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Original article
Effect of Glucosamine Sulfate, Chondrotin Sulfate, Methylsulfonylmethane
Phonophoresis on Knee Osteoarthritis
Soheir SR Samaan 1, Joseph W Saweris 2
1
Assisstant professor of physical therapy, Department of Basic Sciences, Faculty of
Physical therapy, Cairo University, Egypt
2
Physical therapist, Institute of Oncology, Cairo University
Corresponding author:
Soheir Shehata RezkAllah, Department of Basic Sciences, Faculty of Physical therapy,
Cairo University, 7 Ahmed ElZayyaet st., Dokki, Giza, Egypt.
Email: [email protected]
Running heads
Soheir and Joseph
Journal of clinical rehabilitation 0(0)
1
Abstract
Glucosamine sulfate and chondroitin sulfate are believed to relieve pain, decrease
joint narrowing, stimulate the production of new cartilage components, and help
the body to repair damaged cartilage. Methylsulfonylmethane is an analgesic and
anti-inflammatory drug is usually used with the previous drugs. Phonophoresis
was believed to influence drug delivery by increasing cell permeability, causing
particle oscillations within the tissue and drug milieu. Methods: Thirty patients of
both sexes randomly assigned in three groups. Group A received pulsed
ultrasound (50% duty cycle), 1 MHZ, 1.5 w/cm2, 5 min using Glucosamine sulfate,
Chondroitin sulfate and Methylsulfonylmethane gel as a coupling medium in
addition to a traditional physical therapy program included stretch of the
hamstring and calf muscles, and isometric strengthening of the quadriceps, group
B received topical application of Glucosamine sulfate, Chondroitin sulfate and
MSM gel with sham ultrasound in addition to the same traditional physical
therapy program, group C received the traditional exercise program only.
Treatment was provided 3 times per week for 4 successive weeks. Patients were
assessed before and treatment using visual VAS for pain level, electronic
goniometer for ROM, and The WOMAC Index of Osteoarthritis for functional
level of the knee joint. Patients in all groups showed a significant improvement of
pain level, ROM; and functional level of the knee joint, improvement in group A
2
was higher than in group B and both were better than group C. Conclusion:
Glucosamine sulfate, Chondroitin sulfate and Methylsulfonylmethane gel
phonophoresis is effective in the treatment of knee osteoarthritis.
Key
words:
Knee
osteoarthritis,
glucosamine
methylsulfonylmethane, phonophoresis.
3
sulfate,
chondroitin
sulfate,
Introduction
Osteoarthritis (OA) is a disorder that affects the synovial joints; it is characterized by
damaging of focal areas to articular cartilage, changing of the underlying bone and the
formation of osteophytes at joint margins and mild synovitis [1]. Knees are of the most
commonly affected joints by osteoarthritis [2].
The most common symptom of Knee osteoarthritis is pain, it aggravates with joint
movement and relieved by rest. Inflammation leads some patients to experience pain at
rest. Pain is caused by stretch on the periosteum by osteophytes, bony changes at the
ligamentous attachments, and muscle spasm which aim at immobilizing the painful joint
[3].
Pharmacological treatment of knee osteoarthritis includes analgesics, non-steroidal antiinflammatory drugs (NSAIDs), corticosteroids and opiods, and gluco-samine sulfate.
NSAID are widely prescribed and purchased over-the-counter for osteoarthritic
complaints but have significant side effects and are associated with >16,000 deaths
annually
in
the
United
States
[4].
Since
glucosamine
is
a
precursor
for glycosaminoglycans, and glycosaminoglycans are a major component of cartilage,
research has focused on the potential for supplemental glucosamine to beneficially
influence cartilage structure and alleviate arthritis [5].
4
Clinical trials have suggested that glucosamine sulfate (GS) is an effective drug for the
management of symptoms of OA when it used as a medium and long term treatment
[6]. This symptom modification is sustained for years, and there is an intriguing
suggestion of possible disease (structure) modification [7,8]. These long-term effects are
particularly relevant [9], given the chronic and progressive nature of this degenerative
joint disease. Glucosamine sulfate may potentially delay joint structure changes in OA
[7,8].
Chondroitin sulfate (CS) is a major component of the extracellular matrix (ECM) of
many connective tissues, including cartilage, bone, skin, ligaments and tendons [10].
Chondroitin sulfate, as a natural component of the ECM, is a sulfated
glycosaminoglycan (GAG) composed of a long unbranched polysaccharide chain with a
repeating disaccharide structure of N-acetylga-lactosamine and glucuronic acid.
Chondroitin sulfate is responsible for many of the important biomechanical properties
of cartilage, such as resistance and elasticity. Its high content in the aggrecan plays a
major role in allowing cartilage to resist pressure stresses during various loading
conditions [11]. Chondroitin sulfate is recommended as a therapeutic intervention in the
treatment of OA. CS has the capacity to accumulate in joint tissue including synovial
fluid and cartilage after oral administration in humans [12].
GS and CS were administered orally, or by intravenous injection. Topical application of
glucosamine and chondroitin sulfate is effective in relieving the pain from OA of the
5
knee and improvement is evident within 8 weeks [13]. Few studies reported modest
effects of oral glucosamine intake on increasing fasting glucose, increasing the glucose
threshold for insulin secretion, and decreasing insulin sensitivity [14]. Oral or
intravenous administration of GS was reported to have minimal adverse effects; such as
nausea, GIT troubles but it was proved that it does not causes insulin resistance despite
it enters the hexosamine biosynthetic pathway directly [15,16].
Methylsulfonylmethane (MSM) is a popular dietary supplement used as a single agent
and in combination with other nutrients, and reported to be beneficial for arthritis. SM
(3g twice a day) improved symptoms of pain and physical function during the short
intervention without major adverse events. [17]. MSM is an organosulfur molecule that
can be synthesized commercially from dimethylsulfoxide (DMSO). It is even naturally
present in the human body as it is metabolized from ingested DMSO. It can be found in
cerebrospinal fluid and plasma at 0-25 μmol/l concentrations [18]. Minimal knowledge
is known about how these effects may benefit patients with OA of the knee, long-term
trials on MSM may yield additional and greater improvements in knee OA symptoms
[19].
Glucoseamine was used in combination with MSM for treating OA. They produced an
analgesic and anti-inflammatory effect. Combination therapy showed better efficacy in
reducing pain and swelling and in improving the functional ability of joints than the
individual agents [20].
6
Phonophoresis was known to enhance penetration of any medication through the normal
skin by ultrasound irradiation. It can be obtained with the medication gel or cream either
used as a coupling medium for the ultrasound head or with any regular coupling gel, the
actual medication gel or cream being applied on the irradiated area immediately
thereafter [21]. Phonophoresis was believed to influence drug delivery by increasing
cell permeability, causing particle oscillations within the tissue and drug milieu, and
perhaps inducing drug molecule motion through radiation pressure forces. The most
likely mechanical explanation is thought to be intercellular diffusion from high-speed
vibration of drug molecules along with vibration of the cell membrane and its
component [22].
Many trials were attempted to investigate the effect of phonophoresis with different
drugs in the treatment of OA. Drugs used with phonophoresis were ibuprofen [23],
ketoprofin [24], dexamethasone sodium phosphate [25], and piroxicam [26].
Phonophoresis was proved to be effective in pain relief and improving patient
symptoms and function.
Similarly this study was conducted to investigate the efficacy of GS, CS and SMS
phonophoresis versus topical application on symptoms and function of knee OA.
Material and methods
Subjects
7
Thirty patients with knee OA (male and female) participated in the study. Their ages
ranged between 45 to 65 years. They were randomly assigned into 3 groups of equal
number, 2 experimental groups and a control group. The study is a randomized
controlled trial. Group (A): Consisted of 10 patients, they received GS, CS and MSM
gel phonophoresis with pulsed ultrasound therapy (50% duty cycle),1 MHZ, 1.5 w/cm2,
5 min according to Cagnie, et al 2003; plus a traditional exercise program that included
stretching exercises of the hamstrings and calf muscles, straight leg raising (SLR) of the
knee, and isometric strengthening of the quadrecipes. Group (B): Consisted of 10
patients, they received topical application of GS, CS and MSM gel plus the traditional
exercise program. Group (C): Consisted of 10 patients, they received only the
traditional exercise program. The treatment was given three sessions per week for four
weeks.
All patients gave written informed consent prior to entering the study. The protocol was
approved by the Institutional board of the faculty of physical therapy, Cairo University.
The study was conducted at the out clinic of faculty of physical therapy, Cairo
University from September 2013 to February 2014. Eligibility was defined as
symptomatic knee OA for at least 6 months according to the clinical criteria of the
American College of Rheumatology (ACR) [27] and radiographic confirmed knee OA
according to the Kellgren & Lawrence scale [28]. Exclusion criteria included acute
septic arthritis; inflammatory arthritis; any other type of arthritis; history of knee
8
buckling or recent knee injury; lack of physical or mental ability to perform or comply
with the treatment procedure; diabetes mellitus; fibromyalgia or other chronic pain
syndromes; concurrent anti-coagulant/anti-platelet drugs; arthroscopy or intra-articular
injections in the previous 3 months. Patients using other arthritis therapies (CAM, etc.)
and patients using NSAIDs were required to undergo a 10-day washout period before
enrollment.
Enrollment
Thirty patients with knee OA whose age ranged from 45 to 65 years participated in this
randomized controlled trial. The participants were selected randomly from the out clinic
of faculty of physical therapy and from the orthopedics outpatient’s clinic, faculty of
medicine, Cairo University. Over several months at those clinics hundreds of patients
came in to be examined for regular medical problems. 42 patients who were examined
by orthopedists for knee OA problems consented to enter the study. These patients were
assessed by the orthopedists on staff for eligibility to the study according to the
inclusion and exclusion criteria. 30 patients were determined to meet the study criteria
and were enrolled into the study. The 30 selected patients were assigned to
phonophoresis sessions or topical application with sham ultrasound or a traditional
exercise program. For phonophoresis, pulsed ultrasound was used with frequency 1
MHz, intensity 1.5 W/cm², and (50% duty cycle) for 5 minutes /session. Glucosamine
sulfate 30mg/g, Chondroitin sulfate 50mg/g and MSM 10mg/g gel were put on
9
ultrasound head before application. Topical application was done by applying of GS,
CS and MSM gel on the head of US and moving it on the knee for 5 minutes with sham
ultrasound where the device is off and all controls on zero.
Randomization
The study was a 4-week randomized controlled trial by using random numbers. Random
numbers were assigned as follows: Once the orthopedist on staff determined a patient's
eligibility to the study, the patient was given a unique number for the duration of the
study. Assignment in a group was done by asking each patient to select a number from
1-30 from a opaque envelope, then it was put in one of the three groups as follows:
numbers from 1-10 in group A, numbers from 11 to 20 in group B and numbers from
21-30 in group C. After being assigned a number and after being scored in all the study
measurements for baseline data. The serial numbers were examined at the end of the 4
weeks.
The traditional exercise program in the form of: 1) Stretching of the hamstring muscles
from supine lying position for 3 successive times, 30 seconds each with rest for 1
minute in between stretches, 2) Stretching of the calf muscles from supine lying
position for 3 successive times, 30 seconds each with rest for 1 minute in between
stretches [29], 3) Straight leg raising exercise in which the patients were positioned in
the crook lying position with the unexercised limb is the flexed one then the patients
was asked to contract the quadriceps muscle and elevate the limb to 45º and hold for 6
10
seconds, slowly lower the limb and then relax for 6 seconds, three sets of 10 repetitions
were be done [30], 4) Isometric strengthening of the quadriceps muscle in the form of 3
sub maximal isometric contractions of increasing intensity followed by 6 maximal 5
seconds isometric contractions, the isometric contractions were repeated at multiple
knee angles (30º–60º–90º) degrees respectively, each contraction was followed by 30
seconds rest period and each set of contractions at each knee angle was followed by 1
minute rest [31].
Patient evaluation
The patients were scored at baseline and 4 weeks. The primary outcomes of the study
were the VAS for pain, the modified electro-goniometer for knee flexion ROM, and the
WOMAC questionnaire. The VAS is a subjective measurement that the patient reports
on a 10 cm horizontal line, where 0 indicates no pain and 10 the worst pain. The VAS is
particularly useful in assessing changes in pain for individuals receiving therapy [32].
Penny and Giles electrogoniometer (Penny and Giles Biometrics Ltd, Gwent, UK) was
attached by double-sided tape to the lateral aspect of the thigh and lower leg. To allow
the goniometer to be positioned accurately during assessment, the subjects were marked
with ink at the center of the lateral femoral condyle and then 7 (cm) above and below
that point on the line connecting the greater trochanter of the hip to the head of the
fibula. The mechanical signals from the measuring element in the end-blocks were
converted into a digital signal by a datalog acquisition unit which connected the
11
electrogoniometer to a display unit [33]. The WOMAC includes 24 points that includes
pain, stiffness, and physical function. Scoring and interpretation from 0 to 5. 0=none
response, 1=slight, 2=moderate, 3=severe, 4=extreme [34, 35].
Data analyses
Data were analyzed for this randomized controlled trial using descriptive statistics and
with a 3×2 mixed model analysis of variance (ANOVA) with the treatment groups (2
experimental vs. control) used as the between subjects factor and time of assessment
(pretreatment, post treatment) used as the within subjects factor. The software used for
statistical analysis was the SPSS version 20. The P-value was set at 0.05. The dependent
variables were pain level, Knee flexion ROM and functional disability of the knee joint.
Before data analysis, Shapiro–Wilk test was used to test the normality of the data and
Levene’s test was used to test the equality of variances. The differences in demographic
characteristics for both groups were assessed using one way ANOVA test. A
preliminary power analysis with a power 80% determined a sample size of 30 subjects
in each group.
Results
Demographic data of the participant is presented in Table (1). No statistical differences
were found between groups in demographic data. All data of the dependent variables are
normally distributed as revealed by Shapiro– Wilk test and all data showed no
violations of the assumptions of equality of variance as revealed by Levene’s test. All
12
pretreatment dependent variables showed no significant difference between groups
(P>0.05).
Table (1): Demographic data of participates
Group A
Group B
Group C
F-value
P value
57±6.39
0.28
0.75
Age
(Years)
55.4± 6.34
55.2 ± 4.77
Weight (Kg)
81 ± 4.83
80.8 ± 7.37
83.6±6.55
0.6
0.55
Height (cm) 167.4 ± 6.43
166.9 ± 5.7
167.7±5.07
0.04
0.95
BMI (mmHg) 28.98± 2.23
29.1 ± 2.42
29.75±2.12
0.37
0.69
*SD: standard deviation, P: probability, S: significance, NS: non-significant.
Descriptive statistics of pain level, knee flexion ROM and functional disability are
demonstrated in Table (2) and figures (1), (2), (3). The 3×2 mixed-model ANOVA
analysis demonstrated significant reduction in pain level in the three groups as the main
effect of time was statistically significant (p=0.0001). But the experimental groups A
and B showed significant improvement than the control group post treatment as the
main effect of group was statistically significant where (p=0.01) and interaction
13
between time and group was also significant (p=0.0001) as presented in table (3). Post
hoc tests revealed no significant difference between group A and B and between group
B and C (p=0.42,0.25) respectively, while there was a significant difference between
group A and C (p=0.008) as presented in table 4.
Table 2. Pain level, knee flexion ROM and functional disability of the knee joint of the
3 groups pre and 4 weeks post treatment
Variables
Pain level (VAS)
Groups
Pre treatment
Experimental group A
8.47±0.81
4.13±0.95
Experimental group B
8.1±0.87
6.4±1.4
7.98±1.16
7.67±1.2
Control group C
Knee flexion ROM
Functional disability of
the knee (WOMAC)
Post treatment
Experimental group A
104.04±14.75
121.63±12.96
Experimental group B
104.63±8.48
112.2±7.38
Control group C
100.27±7.98
102.39±7.56
Experimental group A
71.6±13.51
26.7±9.93
Experimental group B
65.1±13.69
49±11.05
Control group C
65.2±8.06
59±8.04
Knee flexion ROM was significantly increased post treatment in all groups as the main
effect of time was statistically significant (p=0.0001). All groups showed significant
14
improvement in knee flexion ROM 4 weeks post treatment as the main effect of group
was statistically insignificant (p=0.51) and interaction between time and group was
significant (p=0.0001) as shown in table (3). Post hoc tests revealed no significant
difference between group A and B and between group B and C (p=0.59,0.27)
respectively, while there was a significant difference between group A and C (p=0.042)
as shown in table (4).
The functional disability of the knee joint (WOMAC) showed significant decrease in all
groups post treatment as the main effect of time was statistically significant (p=0.0001).
The experimental groups A and B showed significant improvement than the control
group post treatment as the main effect of group was statistically significant where
(p=0.27) and interaction between time and group was significant (p=0.0001) as shown
in table (3). Post hoc tests revealed no significant difference between group A and B and
between group B and C (p=0.2,0.51) respectively, while there was a significant
difference between group A and C (p=0.02) as shown in table (4).
Table 3. Results of 3x2 mixed model ANOVA
15
Source of variance
Pain level (VAS)
Between groups
F-value
P-value
5.365
0.01‫٭‬
(Main effect of group)
Within subjects
367.811 0.0001‫٭‬
(Main effect of time)
Interaction between time and group 100.08
Knee flexion ROM Between groups
3.331
0.0001‫٭‬
0.51
(Main effect of group)
Within subjects
140.178 0.0001‫٭‬
(Main effect of time)
Functional level
Interaction between time and group 34.793
0.0001‫٭‬
Between groups
0.27
4.138
(Main effect of group)
Within subjects
218.579 0.0001‫٭‬
(Main effect of time)
Interaction between time and group 58.692
Table 4. Multiple comparisons between groups (Post hoc tests)
16
0.0001‫٭‬
Source of variance
Pain level (VAS)
Knee flexion ROM
Functional disability
(WOMAC)
Mean
P-value
Mean
difference
P-value
difference
Mean
P-value
difference
Group A vs. group B
0.77
0.42
4.42
0.59
7.9
0.2
Group A vs. group C
1.5
0.008‫٭‬
11.50
0.042‫٭‬
12.9
0.02‫٭‬
Group B vs. group C
0.75
0.25
7.08
0.27
5.05
0.51
Discussion
The present work is the first study to compare the efficacy of GS, CS and MSM
phonophoresis versus topical application on pain level, ROM, functional disability of
the knee joint in patients with knee OA. The current study primary end point was the
functional impact of treatment based on a validated instrument such as VAS, modified
electrogoniometer, and WOMAC scale. Significant improvements in pain level, knee
ROM were attained with phonophoresis, topical application, and traditional exercise.
The degree of improvement was different in the three groups; phonophoresis was
superior to topical application and traditional exercise that may be due to the deeper
penetration of the GS, CS and MSM by the action of the ultrasound in addition to the
primary ultrasound effect (double action).
17
Therapeutic ultrasound is frequently used in physiotherapy clinics to treat various
musculoskeletal disorders [36]. Phonophoresis is the use of US with specific medication
to encourage transdermal penetration of the compound. Significant amounts of drug are
picked up by the subcutaneous circulation with phonophoresis. Both the thermal and
non-thermal characteristics of high frequency sound waves can enhance the diffusion of
topically applied drugs. Heating from US increases the kinetic energy of the molecules
in the drug and in the cell membrane, dilates points of entry such as the hair follicles
and the sweat glands, and increases the circulation to the area treated with US. These
physiological changes enhance the opportunity for drug molecules to diffuse through
the stratum corneum and be collected by the capillary network in the dermis. Both the
thermal and non-thermal effects of US increase cell permeability. The mechanical
characteristics of the sound wave also enhance drug diffusion by oscillating the cells at
high speed, changing the resting potential of the cell membrane and potentially
disrupting the cell membrane of some of the cells in the area [37].
Topically applied drugs can induce local and systemic effects that can be distinguished
by examining local tissue drug concentrations (under the site of application) and blood
or urine level. Topically applied drugs with particularly systemic effects diffuse through
the epidermis to the dermis to reach the capillary network. Drugs with local targets
diffuse into the area immediately below the administration site, such as subcutaneous
tissue, muscle, synovium, ligaments, tendons, and joints [38].
18
The current study results come in line with the work of Cagnie et al. who examined the
influence of ultrasound on the transdermal delivery of ketoprofen in humans and to
compare the concentrations found after continuous and pulsed application. The results
indicate that, in contrast to sham phonopheresis, ultrasound can increase the transdermal
delivery of ketoprofen [24].
The findings of this study come also in agreement with the work of Koeke et al who
compared the treatment efficacy of topical application of hydrocortisone and
phonophoresis with hydrocortisone on the rat's Achilles tendon repair process after
tenotomy. Their results showed that the treated group with the topical application of
hydrocortisone has not been delivered transdermally and that the molecule of collagen
responds to the ultrasonic stimulation. The treatment with phonophoresis was the more
efficient method. They concluded that the US stimulates the acceleration of tissue repair
processes and induces the transdermal delivery of hydrocortisone in a therapeutic
concentration on the tendon [39].
Also they are consistent with case report study in which the effect of
Gluucosaminoglycan
phonophoresis
was
investigated
in
the
treatment
of
temporomandibular joint pain; it was reported to reduce pain significantly [40].
They also agree with Zjuzin et al who analysed 130 persons with osteoarthritis of knee
and compared efficiency of Deep Relief gel with phonophoresis and ultrasound with
standard gel. Deep Relief has significant better effect for less pain and better
19
improvement of functional capacity in comparison with ultrasound. There were
significant difference between the phonophoresis and ultrasound group [41].
In this study the pain level was detected using VAS. The validity and the reliability of
this scale in the assessment of the pain level have been demonstrated by Boonstra [42].
The range of motion was measured by the modified electrogoniometer, the validity and
the reliability of this instrument in the assessment of the range of motion have been
demonstrated by Elerian [43].The functional level was measured by the WOMAC
Functional assessment scale. The Reliability, validity and repeatability of this scale in
the assessment of the functional scale have been demonstrated by Salaffi et al. [44].
Within the limitations of this randomized controlled study, statistically significant
difference with varying degrees were detected in the therapeutic phonophoresis group,
topical application group and control group in the pain level (P = 0.0001) , range of
motion (P = 0.001)
and functional level (P = 0.0001), the highest percent of
improvement was in the phonophoresis group.
There was improvement in pain level in the three groups. Group A showed a higher
improvement more than group B and group B more than group C. The highest
improvement in group A may be attributed to the triple effect of higher penetration of
drugs included analgesic (MSM) and cartilage rebuilding enhancer (Gluucosamine
sulfate and chondrotin sulfate) enhanced by phonophoresis , the effect of US itself on
pain and the effect of exercise program. The higher improvement found in group B
20
more than in group C may be attributed to the double effect of drug that include
analgesic (MSM) and cartilage rebuilding enhancer (Gluucosamine sulfate and
chondrotin sulfate) and the effect of exercise program. The improvement found in group
C is attributed only to the effect of stretching and strengthing exercise program.
Pain improvement in Groups A and B may be attributed to the effects of MSM which is
a basic gradient of the gel used for the treatment that evoked a number of
pharmacological effects deep within the knee soft tissues, including analgesia, reducing
inflammation, and inhibition of prostaglandins production [45].
Pain improvement may be also attributed to the Glucosamine sulfate and Chondroitin
sulfate. They are the building blocks for proteoglycans and stimulate chondrocytes to
make new collagen and proteoglycans. Because these supplements stimulate the
production of new cartilage components that may be able to help the body repair
damaged cartilage [46]. On the other hand Glucosamine sulfate serves as a precursor
for, and inhibits the degradation of, proteoglycans (the ground substance of articular
cartilage); it rebuilds experimentally induced cartilaginous damage; and it has
chondroprotective and antiarthritic effects (Vidal, 2008), it has very mild antiinflammatory and antireactive effects on edema-provoking agents
including
carrageenan, dextran, acetic acid and formalin.
Also pain improvement in Group A by phonophoresis may be the attributed to
ultrasound that relieves pain, decreases muscle spasm and increase tissue extensibility
21
[47], it is mostly used in combination with stretching exercises to achieve optimal tissue
length. The non-thermal mechanical characteristics of ultrasound also can enhance drug
diffusion by oscillating the cells at high speed, changing the resting potential of the cell
membrane and potentially disrupting the cell membrane of some of the cells in the area
sonicated. There may be some pushing and pulling of the cells with the propagation of
the sound wave through the tissues, the effect of ultrasound on a biological system also
may be associated with cavitation that is the formation of small gaseous bubbles.
Cavitation may cause mechanical stress, temperature elevation, or enhanced chemical
reactivity, thus affecting drug transport. The US helps more and efficient absorption of
the gel which infiltrates the tissue to a higher depth than topical application [48].
Range of motion improvement in Group A, B might be due to the effects of the
introduced drugs that regenerate the cartilage and inhibit pain, this allowed easier
application of stretching and strengthening techniques. The increased ROM enables the
patients to maintain more active knees and reduce its immobilization. The accumulated
effect of stretching exercises through 12 sessions that tend to increase knee capsule
extensibility and increase joint range of motion in addition to its sedative effect [49].
For Group C (the traditional exercise group) the significant difference after treatment
might be due to the influence of stretching exercise which leads to increase muscle
flexibility so minimize shortening of muscle and capsule and decrease pain and increase
range of motion which maintained by strengthening exercise leading to more practice
22
and activities that patient can do through daily living activities so improve functional
performance.
Range of motion improvement might be due to the effects of the introduced materials
that inhibit pain; this allowed the application of stretching techniques and the
therapeutic exercises program. In addition to that the increased ability of the patients to
maintain their daily living activities and to maintain their home care program, enable
them to maintain more active knees and avoid its immobilization. The accumulated
effect of stretching exercises through 12 sessions that tend to increase knee capsule
extensibility and increase joint range of motion in addition to its sedative effect. Pain
level improvement was due to the effects of MSM gel that evoked a number of
pharmacological effects deep within the knee soft tissues, including analgesia, reducing
inflammation [17]. The effect of therapeutic ultrasound on ROM would be caused by a
combination of the changes in SP threshold and tissue extensibility. One of these
changes in the SP threshold and tissue extensibility is due to the thermal effect of
ultrasound [50].
This come in line with a double-blind, placebo controlled study; used indomethacin
phonophoresis in the treatment of temporomandibular joint pain in 20 patients, and
significant pain relief was reported [51]. Similarly, the efficacy of trolamine salicylate
phonophoresis and ultrasound therapy was evaluated on delayed onset muscle soreness.
23
The investigators found that ultrasound enhanced the development of delayed onset
muscle soreness but this effect was prevented by the application of salicylate
phonophoresis [52].
Conclusions
Within the limitation of this study; the use of ultrasound phonophoresis or topical
application of Glucosamine sulfate, Chondroitin sulfate and Methylsulfonylmethane gel
are effective and safe modalities for the treatment of OA but ultrasound phonophoresis
may be better for drug transportation than topical application.
Acknowledgments
Authors of this paper are very thankful to our patients who have helped us in making
the present study possible.
Funding source
This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
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