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Abstract
Introduction. Osteoarthritis is considered to be the most common form of arthritis and a leading disability cause worldwide,
especially due to the painful symptom. The latter is a clinical marker in evaluating the limits of joint mobility and therefore, the
pain reduction is a goal of the recovery treatment for patients with knee osteoarthritis. The purpose of this study was to show
whether the pain phenomenon characteristic of knee osteoarthritis can be reduced by electrotherapy, even in the context of the
COVID-19 pandemic. Material and method. The study lasted 5 months and included 171 patients diagnosed clinically and
radiologically with knee osteoarthritis. The followed parameters were pain, physical dysfunction in daily activities, anxiety and
quality of life. Results and discussions. The two groups of studied patients were homogeneous in terms of weight by gender and
age groups. The evaluation of patients according to scales enabled the registration of statistically significant values, the value of p
<0.05, which explains the validation of the working hypothesis. The feeling of pain is closely related to the level of anxiety.
Conclusions. Analgesic electrotherapy significantly reduced the pain syndrome of the patients for whom it was used. It has been
shown that the patients' anxiety can influence the pain phenomenon. Given the conditions caused by the Covid-19 pandemic, the
anxiety of the patients who were in the outpatient department to receive recovery treatment was increased, but after the recovery
treatment there was a decrease, so these patients' quality of life increased.
Keywords: pain, analgesic electrotherapy, knee osteoarthritis, recovery treatment,
Introduction
Osteoarthritis is considered to be the most frequent form
of arthritis and a leading disability cause worldwide,
especially due to the painful symptom that determines the
patient to address the doctor. At first the pain has an
intermittent character, then it becomes chronic and
persistent, affecting the joint mobility and implicitly
these patients' quality of life (1). The chronic pain is a
risk factor in the increase in the physical disability.
The most vulnerable category of the population is
represented by the elderly who have bone fragility,
increased risk of falling down whereas the pain
phenomenon is not always treated properly (2,3). The
knee osteoarthritis, due to pain, limitation of joint
mobility and the affected age group, is considered a
chronic condition that can cause significant functional
disability, with medical and socio-economic costs (4).
The presence of the pain symptom as well as the degree
of knee damage by osteoarthritis of the knee can
influence both the mobility of patients diagnosed with
this condition and the development of these patients'
daily activities and quality of life (5).
When the physical activity of patients with knee
osteoarthritis is affected, the functionality of other
systems can be influenced, such as the respiratory system
and the cardiovascular one (1).
The incidence of knee osteoarthritis is expected to
increase significantly in the coming decade due to the
aging of the world's population (6).
Murphy's study in 2008 (7) shows that the risk of
developing a symptomatic form of knee osteoarthritis is
estimated at approximately 40% (47% in women and
40% in men ). This risk may reach even 60% in the obese
persons, in comparison to 30% in the persons with
normal weight or in the overweight persons. From an
etiological point of view, the pain is multifactorial,
involving both intra-joint and extra- joint risk factors (8).
The pain due to knee osteoarthritis is explained by the
fact that some anatomical structures (ligaments, tendons,
joints) become more sensitive to painful stimuli, whereas
the activity of nociceptors located in these structures is
influenced (9). One of the technique used to explore
osteoarticular functionality and changes is Raman
spectroscopy (10).
A study of 2016 (11) shows that it is important to make a
biopsychosocial clinical evaluation before using the
recovery treatment. This is because pain involves several
factors: somatic, behavioral, cognitive, social, emotional
and motivational (12).
This study also tries to establish which is the dominant
mechanism of pain (nociceptive, neuropathic
sensitization or central neuropathy), but at the same time
to evaluate the possible biopsychosocial factors involved
in the pain phenomenon (11).
The pain symptom is a clinical marker in assessing the
limitation of joint mobility and therefore pain reduction is
The role of electrotherapy in reducing the pain of patients with knee osteoarthritis during the
COVID-19 pandemic
ANTONESCU Elisabeta1,2, SILIŞTEANU Sînziana Călina3,4, TOTAN Maria1,5
Corresponding author: SILIŞTEANU Sînziana Călina, E-mail: sinzi_silisteanu@yahoo.com
1. Lucian Blaga University of Sibiu, Faculty of Medicine, Sibiu, România
2
. County Clinical Emergency Hospital, Sibiu, România
3. Railway Hospital Iasi - Specialty Ambulatory of S
uceava
4. "Stefan cel Mare" University of Suceava FEFS-
DSDU
5.
Children’s Hospital, Sibiu, Romania
Balneo Research Journal DOI: http://dx.doi.org/10.12680/balneo.2020.390 Vol.11, No.4, December 2020 p: 512–515
513
one of the goals of recovery treatment for patients with
knee osteoarthritis (13).
The study of Abdel-Aziem in 2018 (14) showed the
effect of the physiotherapeutic program on knee
osteoarthritis according to the intensity of the pain. This
parameter, pain, is considered one of the factors
responsible for the evolution of knee osteoarthritis.
Dworkin et al. in 2011 concluded that the pain and
severity degree are correctly assessed by using the VAS
scale and the WOMAC pain subscale (15).
It was found that people diagnosed with knee
osteoarthritis had higher pain intensities in comparison to
witness for the same level of pressure stimuli, but also for
lower pain or pressure level (16).
Some research has shown the role and importance of
spinal relief in the perception of pain, because at this
level there are mechanisms that can modulate the
nociceptive transmission.
The pain transmission can be influenced at this level by
inflows coming from the periphery as well as from the
superior nerve structures (17). In this context,
electrotherapy in knee osteoarthritis is also used for
analgesic purposes by blocking the conduction of the
impulse through the sensitive nerve fibers.
The purpose of this study was to show whether the pain
phenomenon characteristic of knee osteoarthritis can be
diminished by electrotherapy, even in the context of the
COVID-19 pandemic.
Material and method
The study was conducted over a period of 5 months, from
April to August 2020, on outpatients and included a
number of 171 patients diagnosed clinically and
radiologically with knee osteoarthritis. They followed, in
series, a number of 15 days of treatment, in a rhythm of 1
session per day. The used treatment was
pharmacological, according to the guidelines (NSAIDs in
general administration and in topical one, analgesics)
(18) and non-pharmacological (weight loss, avoidance of
rough terrain, prolonged orthostatism, electrotherapy and
physiotherapy). The patients were evaluated in the
beginning of the treatment and at its end, and also 6
weeks later, when they returned to control.
The criteria for the inclusion in the group were: patients
with a clinical and radiological diagnosis of knee
osteoarthritis over 3 months, over 40 years old, without
comorbidities in decompensated stages, without neuro-
mental disorders, patients who agreed to participate in
the study.
The criteria for the exclusion from the group were:
patients under the age of 40, who also had cardiac,
respiratory, renal, digestive disorders in a decompensated
stage, non-compliant, who did not agree to participate in
the study.
The patients signed the consent for the applied recovery
treatment, then the study was carried out by respecting
the norms of ethics and deontology according to the
legislation in force.
The followed parameters were pain, physical dysfunction
in daily activities, anxiety and quality of life. For pain
we applied the VAS scale (0- no pain, 10 – maximum
pain) and also the WOMAC pain subscale. The static
pain was assessed (while sitting, sleeping, orthostatism)
and the dynamic pain (while walking, climbing /
descending stairs) in which 0 = no pain and 20 =
maximum pain.
For the physical dysfunction, the WOMAC subscale was
considered (activities at home and outside), the value 0 =
optimal development of activities and 68 = limitation of
daily activities.
In assessing the patients' quality of life we used the QOL
scale (16 means a quality of life influenced by
nociceptive factors, the value 112 = well-being, without
pain or other symptoms). We considered it useful, in the
situation created by the COVID - 19 pandemic, to apply
the anxiety assessment scale strictly related to the
disease, not the one determined by previous anxiety
states. In this sense we used the State Trait Anxiety
Inventory (S.T.A.I.) scale and namely the subscale STAI
–X1 where the values vary from 20 (reduced anxiety) to
80 (increased anxiety).
For this purpose, for the recovery treatment the patients
of the group were divided into 2 study groups, namely:
the L1 group (83 patients) who received, in addition to
the pharmacological treatment, low frequency currents
(Transcutaneous electrical nerve stimulation -frequency
of 15-100 Hz, duration of 30-200 ms, Intensity 10-40
mA, with the rapid installation of the analgesic effect),
medium frequency (interferential -with analgesic effect
by increasing the pain level and changing the pain
perception, vasomotor, hyperemic and resorptive) and
ultrasound (analgesic effect by inhibiting the
transmission of nociceptive information, anti-
inflammatory due to vasomotor and metabolic action, but
also muscle relaxant - frequency 1 MHz,intensity of 0.5 -
0.7W/cm2, duration of 5 minutes, pulse application
regime to eliminate the thermal effect (19).
The L2 group (88 patients) who received only
pharmacological treatment (they showed increased
anxiety in the context of the pandemic and did not want
to participate in electrotherapy sessions).
However, the patients of the L2 group accepted to
participate in individual physiotherapy sessions, as well
as the patients in the L1 group.
The kinetotherapy program lasted for 30 minutes a
session, it took place daily and included passive
mobilizations, active mobilizations and active
mobilizations with resistance, but also coordination and
balance exercises, useful in recovering posture and gait.
The L1 group included 83 patients, of which 41 (49.39%)
were female and 42 (50.61%) were male, whereas the L2
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study group included 88 patients, of which 7 (53.41%)
were female and 41 ( 46.59%) male.
Table no. 1. Distribution of patients according to the
study groups and age groups
The demographic data in the study were: patients' age,
gender, living environment and body mass index. The
patients' average age was 62±12.69 in the L1 group
(min. 40, max. 82) and 60.5±12.91 in the L2 group (min.
40, max. 84).
Table no. 2. Distribution of patients according to body
mass index
Statistical analysis
The data obtained from the initial, final and control
evaluations were statistically processed by using
Microsoft Excel 10. The median, the standard deviation,
and the t-student test were calculated to test the working
hypothesis. The chosen level of statistical significance
was 5%, ie. its value should be p<0.05.
Results
The pain evaluated by the VAS scale showed statistically
significant results in both groups, registering in L1 group
a decrease by 42.86% at the end of the treatment and
50% during the control, in comparison to L2 group in
which the pain decreased by 28.57% at the end of the
treatment and by 40% during the control. The pain
phenomenon assessed with the WOMAC subscale
registered a decrease by 28.57% in the L1 group at the
end of the treatment and of 50% during the control,
whereas in the L2 group the reduction of pain was by
21.43% at the end of the treatment and by 45.46% during
the control.
The body mass index decreased in the L1 group by
2.44% at the end of the treatment and by 2.55 during the
control, whereas in the L2 group it decreased by 1.59% at
the end of the treatment and by 2.69% during the control.
Also, the daily activities improved in the L1 group by
36.17% at the end of the treatment and by 50% during the
control, whereas in the L2 group the improvement was by
29.41% at the end of the treatment and by 50% during the
control. Anxiety decreased in the L2 group by 40.47% at
the end of the treatment and by 32.25% during the
control, whereas in the L2 group, anxiety decreased by
36.84% at the end of the treatment and by 29.63% during
the control.
Table no. 3. Evolution of the parameters in the two
groups
Discussions
The objectives of the treatment for the patients
diagnosed with knee osteoarthritis were mainly: the
reduction of pain, anxiety caused by the COVID-19
pandemic, increased muscle strength, muscle toning,
coordination to achieve static and dynamic balance,
increased mobility of the joints, quality of life and
rapid reintegration into the socio-familial
environment.
The applied electrotherapy had an analgesic, anti-
inflammatory, resorbive purpose. Kinetotherapy
was applied in order to improve physical and mental
function, whereas the inhibiting role of nociception
is known at the local and central level.
The two studied groups of patients were
homogeneous in terms of weight, gender and age.
The evaluation of patients based on scales enabled
the registration of statistically significant values, the
value of p <0.05, which explains the validation of
the working hypothesis.
Table 4. The values of the t-student test in the two
groups of patients (T1-T2)
The L1 group that received analgesic electrotherapy
recorded statistically significant values, as it is seen
in the literature of specialty. The application of the
kinetotherapy program also had a role in reducing
the pain phenomenon. On the other hand, the results
obtained by reducing the value of the body mass
index by doing physical exercises correspond to the
data in the literature that explain the role of physical
activities in reducing pain and reducing body mass
index (7).
515
The pain phenomenon in the context of knee
osteoarthritis recorded a more significant decrease in
the L1 group, which enabled the increase of patients'
quality of life and the reduction of the anxious state
caused by the disease and the pandemic context. The
sensation of pain is closely related to the anxiety
level, an observation that is also found in the study
of Zubieta who showed that pain is a subjective
experience having a genetic predisposition and being
partially influenced by the administration of
analgesics (20).
Conclusions
The individualized recovery treatment associated to
the kinetotherapeutic program and an adequate diet
enabled the attainment of statistically significant
results. The analgesic electrotherapy significantly
reduced the pain syndrome of the patients for whom
it was used. It has been shown that patients' anxiety
can influence the pain phenomenon.
Given the conditions caused by the Covid-19
pandemic, the anxiety of the patients who were in
the outpatient department to receive recovery
treatment was increased. During the treatment, the
anxiety condition decreased while the level of pain
decreased.
Acknowledgements
All authors have read and approved this publication
and had equal scientific contribution in publishing
this material.
Abreviations
NSAID -The non-steroidal anti-inflammatory drugs
VAS scale - Visual Analog Scale for Pain
WOMAC scale - Western Ontario and McMaster
Universities Osteoarthritis Index
QOL scale –Quality of life
STAI -State Trait Anxiety Inventory
BMI-Body mass index
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