Pulsed Short Wave Effect in Pain

and Function in Patients with Knee

Osteoarthritis
Thiago Yukio Fukuda, M.Ph.T
Post-graduate Professor, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo,
Brazil; Nucleus of support to research in analysis of the movement (NAPAM);
Vanessa Ovanessian, Ph.T
Post-graduate student, Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP),
São Paulo, Brazil;
Ronaldo Alves da Cunha, Ph.T
Post-graduate student, Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP),
São Paulo, Brazil;
Ziqui Jacob Filho, Ph.T
Post-graduate student, Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP),
São Paulo, Brazil;
Cláudio Cazarini Júnior, Ph.T
Post-graduate student, Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP),
São Paulo, Brazil;
Fabio Albanez Rienzo, Ph.T
Physical therapist specialist, Institute of Orthopaedic and Traumatology of the University of
Sao Paulo - USP, São Paulo, Brazil;
Aline Almeida Centini, Ph.T
Physical therapist, Institute of Orthopaedic and Traumatology of the University of Sao Paulo -
USP, São Paulo, Brazil

KEY WORDS: Osteoarthritis; Pulsed participated in this study had knee

short wave; Knee. osteoarthritis and were submitted to 17
and 33 KJ PSW doses and evaluated by
a Lequesne’s Algofuncional
ABSTRACT Questionnaire, Lysholm Knee Scoring
There is a divergence in the literature Scale, visual analogical scale (VAS), and
about the pulsed short wave (PSW) clin- knee goniometry. After 9 sessions of
ical application. However, some studies PSW, the patients of the17 and 33 KJ
have shown good benefits in the and placebo group were compared with
osteoarthritis patient’s treatment. the control group. In the Lequesne’s
Considering the controversial results in Questionnaire, pain improvement was
this condition, the aim of this study was found in the 33 KJ group when com-
to evaluate the effects of PSW therapy pared with the placebo and control
with doses of 33 KJ and 17 KJ in the groups. The 17 KJ group presented sig-
pain and function in patients with knee nificant results only when compared
osteoarthritis. Eighty-four patients that with the control group. A significant dif-

The Journal of Applied Research • Vol. 8, No. 3, 2008 189

Figure 1: Diagram block-type delineating the proposed study.

ference in the Lysholm Scale was also crepitation, joint effusion, and
established between the 33 and 17 KJ deformity.3,24
when compared to the placebo and con- This disease affects over 60% of the
trol. For knee flexion, there were statisti- world’s adult population over the age of
cal differences among the treatment 40, especially women, and its incidence
groups when compared to the control. In is augmenting as the population ages.
summary, in the VAS, the 33 KJ group Among all of the joints, the knee is usu-
presented a significant improvement ally the most commonly affected.14,15
when compared to the 17 KJ, placebo The etiology of OA has yet to be dis-
and control groups. Significant therapeu- covered, however, it is frequently associ-
tic results were shown in the 33 and 17 ated with excessive loads and repeated
KJ groups when compared to the place- micro traumas related to occupational
bo and control. The PSW is effective to tasks, as well as hereditary, metabolic,
relieve pain and improve function in and endocrinological factors.2
patients with knee OA. The goal for knee OA treatment is to
alleviate pain, improve function, prevent
INTRODUCTION and correct deformities, and retard this
Osteoarthritis (OA) is a clinical syn- disease’s progression.4,13 Many interven-
drome characterized by inflammation tions have been used for this, including
and degeneration that generally results changes in the affected individual’s
in the progressive loss of joint cartilage lifestyle, drugs, surgical and physical
associated with sclerosis of the subchon- therapy that use specific techniques such
dral bone, which, in many cases, leads to as exercise, and other physical
the formation of bone cysts and osteo- resources.11,23
phytes. In addition to joint alterations, Among the techniques used in physi-
other signs and symptoms may also be cal therapy, electromagnetic radiation is
present, such as joint pain, reduced or commonly referred to as short wave
restricted movement of the affected site, (SW), and can be applied in a continu-

190 Vol. 8, No. 3, 2008 • The Journal of Applied Research

 * statistically significant difference in relation to the control group (p < 0.05)
** statistically significant difference in relation to the c

Figure 2: Comparison between the (F-I)/I indexes obtained from the Lequesne Questionnaire in
the 4 studied groups.

ous or pulsed form.20 of PSW therapy on pain and function in

Authors have used pulsed short wave patients with knee OA, and to deter-
(PSW) therapy with the goal of minimiz- mine if there is any difference in efficacy
ing thermal effects generated by con- between the groups treated with 33 KJ
ventional continuous applications, while and 17 KJ.
emphasizing the effects of incremental
cellular tropism.6,7 METHODS
Among the effects of PSW applica- Patients
tion are: to increase local cell activity, This is a prospective, randomized, and
reduce the inflammatory process, controlled study in which the studied
reduce edema, increase the rate of fib- subjects diagnosed with knee OA were
rin and collagen deposits, and aid in tis- selected by means of medical referrals
sue regeneration without interfering to the Physical Therapy Department of
with the central nervous system, nor the Irmandade Santa Casa of Misericórdia
hypothalamus.5,12,13 in São Paulo (ISCMSP), and the
Few recent studies have demonstrat- Institute of Orthopaedic and
ed the positive therapeutic effects of Traumatology of the Clinics Hospital at
PSW in patients with OA,7,23 however, the University of Sao Paulo Medical
unsatisfactory results were found in School (IOT/HCFMUSP), between
greater quantity.4,9,17,22 These conflicting February and December 2007. Eighty-
results seem to be related to the great four individuals were selected and ran-
variation of the applied energy and domly distributed into 4 groups: 18
treatment duration, which ranged patients in the control group (60 years ±
between 2.1 and 180 KJ and 15 to 40 10); 20 individuals in the placebo group
minutes, respectively.4,7,9,17,22,23 (57 years ± 09); 24 patients in group I
This single-investigator blinded, con- (63 year ± 09); and 22 patients in group
trolled study aims to evaluate the effects II (62 years ± 08).

The Journal of Applied Research • Vol. 8, No. 3, 2008 191

 ** statistically significant difference in relation to the control and placebo group (p < 0.05)

Figure 3: Comparison between the (F-I)/I indexes obtained by the Lysholm scale in the 4 studied
groups.

Female patients were included, over procedures that would be performed

the age of 40 years, having a diagnosis of and they signed an Informed Consent
knee OA, grade II or III, based on the form according to the norms of the
criteria of Gupta et al,8 and chronic National Health Council, Resolution
knee pain for more than 3 months. 196/69. This study was approved by the
There was no superior age limit for Ethics Committee on Research of the
exclusion. ISCMSP, protocol 403/06.
The exclusion criteria included sur- The inclusion criteria had been pre-
gery, or any invasive procedure of the viously established, and patient selection
affected knee, physical therapy in the was performed by an examiner without
last month for knee problems, use of knowledge of the treatment that was to
controlled medication or derivatives of be employed. It consisted of a question-
glycosamine, and hormonal anti-inflam- naire that defined which individuals
matory. Only the use of the analgesic were going to participate in the study.
acetaminophen was permitted in case of The patients were assigned to 4 specific
pain during the days of evaluation. Also groups and were randomly distributed.
excluded were patients with a body mass The same “blind examiner” was respon-
index (BMI) over 40; neurological alter- sible for the pre and post-treatment
ations such as paresthesia of the limb; evaluations (Figure 1).
associated diseases of the locomotive
system such as fibromyalgia; traumatic Intervention
lesions of the meniscus and/or ligaments; The individuals in the active groups
presence of metallic implants; cardiac (Groups I and II) were submitted to 3
pacemakers; or a history of tumors. 4,13,17 applicationS of PSW per week for 3
months, totaling 9 sessions. The instru-
Procedures ment used was the Diatermed II, previ-
All the volunteers were informed of the ously calibrated to a carrying frequency

192 Vol. 8, No. 3, 2008 • The Journal of Applied Research

 Table 1: Characterization of the 4 studied groups

Control Placebo Group I Group II

Age (years) 60 ± 10 57 ± 09 63 ± 09 62 ± 08
Weight (Kg) 68.9 ± 20 65.9 ± 14.4 67.2 ± 14.4 66.9 ± 14.4
Height (m) 1.63 ± 0.04 1.59 ± 0.06 1.62 ± 0.06 1.58 ± 0.06
Affected knee Left 05 (35.7%) 2 (11.1%) 3 (13.6%) 4 (21.1%)
Right 09 (64.3%) 16 (88.9%) 19 (86.4%) 15 (78.9%)

of 27.12 MHz, with a peak power Evaluations

(Ppeak) of 250 watts and pulse duration The patients were evaluated twice, first
of 400 µs. The maximum power that the with an initial evaluation (pre-treat-
equipment could provide was used, with ment) and then with an evaluation at
a pulse frequency (f) of 145 Hz in order the end of the treatment (post-treat-
to obtain a mean power (Mp) of 14.5 ment). The patients that reported the
watts. daily use of medications, such as anti-
To calculate the mean potency, the inflammatories and chondro-protectors
following formula was used: were oriented to interrupt use during
Mp (W) = Ppeak (W) x Pulse the study period.
Duration (s) x f (Hz) Two nationally and internationally
The application of the PSW was validated evaluation scales were admin-
administered using a standard size mal- istered: the “Lysholm Knee Scoring
leable electrode upon the anterior area Scale” proposed by Peccin et al,19 and
of the thigh, 5 cm above the superior the Lequesne Algofunctional
border of the patella and a second elec- Questionnaire for Knee Osteoarthritis,
trode on the posterior area of the leg, proposed by Marx et al.16
with the patient recumbent face-up. The The Lequesne Algofunctional
knee was kept in a semi flexion at 20º. Questionnaire for Knee Osteoarthritis is
In group I, the treatment had a dura- composed of 11 questions concerning
tion of 38 minutes per session, with an pain, discomfort, and function; 6 ques-
approximate 33 KJ of total energy. tions pertaining to pain and discomfort;
Group II received 19 minutes of PSW 1 question about distance when walking;
application, totaling 17 KJ of energy. To and 4 questions about daily activities.
calculate these energy values, the follow- The sum total is 24 points.
ing equation was used:1,12 The Lysholm Knee Scoring Scales
Total energy (J) = Mp (W) x questionnaire is composed of 8 ques-
Application time (s) tions and multiple alternatives, with a
The control group was composed of final result expressed in ordinal form
individuals that were not submitted to totaling 100 points.
any form of treatment. A placebo group Passive goniometry in joint flexion of
was established, in which the apparatus the knee, according to the Hoppenfeld 10
was turned on but kept in stand-by criteria and subjective analysis of pain
mode during 19 minutes without any using the analogical visual scale (VAS)
electrical current being applied in the were also used.
patients. The control and placebo groups It is important to emphasize that
were used to compare the results to the higher values of the evaluations using
groups that received 33 KJ and 17 KJ of the Lysholm questionnaire and the knee
energy, respectively. goniometry, represent a better therapeu-

The Journal of Applied Research • Vol. 8, No. 3, 2008 193

 Table 2: Results of the mean ± standard deviation and median of the (F-I)/I index of the
Lequesne, Lysholm, ROM and VAS.

Control Placebo Group I Group II

Lequesne 0.10 ± 0.20 (0.06) -0.08 ± 0.27 (-0.12) -0.31 ± 0.13 (-0.31) -0.27 ± 0.37 (-0.33)
Lysholm 0.22 ± 0.27 (-0.04) 0.28 ± 0.55 (0.21) 0.64 ± 0.57 (0.51) 0.76 ± 0.86 (0.52)
ROM -0.02 ± 0.04 (0.00) 0.04 ± 0.08 (0.01) 0.05 ± 0.10 (0.02) 0.07 ± 0.08 (0.04)
VAS -0.02 ± 0.34 (-0.04) -0.21 ± 0.38 (-0.22) -0.18 ± 0.30 (-0.19) -0.42 ± 0.42 (-0.45)

tic result. On the other hand, the final, the final evaluation minus the initial
higher values of the evaluations using evaluation divided by the initial evalua-
the Lequesne questionnaire and VAS, tion (F-I)/I, and the values obtained
represent a worse therapeutic result. were compared between the groups.
Table 2 demonstrates the specific
Statistical analysis results of means, ± standard deviations,
After data acquisition, the statistical and median obtained in the study.
software package GraphPad Instant was
used to process the values obtained Lequesne Algofunctional Questionnaire
from the 4 groups. For the Lysholm, In the analysis of this questionnaire, the
Lequesne and knee goniometry, the obtained values were: control group 0.10
analysis of variance (ANOVA) - Tukey ± 0.2 (0.06); placebo group -0.08 ± 0.27
test and, afterwards, the non-paired t- (-0.12); group I -0.31 ± 0.13 (-0.31) and
test for parametric samples was used. group II -0.27 ± 0.37 (-0.33), with a sig-
For the values obtained from VAS, the nificant difference between the placebo
Kruskal-Wallis test and non paired t-test group (p < 0.05), group I (p < 0.0001)
for non-parametric samples were used. and group II (p < 0.001) when compared
The values were expressed in mean, to the control group. A significant differ-
± standard deviation, and median, with ence was also established between group
statistical significance considered when I and the placebo group (p < 0.005)
p < 0.05. (Figure 2).

RESULTS Lysholm Scale

Eighty-four patients began treatment, In the analysis of this scale, the obtained
however, 11 patients did not undergo values were: control group 0.02 ± 0.27 (-
the final evaluations due to lack of regu- 0.04); placebo group 0.28 ± 0.55 (0.21);
larity, and were automatically excluded. group I of 0.64 ± 0.57 (0.51); and group
In a pre-treatment analysis of all the II of 0.76 ± 0.86 (0.52), with a significant
groups, homogeneity was found in rela- difference between group I (p < 0.0001)
tion to the scales used. and group II (p < 0.001) when compared
Table 1 characterizes the patients by to the control group. Significant differ-
means, standard deviations, age, weight, ences were also found between groups I
height, and knee affected in all of the (p < 0.05) and II (p < 0.05) when com-
groups analyzed. pared to the placebo group (Figure 3).
Based on the results obtained from
the Lysholm and Lequesne scales, Knee flexion
goniometry of knee flexion and VAS, a The values obtained from the (F-I)/I
standardization of the data was per- index in the knee flexion goniometry for
formed using an index with the value of the 4 groups was: control group -0.02 ±

194 Vol. 8, No. 3, 2008 • The Journal of Applied Research

 * statistically significant difference in relation to the control group (p < 0.05)

Figure 4: Comparison between the (F-I)/I indexes obtained by knee goniometry in the 4 studied
groups.

0.04 (0.00); placebo group 0.04 ± 0.08 doses of 17 and 33 KJ, these were based
(0.01); group I of 0.05 ± 0.10 (0.02); and on the time of application normally used
group II of 0.07 ± 0.08 (0.04). There clinically with Brazilian equipment,
were statistical differences between the which is between 20 to 40 minutes.
placebo group (p < 0.05), group I (p < The evaluation of pain and function-
0.05), and group II (p < 0.0001) when al capacity of the patients was measured
compared to the control group (Figure using the Lysholm and Lequesne scales,
4). goniometric measures of knee flexion
and VAS. The questionnaires selected
Visual Analogical Scale were designed for patients with OA of
Figure 5 presents the standardized the knee, and had national and interna-
results of the VAS of the 4 groups: con- tional validation.
trol group -0.02 ± 0.34 (-0.04); placebo The option of working with female
group -0.21 ± 0.38 (-0.22); group I -0.18 patients in this study was based in the
± 0.30 (-0.19); and group II with -0.42 ± higher incidence of OA in this group.
0.34 (-0.45). Group II presented a statis- The choice of the knee joint and
tically significant improvement when patient’s age followed the same crite-
compared to the control group (p < ria.3,14,15,24
0.005) and group I (p < 0.05). The results of this study suggest that
PSW therapy is effective for the treat-
DISCUSSION ment of knee OA when compared to the
The aim of this study was to evaluate active groups (17 and 33 KJ), and the
the effects of PSW therapy in patients control and placebo groups. Such find-
with OA of the knee. In order to per- ings, when confronted with the litera-
form an application that would minimize ture, present discordances.
the thermal effects of the equipment, we Moffet et al,17 in a similar study did
used Mp of 14.5 W. Concerning the not find significant differences between

The Journal of Applied Research • Vol. 8, No. 3, 2008 195

 *** statistically significant difference in relation to the control group and group I (p < 0.05)

Figure 5: Comparison between the (F-I)/I indexes obtained by VAS in the 4 studied groups.

the active group and the placebo and improvement in the range of movement
control groups. In this study, the Mp (ROM) of the knee in the placebo
used was of 23 W, which is considered group. In the present study, very similar
sub-thermal. The application time was parameters were used with those cited
15 minutes and the patients received 3 previously, yet with satisfactory results.
applications per week, for a total of 9 There are few studies in the litera-
applications. ture that demonstrates positive results
When comparing the active groups with the use of PSW for OA of the knee.
with the control and the placebo groups, However, in a study similar to the pres-
Laufer et al,13 evaluated 103 patients ent one, Tuzun et al,23 applied PSW with
that received 20-minute applications of a Mp of 8 and 26 W, and providing doses
1.8 and 18 W. The results indicated a of 7.2 KJ and 23.8 KJ with significant
reduction in pain and knee stiffness, results compared to the control group.
however, statistical significance was not However, in their study, ultrasound and
established between the groups. exercise were also utilized.
Callaghan et al,4 evaluated 27 Corroborating these findings, Nadasdi,18
patients that were divided into two and Svarcova et al,21 found a reduction
active groups and one control group. of pain and an inhibition of inflammato-
The active groups received a Mp of 10 ry processes.
W, which is considered low potency, and The ideal dose for PSW application
a 20 W, which is considered high poten- has also been a reason for discussion in
cy. Three weekly applications of 20 min- the literature. In order to obtain thera-
utes each were applied for 2 weeks. The peutic doses, applications with a total
authors concluded that PSW presented dose over 40 KJ have been recommend-
little or no anti-inflammatory effects and ed.4,13,21 Conversely, in the present inves-
that the objective and functional meas- tigation, doses of 17 and 33 KJ were
ures did not reveal significant differ- used with a time of 19 and 38 minutes
ences between the groups, except for the respectively, with significant results

196 Vol. 8, No. 3, 2008 • The Journal of Applied Research

when compared to the control and CONCLUSION
placebo group. Because a significant dif- PSW therapy is an effective resource for
ference was not established between the alleviating pain and providing functional
active groups, we believe that long-term improvement in the treatment of
treatment should not be necessary. patients with knee OA, regardless
In the evaluations of the results from whether the dose is 17 KJ or 33 KJ.
the Lequesne and Lysholm scales, the
groups treated with 17 and 33 KJ pre- Acknowledgment
sented significant differences when com- We are grateful to the Support Center
pared to the control and placebo groups, for Scientific Publications of Santa Casa
demonstrating that the active groups de São Paulo – Faculty of Medical
had a greater reduction of the symptoms Sciences for the editorial assistance.
and functional improvement. The goal of
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