Guideline for the management of knee and hip osteoarthritis

Recommendations

Electrotherapies

Guideline for the management of knee and hip osteoarthritis
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Non-pharmacological interventions 

Electrotherapies


 

Pulsed electromagnetic/ shortwave therapy – Knee and/or hip

Recommendation

We are unable to recommend either for or against electromagnetic/shortwave therapy for people with knee and/or hip osteoarthritis (OA).

Strength of recommendation

Conditional (neutral) recommendation

Quality of evidence

Low (knee)
Very low (hip)

What is it? 

Pulsed electromagnetic therapy, also known as pulsed shortwave therapy, is the application of pulsed electromagnetic fields to the body. As a pulsed mode of delivery, it does not produce a heating effect in the tissues, but is purported to have physiologically beneficial effects at the cellular level based on magnetic field effects. Traditionally, healthcare providers in clinical settings have administered pulsed electromagnetic therapy, but advances in technology have led to the increasing availability of small portable devices for self-application.

Rationale 

There is low-quality evidence that pulsed electromagnetic therapy significantly improves pain and function in people with knee OA (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document) by clinically relevant amounts. There is very low-quality evidence that pulsed electromagnetic therapy has no statistically significant effect on pain or function in people with hip OA (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). Most studies involved clinician-delivered treatments, at high frequency of servicing, ranging from three to five times per week. A minority of studies used portable devices that individuals applied themselves at home, with treatment dosage ranging from two to 12 hours per day. Although the evidence suggests moderate effect sizes and a low risk of harms for pulsed electromagnetic fields in people with knee OA, the working group noted that current evidence is restricted to short-term (two to 10 weeks) follow-up only, so maintenance of a therapeutic effect remains uncertain. The available evidence suggests that three to five treatment sessions per week are required for benefits when this treatment is administered by clinicians. Given the large number of visits to a healthcare professional required for a treatment modality that is passive, the financial cost this may impose on an individual, and the evidence suggesting no benefit for hip OA, the working group felt that clinician-delivered pulsed electromagnetic therapy should not be offered to people with knee and/or hip OA. The working group noted some promising data from a limited number of small trials investigating portable devices, but felt further research is required regarding effectiveness, acceptability and adherence. 

Harms 

There is a low risk of adverse events, with no serious adverse events reported.

Other electrotherapy – Knee and/or hip (eg shockwave, interferential, laser)

Recommendation

We suggest not offering electrotherapy modalities of shockwave, interferential or laser for people with knee and/or hip OA.

Strength of recommendation

Conditional against recommendation

Quality of evidence

Low (laser)
Very low (shockwave, interferential, laserhip)

What is it? 

Electrotherapy modalities (eg shockwave, interferential electrical current, laser therapy) are purported to induce physiologically beneficial effects on body tissues at a cellular level, including:

  • promotion of cell growth and angiogenesis
  • minimising inflammatory processes
  • modulating pain through actions on the peripheral nervous system.

Shockwave therapy is typically delivered by clinicians, while portable units are available for interferential and laser modalities. 

Rationale

While very low-quality evidence suggests some possible benefits from shockwave and interferential current modalities on pain and function, these findings were limited trials (one for shockwave and two for interferential), with a limited sample size and serious or very serious risk of bias (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). The working group also felt that the cost burden and requirement for frequent clinical visits (for shockwave) were additional factors contributing the recommendation to not offer these interventions.

Seven trials using laser therapy among people with knee OA suggest clinically meaningful benefits in short-term pain and function (up to three weeks); however, the quality of evidence is low to very low (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). Despite these positive indications, the working group felt that it was inappropriate to recommend the use of laser for people with knee OA. This is because the evidence was derived from trials where clinicians were required to deliver the intervention two to three times per week (other than the trial by Stellian,94 where the intervention was self-administered), and the fact that the current evidence is restricted to short-term follow-up of three weeks. Furthermore, based on the model of service delivery used in the majority of trials, a considerable cost and time burden is likely to be placed on individuals. While there is no direct evidence available for the effects of these modalities in people with hip OA, the working group felt the modes of proposed physiologic action of the interventions would be transferable to the hip and the same concerns about cost, time, frequency of clinical visits and very short-term effects would similarly apply. 

Harms

There is no evidence of harm across these modalities.

Transcutaneous electrical nerve stimulation (TENS) – Knee and/or hip

Recommendation

It may be appropriate to offer TENS that can be used at home for some people with knee and/or hip OA. Clinicians need to provide sufficient instructions on self-use, and consider individual accessibility and affordability.

Strength of recommendation

Conditional for recommendation

Quality of evidence

Very low

What is it? 

TENS uses low voltage electric current delivered through electrodes fixed to the skin to affect peripheral nerve activity (neuromodulation) as a mechanism to modify nociception and the experience of pain. Portable TENS units are now widely available for people to use at home as a self-management strategy. Unlike other electrotherapy devices, portable TENS may be used as a continuous therapy by individuals to modulate pain, allowing them to engage in other activities while the unit is active.

Rationale 

Very low-quality evidence from four trials in people with knee OA suggests that TENS has a clinically meaningful effect on pain and function (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). While no direct evidence is available from trials in people with hip OA, the working group felt that the mode of action with TENS could be transferable to the hip. Trials were limited to four weeks follow-up, so it remains uncertain whether treatment effects are maintained beyond this period. Accordingly, the working group felt it would be reasonable to offer TENS to individuals with knee and/or hip OA as a home-based, pain-modulating adjunct to active rehabilitation interventions.

Harms 

No adverse events have been reported in the included trials. However, clinicians should provide information to people about how to use portable TENS units safely and minimise the risks of possible skin irritation.

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Related documents

  Administrative-report.pdf (PDF 2.76 MB)

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