American Journal of Therapeutics 24, e693–e700 (2017)

Radiofrequency Thermocoagulation in Relieving Refractory

Pain of Knee Osteoarthritis

Wen-Sheng Shen,1* Xiao-Qi Xu,1 Nan-Nan Zhai,1 Zhi-Shui Zhou,1 Jin Shao,2
and Ya-Hong Yu2

To investigate the efficacy of radiofrequency thermocoagulation (RFTC) in relieving refractory pain of

knee osteoarthritis (OA), we selected 54 patients with chronic knee OA pain, 27 treated with RFTC
(case group) and 27 receiving regular treatments (control group). Response evaluations were con-
ducted before treatment, and at the termination of treatment, and 3-month follow-up, applying the
visual analog scale, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and
American Knee Society Score (AKSS). Data analyses were performed with SPSS 21.0. At the termina-
tion of treatments and 3-month follow-ups, cases gained significantly increased scores in vitality,
bodily pain, general health perceptions, physical functioning, and social role functioning by SF-36
scaling and in pain, range of motion, stability, walking, and stair climbing by AKSS (all P , 0.05).
Controls received higher scores by AKSS in pain at the termination of treatments and in pain, range of
motion, and walking at the termination of 3-month follow-ups (all P , 0.05). Both cases and controls
presented significant difference between visual analog scale scores before treatments and those at the
termination of 3-month follow-ups (both P , 0.05). All patients felt less pain after treatments, cases
presenting better improvement (P , 0.05). Pain was stronger in females compared with males and in
a positive correlation with age while had no obvious relation to disease course. In conclusion, RFTC
may have better efficacy in relieving refractory pain and promoting function recovery in patients with
knee OA than regular treatment.

Keywords: radiofrequency thermocoagulation, refractory pain, knee osteoarthritis, visual analog

scale, MOS 36-Item Short-Form Health Survey, American Knee Society Score

INTRODUCTION quality of patients with knee OA.2 Until now, OA re-

Knee osteoarthritis (OA), one of the most common
OAs, is most frequent in the elderly, with relatively
high prevalence of 40% in the population at age of
70–74 years.1 Knee OA clinically presents with knee
pain and limited movement in walking, which
develop into stiffness and permanent pain in the knee
joins at the advanced stage, severely lowering life
Departments of 1Pain Clinic and 2Anesthesiology, Shaoxing
Traditional Chinese Medical Hospital, Shaoxing, China.
The authors have no conflicts of interest to declare.
*Address for correspondence: Department of Pain Clinic, Shaoxing
Traditional Chinese Medical Hospital, Renmin Zhong Road, No 641,
Shaoxing 312000, Zhejiang, China. E-mail: shenwensheng1014@
126.com
1075–2765 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
mains to be an incurable disease and its pathogenesis
has not been clearly understood; therefore, treatments
for knee OA mainly focus on relieving the refractory
pain, improving the life quality of patients and their
ability of mobility and walking, and slowing down
the OA progression.3 Based on the severity of OA, pa-
tients receive conservative treatment, joint-preserving
surgical treatment, and joint replacement surgery.4 For
patients with severe OA, joint replacement surgery is
usually suggested as an effective treatment.5 However,
the acceptability of joint replacement by patients is
damaged by the long convalescence phase and the pain,
and the possible risk of deep venous thrombosis and
infection in that period.6 It will be a great relief to pa-
tients suffering from refractory pain to provide an effec-
tive treatment other than join replacement surgery.
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e694 Shen et al

Radiofrequency (RF), mainly comprising radiofre-
quency thermocoagulation (RFTC) and pulse radiofre-
quency, is a minimally invasive technique that usually
aims at the neuropathic pain.7 To our knowledge, 1
important mechanism for the chronic pain mediated
by OA is peripheral sensitization, which increases
the transmission of pain signals.8 Through conduction
block in pain-transmitting nerve fibers by thermal
damage, RF could ease pain without destroying the
antennal nerve.9 So far, RF has been widely applied
to control the cancer pain, the pain after surgery, tri-
geminal neuralgia, the pain at the sacroiliac joint, and
so on and turns out to be a good choice for pain man-
agement.10–13 In a prospective review, it is suggested
that percutaneous RFTC is the most applied invasive
procedure in treatment of trigeminal neuralgia, with
13.8 procedures per 1 million person-years per calen-
dar year.14 However, to our knowledge, there are few
studies reporting RF application to the treatment of
knee OA and its substantive effects in controlling the
refractory pain of knee. In this context, we applied
RFTC to the peripheral nerve of the knee joint in the
treatment of knee OA, aiming to figure out a more
acceptable therapy for patients suffering from refrac-
tory pain by knee OA.
MATERIALS AND METHODS
Ethic statement
Our study was approved by the Ethics Committee
Shaoxing Traditional Chinese Medical Hospital.15 All
experiments were performed in compliance with the
Declaration of Helsinki. Before we started this study,
written consents were obtained from patients. This
study has been approved by the local institutional
review board.
Subjects
Our study enrolled 54 patients clinically diagnosed
with chronic knee OA pain in Shaoxing Traditional
Chinese Medical Hospital between December, 2011
and June, 2013.16 Of 54 patients, 16 were male and
38 were female (age range of 35–79 years; mean age
of 62.30 6 9.94 years). Inclusion criteria were patients
with unilateral or bilateral knee pain; patients with
a disease course of more than 3 months; patients with
scores of 6–9 by the visual analog scale (VAS) (mean
score of 7.13 6 1.04); patients with poor response or
high resistance to nonsteroid anti-inflammatory drug;
patients with no coagulation abnormality or infection
to peripheral tissues of knee; and patients with no
history of intraarticular steroid injection in the last 3
months. Exclusion criteria were patients with acute
pain; patients with connective tissue diseases; patients
with severe cardiopulmonary insufficiency; and pa-
tients with nervous system diseases or mental illness.
Enrolled patients were randomly allocated into case
group (n 5 27) and control group (n 5 27).
Treatments
The control group was treated with injection of
platelet-rich plasma and sodium hyaluronate. Whole-
blood samples (5 mL/sample) were drawn from

Table 1. Presentation of baseline data of case group and control group.

Case group Control group t/x2 P

Gender 0.355 0.551

Male 7 (25.92%) 9 (33.33%)
Female 20 (74.08%) 18 (66.67%)
Mean age (yr) 62.24 6 10.35 62.35 6 9.70 0.04 0.968
Age stratification (yr) 1.543 0.672
35–49 4 (14.81%) 3 (11.11%)
50–59 2 (7.41) 5 (18.52)
60–69 14 (51.85) 13 (48.15)
.70 7 (25.93) 6 (22.22)
Mean disease course (yr) 5.01 6 3.29 4.96 6 3.40 0.055 0.956
Stratification of disease course (yr) 0.524 0.914
,1 6 (22.22) 5 (15.52)
1–5 9 (33.33) 10 (37.04)
5–10 10 (37.04) 11 (40.74)
.10 2 (7.41) 1 (3.70)

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RFTC and Knee OA e695

patients and centrifuged to produce platelet-rich
plasma. Patients were required to lie down with their
knees bent at 90 degree. The depression 1 cm away
from the ligamentum at the inferior border of patella
was selected as the puncture point for the injection of
platelet-rich plasma and sodium hyaluronate. If intra-
articular effusion existed, injection should be per-
formed with the effusion swab-off. After injection,
a band-aid was stuck to the pinhole and patients were
instructed to appropriately move their joints for a uni-
form distribution of drugs on the surface of synovium
and cartilage wound. Treatments were given at an
interval of 7 days for 5 times in a row. The case group
was treated with RFTC in combination with injection
of platelet-rich plasma and sodium hyaluronate. With
the radiofrequency generator turned on, sensory stim-
ulation was conducted at a frequency of 50 Hz and
voltage of .0.7 V, followed by motor stimulation at
a frequency of 2 Hz and voltage of around 1 V with no
observable muscle jerk. RFTC was performed at 70°C
for 120 seconds. All patients took no painkiller and
were followed up for 3 months after treatment.
Clinical indexes
General indexes included gender, age, disease course,
weight, medical history, and allergic history. Therapeutic

Table 2. Assessment of life quality of cases and controls with the Medical Outcomes Study 36-Item Short-Form Health
Survey.

At termination of At termination of 3-month

Before treatment treatment follow-up

Physical functioning
Case group 58.17 6 9.76 73.41 6 6.79*† 72.56 6 5.89‡§
Control group 57.31 6 8.86 63.26 6 14.15 63.01 6 13.26
Physical role functioning
Case group 49.29 6 10.02 50.78 6 9.69 51.67 6 8.58
Control group 48.28 6 11.08 51.00 6 7.38 51.16 6 7.29
Bodily pain
Case group 54.36 6 12.32 75.28 6 5.12*† 78.04 6 4.19‡§
Control group 53.85 6 11.49 56.16 6 7.37 57.16 6 6.45
General health perceptions
Case group 35.66 6 7.53 42.15 6 10.69† 44.01 6 9.57‡§
Control group 35.70 6 8.01 36.89 6 11.48 37.59 6 11.32
Vitality
Case group 39.01 6 8.19 54.14 6 9.67*† 53.88 6 9.30‡§
Control group 37.97 6 8.69 41.15 6 8.29 41.97 6 8.33
Social role functioning
Case group 38.31 6 7.68 44.96 6 11.28† 46.98 6 10.45§
Control group 39.02 6 8.67 42.13 6 8.14 42.34 6 8.24
Emotional role functioning
Case group 41.98 6 8.24 42.05 6 9.08 42.07 6 8.88
Control group 42.34 6 8.24 42.86 6 8.17 43.04 6 8.59
Mental health
Case group 43.19 6 15.38 44.11 6 12.63 45.12 6 11.93
Control group 42.88 6 9.69 43.13 6 8.07 44.03 6 9.07
Total points
Case group 359.97 6 26.41 427.88 6 30.58*† 434.33 6 32.27‡§
Control group 357.02 6 27.05 376.58 6 29.44¶ 380.30 6 30.12#

*Refers to P , 0.05 in the comparison between cases and controls at termination of treatment.
†Refers to P , 0.05 in the comparison between cases before treatment and cases at termination of treatment.
‡Refers to P , 0.05 in the comparison between cases and controls at termination of 3-month follow-up.
§Refers to P , 0.05 in the comparison between cases before treatment and cases at termination of 3-month follow-up.
¶Refers to P , 0.05 in the comparison between controls before treatment and controls at termination of treatment.
#Refers to P , 0.05 in the comparison between controls before treatment and controls at termination of 3-month follow-up.

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e696
effect indexes were pain intensity, life quality, and knee
function. Pain intensity was scaled with VAS, the VAS
score (0–10) increasing with pain intensity.17 Life quality
was determined using the Medical Outcomes Study 36-
Item Short-Form Health Survey (SF-36), with a higher
score indicating better life quality.18 Knee function
was assessed adopting American Knee Society Score
(AKSS).19 The scores of the above-mentioned indexes
were recorded before treatment and at the termination
of treatment and 3-month follow-up.
Statistical analyses
Data analyses were conducted with SPSS 21.0 (SPSS
Inc, Chicago, IL). Measurement data presented as
mean 6 SD ( x 6 s) whereas categorical data as cases
or percentage. Comparisons were conducted using
t test or x2 test. The correlations of knee pain with
gender, age, and disease course were analyzed by
Pearson correlation analysis. P , 0.05 indicated signif-
icant differences.
RESULTS
Clinical data
As shown in Table 1, cases and controls presented no
statistically significant difference in gender, mean age,
age stratification, mean disease course, and stratifica-
tion of disease course (all P . 0.05).
Life quality assessment by SF-36
The results of life quality assessment were presented in
Table 2 and Figure 1. Before treatment, no statistically
significant difference was identified between 2 groups
in vitality, physical functioning, bodily pain, general
health perceptions, physical role functioning, emo-
tional role functioning, social role functioning, and
mental health (all P . 0.05).
At the termination of treatments, cases gained signif-
icantly higher scores in physical functioning, bodily
pain, and vitality (all P , 0.05) whereas similar scores
in general health perceptions, physical role functioning,
emotional role functioning, social role functioning, and
mental health compared with controls (all P . 0.05). In
comparison with the scores before treatment, the scores
of cases at termination of treatment were markedly
higher in vitality, physical functioning, bodily pain,
general health perceptions, and social role functioning
(all P , 0.05) whereas similar in physical role function-
ing, emotional role functioning, and mental health (all
P . 0.05). At the termination of treatments, controls
showed no significant improvement in vitality, physical
functioning, bodily pain, general health perceptions,
physical role functioning, emotional role functioning,
American Journal of Therapeutics (2017) 24(6)
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Shen et al
FIGURE 1. The representation of life quality assessment
with the Medical Outcomes Study 36-Item Short-Form
Health Survey. &Refers to P , 0.05 in the comparison
between cases and controls at termination of treatment;
:refers to P , 0.05 in the comparison between cases
and controls at termination of 3-month follow-up;
*refers to P , 0.05 in the comparison between cases
before treatment and cases at termination of treatment;
#refers to P , 0.05 in the comparison between cases
before treatment and cases at termination of 3-month
follow-up; drefers to P , 0.05 in the comparison
between controls before treatment and controls at termi-
nation of treatment; ★refers to P , 0.05 in the compar-
ison between controls before treatment and controls at
termination of 3-month follow-up.
social role functioning, and mental health than they
did before treatment (all P . 0.05).
At the termination of 3-month follow-ups, cases
scored significantly higher in physical functioning,
bodily pain, general health perceptions, and vitality
than controls (all P , 0.05). However, no statistical
significance was identified between cases and con-
trols in the comparisons of physical role functioning,
social role functioning, emotional role functioning,
and mental health (all P . 0.05). Comparing with
the scores before treatment, the scores of cases were
much higher in physical functioning, bodily pain,
general health perceptions, vitality, and social role
functioning (all P , 0.05) whereas similar in physical
role functioning, emotional role functioning, and
mental health (all P . 0.05). No significant difference
was identified between the scores of controls before
treatment and those at termination of 3-month
follow-up in vitality, physical functioning, bodily
pain, general health perceptions, physical role func-
tioning, emotional role functioning, social role func-
tioning, and mental health (all P . 0.05).
Knee function assessment
Results of AKSS assessment were presented in
Table 3. Before treatment, the cases and the controls
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RFTC and Knee OA e697

Table 3. Knee function of cases and controls determined with AKSS.

At termination of At termination of 3-month

Before treatment treatment follow-up

Pain
Case group 15.63 6 8.96 35.72 6 8.54*†‡ 39.68 6 8.65§¶
Control group 17.04 6 8.87 25.19 6 8.35 27.22 6 8.21#
Range of motion
Case group 14.02 6 5.00 20.13 6 4.51*† 24.67 6 4.09§¶
Control group 13.36 6 5.49 15.66 6 5.38 17.51 6 5.21#
Stability
Case group 13.11 6 6.02 20.09 6 4.60*† 23.04 6 4.38§¶
Control group 12.89 6 5.97 14.65 6 4.35 16.37 6 4.10#
Walking
Case group 20.00 6 7.89 35.17 6 8.10*† 36.97 6 8.09§¶
Control group 21.13 6 8.44 25.91 6 10.12 27.02 6 10.24#
Stair climbing
Case group 19.21 6 11.12 36.35 6 8.12*† 38.19 6 8.27§¶
Control group 18.85 6 10.80 23.50 6 9.29 24.44 6 10.18

*Refers to P , 0.05 in the comparison between cases and controls at termination of treatment.
†Refers to P , 0.05 in the comparison between cases before treatment and cases at termination of treatment.
‡Refers to P , 0.05 in the comparison between controls before treatment and controls at termination of treatment.
§Refers to P , 0.05 in the comparison between cases and controls at termination of 3-month follow-up.
¶Refers to P , 0.05 in the comparison between cases before treatment and cases at termination of 3-month follow-up.
#Refers to P , 0.05 in the comparison between controls before treatment and controls at termination of 3-month follow-up.

showed no significant difference in pain, range of
motion, stability, walking, and stair climbing (all
P . 0.05).
At the termination of treatments, cases had higher
scores in pain, rang of motion, stability, walking, and
stair climbing than controls (all P , 0.05). Cases at the
termination of treatments had significantly increased
scores in pain, range of motion, stability, walking, and
stair climbing than they had before treatment (all P ,
0.05). In comparisons with the scores before treatment,
scores of controls at termination of treatment were
apparently higher in pain (P , 0.05) and remained
similar in range of motion, stability, walking, and stair
climbing (all P . 0.05).
At the termination of 3-month follow-ups, cases had
significantly higher scores in pain, range of motion,
stability, walking, and stair climbing than controls
(all P , 0.05). Cases received obviously higher scores
in pain, range of motion, stability, walking, and stair
climbing than they did before treatment (all P , 0.05).
Controls made great progress in pain, range of motion,
stability, and walking whereas no significant improve-
ment in stair climbing at termination of 3-month
follow-up (all P . 0.05).

Table 4. Scores of cases and controls by VAS.

At termination of At termination of 3-month

Before treatment treatment follow-up

VAS
Case group 7.12 6 1.08 3.36 6 1.09*† 4.28 6 1.12‡§
Control group 7.14 6 1.03 5.69 6 1.21¶ 6.32 6 1.18#

*Refers to P , 0.05 in the comparison between cases and controls at termination of treatment.
†Refers to P , 0.05 in the comparison between cases before treatment and cases at termination of treatment.
‡Refers to P , 0.05 in the comparison between cases and controls at termination of 3-month follow-up.
§Refers to P , 0.05 in the comparison between cases before treatment and cases at termination of 3-month follow-up.
¶Refers to P , 0.05 in the comparison between controls before treatment and controls at termination of treatment.
#Refers to P , 0.05 in the comparison between controls before treatment and controls at termination of 3-month follow-up.

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e698 Shen et al

Pain intensity
Table 4 and Figure 2 were presentation of the results
of VAS. Before treatment, cases and controls had sim-
ilar VAS scores (P . 0.05). At termination of treatment,
VAS scores of both groups apparently decreased com-
pared with those before treatment, with significantly
lower scores in cases than controls (all P , 0.05). At the
termination of 3-month follow-ups, both cases and
controls received significantly lower VAS scores than
they did before treatment, cases scoring much lower
than controls (all P , 0.05).
Other factors in relation to refractory pain of
knee OA
As shown in Figure 3–5, our correlation analyses dem-
onstrated that gender was in a negative correlation with
pain, age in a positive correlation with pain, and disease
course in a slightly positive correlation with pain (r 5
20.564, P , 0.001; r 5 0.471, 0.3 # r , 0.5, P , 0.001;
r 5 0.273 . 0, 0 , jrj , 0.3, P 5 0.046).
DISCUSSION
As suggested in the introduction part, the focus of the
treatment of knee OA lies in relieving the refractory
pain, promoting the quality of life and improving the
knee function. In our study, we applied RFTC to the
peripheral nerve of the knee joint, to investigate
the therapeutic value of RFTC in the patients with
FIGURE 3. Analysis on the correlation of gender with
refractory pain of knee OA by Pearson correlation anal-
ysis. Horizontal axis represents gender and vertical axis
refers to VAS scores before treatment.
severe knee OA from the above-mentioned 3 aspects.
With detailed records of the scores of VAS, SF-36, and
AKSS at the beginning of treatment and at the termi-
nation of treatments and 3-month follow-ups, we
made comparisons between the case group and the
control group, finding that RFTC was an effective
way for treating patients with knee OA.
It is reported that RF might block the pathway of
pain signals by suppressing the excitatory C-fiber
response and the synaptic transmission, and thus RF
results in the relief of pain.20,21 Besides, RF may take
effects on the immune cells through the electric field
and therefore regulates the intercell communication by
mediating such cytokines and triggers as interleukin-
1b, tumor necrosis factor-a, and interleukin.21 As we
know, several inflammation pathways are involved in
the development of OA.22 Therefore, RF may aid in the
treatment of knee OA through the involvement in the
inflammation pathways. In the light of VAS score, we
found that both cases and controls felt less pain at
the termination of the treatment and the 3-month

FIGURE 2. Comparisons of scores by VAS between

cases and controls. &Refers to P , 0.05 in the compari-
son between cases and controls at termination of treat-
ment; :refers to P , 0.05 in the comparison between
cases and controls at termination of 3-month follow-up;
*refers to P , 0.05 in the comparison between cases
before treatment and cases at termination of treatment;
#refers to P , 0.05 in the comparison between cases
before treatment and cases at termination of 3-month
follow-up; drefers to P , 0.05 in the comparison
between controls before treatment and controls at termi- FIGURE 4. Analysis on the correlation of age with refrac-
nation of treatment; ★refers to P , 0.05 in the compar- tory pain of knee OA by Pearson correlation analysis.
ison between controls before treatment and controls at Horizontal axis represents age and vertical axis refers
termination of 3-month follow-up. to VAS scores before treatment.

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RFTC and Knee OA
FIGURE 5. Analysis on the correlation of disease course
with refractory pain of knee OA by Pearson correlation
analysis. Horizontal axis represents disease course and
vertical axis refers to VAS scores before treatment.
follow-up than they did before treatment, suggesting
that both treatments had good response. Interestingly,
in the comparisons with controls, cases received sig-
nificantly lower VAS scores at the termination of the
treatment and the 3-month follow-up. Consistently,
previous studies, both cohort studies and case–control
studies, also identified decreased VAS scores in pa-
tients with knee OA after the RF treatment, indicating
that RF is of great help in the management of the
refractory pain by knee OA.2,9 In our assessment of
life quality, cases had significantly increased SF-36
scores at the termination of the treatment and the 3-
month follow-up than they had before treatment, sug-
gesting that they lived a life of significantly higher
quality after the RFTC treatment. However, the con-
trols had no pleasing improvement in their life quality,
presenting no statistically significant increment in the
SF-36 score. For this reason, we suggest that RFTC
plus pharmaceutical drug has overwhelming advan-
tages over pharmaceutical drug alone. Likewise, pre-
vious studies measured changes in pain, analgesic use,
paid employment status, and patient satisfaction of
patients with sacroiliac joint after RF neurotomy, find-
ing that patients had reduced pain and analgesic use,
improved employment capacity, and high satisfac-
tion.23,24 What is more, Vas et al and Bellini et al re-
ported reduced pain and stiffness in knee joint of
patients with OA treated with pulsed RF, suggesting
that RF treatment is rather effective in promoting the
recovery of knee function.25,26 According to our AKSS
assessment on the knee function, cases made signifi-
cantly greater progress in the knee function at the ter-
mination of the treatment and the 3-month follow-up,
whereas controls exhibited no such a progress. Judg-
ing from all these findings, we conclude that RFTC
may be an effective treatment in relieving pain and
improving the knee function and life quality. Another
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e699
observation in our study should also be noticed that
gender and age were slightly correlated with pain. In
our study, the female patients and patients with higher
age presented higher pain intensity. Based on these 2
results, we suggest that RFTC scheme should be made
according to patient’s gender and age for optimum
efficiency. However, the exact mechanism about how
these 2 correlations built remains unclear in this study.
RF could be applied to the peripheral nerves and the
inside joints without causing neuronal damage or tis-
sue damage.2 Furthermore, RFTC is simple to operate,
requiring only RFTC generator and standard electro-
myography.27 Our study showed that patients treated
with RFTC had lower VAS scores and higher SF-36
scores and AKSS scores in the comparisons with them-
selves before treatment and with the controls at the
termination of the treatment and the 3-month follow-
up. Taking all these facts into consideration, we
strongly recommended the use of RFTC in the treat-
ment of patients with knee OA for its beneficial role in
relieving pain and improving the knee function and
life quality.
ACKNOWLEDGMENTS
The authors acknowledge the reviewers for their help-
ful comments on this article.
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