Int J Physiother Res 2015;3(2):978-85. ISSN 2321-1822 978

Original Article

UTILIZATION OF PULSED ELECTROMAGNETIC FIELD ANDTRADITIONAL PHYSIOTHERAPY IN KNEE OSTEOARTHRITISMANAGEMENTKadrya H. Battecha 1, Elsadat Saad Soliman *2.1 Assistant Professor, Basic Science Department, Faculty of Physical Therapy, Cairo University,Egypt.*2 Lecturer, Physiotherapy Department for Musculoskeletal Disorders and its Surgery, Faculty ofPhysical Therapy, Cairo University, Egypt.

Background and Objectives: Pulsed Electromagnetic Field (PEMF) has been suggested as a treatment method formusculoskeletal system disorders. The present study was conducted to determine whether the addition of PEMFto traditional physical program produces better clinical outcomes than traditional physical program alone inthe management of moderate knee osteoarthritis (OA).Design: A single-blinded, randomized controlled studyMethods: Twenty subjects (5 men and 15 women) with unilateral moderate knee OA (Kellgren-Lawrence criteriagrade 2). They were randomly allocated in 2 groups to receive: group (A) PEMF plus ultrasound plus exercises;or (B) ultrasound plus exercises. Both groups received the respective treatments 3 times per week for 4 weeksand underwent the same pretreatment and post treatment evaluation that included active knee range of motion(ROM) by universal goniometer, knee pain score by visual analogue scale (VAS) and knee functional performanceby Western Ontario and McMaster Universities osteoarthritis index (WOMAC).Result: There was an improvement in both groups in active knee flexion ROM, reduced VAS score and improvedWOMAC index , however, all outcomes were significantly better in group (A) (p <0.05). Moreover, the percentagesof outcomes improvement were in favor of group (A).Conclusion: The addition of PEMF to traditional physical program in managing OA produced a greaterimprovement in pain relief, range of motion and resulted in better functional performance than did traditionalphysical program alone. The improvement in current study should be limited to short term outcomes of PEMF.KEY WORDS: Knee osteoarthritis, Pulsed electromagnetic field, Traditional physiotherapy.

ABSTRACT

INTRODUCTION

Address for correspondence: Dr. Elsadat Saad Soliman, PhD, PT. Lecturer, PhysiotherapyDepartment for Musculoskeletal Disorders and its Surgery, Faculty of Physical Therapy, CairoUniversity, Egypt. E-Mail: elsadaat.saad@pt.cu.edu.eg, sadatsaad@yahoo.com

International Journal of Physiotherapy and Research,Int J Physiother Res 2015, Vol 3(2):978-85. ISSN 2321-1822

DOI: http://dx.doi.org/10.16965/ijpr.2015.119

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DOI: 10.16965/ijpr.2015.119

Received: 09-03-2015Peer Review: 09-03-2015Revised: None

Accepted : 23-03-2015Published (O): 11-04-2015Published (P): 11-04-2015

Degenerative osteoarthritis (OA) is the mostcommon joint disease that is caused bybiomechanical stresses affecting the articularcartilage and subchondral bone of the joint [1].The degenerative OA is the most common form

of arthritis and is a major cause of morbidity,limitation of activity and health care utilization,especially in elderly patients [2].Knee OA occurs in approximately 10% ofindividuals over 65 years of age and may affectup to 2% of the adult population with greater

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Kadrya H. Battecha, Elsadat Saad Soliman.UTILIZATION OF PULSED ELECTROMAGNETIC FIELD AND TRADITIONAL PHYSIOTHERAPY INKNEE OSTEOARTHRITIS MANAGEMENT.

incidence, prevalence and severity in womenthan in men [3, 4]. The physical disability arisingfrom knee OA prevents the performance of dailylife activities and negatively affects life quality.Several causes lead to the occurrence ofphysical disability. These include pain, jointmovement restriction, muscle weakness andcoordination [5].Pain associated with OA of the knee is the mostcommon complain of patients suffering from OA.The chronicity of the disorder often leads tomuscle weakness, joint stiffness or instabilityand reduced physical function with subsequentlosses in functional independence and healthrelated quality of life [6].Current recommendations for managing OAfocus on relieving pain and stiffness andmaintaining or improving physical function asimportant goals of therapy. Both pharmacologicand nonpharmacologic management arefocusing on controlling pain and reducingfunctional limitation [2].Patients with arthritis are more likely to beidentified as ‘disabled’ compared to those withother chronic conditions. They may experiencepsychological symptoms, including anxiety,depression and helplessness. It has beenreported that 10% of people with OA aredepressed, and that psychological symptomsexacerbate pain and disability [7].Pulsed electromagnetic field (PEMF) is relativelya newly born option for treating selectedpathological conditions [8]. PEMF can penetratethrough highly resistance structures such asbone, fat, skin or even plaster cast. PEMF providea practical exogenous method for cell andtissues modification [9]. PEMF control pain incertain neurological conditions, diabeticneuropathy, multiple sclerosis and arthriticconditions [10].PEMF has been suggested as a treatment methodfor musculoskeletal system disorders.Electromagnetic field causes biological changesto the cell environment and restores its integrityand function. In addition to that, it increasesmembrane potentials of erythrocytes, increasesoxygen content of tissue, vasodilates bloodvessels and relieves pain without increasinglocal temperature. PEMF was effective in

reducing pain and edema after soft tissue injury[11].Among the treatments available, PEMF is acontroversial treatment modality. However,PEMF have been used with increasing frequencyover the prior two decades [12]. Furthermore,numerous randomized trials revealed thepotential of PEMF to improve OA symptoms werepublished [13]. The European League againstRheumatism (EULAR) recommendationsconsidered PEMF as a good treatment option forknee OA [14].The pharmacological modalities are effective inreducing pain and inflammation, but their long-term use is associated with a high incidence ofside effects or may not be applicable to somepatients [15]. Based on these findings,alternative therapies for this pathologicalcondition might be helpful. PEMF therapy hasproved to be safe and has also shown promisingtherapeutic effectiveness on bone- and cartilage-related pathologies, including knee and cervicalspine [16, 17].This study was conducted to clarify whether ThePEMF together with traditional physiotherapymight help patients with knee OA to improvetheir functional performance, knee flexion rangeof motion (ROM) and reduce pain encounteredwith the disease or not.

MATERIAL AND METHODS

Subjects: Twenty subjects (5 men and 15women, their age ranged 45- 55 years; BMI was< 30 kg/m2 with unilateral moderate knee OAparticipated in this study. The diagnosis andgrading of knee OA was made by an orthopedicsurgeon and according to Kellgren and Lawrencesystem for classification of knee OA [18].Subjects were included if they had experiencedknee pain, stiffness and difficulty in stairclimbing, walking and cross legged sitting.Subjects were excluded if they had a history ofrecent trauma to the knee, acute signs ofinflammation over the knee, other kneepathology, were taking analgesic or anti-inflammatory drugs, had metal implants, or hada cardiac pacemaker.Design of the study: This single-blinded,randomized controlled study was conducted in

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3. Measurement of the limitation of functionalperformance: Each patient’s disability wasevaluated with the Western Ontario andMcMaster Universities osteoarthritis index(WOMAC).Treatment procedures: Group (A) receivedPEMF and all treatment groups (A and B)received a standard set of stretching andstrengthening exercises and US. A pulsedelectromagnetic field device (ASA Easy terzaseries, Italy) was used to provide anelectromagnetic field to the connectedapplicators /solenoids. The pulse frequencieswere 50 HZ for the solenoids and up to 100 HZfor the applicators. The PEMF device was placedon a trolley of a suitable height near to the plinthto be easily accessible to the operator and avoidunduly stretching of the flexes during treatment.The device was routinely inspected to ensureeffective treatment. The solenoid encircled thetarget limb at the level of the affected knee. Eachpatient was exposed to low intensity 15 GPMF(Gauss per magnetic field) with frequency 50Hzfor 30 minutes/ session, 3 times per week for 4weeks [22].An ultrasound device (ITO, US-100, Japan) wasused to provide a deep heating treatment. Theskin was coated with an acoustic neutral gel.US waves were then applied to the knee by thesame therapist. The stroking transducer headwas applied to the therapy region at a right angleand in a circular manner. Continuous US waveswith 1 MHz frequency and 1 watt/cm2 powerwere applied with a 4 cm2 diameter applicator.US therapy lasted 5 minutes /session, 3 timesper week for 4 weeks [23].Immediately after PEMF plus US application ingroup (A) and US application in group (B),subjects in both groups were asked to performstretching exercises and strengthening exercisesin the following fixed sequence: hamstringsmuscle stretching, calf muscle stretching. Thephysical therapist repeated the stretches 3times/session .Each stretch was sustained for30 sec, with 10 sec rest between each stretch[24]. After a rest of 5 min, the subjects in bothgroups were asked to do (1) isometricquadriceps contraction in full knee extensionwith holding for 5 sec followed by 5 sec rest

outpatient clinic of physical therapy faculty,Cairo University and was approved by the EthicalCommittee of the Faculty of Physical Therapy,Cairo University. All subjects were requested tosign a written informed consent before startingthe study. The subjects were randomly allocatedinto one of the following 2 groups: (A) PEMF plusultrasound (US) plus exercises. (n = 10); or (B)exercises plus US (n = 10).Evaluation procedures: Each subjectunderwent the same evaluation that wasperformed by the same therapist at thebeginning and at the end of the study period (4weeks). All subjects were asked to maintain theiractivity levels during the period of the study [19].1. Measurement of active Knee flexion ROM:While the subject was lying supine on anexamination couch, Active knee flexion ROMwas measured with a large plastic universalgoniometer with 25cm arms (the fulcrum wasthe lateral epicondyle of the femur, the fixed armplaced over a line extending between greatertrochanter and lateral epicondyle of the femur,the movable arm placed over the long axis ofthe fibula and the goniometer arms were fixedwith straps) (Figure 1) [20]. The subjectmaintained maximum flexion of knee joint withthe hip flexion. Concomitant hip flexionprevented premature limitation of knee motionfrom possible rectus femoris shortening. Thedegrees of maximum flexion, maximumextension and extension deficits whenpresented they all were recorded. The anglebetween maximum flexion and maximumextension was described as the excursion range.The range was measured 3 times and the meanvalue was [21].

2. Measurement of Pain Severity: The intensityof knee pain was evaluated by the visualanalogue scale (VAS) after patients hadremained in a weight-bearing state for 5 minutes(walking or standing) [21].

Fig.1: Measurement of knee flexion.

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(subjects were in long sitting position on floorwith back supported and legs extended, withrolled up towel under one knee and subjectswere asked to contract quadriceps by pushinginto the ûoor against towel), the exercise wasperformed for 20 repetitions /session [25]. (2)Straight leg raising exercise (The patients werepositioned in crock lying position with theunexercised limb was the flexed one then thepatient was asked to contract the quadricepsmuscle and elevate the limb to 450 and hold for6 sec, slowly lower the limb and then relax for 6sec), the exercise was performed for 3 sets of10 repetitions/session [24]. Both stretching andstrengthening exercises were performed 3sessions per week for 4 weeks.Data analysis: Statistical analyses wereperformed using the software package SPSS forWindows, version 20. Non parametric tests wereapplied for not normally distributed data.Pre-treatment and post-treatment knee flexionROM, pain intensity and patient’s disabilityvalues were compared within each group with aWilcoxon signed rank test. Comparisons of kneeflexion ROM, pain intensity and patient’sdisability values were made by Mann Whitney-U test between the two therapy groups. A chisquare (X2) statistic was used to investigatewhether sex variable differs in both groups. Thelevel of significance (alpha) was set at 0.05.

RESULTS AND TABLES

None of the subjects in any of the treatmentgroups dropped out throughout the study period.There was no significant difference (p > 0.05)between the 2 groups as regards demographicdata as well as ratio of sex (Table 1).No significant difference (p > 0.05) was foundamong all of the outcome measures (kneeflexion ROM, pain intensity (VAS) and functionalperformance (WOMAC) at the pre-treatmentcondition, while there was an improvement inactive knee flexion ROM, functionalperformance (WOMAC) values and reduced painscores (VAS) in both groups at the post-treatment condition (p <0.05) (Tables 2, 3 and4). The percentage of improvement of active kneeflexion ROM in group (A) was 10.8%, and ingroup (B) was 2.5%.

The percentage of reduction of pain scores (VAS)in group (A) was 81.6%, and in group (B) was29.8%. The percentage of improvement offunctional performance (WOMAC) in group (A)

Table 1: Demographic data for the subjects in the 2groups (mean ±SD).

Group (A) Group (B)(n=10) (n=10)

Age (years) 47.1(±2.51) 48.9 (±1.91)Weight (Kg) 81.7(±6.25) 83.05 (±7.72)Height (cm) 165.8 (±6.69) 167.3 (±7.51)

Sex F/M 7/3 8/2There is no significant difference shown in between-group (p>0.05)SD: standard deviation; F: female; M: male.

Table 2: Average group mean (±SD) of the active kneeflexion ROM.

Pre-treatment 118.5(±3.97) 118.1(±5.34) 0.88Post-treatment 131.3(±2.9) 121.1(±5.23) 0.0001

0.0001 0.0001p-value

(within-group)

Groups: (B) (n = 10)

Groups: (A) (n = 10)

p-value (between group)

There is no significant difference shown in between-group in pre-treatment. There is significant differenceshown in between-group in post-treatment Overallwithin-group difference is there. SD: standard deviation.

Table 3: Average group mean (±SD) of pain intensity (VAS).

Pre-treatment 6.0 (±1.24) 5.7(±1.49) 0.71Post-treatment 1.1 (±0.87) 4.0(±1.49) 0.0001

Groups: (A) (n = 10)

Groups: (B) (n = 10)

p-value (between group)

p-value (within-group)

0.0001 0.0001

There is no significant difference shown in between-group in pre-treatment. There is significant differenceshown in between-group in post-treatment. Overallwithin-group difference is there.SD: standard deviation.

Table 4: Average group mean (±SD) of functionalperformance (WOMAC).

Pre-treatment 41.2 (±3.25) 41.9(±6.83) 0.89Post-treatment 12.2 (±3.42) 33,2(±6.52) 0.0001

Groups: (A) (n = 10)

Groups: (B) (n = 10)

p-value (between group)

p-value (within-group)

0.0001 0.0001

There is no significant difference shown in between-group in pre-treatment. There is significant differenceshown in between-group in post-treatment. Overallwithin-group difference is there.SD: standard deviation.

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DISCUSSION

Fig.2: The percentage of outcomes improvement I bothgroups.

10.8%

81.6%

70%

2.5%

29.8%20%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Active knee ROM Pain reduction WOMAC index

Impr

ove

me

nt

%

Group A

Group B

difference was observed when comparing thepost treatment results of the two groups in thefavor of the group A. These findings were in linewith the findings of the research work that wasdone by Pawluk [22] who investigated the effectof PEMF at 5 to 15 G, from 70 Hz to 40 kHz andwas used at the site of pain and related triggerpoints for 20 to 45 minutes, he found that somepatients remain pain free 6 months aftertreatment. He explained that short term effectswere due to decrease in cortisol andnoradrenalin and an increase serotonin,endorphins and enkephalins. While, longer termeffects in the present study was not recorded.Improvement fulfilled in the study group A mightbe attributed to the effect of the piezoelectricsignal of PEMF that normally stimulateschondrocyte activity by creating a streamingpotential in the extracellular matrix when boneis subjected to pressure. Although thetransmission of this signal is impaired in OA,Pfeiffer [29] suggested that PEMF can reproducethis streaming potential in affected joints underno load. Non-invasive treatments are devoid ofany adverse side effects. Long term follow upconfirms sustained pain relief, improved mobility,and a high safety profile. This explanation couldbe also supported by various studies (animalmodels of arthritis, cell culture systems andclinical trials) reporting the use of PEMF forarthritis cure, they have shown that PEMF notonly alleviates the pain in the arthritis conditionbut it also affords chondro-protection, exertsanti-inflammatory action and helps in boneremodeling and this could be developed as aviable alternative for arthritis therapy [30].The reduction of pain intensity was better ingroup A that was treated by PEMF plustraditional treatment than group B that wastreated by traditional treatment at the end oftreatment. This result come in agreement withothers who postulated that magnetic therapy hasbecome one of the most rapidly emergingalternative therapies where magnets have beenpromoted for their analgesic and energizingeffects with no side effects unlike drugs [31].The analgesic effect of pulsed electromagneticfield therapy could be attributed to thephysiologic mechanisms of pain relief, whichmay be due to presynaptic inhibition, or

OA is one of the most prevalent articulardisorders affecting humankind and a majorcause of disability and socioeconomic burden[26]. However, the treatment of knee OA iscurrently limited to the management ofsymptoms rather than reducing diseaseprogression [27]. Analgesic and anti-inflammatory drugs are widely used inmanagement, despite known serious adverseeffects associated with long term use and doubtsabout their efficacy [28]. Based on thesefoundations, PEMF therapy has proved to besafe and has effectiveness on bone- andcartilage-related pathologies.This study aimed to investigate the effect ofPEMF with intensity of 15 Gauss and frequencyof 50Hz for 30 minutes/ sessions 3 times perweek for 4 weeks on pain intensity, ROM andfunctional performance in patients with kneeOA.The present study showed that there was asignificant improvement in the both group A(PEMF plus traditional treatment) and group B(traditional treatment) pre and post treatmentfor knee flexion ROM, limitation of functionalperformance and pain intensity. Significant

was 70%, and in group (B) was 20 % (Fig. 2).Improved active knee flexion ROM, reduced painscores (VAS) and improved functionalperformance (WOMAC) were, however, signifi-cantly better in the group (A) (p <0.05).

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decreased excitability of pain fibers [32].Moreover, PEMF can modulate the actions ofhormones, antibodies and neurotransmitterssurface receptor sites of a variety of cell types.This may cause changes in the transfer rate ofelectrons during the electron exchange betweensingle molecules that may either slow down oraccelerate chemical reaction [12].Similarly, pain reduction by PEMF results fromthe membrane to be lowered to a hyper-polarization level of about (-90 mV) and so itblocks the pain signal transmission. Magneticfield also influence ATP production; increasesthe supply of oxygen and nutrients via thevascular system; improves the removal of wastemetabolites via the lymphatic system and helpto rebalance the distribution of ions across thecell membrane thus reducing pain; reducingmuscle spasm [33].The results of our study come in agreement withRyang and his colleagues [34] who investigatedthe effect of (PEMF) on the management of kneeOA as compared with a placebo. Fourteen trialswere analyzed, comprising 482 patients in thetreatment group and 448 patients in the placebogroup. Highly significant effects were observedon pain level when trials employing high-qualitymethodology were analyzed, PEMF wassignificantly more effective at 4 and 8 weeksthan the placebo. A significant improvement infunction was observed 8 weeks after thetreatment initiation while in the present studyit was observed after 4 weeks. The results ofthis study provided suggestive evidencesupporting PEMF efficacy in the managementof knee OA.The results of knee flexion ROM obtained in thecurrent study showed that there was asignificant increase of knee flexion ROM aftertreatment for both groups in favor of group (A).These results come in consistent with Diniz andhis collogues who explained that this occurredbecause the knee mobility was affected in KneeOA patients as a result of pain avoidancebehavior which caused the muscles andligaments not to be used to their ultimate limitsor full ROM. Improvement in stiffness level ofPEMF group might be due to enhanced bloodcirculation in the periarticular compartment, to

activate synthesis of nitric oxide whichmayenhance blood flowThese results were supported by Jari and hiscolleagues [32] who reported that theapplication of magnetic field to themusculoskeletal problems can reduce pain,inflammation and enhance movement.Other study assessed the efficacy of PEMFtherapy on patients with knee OA in arandomized, placebo-controlled, double-blindstudy of six weeks duration. 75 patients wererandomized to receive active PEMF treatmentby unipolar magnetic devices versus placebo.The primary outcome measure was reduction inoverall pain assessed on a four-point Likertscale. Secondary outcome measures showedsignificant improvements in the actively treatedgroup in the WOMAC score and EuroQol scoreat study end compared to baseline. In contrast,there were no improvements in any variable inthe placebo-treated group. These resultssuggested that the magnetic field was beneficialin reducing pain and disability in patients withknee OA resistant to conventional treatment inthe absence of any side-effects[36].The present study could explain that, based onboth the significant pain reduction and theincreased knee flexion ROM that were observedin group A the functional performance wasconsequently improved significantly in group Acompared with group B.The improvement in all outcome measures inthis study comes in consistent with findings fromFischer [37] who showed improvement in kneeOA patients that treated with low-frequencyPEMF therapy for 6 weeks. Patients had anincrease in mobility and distance of walking.Moreover, long-term analgesic and functionaleffects were observed at 4 weeks after the endof treatment.

CONCLUSION

From this study, it could be concluded that bothtraditional physiotherapy and PEMF withtraditional physiotherapy are effective inimproving knee OA symptoms with a favor forusing PEMF in addition to traditional physio-therapy. Also the results should be limited toshort term outcomes of PEMF.

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Kadrya H. Battecha, Elsadat Saad Soliman.UTILIZATION OF PULSED ELECTROMAGNETIC FIELD AND TRADITIONAL PHYSIOTHERAPY INKNEE OSTEOARTHRITIS MANAGEMENT.

Abbreviations

ROM - Range Of Motion.PEMF - Pulsed Electomagnetic Field.VAS - Visual Analogue Scale.OA - Osteoarthritis.WOMAC - Western Ontario and McMasterUniversities.EULAR - European League against Rheumatism.US - Ultrasound.X2 - Chi square.

Conflicts of interest: None

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How to cite this article:Kadrya H. Battecha, Elsadat Saad Soliman. UTILIZATION OF PULSEDELECTROMAGNETIC FIELD AND TRADITIONAL PHYSIOTHERAPY IN KNEEOSTEOARTHRITIS MANAGEMENT. Int J Physiother Res 2015;3(2):978-985.DOI: 10.16965/ijpr.2015.119

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