Aaa -THAMARA - Comparing Hot Pack, Short-wave Diathermy, Ultrasound, And Tens on Isokinetic Strength, Pain and Functional Status

Authors:Nuri Cetin, MDAydan Aytar, PT, MScAyce Atalay, MDMahmut Nafiz Akman, MD

Affiliations:From the Department of PhysicalMedicine and Rehabilitation, BaskentUniversity Faculty of Medicine,Ankara, Turkey (NC, A Atalay, MNA);and Department of Physical Therapyand Rehabilitation, BaskentUniversity Faculty of Health Sciences,Ankara, Turkey (A Aytar).

Correspondence:All correspondence and requests forreprints should be addressed to NuriCetin, MD, Bahcelievler 5. sok no: 48,06490, Cankaya, Ankara, Turkey.

0894-9115/08/8706-0443/0American Journal of PhysicalMedicine & RehabilitationCopyright 2008 by LippincottWilliams & Wilkins

DOI: 10.1097/PHM.0b013e318174e467

Comparing Hot Pack, Short-WaveDiathermy, Ultrasound, and TENS onIsokinetic Strength, Pain, andFunctional Status of Women withOsteoarthritic KneesA Single-Blind, Randomized, Controlled Trial

ABSTRACT

Cetin N, Aytar A, Atalay A, Akman MN: Comparing hot pack, short-wavediathermy, ultrasound, and TENS on isokinetic strength, pain, and functionalstatus of women with osteoarthritic knees: a single-blind, randomized, controlledtrial. Am J Phys Med Rehabil 2008;87:443451.

Objective: To investigate the therapeutic effects of physical agentsadministered before isokinetic exercise in women with knee osteoarthritis.

Design: One hundred patients with bilateral knee osteoarthritis wererandomized into five groups of 20 patients each: group 1 received short-wave diathermy hot packs and isokinetic exercise; group 2 receivedtranscutaneous electrical nerve stimulation hot packs and isokinetic exer-cise; group 3 received ultrasound hot packs and isokinetic exercise; group4 received hot packs and isokinetic exercise; and group 5 served as controlsand received only isokinetic exercise.

Results: Pain and disability index scores were significantly reduced ineach group. Patients in the study groups had significantly greater reduc-tions in their visual analog scale scores and scores on the Lequesne indexthan did patients in the control group (group 5). They also showed greaterincreases than did controls in muscular strength at all angular velocities. Inmost parameters, improvements were greatest in groups 1 and 2 com-pared with groups 3 and 4.

Conclusions: Using physical agents before isokinetic exercises in womenwith knee osteoarthritis leads to augmented exercise performance, reducedpain, and improved function. Hot pack with a transcutaneous electrical nervestimulator or short-wave diathermy has the best outcome.

Key Words: Knee Osteoarthritis, Physical Therapy Modalities, Isokinetic Strength,Disability

June 2008 RCT on Physical Therapy Modalities 443

ORIGINAL RESEARCH ARTICLE

Knee Osteoarthritis

Knee osteoarthritis (OA) is the most commonform of symptomatic OA. Radiographic evidence ofknee OA in men and women older than 65 yrs isreported to be 80%, and approximately one third ofthese people are symptomatic.1,2 The risk of dis-ability from knee OA alone is comparable with thatof cardiac disease and is greater than those forother medical disorders in the elderly.1,3 A recentreport by the World Health Organization on theglobal burden of disease indicates that knee OA islikely to become the fourth-most-important globalcause of disability in women and the eighth-most-important cause in men.4

The American College of Rheumatology and theEuropean League Against Rheumatism have pub-lished clinical guidelines as systematically developedstatements to inform practitioners and patientsabout appropriate health care for specific clinicalconditions. The guidelines for managing knee OArecommend a combination of nonpharmacological(i.e., education, exercise, lifestyle changes, andphysical therapy) and pharmacologic (i.e., parac-etamol, nonsteroidal antiinflammatory drugs, andtopical agents) treatments. Given these guidelines,conservative management plans for patients withknee OA must be individualized and adjusted ac-cording to the responses of the patients.57

Many researchers have demonstrated the ben-eficial effects of exercise programs (e.g., isometric,isokinetic, progressive resistive, aerobic, hydro-therapeutic) in improving muscle strength, de-creasing pain, and helping patients with knee OAbetter perform their activities of daily living.812

These recommended exercise therapies are basedlargely on expert opinion and the results of large,randomized, controlled trials.1319 Several recentlongitudinal studies have concluded that carefullycontrolled exercise programs designed primarily toaddress knee OA are beneficial. The American Collegeof Rheumatology and European League AgainstRheumatism have approved regular exercise as atherapeutic approach for knee OA. Exercises thatstrengthen the quadriceps lead to decreased kneepain and improved function. Although aerobic, pro-prioceptive, and hydrotherapeutic exercises are usedto treat patients with knee OA, strengthening exer-cises (i.e., isometric, isokinetic, and progressivere-sistive) are particularly recommended.57

Ytterberg et al.20 have addressed the impor-tance of appropriate dosing of the exercise to im-prove joint motion, muscular strength, and cardio-vascular fitness for patients with OA of the knee.Exercise therapy is important in OA management,but the mode of exercise that would induce maximalfunctional outcome is not clear. Isotonic exercise issuggested for initial strengthening in patients withknee OA. Isokinetic exercise is suggested for improv-

ing joint stability, walking endurance, and disabilityin these patients.10,14 Isokinetic exercise seems tostrengthen type II fast-twitch fibers more than othertype of muscle fibers in human knee extensormuscles.21

There is growing evidence that increasing isoki-netic muscle strength is one of the most commonmethods whenever muscle strength is thought to bea major factor in sports success and rehabilitation.Many publications during recent years have con-cerned peak torque (PT) and flexor/extensor ratio forthe evaluation of knee disorders.2225

The primary goals for OA therapy are to relievepain, maintain or improve functional status, andminimize deformity and instability. Physical agentslike short-wave diathermy (SWD), transcutaneouselectrical nerve stimulation (TENS), ultrasound (US),and hot packs (HP) are noninvasive modalities thatare commonly used to control both acute and chronicpain arising from several conditions. There is a pau-city of information regarding the efficacy of theseagents in treating knee OA. Despite the use of differ-ent combinations of these modalities in treating kneeOA, there is no consensus regarding which of theseagents is more effective than the other. A number oftrials evaluating the efficacy of these agents in OAhave been published. The heterogeneity of the in-cluded studies was observed, which might have beenattributable to the different study designs and out-comes used. Better-designed studies with a standardprotocol and adequate numbers of participants areneeded to make conclusions regarding the effective-ness of these physical agents in the treatment ofknee OA.57,2628

Physical treatment modalities are widely pre-scribed together with exercises; however, there is noagreement about which modality might be betterthan the other when combined with exercises.5,6 Pre-scription of different modalities leads to an increasein treatment costs. The optimum combination oftreatment modalities has yet to be clarified. As aresult, questions regarding the effectiveness of a par-ticular modality over others must be addressed.

Most previous studies have used exercise orphysical agent therapy for knee OA alone. We com-bined these therapies specifically for use in patientswith knee OA. To our knowledge, only two previousreports have considered these relationships.29,30

Our aim was to analyze the therapeutic effects ofSWD, TENS, US, and HP when applied before iso-kinetic exercises in women with knee OA.

MATERIALS AND METHODSOne hundred women from the local commu-

nity (mean age, 59.82 9.05 yrs) with clinical andradiologic diagnoses of knee OA were included.Informed consent was obtained from all patients,and the study protocol was approved by the

444 Cetin et al. Am. J. Phys. Med. Rehabil. Vol. 87, No. 6

Baskent University ethics committee for clinicalstudies (No. KA05/216). American College of Rheu-matology classification criteria for OA were used.31

Patients were consecutive outpatients at the de-partment of physical medicine and rehabilitation atBaskent University in Ankara, Turkey. Patients hadno previous history of knee surgery, lower-extrem-ity arthroplasty, or intraarticular injection of hyal-uronic acid or steroids in the last 6 mos. Selectioncriteria were clinical presentation of bilateral kneeOA, ability to walk at least 100 m on an evensurface, and full or near-full passive range of mo-tion at each knee. All participants were initiallyexamined by the same physician with regard to theselection criteria, and, if found to be appropriate,the participants were included in the study. Demo-graphic data including age, weight, height, andbody mass index were obtained. Body mass indexwas calculated as kilograms per square meter. Bodyweight was measured with patients dressed in lightindoor clothing without shoes, using a SECA elec-tronic stadiometer (Seca Ltd, Medical Scales andMeasurement Systems, Birmingham, UK). Antero-posterior and lateral knee joint radiographs wereobtained in weight-bearing position. The radio-graphs were graded by the same physiatrist accord-ing to the Kellgren and Lawrence scale, wheregrade 0 normal and grade 4 severe.32

One hundred patients were randomly assigned tofive groups of 20 patients each. Patients were evalu-ated at baseline and at the end of the treatment sessionsby the physician, who was blinded with regard to thetype of treatment the patients would receive. All pa-tients received treatment three times weekly for 8wks. Patients in group 1 received SWD HP isoki-netic exercises; group 2 received TENS HP isokinetic exercises; group 3 received US HP isokinetic exercises; group 4 received HP isoki-netic exercises; and group 5 served as the controlgroup and received only isokinetic exercises. Afterapplication of physical agents, each patient under-went individual warm-up exercises on a stationarybike set for 20 cycles/min for 5 mins before under-going muscle-strengthening exercises. The thera-peutic effects of these programs were evaluatedwith regard to pain, disability, ambulation, andmuscle strength. Patient compliance also was as-sessed. Participants were instructed to continuetaking any current medications and not to start anynew therapies for knee OA during the 8-wk study.

Measurement of DisabilityDisability of patients with knee OA was evaluated

using the index of severity for knee osteoarthritis(ISK),33 which includes questions about knee dis-comfort, endurance of ambulation, and difficulties inactivities of daily living.

Measurement of Ambulation ActivityAmbulation was evaluated by recording the

time (secs) to walk a predetermined distance (50m) as comfortably and as quickly as possible. Walk-ing time was recorded with a stopwatch by thesame physiatrist.

Measurement of PainKnee pain severity was evaluated with a visual

analog scale (VAS) after a 50-m walk.

Isokinetic Test ProtocolsA computerized isokinetic dynamometer (Cy-

bex 770 Norm, Lumex Inc., Ronkonkoma, NY) wasused for the testing and training procedures. Thesame examiner performed isokinetic dynamomet-ric measurements using the same test protocol inall participants. We created a new test protocol andadded it to the isokinetic concentric exercise modemenu of the device to standardize the measure-ments. Subjects were seated on the isokinetic dy-namometric bench at 80 degrees of hip flexion and90 degrees of knee flexion, with the ankle unre-stricted. The trunk and legs were stabilized usingstraps across the chest, waist, and upper thighs.The range of movement of the knee was measuredby the dynamometer from the points of maximumpossible flexion to maximum possible extension.Five consecutive concentric motions were per-formed at three preselected velocities (60, 120, and180 degrees/sec) within the maximum joint range,with a 30-sec rest period between velocities.8,10

The highest torque generated in each move-ment was recorded from strip chart recording. Theeffect of gravity was corrected. The maximum PTvalues in newton-meters for each subject were cal-culated for each set of repetitions.

ComplianceAlthough patients were instructed to fill in an

exercise diary program, we could not obtain satis-factory data for statistical analysis. Hence, compli-ance was calculated as the number of patients whohad completed the treatment sessions divided bythe number of initial patients.34 But the strongestand most consistent predictor of compliance in thisstudy was the behavior of patients.

Treatment ProtocolsA TENS MED911 unit (Enraf-NoniusB Delftech-

park 39, 2600 AV, Delft, The Netherlands) was used toadminister TENS therapy. Sessions lasted 20 mins.The frequency of the TENS unit was set to 60100Hz, and the pulse duration was set to 60 msecs.Patients remained in the supine position with bothknees at full extension while electrodes were placedaround the painful areas. The intensity of the current


was increased to the point of seeing no contractionwhile the patient felt comfortable.

A Sonopuls 590 US machine (Enraf-NoniusBDelftechpark 39) was used for continuous US ther-apy. A 1-MHz US head was used, set to an intensityof 1.5 W/cm2. US was applied around the knee jointwith full contact for 10 mins. The patient remainedin the supine position with both knees fully ex-tended while US was applied.

SWD was applied using a Curapulas 419 (En-raf-NoniusB Delftechpark 39) at a frequency of27.12 MHz. The condenser field technique wasused for 15 mins as each patient sat on a chair andplaced her legs on a table with both knees fullyextended during treatment.

After applying the physical agents and warm-ing up, the isokinetic muscle-strengthening exer-cise protocol was performed individually under thesupervision of the same physical therapist. Thesubjects underwent isokinetic strength training ofthe knee flexor and extensor muscle groups, andeach subject was encouraged to move her kneejoint with maximum effort at each velocity. Theisokinetic exercises program was applied threetimes a week for 8 wks, for a total of 24 sessions.The intensity of isokinetic exercises increased fromone to five sets during the first through fifth ses-sions and remained at five sets through the re-maining 19 sessions. Each set consisted of fiverepetitions of concentric contractions of the kneeextensors and flexors at angular velocities of 60,120, and 180 degrees/sec. Patients were allowed torest for 20 secs between sets and for 60 secs be-tween the right and left knee.

Statistical AnalysesStatistical analyses were performed with SPSS

software (Statistical Package for the Social Sci-ences, version 11.0, SSPS Inc, Chicago, Ill). Be-cause most of the data were not normally distrib-uted, we used nonparametric tests in all statisticalanalyses. The KruskalWallis test was used to testfor differences in outcome measures at baseline bytreatment groups, and the MannWhitney U testwith a Bonferroni correction was used for subse-

quent post hoc pairwise comparisons. To comparepretreatment and posttreatment values, the Wil-coxon test was used. Also, the 2 test was used totest for differences of Kellgren and Lawrencegrades and compliance by treatment groups. Sta-tistical significance was set at P 0.05.

RESULTSTable 1 provides the demographic data of the

patients. Of the 100 patients enrolled, 15 withdrew.Compliance was lowest in the fifth group, althoughthere were no significant differences between thegroups (P 0.694; Table 1). Increased knee painwas the major reason for discontinuing treatment.Fifteen people refused to continue the exerciseprogram because of exercise-induced pain. At base-line, age, body mass index, Kellgren and Lawrencegrade, ambulation time, PT values, ISK, and VASscores in each group were similar (Table 16).

Changes in mean VAS scores for knee pain ineach group are shown in Table 2. VAS scores de-creased significantly in all groups after treatment.Patients in groups 1 through 4 showed the greatestdegree of pain reduction, and these scores weresignificantly different from those of patients in thecontrol group (P 0.019). A pairwise comparisondemonstrated that changes in VAS scores weresimilar among groups 1 through 4 (P 0.05).

Walking time significantly decreased in allgroups, but there were no statistically significantdifferences between the groups (P 0.589).Changes in mean Lequesne index scores are shownin Table 2. Average ISK scores decreased signifi-cantly in all groups after treatment. There was asignificant difference in Lequesne index scoresamong groups (P 0.018). A pairwise comparisondemonstrated that groups 1 and 2 were signifi-cantly different from the control group (P 0.022and 0.001, respectively); however, there was nostatistical difference between groups 3 and 4 whencompared with the control group (P 0.102 and0.073, respectively).

Regarding isokinetic performance (Table 36),changes in mean PT values of knee extension andflexion at all angular velocities in groups 1 through

TABLE 1 Demographic data of the study groups

Group 1 Group 2 Group 3 Group 4 Group 5 P

Age, yrs 59.75 11.63 61.85 8.64 57.60 7.33 61.05 8.26 58.85 9.08 0.549Body mass index, kg/m 27.94 4.24 29.49 4.60 29.80 5.71 27.71 4.17 27.40 4.24 0.221Compliance (%) 90 85 90 85 75 0.694Severity on radiograph

Grade 1 1 1 1 2 0 0.976Grade 2 9 9 7 9 11Grade 3 8 8 9 7 7Grade 4 2 2 3 2 2


4 increased significantly. Also in the control group,significant increases in PT values were observedafter treatment during right and left knee exten-sion measurements (Tables 3 and 5). Pairwise com-parisons reveled that groups 1, 2, and 3 demon-strated significantly higher PT values comparedwith the control group at all angular velocitiesduring all four measurements (P 0.05).

However, when we compared group 4 with thecontrol group, no significant difference was foundwith regard to peak PT values during right kneeextension at 180 degrees/sec (P 0.114) and leftknee extension at all angular velocities (P 0.142

at 60 degrees/sec, P 0.102 at 120 degrees/sec, andP 0.076 at 180 degrees/sec).

Comparisons among groups 1 through 4 re-vealed that all groups were similar at all angularvelocities during right and left knee flexion mea-surements. However, during right knee extensionmeasurements, statistically significant differenceswere found between groups 1 and 4 (P 0.037 at60 degrees/sec, P 0.008 at 180 degrees/sec), 2and 3 (P 0.01 at 120 degrees/sec), and 2 and 4(P 0.01 at 180 degrees/sec). Also, during left kneemeasurements, statistically significant differenceswere found between groups 1 and 4 (P 0.005 at

TABLE 3 Mean peak torque levels (Nm) for right knee extension in each group beforeand after treatment

AngularVelocity Time Group 1 Group 2 Group 3 Group 4 Group 5 P

60 degrees Baseline 34.80 9.43 37.15 14.84 36.00 8.32 33.80 9.20 38.25 9.08Final 54.65 12.35 57.80 17.21 52.35 10.89 47.60 13.80 47.60 13.80 19.85 9.63 20.65 12.00 16.35 7.86 13.80 8.88 3.80 5.55 0.0001*P 0.0001 0.0001 0.0001 0.0001 0.009



Significant differences in mean peak torque values for right knee flexion in each group after treatment (P 0.05). P valuesare computed using the Wilcoxon test.

* Significant differences of change in mean peak torque values for right knee flexion between groups (P 0.05). P valuesare computed using the KruskalWallis test.

TABLE 2 VAS, WT, and LI scores at baseline and at the end of the study period, and thegroup differences

Group 1 Group 2 Group 3 Group 4 Group 5 P

Baseline VAS 5.69 1.55 5.85 1.34 5.90 1.45 5.76 1.48 5.93 1.15 0.888Final VAS 3.36 1.33 3.52 1.18 3.55 1.41 3.49 1.28 4.10 1.32 0.325 VAS 2.33 0.77 2.32 0.60 2.34 0.94 2.27 0.88 1.83 1.32 0.019*P 0.0001 0.0001 0.0001 0.0001 0.0001

Baseline WT 51.35 6.49 52.95 10.77 53.10 9.84 49.65 6.93 49.70 10.17 0.727Final WT 39.90 6.47 42.40 8.40 42.60 11.50 40.60 6.04 39.95 8.89 0.812 WT 11.45 5.78 10.55 4.70 10.50 3.85 9.05 4.48 9.75 3.86 0.589P 0.0001 0.0001 0.0001 0.0001 0.0001

Baseline LI 10.95 2.73 11.70 1.93 11.40 2.45 10.77 3.12 10.80 1.56 0.582Final LI 6.81 2.69 7.22 2.06 7.67 2.30 6.87 2.58 7.72 2.06 0.562 LI 4.14 1.24 4.47 1.11 3.72 1.08 3.90 1.15 3.07 1.38 0.018*P 0.0001 0.0001 0.0001 0.0001 0.0001

VAS, visual analog scale; WT, walking time; LI, Lequesne index.Values are expressed as means standard deviations. Significant differences in VAS, WT, and LI in each group after treatment (P 0.05). P values are computed using the

Wilcoxon test.* Significant differences in VAS and LI in each group when compared with group 5 (P 0.05). P values are computed using

the KruskalWallis test.


60 degrees/sec, P 0.01 at 120 degrees/sec), 2 and4 (P 0.038 at 60 degrees/sec), and 3 and 4 (P 0.015 at 60 degrees/sec).

DISCUSSIONWe conducted a randomized, single-blind,

controlled trial to clarify which physical agent(s)used in varying combinations with exercises wouldincrease exercise performance in community-dwelling volunteers with symptomatic knee OA.Significant improvements were found in patientsin all groups with regard to pain, walking time,functioning, and isokinetic performance. Patientsin the treatment groups (groups 14) demon-

strated significant improvements compared withpatients in the control group (group 5). Theseimprovements were statistically significant.

In our study, pain reduction was similar in allphysical agent treatment groups. VAS score de-creases in all treatment groups were significantlygreater than those of the control group.

Osiri et al.27 performed a recent meta-analysisof literature concerning the use of TENS for kneepain in individuals with knee OA. They concludethat TENS was more effective than placebo when itwas used for a duration of 4 wks or more.

Cheing et al.35 evaluated the effect of repeatedTENS alone and TENS combined with isometric

TABLE 5 Mean peak torque values for left knee extension in each group before and aftertreatment (Nm)





Significant differences in mean peak torque values for left knee extension in each group after treatment (P 0.05). P valuesare computed using the Wilcoxon test.

* Significant differences of change in mean peak torque values for left knee extension between groups (P 0.05).

TABLE 4 Mean peak torque values for right knee flexion in each group before and aftertreatment (Nm)





Significant differences in mean peak torque values for right knee flexion in groups 14 after treatment (P 0.05). P valuesare computed using the Wilcoxon test.

* Significant differences of change in mean peak torque values for right knee flexion between groups (P 0.05). P valuesare computed using the KruskalWallis test.


exercise on OA knee pain during a 4-wk prospectivecontrolled trial. They report that there was nosignificant difference between the groups.

Welch et al.36 conducted a systematic reviewon the effectiveness of therapeutic US therapy fortreating knee OA. They conclude that US therapyseemed to have no benefit over placebo or SWD forpatients with knee OA. We also found US to be lesseffective than SWD and TENS in knee OA.

The mechanism of action of physical modali-ties on alleviation of joint pain is not clear yet. Agroup of agents called superficial and deep heatersare said to act by elevating the temperature oftissues that induce increases in blood flow. In-creased blood flow leads to better tissue perfusion,increased metabolic activity, and muscle relax-ation. Another possible mechanism of action is theinhibition of nociceptive transmission by activationof A-alpha and A-beta fibers, known as gait controltheory.37 Low-frequency electrical currents (i.e.,TENS) are also thought to induce endogenous opi-oid secretion and modulate ascending pain-controlpathways.38

Walking time significantly decreased in allgroups after the treatment, but there were no sta-tistically significant differences between groups.Exercise, both alone and combined with physicalagents, improved the patients walking ability.

We evaluated the functional status of patientsusing ISK scores. After treatment protocols in allgroups, average ISK scores decreased significantly.Pairwise comparison tests among groups 1, 2, andthe control groups yielded significant differences.In a similar study, Huang and coworkers10 com-pared the therapeutic effects of different musclestrengthening (i.e., isotonic, isometric, isokinetic)

exercise on the functional status of patients withknee OA. Their results show that patients in eachtreatment group had significant improvements inpain reduction, function, and walking speed aftertreatment. When the authors compared the treat-ment groups, they found that patients in the iso-tonic exercise group had the greatest reduction inpain, but patients in the isokinetic exercise groupshowed the greatest increases in walking speed andfunction and in muscle strength gain at 60 and 180degrees/sec at angular velocities. Huang et al.10

state that isokinetic strengthening exercise had thegreatest therapeutic effects on the functional statusof patients with knee OA; it also had the lowestlevel of compliance with treatment when comparedwith isotonic or isometric exercise, because of ex-ercise-induced knee pain.

When we checked isokinetic performance, wenoted a more significant increase in groups 1, 2,and 3 than in groups 4 and 5. Comparison of group4 with group 5 revealed no significant differenceregarding the PT values during right knee exten-sion at 180 degrees/sec and left knee extension atall angular velocities. Our results were similar withthose of several randomized controlled trials inwhich it has been reported that significant progressis achieved in muscle strength after isokinetictraining.10,24,29,39

The reliability of the isokinetic measurementswas not evaluated in our study. However, quadricepsand hamstring muscle strength measurements onisokinetic devices have been demonstrated to be reli-able in recent studies.25,40 We used isokinetic exercisetesting and training protocols because they have theadvantage of providing objective data and of enhanc-ing motivation with visual and auditory stimuli. Also,

TABLE 6 Mean peak torque values for left knee flexion in each group before and aftertreatment (Nm)





Significant differences in mean peak torque values for left knee flexion in each group after treatment (P 0.05). P valuesare computed using the Wilcoxon test.

* Significant differences of change in mean peak torque values for left knee flexion between groups (P 0.05). P values arecomputed using the KruskalWallis test.


the isokinetic programs were carried out in hospitalconditions and under supervision.

In our study, improvements were more markedafter treatment in the four treatment groups, reflect-ing the additional benefits of physical agents. A pos-sible explanation for our results involves the specifictreatment effects of the physical agents we used act-ing as local heaters and pain relievers. On the otherhand, one could argue that a placebo effect mighthave been responsible for this condition. Unfortu-nately, we did not include sham physical therapygroups in this study because it would be technicallychallenging, and because there would have beentoo many test groups to compare. In addition, mostpatients can easily differentiate sham from actualtherapy.

Our findings suggest that the physical thera-peutic agents investigated offer benefits for isoki-netic performance as well as physical function.Before our study, one randomized controlled trialhad used US to increase the effectiveness of isoki-netic exercises for knee OA. Huang and associates29

used a physiotherapy protocol similar to ours; theonly differences in their study are that it was con-ducted with four groups and that they used only USfor additional physical therapy. Those authors foundthat all groups had increased muscle PT and reducedpain and disability scores, but using US to treat kneeOA before exercise increased the effectiveness of iso-kinetic exercise. Similarly, we found additional effectsof all physical agents and their combinations used.On the other hand, with regard to most parameters,TENS and SWD combined with HP seemed superiorto US with HP or to HP alone.

Jan and Lai30 investigated the effect of US andSWD with and without therapeutic exercise onknee OA in 61 women. All patients were assessed byfunctional scoring and isokinetic testing before andafter treatment protocols. All patients had signifi-cant improvements in functional and muscle PTvalues. The researchers found no significant differ-ences with regard to treatment effects between USand SWD for knee OA. When the exercise programwas combined with SWD, increased treatment effectswere seen with regard to function and muscle PT.

Patient compliance is another issue, and stud-ies with high patient compliance have shown betterresults. Patient compliance depends on many fac-tors, including consistent education, encourage-ment, follow-up, injury, and complications (e.g.,knee pain) as a consequence of inappropriate exer-cise. Therefore, we aimed to eliminate these factorsas much as possible. In our study, 15 of 100 pa-tients terminated their participation in the study.Exercise-induced knee pain was the most commonreason. The strongest and most consistent predic-tor of compliance in this study was the behavior of

patients. We believe that using physical agents be-fore isokinetic exercises may increase compliance.

We conclude that exercise and physical agentscan reduce pain and improve function and healthstatuses in patients with knee OA. Combined exer-cise therapy with physical agents increases the ef-fectiveness of exercise. In patients with knee OA,physical treatment applied before isokinetic exercisetends to increase performance and compliance. Wefound statistically significant differences with regardto the treatment modalities (i.e., TENS, SWD, US,and HP) for some, but not all, of the parameters (PTvalues, ISK scores) we tested. TENS and SWD seemedsuperior to US. Use of physical agents before isoki-netic exercises in patients with symptomatic knee OAleads to augmented exercise performance and im-proved function. Future research also should focuson economic analyses so that clinicians can use themost cost-effective forms of physiotherapy for kneeOA treatment.

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Aaa -THAMARA - Comparing Hot Pack, Short-wave Diathermy, Ultrasound, And Tens on Isokinetic Strength, Pain and Functional Status