Application of kinesiotherapy and electrothermotherapy in the treatment of elderly with knee osteoarthrosis : a comparative study

Introduction: Among the treatment modalities in this disease , the surgical and conservative means stand out through therapy resources such as electro-thermotherapy and kinetic therapy. The general objective of this study was to evaluate the effects from two protocols of physical therapy in elder women with knee osteoarthritis. Methods: An experimental clinical trial type study consisting of pre and post tests was performed, in which 30 female patients were selected, all between 61 and 80 years old, diagnosed with primary knee OA, treated at the Center for Comprehensive Health Care for the Elder (CAISI – Centro de Atenção Integral à Saúde do Idoso). They were divided into 2 groups of 15 persons for each type of treatment: Group *FJFA: MSc, e-mail: almeidafur@hotmail.com AERAA: PhD, e-mail: euggenia@hotmail.com CAC: Doctoral student, e-mail: carol.103@me.com PCAF: Doctoral student, e-mail: poliana.nutri_ufv@yahoo.com.br VJSN: PhD, e-mail : rvnina@terra.com.br EGM: PhD, e-mail : elba@ufma.br


Introduction
The World Health Organization (WHO) emphasizes that Osteoarthritis (OA) would be the fourth most important cause of disability among women, and the eighth among men.It is estimated that 10% of the global population aged over 60 years suffer from the symptoms of this degenerative disease that is inherent to the aging process that affects organs, tissues and organic systems (1,2).
OA is a chronic degenerative rheumatic disease, multifactorial, of unknown etiology.It is the most common form of compromising the diarthrodial joints that affect elderly with cartilage changes resulting from age and, especially, by wear of the joints present at this this stage of life (1).Among the rheumatic diseases, it is the most usual, affecting nearly one ifth of the world's population, around 50% of seniors over 60 and 80% of the population over 75 years (3,4).
Osteoarthritis affects 16.2% of the brazilian population, representing about 30% to 40% of appointments specialized in osteomuscular articular system (5).In Brazil, this disease is responsible for 7.5% of all leaves of absences and it is the fourth cause to determine retirement, with 6.2% (6).
However, its incidence in aging is higher among women, due to changes in their hormone levels and mechanical alterations found in knee joint (7).
The most common places affected by the disease are the joints of the hands, feet, knees, hips, cervical and lumbar spine.The knee is highlighted for supporting great impacts, which compromises the quality of life, especially the elderly, may lead to functional disability (8,9).
It is noteworthy that the functional disability arising from degenerative diseases, including OA, lead to high costs to public health in Brazil, as a consequence of reduced capacity of human beings to develop labor activities and the increased risk of morbidity and mortality (10).
Recent breakthroughs in the treatment of osteoarthrosis have allowed better conditions in the evolutive course of the disease, favoring a better prognosis of patients (11,12).Among the types of treatments most commonly used by the physiotherapist in physical therapy procedures of osteoarthrosis, it is highlighted the conservative manner, through the use of techniques of kinesiotherapy, electrotherapy, mechanotherapy, thermotherapy and hydrotherapy.These techniques are employed as an intervention measure, whose induced effects enhance joint mobility and muscle strength, optimizing the quality of life of patients (13,14).
It is still controversial the effectiveness of several treatment modalities in degenerative diseases such as OA, especially when studied in women, due to hormonal differences and associated factors in this population.Thus, the present study aimed to verify the effectiveness of two physical therapy protocols with knee OA in elderly women.

Methods
This study is a uncontrolled clinical essay, conducted at the Centro de Atenção Integral à Saúde do Idoso (CAISI) in São Luís, Maranhão, in 2009, with a convenience sample.Initially, 60 patients were recruited.Of these, 50 ful illed the inclusion criteria of the study, but, at the end, 30 patients agreed to participate.This study was conducted after the approval of the Research Ethics Committee (CEP) of the University Hospital of the Federal University of Maranhão (Process No 004975 / 2008-70).All patients who agreed to participate signed the informed consent.
The study included patients over the age of 60, female, lack of regular exercise for at least four months, absence of any treatment for at least 6 months, and medical referral with clinical diagnosis of OA accompanied by examination of radiological image.The exclusion criteria were patients with cognitive impairment, who presented hypersensitivity to thermal and physical means applied in the treatment, previous knee surgery, exclusive locomotion by wheel chairs or knee prosthesis.
The patients were allocated randomly into two physiotherapy groups (Group I -Kinesiotherapy and Group II -electrothermotherapy).
The intervention was simply-blinded, featured conducted by a team of three professionals.The professional responsible for assessing the pre-and post-treatment of the study had no information of the data that were archived and not manipulated, besides not participating of the intervention and not knowing groups of both treatment modalities avoiding possible bias in research.
All professionals were quali ied and had extensive clinical experience with the research instruments.
The clinical and radiographic diagnosis was obtained from the American College of Rheumatology (15) criteria, based on the main complaint of women during the investigation.
It was applied a standardized questionnaire through an evaluation protocol of the clinic services composed of a full investigation about the clinical manifestations present in OA and other complaints, besides socioeconomic information.
The presence of knee pain and range of motion before and after treatment was assessed.Some additional clinical data such as blood pressure, heart rate, symptomatic knee and joint deformities were also obtained.
It was used as a parameter a visual scale analogic for the assessment of the perception of pain related to the last 24 hours (16).The measurement of the range of motion for lexion and extension of the knees was conducted through a universal goniometer (brand Carci, SP, Brazil) consisting of a complete circle (360 degrees) or half circle (180°), with two arms (one mobile and one ixed) being measured by passive goniometer.
During the measurement of knee lexion the patient was positioned in supine with knees and hips lexed.The ixed arm was positioned parallel to the longitudinal axis of the femur toward the greater trochanter, on the surface of the thigh.The other rod was parallel to the longitudinal axis of the ibula on the side surface and aiming at the lateral malleolus.
When measuring the knee extension the patient should be positioned in the supine position, and this measure corresponds to the return of knee lexion, therefore, with the patient's knee extended and hip in neutral position.The ixed arm of the goniometer was positioned laterally along the longitudinal axis of the femur towards the greater trochanter.The mobile arm was positioned parallel to the side of the ibula toward the lateral malleolus.
The measurements of weight and height were assessed, and the body mass index (BMI) was calculated using the formula: weight (kg) / height (m)2.BMI classi ication used the cutoff points recommended by the WHO (17).

Physiotherapy Intervention
In group 1 (GI), it has been developed the kinesiotherapy, through passive stretching of ischio-crural, fascia lata tensor and surae triceps (three sets of 30 seconds).Patellar mobilizations, talocrural pump, osteokinematic movements and arthrokinematic (traction and compression), besides isotonic exercises that consisted of lexing the free active knee and hip lexion with extension of the free active knee (three sets of 12-15 repetitions), in addition to a 10-minute session on an exercise bike at the end of each treatment.These treatments were conducted in three alternate weekly sessions, lasting an average of 30 to 40 minutes.
Group II has used the electrothermotherapy, through the electrical nerve neurostimulation (TENS) using the Neurodyn II apparatus (Ibramed, São Paulo, Brazil), with one output channel.The acupuncture mode was used in this technique -T = 150μs, F = 4 Hz with ixed pulse amplitude throughout the period of physiotherapy intervention.For 30 minutes the gel electrodes were positioned in the anterior portion of the affected knee.
The treatment using the ultrasound model sonopulse Compact 1 MHz (Ibramed, São Paulo, Brazil) with continuous frequency, intensity 1 MHz dose 0.8 W / cm2, employed to the anterior portion of the knee ranging from 3 to 5 minutes was still conducted.The application depended on the size of the knee area due to edema presented in patients.They achieved three alternate weekly sessions, lasting an average of 30 to 40 minutes.It is justi ied, this dosimetry as a reference standard since these parameters are most often used in physical therapy, mainly in soft tissue injuries and painful episodes.
After treatment, the patients were advised to continue the treatment, according to their clinical and functional prognostic in CAISI or in their homes.

Statistical Analysis
The data were analyzed with SPSS for Windows 17.0 (2009).A descriptive analysis with the presentation of means and simple frequencies was conducted.In comparisons of ordinal variables (pain and BMI), it was employed the chi-square test and the Mann Whitney test.It was employed for numerical variables of knee extension (right and left) and knee lexion (right and left), the Shapiro-Wilk normality test.As all variables both before and after the intervention presented normal distribution, the parametric Student t test for independent samples was employed in order to assess the difference between treatments (kinetotherapy and electrothermotherapy).After these analyses, within each treatment was employed the Student t test for paired samples, adopting the signi icance level of 5% for all comparisons.

Results
The sample consisted of elderly patients, 40% (12) were widows, 36.7% (11) married and 23.4% (7) were single or separated.The mean age was 68.1 ± 6.35 years (61-80 years).Regarding socioeconomic conditions, more than half (53.3%) had an income of two minimum wages.It was observed that 72.6% of elderly were overweight or obese.
As for the knee OA characteristics, 56.7% (17) of the patients had right knee as the predominant side, 36.7% (11) had the left knee as predominant, and 6.7% (2) diagnosed with bilateral predominance.
When comparing the two therapeutic modalities (GI and GII) it was observed that there was a reduction in the pain level (p < 0.0001) of patients before and after the intervention.The medians of BMI in group I was 29.31 kg / m 2 before and 28.70 kg / m 2 after treatment.For group II 29.68 kg / m 2 and 29.50 kg / m 2 before and after treatment.For BMI values there was no difference (Table 1).
When comparing the average amplitude of the bilateral movement of the knees, it was veri ied that only the variable right knee extension difference was found (p = 0.040) between the GI and GII therapies (Table 2).
In the group submitted to kinesiotherapy (GI), there was difference in the amplitudes means of right knee extension movements (p = 0.009), left knee extension (p = 0.012), right knee lexion (p = 0.001) and left knee lexion (p = 0.001) when compared the pre and post-treatment values (Table 3).Similarly, it was observed in the group submitted to electrothermotherapy (GII) differences in amplitudes means of right knee extension movements (p = 0.004), left knee extension (p = 0.012) and right knee lexion (p = 0.003).There was no difference in the amplitude of the left knee lexion movements (p = 0.051) in relation to pre and post-treatment values (Table 4).contributed to the reduction of pain between the pretreatment phase and medical release.Morgan et al. (27) veri ied that the use of TENS helped in reducing the pain and strengthen knee muscles.In a study conducted by Mascarin (28), using EVA to measure pain, 60 patients were evaluated, divided into 3 groups of 20 patients with different techniques of kinesiotherapy, TENS and Ultrasound.It was observed that, at the end of the treatment, the mean pain decreased in the 3 groups and was homogeneous.This study agrees with these results, due to the observation of the signi icant decrease in the pain level of patients submitted to kinesiotherapy and electro-thermotherapy.Kinesiotherapy is the use of movement caused by muscle activity for therapeutic purposes (5).The kinesiotherapy goals in patients with OA should be the reduction of disability and pain, increase of ADM and lexibility (20).This investigation has observed signi icant difference in the means of range of motion before and after the treatment of the group submitted to kinesiotherapy.In a comparative study by Silva et al. (29), kinesiotherapy proved to be better than cryotherapy and short waves in the increase of range of motion of passive lexion and lexibility of the knee affected by osteoarthrosis.
In the work conducted by Arden & Nevitt (30), it was demonstrated the effectiveness of therapeutic exercise programs whereas studying 201 female patients with hip and knee OA, with a mean age of 68 years, in which the participants received orientations and necessary medications.The patients were divided into 2 groups of therapeutic exercises and 1 control, treated for 12 weeks.After the treatment, the patients with knee and hip OA, belonging to the group of therapeutic exercise, had improved range of motion and functional capacity.
Moreira & Carvalho (31) claim that the limitation of movement in the knee joint is a signi icant cause of osteoarthrosis, but the treatment conducted with kinesiotherapy produces physiological effects such as the preservation of articular cartilage through its best hydration in addition to better joint mobility.
Among the modalities of thermoelectrotherapy, TENS and ultrasound were used in patients of group II of this study.TENS has been used as one of the modalities of physical therapy most used in pain relief for OA.A study shows that TENS reduces pain and improves knee functionality (27).There are still controversies regarding the use of methods using deep

Discussion
This study was mainly focused on comparing two therapeutic protocols (Kinesiotherapy and electrothermotherapy) conservatives in the treatment of OA in elderly women, in order to observe differences in the bene its of both therapies at the pain level, ADM and BMI values of the investigated patients.Fransen (18) reports the need of investigations related to the treatment of OA, as the pain level, ADM and BMI in luence these approaches.The answers to these therapies continue deserving attention by the scienti ic community, since the evidence on physical rehabilitation are often without evidence.
After the initial investigation, the patients were assessed regarding full medical history as proposed by Cipriano (19).The medical history was obtained in the pretreatment phase and constitutes one of the most important steps of the clinical assessment protocol.
The mean age of patients was 68.1 years (± 6.35).The World Health Organization estimates that 25% of those over 65 suffer from pain and disability associated with OA (20).Advanced age and female gender are risk factors for OA (21).Due to the greater prevalence of this disease in women, this study chose to study only female patients.
The median BMI was high in both groups (GI and GII), showing that this is a sample where the majority (72.6%) are women overweight most likely due to physical inactivity and consequent reduction of energy expenditure.There was no signi icant difference when compared the BMI values before and after physical therapy.It is possible that the time of treatment and the exercises performed in two therapies have not been suf icient to promote weight reduction and response in the decrease of BMI among women in this study.Some studies have been conducted with obese women with knee OA, showing that overweight is one of the main risk factors for knee OA (22)(23)(24).Chacur's study (23) with obese women over 40 years has observed that the severity of OA is positively associated with overweight assessed by BMI, indicating that weight control should be part of knee OA prevention in women.
Pain is among the leading causes of physical disability in patients with OA and its improvement constitutes a major goal of therapies (25).Rodrigues (26), in a study with 45 patients with knee osteoarthrosis accompanied by an average time of 246 ± 99 days, showed that the treatment with kinesiotherapy pain presented in both treatment groups possibly for the primary classi ication of OA where these characteristics are not decisive in the clinical aspects in this stage of the disease.
Regarding the BMI, no signi icant changes were observed before and after the interventions, most likely, due to time and goals of their respective treatment modalities, or even, according to overweight characteristics, manifest themselves more frequently in women especially the elderly.Both therapeutic techniques promoted increased range of functional motion of the knee.However, in relation to the left knee lexion, the electrothermotherapy showed no signi icant difference.It is noteworthy that the therapeutic techniques approached in this study relected positively on ADM due to staging in painful episodes, as well as improved lexibility through the techniques of stretching and joint mobilizations that allowed improvements in the release of joint movements.Therefore, these results indicate that both treatments were effective in improving patients with OA.However, it is suggested that future research use control groups with other conservative therapeutic possibilities, as well as comparison between sexes, since this study has investigated a speci ic population.heat in affected joints, although a review study, that brought together studies using deep heat as a form of physical therapy for OA, indicate that there seems to be a positive balance in favor of the analgesic effects, mainly produced by ultrasound and the diathermy by short waves (32).
In a meta-analysis (33), of studies with randomized controlled essays to assess the achievement of the ultrasound in the pain of OA patients by visual analogue scale, were observed, in general, pain reduction.Nevertheless, the heterogeneity present in the de inition of the groups made it dif icult to analyze the results because of parameters such as mode, frequency and intensity that were not well de ined, explaining the inconsistency between groups.
The patients in this study showed improvement represented by the signi icant increase in the amplitude of the knee and pain reduction after treatment with thermoelectrotherapy, demonstrating the effectiveness of ultrasound as a therapeutic modality in OA.
Therefore, the results of this study corroborate other studies that indicate kinesiotherapy and therapies heat-based as a low-cost and safe treatment, with signi icant effects in reducing the pain and improving range of motion of patients studied (34,35).
Among the limitations of this study it can be highlighted the convenience sample which has been used, exposing the results of the effect by chance, it is possible that some of the observed results are due to characteristics of the group rather than the treatment.
The short period of treatment, the sample size, the lack of control over the use of medications and the lack of a control group are other limitations that may be mentioned.However, the study allowed the use of two therapeutic approaches in women with knee OA, and it was possible to observe bene icial effects of both therapies in the disease.
It is necessary to conduct new studies with therapeutic approach related to OA for validation of effective protocols in controlling this disease, since the casuistry and the functional classi ication are some limitations of this study that can be elucidated in further studies.

Conclusion
Comparing the treatment groups, it was observed a signi icant decrease in the pain level after the intervention.It is justi ied, the responsiveness in reducing

Table 1 -
Comparison of ordinal variables BMI and Pain before and after treatment of kinesiotherapy and electrothermotherapy São Luís, MA, 2009

Table 2 -
Comparison of range of motion values in bilateral movements of extension and flexion of the knee before and after the treatment with methods Kinesiotherapy (GI) and Electrothermoterapy (GII) in 30 elderly women.São Luís,MA, 2009

Table 3 -
Range of Motion values of the knee movements before and after the treatment of GI (kinesiotherapy) of Elderly Women, São Luís, MA, 2009

Table 4 -
Range of Motion values of the knee movements before and after the treatment of GII (electrothermotherapy) of Elderly Women, São Luís, MA, 2009