The Effects of Ultrasound Therapy on Knee Osteoarthritis

Central Michigan University

Seth Lashuay, SPT, Megan Powell, SPT, David Szczesny, SPT, Ashley Wejrowski, SPT

Friday November 16th, 2018

 Osteoarthritis (OA) is a chronic degenerative joint disease,2 and is the most common out

of all joint disorders.4 It is most common in joints involved in weight bearing activities such as

the knee, hip, ankles, wrists, and feet and is not curable, but the pain and dysfunction associated

with the affected joints can be managed through treatment.1,4,6 The use of non-steroidal anti-

inflammatory drugs and topical treatments may help reduce pain and dysfunction in patients with

knee OA, but non-pharmacological treatments like education, physical therapy, exercise

programs, weight loss, thermal modalities, and transcutaneous electrical nerve stimulation

(TENS) are recommended. Ultrasound (US) is one thermal modality widely used for the

treatment of knee OA.1,4,5

US is a deep heating modality that can reach depths from 1-5 cm. US can be pulsed or

continuous and can be used to enhance percutaneous absorption of drugs (phonophoresis). As a

heating modality, US has been shown to have many effects that match up with the treatment

goals of knee OA such as: decreasing stiffness, increasing tissue extensibility, decreasing pain,

stimulating synovial fluid production, increasing blood flow, and decreasing muscle spasm.4,7,9

As physical therapists, osteoarthritis is a common condition that will need to be treated as

a primary diagnosis or noted as a comorbidity, and knowing what tools are available to best treat

patients is essential. However, evidence to back-up modality usage in treatment for patients is

crucial, so physical therapists can be as efficient as possible with their and their patients’ time.

The use of ultrasound as a thermal modality for knee OA has been shown to be beneficial to

osteoarthritis symptoms, but this literature review will examine its effectiveness in varying doses

and types of administration, and as compared to other modalities.

 Two studies from the available literature examined continuous US treatment of patients

with knee osteoarthritis compared to sham US treatments, with no other exercise programs or

modalities provided. Draper et al. studied US at a frequency of 3 MHz and an intensity of .132

W/cm2 in knee OA patients (n = 90) between the ages of 35 and 80 who were no higher than

Stage II OA according to their radiographs. Participants wore either a functional or non-

functioning sustained acoustic medicine (SAM) device as part of the active group (n = 55) or

placebo group (n = 35) for 4 hours/day, 7 days a week, over the course of 6 weeks, and recorded

their pain in take-home diaries over the course of the study. Researchers also took measurements

on the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) every other

week when participants visited the clinic, measuring their pain, stiffness, and function, and a

small cohort (n = 17) of participants randomly pulled from both groups had their knee extension

ROM and strength tested via JTECH computerized inclinometry and dynamometry systems at

the beginning and end of the 6 weeks.3

A study by Yeğin et al. also compared continuous US to placebo, but in a different

fashion, using in-clinic US units to perform 8-minute treatments at a frequency of 1 MHz and

intensity of 1 W/cm2 on participants’ knees. Their participants (n = 67), as in Draper et al.’s

study, also had Stage II or less of OA according to radiographs, but were between the ages of 40

and 70 years old and were treated at 10 in-clinic sessions using the true US procedure (n = 34) or

with a sham treatment (n = 33). Researchers assessed baseline and outcome variables before,

immediately after, and a month after the block of treatment sessions, using a Visual Analog

Scale (VAS) for pain at rest and in motion, the WOMAC for severity of symptoms, the Lequesne

index for pain, daily activities, and maximum walking distance, the General Health Scale Short
Form-36 (SF-36) to assess quality of life, a six-minute walking distance measure, and noting the

presence or absence of morning stiffness in each participant.7

Both studies found improvement in participants’ symptoms after US treatment had

concluded. The study by Draper et al. found significant improvement from baseline in pain

scores from the active group (p = 0.04) and WOMAC scores in both the active and placebo

groups (p < 0.0001 and p = 0.0002) after the six weeks of treatment, and only found the strength

in flexed rotation of the knee measured by JTECH to increase significantly in the active

compared to the placebo group (p = 0.03)3. Yeğin et al. found that the treatment group

participants had improved in VAS scores (p = 0.002), six-minute walking distance (p < 0.001),

morning stiffness (p = 0.004), Lequense daily activity (p = 0.001), WOMAC scores (p < 0.001),

and the SF-36 pain, physical function, and physical component scores (p < 0.001) after

treatment. The placebo group, too, had improved in VAS scores (p = 0.02), WOMAC pain (p =

0.039) and physical function (p = 0.017) scores, and SF-36 physical function (p = 0.018) and

physical component (p = 0.027) scores after 10 sessions. Statistical analysis revealed that these

results showed significant improvement in the treatment group compared to the placebo group

immediately after the the treatment sessions had concluded, but no significant difference was

seen between the treatment and placebo groups a month after the sessions.7 Thus, continuous US

has been shown to be beneficial for short-term treatment of OA pain, stiffness, and quality of

life, but there is a lack of evidence for its long-term effects.3,7

US, both continuous and pulsed, has been shown to be effective in the short-term

treatment of OA, but there is not much evidence that shows a difference between the two.4.

Kapci et. al did a study investigating the effectiveness of continuous US versus pulsed US on the
treatment of pain, function, and quality of life in patients with knee OA. Participants (n = 90)

were between the ages of 40 and 65 and were diagnosed with stage 2 and 3 primary knee OA.

They were divided into one of three groups. Group one received continuous US at frequency of 1

MHz and intensity of 1.5 W/cm2 for 5 minutes while group 2 received pulsed US at a duty cycle

of 20% with the same frequency and intensity. Group 3 received a sham US treatment during

which the machine was not powered on. Participants received treatments five times a week for

two weeks. In addition to US treatment, participants in all three groups were taught a home

exercise program and had the option to take 500 mg of paracetamol up to three times per day for

pain. The primary outcome measures were ROM for each knee, a VAS for pain during sleep,

rest, and with movement, the Lequesne functional index for evaluation of function, and a Short-

Form-36 (SF-36) for quality of life. Measures were recorded at the end of treatment and two

months following the conclusion of treatment. The results showed an increase in active and

passive ROM for both knees in both the continuous and pulsed US groups both after treatment (p

< 0.01) and then at the second month following treatment (p < 0.01), but the placebo group

showed no significant difference. Similarly, VAS scores and Lequesne index scores were

significantly improved after treatment and at the second month following treatment (p < 0.01) for

both the continuous and pulsed US groups, but the placebo group again showed no significant

difference. For all measures, there was no significant difference between the continuous and

pulsed US groups (p > 0.05). These findings suggest that both continuous and pulsed US are

effective treatments in improving pain and function in patients with knee OA, but imply that

neither is better than the other.4

 There are parameters associated with US that may affect the efficacy of the treatment.

Kapci et. al explored one possible parameter - the difference between continuous and pulsed

US.4 Another aspect of US that can be adjusted is the time of application. One other study done

by Yildiriim et. al looked at the effectiveness of different durations of US application on patients

with knee OA. Participants (n = 100) were diagnosed with bilateral knee OA and divided into 2

treatment groups. Group one received 4 minutes of ultrasound while the second group received 8

minutes with a frequency of 1 MHz and 1.5 W/cm2. They received 10 treatments over a 2-week

span and also performed exercise and received transcutaneous electrical nerve stimulation. The

primary outcome measures for the study were the WOMAC questionnaire for pain, stiffness, and

function as well as the VAS for pain at rest and with activity. It was found that both groups

improved but the group receiving the 8-minute treatments had better outcomes in pain and

functionality.8 More research would need to be done to figure out what the optimal time

application of US might be, but this study suggests that longer treatment may be more effective

in heating tissues and resulting in a greater improvement in symptoms by decreasing pain and

increasing functionality.

Some other studies have shown that US has minimal or no effect on decreasing pain and

dysfunction when compared with sham US, conventional exercise programs, or other therapeutic

modalities. Cakir et al. looked at the efficacy of therapeutic US comparing whether the use of

continuous US was superior to pulsed US or sham US in the management of knee OA.

Participants (n = 60) were split into three groups. Group 1 received continuous US at 1 MHz

frequency and 1 W/cm2, group 2 received pulsed US with the same parameters as group 1 except

that the US machine was set at a 25% duty cycle, and group 3 received sham US with the
machine powered off. In addition to US treatment, each group received and was instructed to

complete a home exercise program. For pain outcomes, the researchers looked at the WOMAC

for pain as well as the VAS pain scale for pain at rest and with motion. Clinical parameters used

as outcome measurements were the WOMAC-stiffness, WOMAC-function, and 20-meter

walking time. Measurements were taken directly after treatment and at a 6-month follow-up. All

of the groups showed a significant decrease in pain and improvement in functional clinical

parameters (p < 0.05), but there was no difference between groups, suggesting that neither

continuous US nor pulsed US provided any additional benefit in improving pain and function

when provided along with exercise training.2

In a similarly-designed study, Ulus et al. compared the effects of continuous US with a

frequency of 1.0 MHz and intensity of 1.0 W/cm2 for 10 minutes to sham US provided for the

same length of time. Participants (n = 42) received 20 minutes of hot pack, 10 minutes of

interferential current, and 15 minutes of quadriceps isometric exercise in addition to the US

treatment and received treatments five days a week for three weeks. The outcome measures they

examined were the VAS pain scale during rest and activity, WOMAC for pain, stiffness, and

physical function, 50-m walking time, and the Lequesne index for disability. The researchers

found that VAS scores, WOMAC, and ambulation speed all showed significant improvements (p

< 0.05) within groups, but did not show a difference between groups. The Lequesne index scores

significantly decreased within groups, but again were not significantly different between groups.6

These results lend themselves to Cakir et al.’s conclusion that US did not provide any additional

benefit in improving pain and function when combined with other treatments.
 Another study, one performed by Boyaci et. al, compared the effects of continuous US

directly to two other modalities - ketoprofen phonophoresis (PH) and shortwave diathermy

(SWD) - on the treatment of knee OA. Participants (n = 101) were all women with a mean age of

51.91 +/- 6.14 years and were split into one of the three groups. Group 1 received US at a

frequency of 1.0 MHz and intensity of 1.5 W/cm2 for 8 minutes. Group 2 was given PH with the

same US parameters but ketoprofen was used as the medium instead of a neutral gel. Short-wave

diathermy was given in continuous mode (f = 27.12 MHz) at thermal dose for 20 minutes. Each

therapy began with a 20-minute hot pack and patients were not allowed to take NSAID’s for the

7 days prior to the beginning of the study, or during the study itself. Each of the three physical

therapy modalities were applied 5 times a week for 2 weeks (ten treatments total). The outcome

measures were VAS pain scores at rest, 15-m walking time, and WOMAC scores, which were

evaluated before and after treatment. Post-treatment outcome measures were significantly

improved (p < 0.001) in all of the groups, but there was no significant difference found between

groups. Although there was no sham group, this suggests that ultrasound is effective in the

treatment of knee OA, but it is comparable to ketoprofen PH and SWD.1

In contrast to this finding, a study done by Luksurapan & Boonhong found evidence that

phonophoresis (PH) with piroxicam was more effective than US in the treatment of knee OA.

Participants (n = 46) were split into two groups. One group received phonophoresis with

piroxicam and the other group received a standard US treatment. Both the PH and US groups

were treated with continuous US using the stroking technique with an intensity of 1.0 W/cm2 and

frequency of 1.0 Mhz. Treatments were done for 10 minutes per session, 5 times per week, for 2

weeks. Four grams of 0.5% piroxicam gel (20mg of piroxicam drug) was used in the PH group,
while the nondrug coupling gel was used in the US group. The main outcome measures for this

study were the VAS for pain and WOMAC questionnaire for pain, stiffness, and function. The

results showed that both groups had significant decreases in VAS and WOMAC pain scores, as

well as improvement in the WOMAC - function score (p < 0.01). The results also showed that

the PH group showed significantly greater pain reduction than the US group in both VAS and

WOMAC pain scores (p = 0.009 and p = 0.006 respectively). The PH group also had a greater

improvement in WOMAC - function scores but this finding was not significant (p = 0.143). The

results indicate that phonophoresis with piroxicam is more effective at reducing pain in patients

with knee OA, but not necessarily in improving function.5 The difference between this finding

and the findings from the study conducted by Boyaci et. al could be the medication used, but

more research would need to be done to determine if the medication used for phonophoresis

plays a role in the outcomes of treatment of knee OA.

The use of US as a thermal modality for the treatment of knee OA has been shown to be

effective in reducing pain and increasing function,3,7,4,8 especially in the short-term, though

further evidence is required for US’s long-term effects.7 In contrast, there are studies that have

concluded that US has no additional benefit in addition to standard exercise treatment of knee

OA.2,6 These studies were blinded, meaning the patient was unaware of whether or not they were

receiving real or sham US. If they believed they were receiving real US and believed it would

help, then the placebo effect could have played a role in these findings. In comparison to other

thermal modalities, specifically short-wave diathermy and phonophoresis with ketoprofen, US

treatment was found to be just as effective.1 The advantage of US in this situation is that it is less

expensive and more readily available than a SWD unit or the medications required for
phonophoresis. Another study found that phonophoresis with piroxicam was more effective than

traditional US in the treatment of knee OA, suggesting that different medications may have

better effects.5 As it is, more research would need to be done to figure out which medication is

optimal, or if results might have been specific to the patients in a single study.

In conclusion, the use of US as a thermal modality for the treatment of knee OA can be

effective in decreasing pain and increasing function in patients. US cannot replace traditional

treatment and therapeutic exercises as these are essential. However, as an add-on treatment to

further decrease pain and increase functionality, US is a good choice if the patient responds well

to the treatments. In comparison to other thermal modalities, it is a less costly option than SWD

and, while phonophoresis was more beneficial in some cases, more evidence is needed to

determine if it works better for the general population or not. Ultimately, if the patient does not

respond well to US treatment, there are other options that could be employed to improve OA

symptoms.
 References

1. Boyaci A, Tutoglu A, Boyaci N, Aridici R, Koca I. Comparison of the efficacy of

ketoprofen phonophoresis, ultrasound, and short-wave diathermy in knee osteoarthritis.
Rheumatol Int. 2013;33(11):2811-2818. doi:10.1007/s00296-013-2815-z

2. Cakir S, Hepguler S, Ozturk C, Korkmaz M, Isleten B, Atamaz F. Efficacy of Therapeutic

Ultrasound for the Management of Knee Osteoarthritis. Am J Phys Med Rehabil.
2014;93(5):405-412. doi:10.1097/phm.0000000000000033

3. Draper D, Klyve D, Ortiz R, Best T. Effect of low-intensity long-duration ultrasound on

the symptomatic relief of knee osteoarthritis: a randomized, placebo-controlled double-blind
study. J Orthop Surg Res. 2018;13(1). doi:10.1186/s13018-018-0965-0

4. Kapci Yildiz S, Ünlü Özkan F, Aktaş İ, Şílte A, Yilmaz Kaysin M, Bílgín Badur N. The
effectiveness of ultrasound treatment for the management of knee osteoarthritis: a
randomized, placebo-controlled, double-blind study. Turk J Med Sci. 2015;45:1187-1191.
doi:10.3906/sag-1408-81

5. Luksurapan W, Boonhong J. Effects of Phonophoresis of Piroxicam and Ultrasound on

Symptomatic Knee Osteoarthritis. Arch Phys Med Rehabil. 2013;94(2):250-255.
doi:10.1016/j.apmr.2012.09.025

6. Ulus Y, Tander B, Akyol Y et al. Therapeutic ultrasound versus sham ultrasound for the
management of patients with knee osteoarthritis: a randomized double-blind controlled
clinical study. Int J Rheum Dis. 2012;15(2):197-206. doi:10.1111/j.1756-185x.2012.01709.x

7. Yeğin T, Altan L, Kasapoğlu Aksoy M. The Effect of Therapeutic Ultrasound on Pain and
Physical Function in Patients with Knee Osteoarthritis. Ultrasound Med Biol.
2017;43(1):187-194. doi:10.1016/j.ultrasmedbio.2016.08.035
8. Yildiriim M, Uçar D, Öneş K. Comparison of therapeutic duration of therapeutic ultrasound in
patients with knee osteoarthritis. J Phys Ther Sci. 2015;27(12):3667-3670.
doi:10.1589/jpts.27.3667

9. Zipple, JT. Week 7: Clinical Uses of Therapeutic Ultrasound. Central Michigan University,
delivered October 8, 2018