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Jean-Philippe Berteau
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Berteau, J. Physical Therapy Interventions of Osteoarthritis. Encyclopedia. Available online: https://encyclopedia.pub/entry/23956 (accessed on 19 July 2025).
Berteau J. Physical Therapy Interventions of Osteoarthritis. Encyclopedia. Available at: https://encyclopedia.pub/entry/23956. Accessed July 19, 2025.
Berteau, Jean-Philippe. "Physical Therapy Interventions of Osteoarthritis" Encyclopedia, https://encyclopedia.pub/entry/23956 (accessed July 19, 2025).
Berteau, J. (2022, June 13). Physical Therapy Interventions of Osteoarthritis. In Encyclopedia. https://encyclopedia.pub/entry/23956
Berteau, Jean-Philippe. "Physical Therapy Interventions of Osteoarthritis." Encyclopedia. Web. 13 June, 2022.
Physical Therapy Interventions of Osteoarthritis
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This entry is adapted from the peer-reviewed paper 10.3390/jcm11123252

The number of treatments for OA is extensive, but the effectiveness behind many of them is sporadic. Regarding the Physical Therapy Interventions, one of the best ways to measure the efficiency is the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score. The minimum clinical efficiency associated is roughly a decrease of 20% for each WOMAC sub-scales. 

knee pain osteoarthritis physical therapy orthopedics

1. Diathermy

Diathermy, or heat therapy, has been used as a treatment method for varying musculoskeletal issues. The rationale behind diathermy use lies within its ability to increase the temperature of the underlying tissue. An increase in tissue temperature can induce vasodilatation, increase cellular activity, increase pain threshold, increase soft tissue extensibility and reduce muscle spasms [1]. Two forms of diathermy often used are short-wave diathermy (SWD) and microwave diathermy (MD). SWD uses high-frequency electromagnetic energy to generate heat on a particular tissue in a pulsed or continuous wave [2]. MD uses microwaves to generate heat on superficial tissues, as their lower-frequency waves do not penetrate deep muscle [3]. For microwave diathermy, the mechanism of action is believed to increase local blood flow and allow nutrients and oxygen to be delivered to promote tissue repair [3][4]. Indeed, the increased capillary permeability induced by the deep microwave diathermy allows macrophages and granulocytes to reach the affected area, thus removing toxins and necrotic debris. Hyperthermia can interfere with enzymes involved in the inflammatory process, and local microwave diathermy may induce the expression of heat shock proteins, which are essential for proper protein folding and the removal of cellular waste material [3][4].
In Table 1, the analysis of interventions was split into classes of diathermy treatments versus control (sham) diathermy and different kinds of diathermy interventions (continuous vs. pulse and superficial vs. deep diathermy) against each other. Deep microwave diathermy has been shown to reduce synovial thickness—a prognostic marker of cartilage loss—in patients with knee OA, which in turn assists in decreasing pain associated with synovitis and the progression of cartilage loss [3]. Multiple studies found a difference in pain scores for patients treated with diathermy; differences ranged from an 8% to 45% decrease in WOMAC scores for various diathermy treatments. Both diathermy therapy and sham therapy showed an improvement in WOMAC scores. There was no significant difference between short wave diathermy and sham diathermy treatments. However, deep microwave diathermy proved to be the most efficient intervention in treating knee OA.
Table 1. Summary of the findings from the seven papers with interventions regarding diathermy, sample size, and the relative risk reduction for WOMAC pain subscale. H-PSWD (high-pulse short wave diathermy), L-PSWD (low-pulse short wave diathermy), MD (microwave diathermy), SWD (short-wave diathermy), SHT (superficial microwave diathermy), DHT (deep microwave diathermy), CSWD (continuous short-wave diathermy), and PSWD (pulsed short-wave diathermy).
Authors Interventions Sample Size Relative Risk Reduction of Pain WOMAC
Laufer et al., (2005) [5] H-PSWD n (H-PSWD) = 32 9%
L-PSWD n (L-PSWD) = 38 3%
Giombini et al., (2011) [4] MD n (MD) = 30 44%
Rattanachaiyanont et al., (2008) [6] SWD n (SWD) = 50 27%
Rabini et al., (2012) [3] SHT n (SHT) = 27 8%
  DHT n (DHT) = 27 45%
Ozen et al., (2019) [7] CSWD n (CSWD) = 14 26%
  PSWD n(PSWD) = 20 23%
Boyaci et al., (2013) [2] SWD n (SWD) = 35 22%
Sarifakioglu et al., (2014) [1] SWD n (SWD) = 63 39%

2. Exercise Therapy

Quadriceps and hamstring muscle weaknesses worsen knee OA effects by decreasing dynamic muscle actions, losing joint motion [8], and decreasing neuromuscular (proprioceptive) control [9]. Thus, exercise therapy, specifically strength training, has been proven to be an effective non-surgical and non-pharmacological intervention for the effects of knee OA and is recommended in international guidelines [9]. Here, six studies regarding quadriceps and hamstring strength exercises—intended to reduce the pain in patients with knee osteoarthritis—were reviewed (Table 2). All the protocols were significantly effective in increasing quadriceps and hamstring muscle strength and decreasing pain for patients with knee OA. Most protocols were effective after at least 4 weeks of intervention, targeting quadriceps strengthening three times per week. However, the specific type of muscle-strengthening exercise and most effective session duration could not be concluded. The most effective exercise intervention programs—static quadriceps and straight leg raise exercises—revealed a statistically significant reduction in pain intensity (WOMAC scores reducing from 56.75 ± 8.43), increased range of motion (ROM), and improved function [8] after a 6-week intervention.
Table 2. Summary of the findings from the seven papers with interventions regarding exercise therapy, sample size, and the relative risk reduction for WOMAC pain subscale.
Authors Interventions Sample Size Relative Risk Reduction of Pain WOMAC
Vincent et al., (2019) [10] Concentric n = 28 11.3%
Eccentric n = 30 16.9%
Hall et al., (2018) [11] Isometric n = 49 8.4%
No Intervention n = 48  
Hafez et al., (2013) [12] Pre strengthening exercises n = 20 46.1%
Post strengthening exercises    
Al-Johani et al., (2014) [13] Conservative PT+ strengthening exercises n = 20 27.7%
  Versus conservative PT n = 20  
Oliveira et al., (2012) [14] Instructions n = 50 11%
  Versus quadricep strengthening n = 50  
Lin et al., (2009) [15] Strengthening exercises n = 36 42.1%
  No intervention n = 36  
O’Reilly et al., (1999) [16] Strengthening exercises n = 108 30.3%
  No intervention n = 72

3. Ultrasound Therapy

Ultrasound therapy is a technique that can transform electrical energy into heat as it passes through tissues [17]. Due to its thermal and acoustic properties, it has been found that ultrasound therapy can increase pain threshold, influence neuromuscular activity to help with muscle relaxation, and help with tissue regeneration and inflammation reduction [17]. Studies investigating the treatment of knee OA with ultrasound therapy have found marked improvements in pain and joint functioning in patients who had moderate to severe knee OA [18].
Overall, the evidence indicates that all three modalities of ultrasound used in the trials (continuous, pulsed, focused low intensity) affect lowering WOMAC scores in patients (Table 3). Of the nine trials using continuous ultrasound as a treatment, eight reduced WOMAC scores by 20%. While most studies showed favorable relative risk reductions in WOMAC, only a few studies [19][20][21] yielded clinically significant relative risk reductions in stiffness WOMAC score, with −62.5%, the relative risk reduction for pain WOMAC score being the most clinically significant [21]. Discrepancies in findings can be attributed to the combination of ultrasound application with or without rigorous exercise. Of the trials that showed clinically meaningful results, the continuous ultrasound treatments used a 1 MHz frequency with an intensity of 1 W/cm2 or 1.5 W/cm2 for 5 to 10 min [2][21][22]. The pulsed ultrasound interventions similarly used a 1 MHz frequency with an intensity of 1 W/cm2 for 10 min at a pulsed mode of 25% [21][23]. The focused low-intensity treatment used a frequency of 0.6 MHz, a pulse repetition frequency of 300 Hz, and an average intensity of 120 mW/cm [24]. Most of the studies used 10 sessions of ultrasound treatment total, with 5 treatments per week over 2 weeks.
Table 3. Summary of the findings from the eight papers with interventions regarding ultrasound.
Authors Interventions Sample Size Relative Risk Reduction of Pain WOMAC
Boyaci et al., (2013) [2] Continuous Ultrasound (CU) n = 33 16%
Phonophoresis (PhP) n = 33  
Alfredo et al., (2020) [21] CU n = 20 6%
Control Group (C) n = 20  
Özgönenel et al., (2008) [19] CU n = 34 18%
Sham Ultrasound Group (SU) n = 33  
Luksurapan & Boonhong (2013) [17] CU n = 23 108%
  PhP n = 23  
Loyola-Sánchez et al., (2012) [23] Pulsed Ultrasound Group (PU) n = 14 23%
  Sham Ultrasound Group (SU) n = 13  
Kozanoglu et al., (2003) [25] CU n = 30 22%
  Ibuprofen Phonophoresis (PH) n = 30  
Külcü et al., (2009) [26] CU n = 15 44%
  SU n = 15  
Karakaş et al., (2020 [20]) CU n = 39 11%
  C n = 36

4. Knee Brace

Knee braces may alter the alignment of the lower extremity, decreasing the load on a specific compartment of the knee [27]. These braces are called unloader braces. Evidence suggests that unloader braces for medial knee osteoarthritis apply an external valgus force, improving the tibiofemoral alignment, shifting the body’s load away from the degenerated compartment, and reducing mechanical stress [28]. After reviewing the available studies [29][30][31][32][33], there is an overall significant decrease in pain scores after the intervention of unloader or valgus knee braces in patients with osteoarthritis (Table 4). Braces for medial knee osteoarthritis can reduce medial joint loads through three mechanisms: application of an external brace abduction moment, alteration of gait dynamics, and reduced activation of antagonistic muscles [34]. Knee braces reduced medial tibiofemoral loads primarily by applying a direct and substantial abduction moment to each subject’s knee [34]. Evidence [31][32] has found that the brace’s abduction moment reduced pain and, more particularly, that valgus bracing reduced the net varus moment about the knee by an average of 13% (7.1 N•m) and the medial compartment load at the knee by an average of 11% (114 N) in a calibrated 4° valgus brace setting [31]. For braces that deal with predominant lateral tibiofemoral OA and patellofemoral OA, the concept is similar to the unloader braces studied here. However, the number of controlled trials remains too low in the literature to prove their efficiency.
Table 4. Summary of the findings from the five papers with interventions regarding knee brace.
Authors Interventions Sample Size Relative Risk Reduction of Pain WOMAC
Hurley et al., (2012) [29] Valgus Unloader Knee Brace n = 24 21%
Briggs et al., (2012) [30] Valgus Unloader Knee Brace n = 39 57.1%
Pollo et al., (2002) [31] Valgus Unloader Knee Brace n = 11 44.4% (VAS)
Fatani-Pagani et al., (2010) [32] Valgus Unloader Knee Brace n = 11 50%%
Richards et al., (2005) [33] Valgus Unloader Knee Brace n = 30 41% (VAS)

5. Electrical Stimulation

Electrical stimulation on the quadriceps muscle has been proposed to decrease muscle weakness and reduce the worsening of knee OA symptoms. Several types of electrical stimulation are currently used: high-frequency transcutaneous electrical nerve stimulation (h-TENS), low-frequency transcutaneous electrical nerve stimulation (l-TENS), neuromuscular electrical stimulation (NMES), interferential current (IFC), pulsed electrical stimulation (PES), and noninvasive interactive neurostimulation (NIN) [35]. In h-TENS, the simple application of TENS on the skin around the affected knee excites the motor neurons, facilitating movement by overriding the inhibitory mechanoreceptors signaling pain around the injured knee joint [36]. Though h-TENS was previously used for sensory relief of pain, studies have shown that h-TENS can improve motor excitability and decrease voluntary muscle activation. In IFC (considered the “gold standard” for managing knee OA widely), the stimulation works by delivering current to the skin’s deeper layers overriding the skin’s impedance [37]. As the literature shows (Table 5), IFC is the most likely to decrease pain intensity and change pain scores at last follow up [35]. Patients who use IFC have a 88% probability of showing improvement, whereas h-TENS indicates only a 74% probability. In PES, while it is comparable to h-TENS and IFC in the mechanism of action on mechanoreceptors, it differs from other forms of electrical stimulation in that it delivers current at sub-sensory intensity [38].
Table 5. Summary of the findings from the six papers with interventions regarding electrical stimulation.
Authors Interventions Sample Size Relative Risk Reduction of Pain WOMAC
Atamaz et al., (2012) [37] TENS n = 29 11%
  IFC n = 27 11%
Pietrosimone et al., (2020) [36] TENS + TE n = 30 10.57%
  sham TENS + TE n = 30 3.3%
  TE only n = 30 12%
Adedoyin et al., (2005) [39] exercise+ electrical stimulation n = 16 27%
  exercise n = 11 7%
Garland et al., (2007) [40] Active device n = 38 26%%
  Placebo device n = 20 7%
Fary et al., (2011) [38] Pulse Electrical Stimulation n = 34 11%
  placebo n = 36  
Shimoura et al., (2019) [41] TENS Stair climb n = 50 33% (VAS)
  TENS Timed up and go   26% (VAS)
  TENS 6 mi walk test   55% (VAS)

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