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Table of Contents
Year : 2020  |  Volume : 11  |  Issue : 4  |  Page : 185-191

Effectiveness of physiotherapy management in knee osteoarthritis: A systematic review

Department of Physiotherapy, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia

Date of Submission06-Aug-2020
Date of Decision13-Sep-2020
Date of Acceptance25-Sep-2020
Date of Web Publication06-Nov-2020

Correspondence Address:
Dr. Sharick Shamsi
Department of Physiothrapy, Prince Sultan Military Medical City, Riyadh
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INJMS.INJMS_96_20

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Background: Osteoarthritis is a major cause of musculoskeletal disability. Nonpharmacological and nonsurgical treatment is preferred for the management of knee osteoarthritis (OA). However, evidences are lacking regarding the effectiveness of multimodal physiotherapy program including, combination of various physical modalities (TENS, IR, US etc.) with therapeutic exercises, for the management of knee OA. Objectives: To determine recent research evidences for the effectiveness of combination of physical therapy interventions for treatment of knee OA patients. Methods: This systematic review mainly includes randomized controlled trails. Searching done by Google scholar, Pub med and PEDro from 2010 to 2019. We used terms like-knee pain, OA, TENS, exercise, and physiotherapy management. Results: Present outcomes shows that physiotherapy treatment is effective technique in reducing pain in patients with Knee OA without adverse effects. After implementing the inclusion and exclusion criteria, 100 articles were retrieved using the key words, but only 10 articles were selected for the study. Conclusion: Electrotherapy modalities in conjunction with exercise therapy program designed for treating knee OA patients proved to be more superior to exercise alone at improving quadriceps muscle activation by reducing pain and increasing function during exercise.

Keywords: Electrotherapy, exercise, knee osteoarthritis, physiotherapy

How to cite this article:
Shamsi S, Al-Shehri A, Al Amoudi KO, Khan S. Effectiveness of physiotherapy management in knee osteoarthritis: A systematic review. Indian J Med Spec 2020;11:185-91

How to cite this URL:
Shamsi S, Al-Shehri A, Al Amoudi KO, Khan S. Effectiveness of physiotherapy management in knee osteoarthritis: A systematic review. Indian J Med Spec [serial online] 2020 [cited 2023 Jun 9];11:185-91. Available from: http://www.ijms.in/text.asp?2020/11/4/185/300161

  Introduction Top

Knee joint is the most common joint affected by osteoarthritis (OA) in people older than 60 years. About 10%–20% of this population experience knee pain globally.[1],[2] Around 80% of them experience restriction in movement and remaining 20% are not able to perform activities of daily living; certainly, 11% of knee OA patients need assistance in basic individual care.[3]

Current conventional treatments include nonpharmacological measures, medication, and surgical procedures. Among nonpharmacologic interventions, manual therapy is widely used for musculoskeletal conditions.[4]

Exercises are considered as core nonpharmaceutical therapy and recommended by International guidelines for treating patients suffering with OA. Exercises help in improving function and the overall health of individuals and it is also safer than drug therapy.[5]

Many electrical modalities like-transcutaneous electrical nerve stimulation (TENS), ultrasound (US), infrared (IR), and light amplification from stimulated emission of radiation (LASER) therapy are being used in conjunction to drug therapy and exercise for improving symptoms clinically.[6]

Many researchers have shown the effectiveness of these electrotherapy modalities and exercise therapy separately in the management of knee OA. Only few of them, have investigated the combined effect. However, studies that particularly examined different physiotherapy interventions such as electrotherapy, exercise, and manual therapy together are lacking.

Thus, this review was conceived to determine the treatment of OA knee by physiotherapists in order to find out if physiotherapy management approach is consistent with existing recommendations and guidelines for clinical practice.

  Methods Top

This review study is performed in accordance to PRISMA-Preferred Reporting Items for Systematic Reviews and Meta-Analyses.[7]

Search strategy

The searching was done in PubMed, Google scholar and PEDro. Key words like- knee pain, exercise, TENS, ultrasound, knee OA, physiotherapy management, and OA knee combined with exercise or electrotherapy. We included past 10 years articles (mainly RCTs-Randomized controlled trial) published in English language only from 2010 to 2019. This research was carried out from February 2020 to June 2020.

The title and abstracts of all articles in the searches were screened in accordance with the inclusion and exclusion criteria to identify potentially eligible articles. Full texts of potential articles were read and assessed independently by the two reviewers.

Inclusions criteria

  • Age greater than or equal to 40 years
  • Ability to perform physical therapy exercise
  • Chronic knee pain ≥3 months
  • Studies were published in English language only
  • The study patients have no knee surgery history
  • Studies which determined effects of electrotherapy and exercise on Knee OA.

Exclusion criteria

  • Studies including patients <40 years
  • Patients admitted in hospital or in long-term center
  • Studies with surgical treatments for knee OA and those who had total knee replacement within 6 months before the study
  • Diseases and surgeries related to lower limb and spine
  • Neurological disorders and Cardio vascular problems with increased heart rate.

Quality assessment

Methodological quality of selected articles was assessed using PEDro Scale [8] consisting of 11 questions in two aspects. Criteria 2–9 assess internal validity and criteria 10–11 assess statistical information required to make a study interpretable. Scoring of each question is done in accordance to its existence or nonexistence in the assessed study. The final scoring is done by the addition of all positive answers.

Studies considered of high quality scoring ≥5 (5/10) as stated by Moseley et al.[9] Therefore in our review all included studies scoring ≥5 were found to be of high in methodological quality. The studies were analyzed in PEDro scale by two independent investigators.

Data analysis

The screening of included articles was done by two independent investigators. The selected articles were analyzed in an organized manner including parameters given: author-year, study design, subjects-age, interventions, study duration, outcome measures, and results. Differences between the investigators were solved by conversation to reach agreement and settled using Cohen's kappa statistics.

  Results Top

Studies identified

After implementing the inclusion and exclusion criteria, 100 articles were retrieved using the key words-knee pain, OA, TENS, exercise and physiotherapy management. Sixty-five articles were excluded as they were found in more than one database. For eligibility criteria, 35 articles were screened. Further 25 articles excluded because either they were not available in full text, objective not available, they did not meet exclusion and inclusion criteria or no control group [Figure 1]. Finally, 10 articles were selected by agreement for quality assessment phase.
Figure 1: Flow diagram showing the screening and selection of articles

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Quality assessment of study

Average PEDro score of 10 selected articles was 6.9/10, as shown in [Table 1]. This score might be due to various sources of bias which may affect the result. The commonest limitations were dearth of concealed allocation and blinding of patient, therapist, or assessor. Five trials failed to meet the concealed allocation criterion,[11],[12],[13],[16],[18] four trials failed to meet participants blinding criterion,[11],[12],[14],[16] five trials failed to meet therapist blinding criterion,[10],[11],[12],[16],[18] five trials failed to meet assessor blinding criterion,[10],[11],[12],[16],[18] one trial failed to meet the randomization criterion [16] and one trial failed to meet the follow-up [10] criterion. However, when these articles were scanned together, strong scientific proof was found with reliable results showing that the physical therapy interventions especially TENS and exercise had significant effect in reducing pain and disability patients suffering from knee OA.
Table 1: Methodological classification assessed by physiotherapy evidence database ro scale

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While assessing risk of bias through the selected articles, agreement between evaluators for Cohen's kappa value was 0.85. The details of risk of bias of assessed articles are shown [Table 2]. In general, the final assessment for risk of bias specified that it was low in five articles, high in four articles, and unclear in the other one article.
Table 2: Risk of bias of included studies

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General data of the included studies

Selected articles in this review are summarized in [Table 3] including given parameters: author-year, study design, subjects-age, interventions, study duration, outcome measures, and results. Out of the 10 studies included, eight were RCTs,[10],[11],[13],[14],[15],[17],[18],[19] one was experimental design [12] and one was Quasi experimental design [16] study. All studies were conducted between 2010 and 2019. Number of participants in the studies ranged from 15 to 130, while the age ranged from 40 to 80 years. Three studies did not mention the range and two studies did not report age. All articles were experimental, with 9 studies including pre-interventional (baseline) and postinterventional assessments and 1 study with long-term treatment evaluation (1 month, 3 months and 1 year follow-up). Concerning the efficacy of results established in most of the articles, both physiotherapy modalities and exercises were found to be significantly effective on pain and function between pre- and post-intervention assessments.
Table 3: Description of the included studies

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Outcome measures

The main outcome measures are physical function and muscle strength evaluated by stair climb test, Timed Up and Go test, 6 meter walk test, locomotive syndrome risk test, 4 m walk distance, Oxford grading Scale, Knee injury and Osteoarthritis outcome Score questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Disability Index Questionnaire and Patient Assessment Scale (PAS and DIQ) score. Pain was assessed with the help of pressure pain threshold, numeric pain rating scale (NPR) and visual analog scale (VAS).[20]

  Discussion Top

The present systematic review was done to examine the effectiveness of physical therapy interventions in decreasing pain, increasing functional level and improving quality of life in patients with knee OA. Evidences from RCTs and quasi-experimental designs were used to examine the effectiveness of core physiotherapy interventions in knee OA. In this review, 10 studies were evaluated including eight RCTs, one quasi experimental and one experimental study. In the present review, all articles were assessed according to PEDro scale [8] and proved to be high in methodological quality. Our findings are consistent with guidelines [21],[22],[23] and systematic reviews [4],[24],[25] about basic physical therapy management, published previously. The analysis indicated that physical therapy modalities along with exercises under supervision are frequently involved in clinic-based physiotherapy management for persons suffering from knee OA.

In this review, 6 studies [10],[11],[12],[15],[16],[17] revealed TENS interventions, with or without therapeutic exercise were effective in decreasing pain and improving function in knee OA patients. TENS alone [10] is proved to be beneficial and effective in managing pain at rest as well as while performing functional activities irrespective of the frequency used as stated by Mukesh yadav.[12] However, when TENS applied in conjunction with exercise,[11],[15],[17] TENS after exercise was proved to be more effective in increasing function and reducing disability in knee OA patients.[16]

One study showed combination of strengthening exercise and IR radiation along with analgesics was superior to analgesics alone in decreasing pain, improving muscle strength and function in knee OA patients.[13] According to RCT conducted with 1 year follow-up in knee OA patients showed significant improvement in pain and function in group receiving exercise along with nonsteroidal anti-inflammatory drugs, acupuncture and physiotherapy modalities like TENS, US and IR when compared nonexercise group.[14]

Concerning the evaluated outcome measures, using reliable and valid tools in the articles reinforces their quality. The WOMAC and VAS scales were most reliable and valid instruments commonly used for assessing pain and function in knee OA patients.

The diagnosis of knee OA was done on the basis of criteria described by American college of Rheumatology in 6 articles.[13],[14],[15],[17],[18],[19]

In this criterion, clinical and radiographic assessment of knee OA is according to Kellgren and Lawrence Scale having I to IV grades. Radiographic imaging criteria was used in 2 articles,[10],[11] Altman clinical criteria in 1 article [12] and no report about the diagnostic criteria was mentioned in remaining 1 article.[16] OA knee is most widely diagnosed using these criteria in observational and clinic-based research articles. Five articles out of 10 selected, mentioned about the degree (grades) of OA in the knee joint in their sample.[14],[15],[17],[18],[19]

Regarding prior sample size calculation, only three articles have described about sampling method to decide minimum number of participants essential in each group for acceptable results.[10],[13],[18] Although the methods and interventions utilized in these articles varied widely, the outcome measures improved significantly in most of these articles after application of electrotherapy modalities with or without therapeutic exercises. The duration and the type of the exercise protocol used in our review also varied considerably. The duration of interventions recorded from immediate effect to 12 months involving various treatment interventions like TENS, IR, US, while most of them used exercise protocol including several types of exercises such as isometric and isotonic strengthening exercises for quadriceps and hamstrings, pilates, stretching, balance and proprioception exercise, range of motion, and resistance exercise. Most of high-quality articles involved combining of electrotherapy and exercise therapy with consistent positive outcomes.[11],[12],[13],[14],[15],[16],[17],[18]

The validity of this review can be considered low due to the variability in design, structure and selection of outcome measures in the selected articles. Such as, the total length intervention varies from immediate effects to 12 months as two studies showed immediate effect of physiotherapy treatment and only one study investigated adherence and compliance for exercise with 1 year follow-up after treatment.[13] The size of the sample also had a wide range, from 15 subjects [16] to 130 subjects [13] in this review articles.

Our concentration was focused on treatment protocols related to physical therapy practice, but we did not consider that losing weight might be beneficial in obese individuals having knee OA, which is related with decreasing self-reported disability significantly.[10],[14],[19] In addition, majority of patients in this review were females (F = 209, M = 103), so we recommend that males and females to be included equally in future studies. For the adherence and compliance of treatment protocol, further reviews on the effect of motivation and supervision by therapist with a longer follow-up period is recommended.

  Conclusion Top

We conclude that electrotherapy and therapeutic exercise program designed for knee OA treatment can be more effective at increasing quadriceps muscle activation by reducing pain during exercise. In addition, knee OA patients can improve self-reported function with exercises including strength and balance training, either with or without electrotherapy.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Goh SL, Persson MSM, Stocks J, Hou Y, Lin J, Hall MC, et al. Efficacy and potential determinants of exercise therapy in knee and hip osteoarthritis: A systematic review and meta-analysis. Ann Phys Rehabil Med 2019;62:356-65.  Back to cited text no. 1
Abdullah SB, Nezar AT, Shabana K, Sharick S. Efficacy of physiotherapy exercises after elective total knee arthroplasty. J Adv Scholar Res Allied Educ 2019;16:6:785-792.  Back to cited text no. 2
Abolhasani M, Halabchi F, Afsharnia E, Moradi V, Ingle L, Shariat A, et al. Effects of kinesiotaping on knee osteoarthritis: A literature review. J Exerc Rehabil 2019;15:498-503.  Back to cited text no. 3
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Moseley AM, Herbert RD, Sherrington C, Maher CG. Evidence for physiotherapy practice: A survey of the Physiotherapy Evidence Database (PEDro). Aust J Physiother 2002;48:43-9.  Back to cited text no. 9
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Ebere YI, Chima CI, Egwuonwn AV. Okonkwo uchenna prosper, comparative efficacy of quadriceps strengthening, infrared radiation therapy and oral Diclofenac sodium in the management of symptomatic osteoarthritis of the knee. J Health Sci 2018;1:12-8.  Back to cited text no. 14
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Akodu AK, Fapojuwo OA, Quadri AA. Comparative effects of pilates and isometric exercises on pain, functional disability and range of motion in patients with knee osteoarthritis. Res J Health Sci 2017;5:94-103.  Back to cited text no. 16
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Pietrosimone BG, Saliba SA, Hart JM, Hertel J, Kerrigan DC, Ingersoll CD. Effects of transcutaneous electrical nerve stimulation and therapeutic exercise on quadriceps activation in people with tibiofemoral osteoarthritis. J Orthop Sports Phys Ther 2011;41:4-12.  Back to cited text no. 18
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Richmond J, Hunter D, Irrgang J, Jones MH, Snyder-Mackler L, Van Durme D, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of osteoarthritis (OA) of the knee. J Bone Joint Surg Am 2010;92:990-3.  Back to cited text no. 22
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Chi Z, Yujie X, Xiaotian L, Qiaodan J, Chunlan L, Chengqi H, et al. Effects of therapeutic ultrasound on pain, physical functions and safety outcomes in patients with knee osteoarthritis: A systematic review and meta-analysis. Clin Rehabil 2015;30:960-71.  Back to cited text no. 24
Rutjes AW, Nüesch E, Sterchi R, Kalichman L, Hendriks E, Osiri M, et al. Transcutaneous electrostimulation for osteoarthritis of the knee. Cochrane Database Syst Rev 2009;7:1-68.  Back to cited text no. 25


  [Figure 1]

  [Table 1], [Table 2], [Table 3]

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