 4 weeks.
perfect contact and allow maximum Statistical Analysis
transmission of the sonic waves. The Standard descriptive statistics (mean
patients of this group were treated in the ± standard deviation) were determined for
similar manner for 5 sessions/week for 4 directly measured and derived variables.
weeks. Student’s t-test was used for the comparison
Transcutaneous Electric Nerve of various variables between patients treated
Stimulation (TENS) with ultrasound plus strengthening exercises
In this group, patients were treated and TENS. Data were analyzed using SPSS
with transcutaneous electric nerve (Statistical Package for Social Science)
stimulation for 4 weeks. Patients of this version 20.0. A 5% level of probability was
group were positioned for treatment lying used to indicate statistical significance.
supine on the treatment bed. Knee

RESULTS
Table 1: Descriptive statistics of selected variables in acute knee osteoarthritis patients treated with ultrasound plus strengthening
exercises and TENS
Variables PUS+SE (n =25 ) PTENS (n =25 ) t-value p-value
Mean SD Mean SD
Age (years) 50.76 6.41 49.24 4.94 0.964 0.340
HT (cm) 160.20 6.19 158.56 5,52 1.013 0.326
WT (kg) 61.64 12.66 62.00 7.05 0.124 0.902
BMI (kg/m2) 24.02 4,81 24.78 3.52 0.631 0.531
SMQBT (%) 44.36 6.53 39.08 5.07 3.192 <0.002
SMQAT (%) 41.20 6.18 37.40 5.14 2.364 <0.022
VASBT 7.16 1,28 6.84 0.85 1.041 0.303
VASAT 4.68 1.60 5.84 0.94 3.123 <0.003
PUS+SE = patients with ultrasound plus strengthening exercises, PTENS = patients with TENS, HT = height, WT = weight, BMI = b ody
mass index, SMQBT = Samual-Greenguard Questionnaire score before treatment, SMQAT = Samual-Greenguard Questionnaire score after
treatment, VASBT = Visual Analog Scale before treatment, VASAT = Visual Analog Scale after treatment.

Table 2: Descriptive statistics of selected variables in male and female acute knee osteoarthritis patients treated with ultrasound
plus strengthening exercises
Variables Female patients (n =21 ) Male patients (n =04 ) t-value p-value
Mean SD Mean SD
Age (years) 50.43 6.93 52.50 1.73 0.584 0.565
HT (cm) 160.52 6.39 158.50 4.45 0.591 0.560
WT (kg) 61.00 12.83 65.00 12.91 0.571 0.574
BMI (kg/m2) 23.67 4.81 25.87 5.09 0.832 0.414
SMQBT (%) 44.86 6.47 41.75 7.13 0.868 0.395
SMQAT (%) 41,28 6.67 40.75 2.87 0.156 0.878
VASBT 7.28 1.27 6.50 1.29 1.131 0.270
VASAT 4.76 1.64 4.25 1.50 0.578 0.569

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Vol.9; Issue: 5; May 2019
Monica Preet Kour et.al. Comparison of Effectiveness of Ultrasound plus Strengthening Exercises and
Transcutaneous Electric Nerve Stimulation in Managing Functional Activity and Pain in Patients with Acute
Knee Osteoarthritis
Table 1 showed the descriptive statistics of selected variables in acute knee osteoarthritis
patients treated with ultrasound plus strengthening exercises and TENS. Statistically
significant differences (p<0.022-0.002) were found in SMQ score (before and after treatment)
and VAS (after treatment) between the two sets of data.

Table 3: Descriptive statistics of selected variables in male and female acute knee osteoarthritis patients treated wit h TENS
Variables Female patients (n =21 ) Male patients (n =04 ) t-value p-value
Mean SD Mean SD
Age (years) 48.95 4.25 50.75 6,70 0.710 0.485
HT (cm) 158.76 5.37 157.50 4.93 0.436 0.667
WT (kg) 60.57 6.17 69.50 7.37 2.582 <0.017
BMI (kg/m2) 24.14 3.18 28.12 3.74 2.240 <0.035
SMQBT (%) 38.90 5.17 40.00 5.10 0.389 0.701
SMQAT (%) 37.28 5.26 38.00 5.10 0.250 0.805
VASBT 6.86 0.91 6.75 0.50 0.226 0.823
VASAT 5.86 1.01 5.75 0.50 0.204 0.840

The descriptive statistics of selected 7.12%, whereas, using transcutaneous

variables in male and female acute knee electric nerve stimulation, the increment
osteoarthritis patients treated with was 4.30%. So far decrement of pain was
ultrasound plus strengthening exercises concerned, patients treated with ultrasound
were shown in table 2. Statistically no plus strengthening exercises had the value
significant differences (p>0.05) were found of 34.64% and with transcutaneous electric
in any case between them. nerve stimulation, the decrement was
Table 3 showed the descriptive statistics of 14.62%. Thus, it might be concluded that
selected variables in male and female acute ultrasound plus strengthening exercises
knee osteoarthritis patients treated with were more effective than transcutaneous
TENS. Statistically significant differences electric nerve stimulation for increment of
(p<0.035-0.017) were found in weight and functional activity and reduction of pain in
BMI between the two sets of data. patients with acute knee osteoarthritis. As it
is known that ultrasound is a modality of
DISCUSSION treatment that uses sound waves to generate
Osteoarthritis is widely believed to heat within a body part [8] and knee
result from local mechanical factors acting strengthening exercises program aims to
within the context of systemic susceptibility. reduce the medial knee load and pain and
[24]
For clinicians, researchers and improve function in people with medial
policymakers, it is important to be able to compartment osteoarthritis. [25] Rutjes et al.
[26]
determine the most successful treatment failed to confirm that transcutaneous
protocol for managing functional activity electric nerve stimulation was effective for
and pain in patients with acute knee pain relief in patients with acute knee
osteoarthritis. In the present study, four osteoarthritis. The findings of the present
weeks interventions with ultrasound plus study followed the same direction. The
strengthening exercises were given to 25 limitation of the study was small sample
patients and transcutaneous electric nerve size, especially in male patients. For this
stimulation for four weeks were given to reason, when the comparison of functional
another 25 patients. Statistically significant activity and pain between male and female
differences were found between the two sets patients were done, no significant
of population in functional activity (before differences were found (except in two
and after treatment) and pain (after cases). More extensive studies are required
treatment) (table 1). The findings of the considering greater sample size to validate
present study showed that patients treated the data.
with ultrasound plus strengthening exercises
had increased their functional activity with

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Vol.9; Issue: 5; May 2019
Monica Preet Kour et.al. Comparison of Effectiveness of Ultrasound plus Strengthening Exercises and
Transcutaneous Electric Nerve Stimulation in Managing Functional Activity and Pain in Patients with Acute
Knee Osteoarthritis
CONCLUSION treatment of knee osteoarthritis. Expert Opin
From the findings of the present Pharmacother 2008; 9(10): 1797–1804.
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plus strengthening exercises were more Osteoarthritis year 2010 in review: non
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effective than transcutaneous electric nerve
2011; 19(4):366–374.
stimulation for increment of functional 11. Suarez-Almazor ME, Looney C, Liu Y, Cox
activity and reduction of pain in patients V, Pietz K, Marcus DM, Street RL Jr. A
with acute knee osteoarthritis. randomized controlled trial of acupuncture
for osteoarthritis of the knee: effects of
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How to cite this article: Kour MP, Koley S. Comparison of effectiveness of ultrasound plus
strengthening exercises and transcutaneous electric nerve stimulation in managing functional
activity and pain in patients with acute knee osteoarthritis. Int J Health Sci Res. 2019; 9(5):129-
134.

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