The effects of various physical modalities on pain in patients with knee osteoarthritis: A network meta-analysis

Xin Zhou; Yating Yu; Jinwei Guo; Liezhen Cao; Xiaohua Zhang; Zhongliang Deng

doi:10.1016/j.jor.2025.03.045

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63 (); 171-180

doi:

10.1016/j.jor.2025.03.045

The effects of various physical modalities on pain in patients with knee osteoarthritis: A network meta-analysis

Xin Zhou^a,b, Yating Yu^b, Jinwei Guo^b, Liezhen Cao^b, Xiaohua Zhang^b, Zhongliang Deng^a,

a Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, PR China

b Department of Orthopedic Surgery, Chongqing University Jiangjin Hospital, Centre Hospital of Jiangjin District, Chongqing, 402260, PR China

⁎Corresponding author: Zhongliang Deng. zhongliang_deng@yeah.net

Received: 2024-11-16, Accepted: 2025-3-23, Published: 2025-4-3

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

This study aims to evaluate the effectiveness of various physical therapy methods in reducing pain for patients with knee osteoarthritis (KOA) through a network meta-analysis.

We conducted a comprehensive search across multiple databases, including PubMed, Embase, Cochrane Library, VIP, WanFang Data, and CNKI, to identify randomized controlled trials (RCTs) on physical therapies for KOA. The search spanned from the inception of each database to October 2024. The methodological quality of the studies was assessed using the Cochrane Handbook. Pain was measured using tools such as the visual analog scale, numeric pain rating scale, and the Western Ontario and McMaster University Osteoarthritis Index. All pain scores were standardized to a 10-point scale. Data collection and analysis were performed independently by two researchers using Stata 15.0 software.

The analysis included 64 studies with 3855 patients and 12 physical therapy modalities. Based on the surface under the cumulative ranking curve (SUCRA), the most effective treatments were HILT, ESWT, Hydrotherapy, Land-EX, LLLT, Braces, tDCS, US, IFCs, SWD, Insoles, and TENS.

HILT appears to be the most effective treatment for pain relief in KOA patients. Further large-scale RCTs are needed to confirm these findings.

Keywords

Osteoarthritis

Knee

Physical therapy

Systematic review

Pain

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1 Materials and methods

1.1

1.1 Literature search

We conducted a comprehensive search across multiple databases, including Wanfang, CNKI, Vip, PubMed, Google Scholar, Embase, Cochrane Library, and Scopus, to identify randomized controlled trials (RCTs) examining various physical therapies for pain management in KOA patients. The search period spanned from the inception of each database to September 2024. Our search strategy incorporated a mix of subject headings and free-text terms, such as “knee,” “osteoarthritis,” “low-level laser therapy,” “high-intensity laser therapy,” “transcutaneous electrical nerve stimulation,” “shortwave diathermy,” “interferential current,” “exercise,” “ultrasound,” “transcranial direct current stimulation,” “hydrotherapy,” “extracorporeal shockwave therapy,” “brace,” and “insole.” Additionally, we manually examined the reference lists of relevant articles that met our inclusion criteria.

1.2

1.2 Eligibility criteria

Inclusion in this network meta-analysis was restricted to studies that met all the following criteria: (1) Randomized controlled trials (RCTs) evaluating physical therapy interventions for knee osteoarthritis; (2) Patients diagnosed with knee osteoarthritis via imaging or clinical criteria, irrespective of nationality, age, disease duration, or sex; (3) Interventions involving standalone physical therapy modalities (e.g., laser therapy, exercise, ultrasound); (4) Outcome measures including pain scores (Visual Analog Scale [VAS], Numeric Pain Rating Scale [NPRS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) collected post-intervention with ≥2 weeks follow-up. Exclusion criteria comprised studies that (1) Involved joint cavity perfusion (e.g., hyaluronic acid injections), oral pharmacological agents (e.g., NSAIDs), surgical procedures (e.g., arthroplasty), or combination therapies (e.g., physical therapy + oral drugs); (2) Represented duplicate publications (i.e., overlapping datasets from the same research group) (3) Lacked critical data (e.g., baseline characteristics, post-intervention pain scores); without author clarification within two weeks; (4) Primarily evaluated non-physical therapy interventions.

1.3

1.3 Data extraction

Initially, two researchers screened the studies; any differences were settled by discussion; and a third independent researcher came to an agreement. In cases where key data were missing, efforts were made to obtain the necessary information from the corresponding author of the original study via email; however, literature for which data could not be extracted was subsequently excluded. Data collection was conducted by two researchers and subsequently cross-checked and summarized. The collected data encompassed: basic information, which included the following:basic duration and follow-up time; interventions that included different kinds of physical therapy; and outcome measures for patients with knee osteoarthritis that included the VAS pain score, WOMAC score, and NPRS pain score. All assessment criteria are scored on a 0-point Likert scale, with 0 denoting no pain and 10 denoting the most severe pain,in order to standardize the results.

1.4

1.4 Bias risk assessment

The potential for bias in the randomized controlled trials was evaluated using the Cochrane risk assessment tool, which examines factors like the generation of random sequences, the concealment of allocation, blinding of researchers and participants, outcome assessment, data integrity, reporting consistency, and other possible sources of bias.

1.5

1.5 Statistics

For this study, network meta-analysis was conducted via Stata 15.0 software.⁸^,⁹ The credibility of Stata software and network meta-analysis tools is crucial for performing network meta-analyses. The inconsistency of various physiotherapy treatments was evaluated via the inconsistency factor (IF), with a 95 % CI value of 0 indicating a good inconsistency factor in each study. Moreover, the Surface Under the Cumulative Ranking (SUCRA) was utilized to evaluate and contrast the efficacy of various physical treatments for pain management in individuals with knee osteoarthritis. The results were structured based on the prior assessment. The significance level for the analysis was established at α = 0.05.

2 Results

2.1

2.1 Study characteristics and quality assessment

A total of 2744 articles were initially identified. After removing 454 duplicates and reviewing titles and abstracts, an additional 2290 studies were excluded. Following a full-text review of the remaining 652 papers, 64 studies were ultimately included^[10–72. These studies encompassed 12 different physical therapy approaches and involved a total of 3855 patients. Fig. 1 illustrates the flowchart of the study selection process, while Table 1 provides a summary of the included studies. In Fig. 2, the straight lines in the evidence network depict direct comparisons between two related interventions, whereas unrelated interventions were compared indirectly through network meta-analysis. The methodological quality of the 64 RCTs was assessed using the Cochrane guidelines, as shown in Fig. 3.

Literature screening process and results.

Table 1 Basic characteristics of the included studies.

Study	Year	Country	Design	Age		Sample		Intervention		Follow-up(month)	Assessmentcriteria
Study	Year	Country	Design	Arm 1	Arm 2	Arm 1	Arm 2	Arm 1	Arm 2	Follow-up(month)	Assessmentcriteria
Ekici	2023	Turkey	RCT	61.1 ± 7.0	57.9 ± 7.0	30	30	HILT	Sham	3	VAS; WOMAC
Ahmad	2023	Malaysia	RCT	57.9 ± 10.6	51.2 ± 9.8	17	17	LLLT	HILT	3	NPRS
Martorella	2022	USA	RCT	65.3 ± 8.4	66.0 ± 8.4	60	60	tDCS	Sham	3	NPRS
Reichenbach	2022	Switzerland	RCT	64.8 ± 9.9	66.3 ± 10.3	108	112	TENS	Sham	3.75	VAS; WOMAC
Soheir	2022	Egypt	RCT	55.4 ± 6.3	55.2 ± 4.8	20	20	HILT	US	0.5	VAS
Mostafa	2022	Egypt	RCT	46.6 ± 8.7	40.1 ± 9.4	20	20	HILT	ESWT	1	VAS
Azizi	2021	Iran	RCT	61.3 ± 13.5	56.4 ± 11.7	27	27	tDCS	Sham	3	VAS
Tavares	2021	Brazil	RCT	74.8 ± 7.4	73.1 ± 8.5	51	53	tDCS	Sham	3	VAS
Khruakhorn	2021	Thailand	RCT	64.9 ± 7.4	57.9 ± 7.8	17	17	Hydrotherapy	Land-EX	4.5	WOMAC
Sajadi	2020	Iran	RCT	56.9 ± 5.8	59.3 ± 6.1	20	20	TENS	tDCS	3	VAS
Pietrosimone	2020	USA	RCT	60.8 ± 7.3	62.5 ± 7.7	18	19	TENS	Sham	1	WOMAC
Karakas	2020	Turkey	RCT	59.1 ± 7.5	60.8 ± 7.5	39	36	US	Sham	3	VAS; WOMAC
Lizis	2020	Poland	RCT	61.0 ± 7.8	59.0 ± 9.0	30	30	ESWT	Land-EX	1.25	VAS; WOMAC
Mahler	2019	Holland	RCT	62.0 ± 9.0	68.0 ± 8.8	27	28	LLLT	Sham	3	WOMAC
Maria	2019	Brazil	RCT	63.9 ± 7.1	64.1 ± 9.8	15	15	tDCS	Sham	3	VAS
Zhong	2019	China	RCT	62.5 ± 8.2	63.2 ± 7.7	32	31	ESWT	Sham	3	VAS; WOMAC
Roberta	2019	Brazil	RCT	58.2 ± 8.0	58.6 ± 7.4	15	15	LLLT	Land-EX	2	VAS; WOMAC
Nazari	2019	Iran	RCT	61.5 ± 3.9	62.2 ± 3.9	30	30	HILT	Land-EX	3	VAS; WOMAC
Thoumie	2018	France	RCT	64.8 ± 11.7	66.6 ± 7.2	32	35	Braces	Sham	1.5	VAS
Nazari	2018	Iran	RCT	61.5 ± 3.5	62.2 ± 3.87	30	30	HILT	Land-EX	3	VAS; WOMAC
Lizis	2018	Poland	RCT	59.8 ± 3.9	60.7 ± 4.8	30	30	ESWT	US	1.25	VAS; WOMAC
Patrícia	2018	Brazil	RCT	/	/	20	20	LLLT	Sham	6	VAS; WOMAC
Chang	2017	Australia	RCT	59.8 ± 9.1	64.1 ± 1.1	15	15	tDCS	Sham	2	VAS
Tugba	2017	Turkey	RCT	/	/	30	30	US	Sham	1	VAS; WOMAC
Dias	2017	Brazil	RCT	70.8 ± 5.0	71.0 ± 5.2	37	36	Hydrotherapy	Sham	3	VAS
Nambi	2016	Saudi Arabia	RCT	58.0 ± 6.0	60.0 ± 8.0	17	17	LLLT	Sham	2	VAS
Lewinson	2016	Canada	RCT	59.9 ± 7.4	59.6 ± 7.7	9	19	Insoles	Sham	3	VAS
Cherian	2016	USA	RCT	6	58	33	37	TENS	Sham	3	VAS
Jia	2016	China	RCT	63.4 ± 9.7	61.3 ± 10.3	53	53	US	Sham	3	VAS
Anna	2016	Bulgaria	RCT	65.1 ± 1.4	64.7 ± 2.0	37	35	HILT	Sham	3	VAS
Shirley	2015	Australia	RCT	67.7 ± 9.2	67 ± 10.6	86	68	Braces	Sham	3	VAS
Grace	2015	USA	RCT	57.7 ± 11.8	57.0 ± 10.9	25	25	TENS	Sham	2	VAS
Callaghan	2015	England	RCT	54.5 ± 6.7	56.4 ± 8.1	63	63	Braces	Sham	1.5	VAS
Yildiz	2015	Turkey	RCT	54.6 ± 6.5	57.8 ± 7.2	30	30	US	Sham	2	VAS
Kheshie	2014	Saudi Arabia	RCT	52.1 ± 6.4	56.6 ± 7.9	17	17	HILT	LLLT	1.5	VAS; WOMAC
Fukuda	2011	Brazil	RCT	62.0 ± 8.0	57.0 ± 9.0	30	21	SWD	Sham	3	VAS
Anwer	2014	Saudi Arabia	RCT	54.9	56	21	21	Land-EX	Sham	1.25	VAS; WOMAC
Rashoud	2014	England	RCT	52.0 ± 9.0	56.0 ± 11.0	26	23	LLLT	Sham	6	VAS
Cakir	2014	Turkey	RCT	58.2 ± 9.9	57.1 ± 7.8	20	20	US	Sham	6	VAS; WOMAC
Palmer	2013	England	RCT	61.2 ± 11.4	60.9 ± 10.8	73	74	TENS	Sham	6	WOMAC
Jones	2013	England	RCT	66.3 ± 8.2	/	28	28	Braces	Insoles	0.5	VAS; WOMAC
Alghadir	2013	Saudi Arabia	RCT	55.2 ± 8.1	57.0 ± 7.8	20	20	LLLT	Sham	1	VAS; WOMAC
Mascarin	2012	Brazil	RCT	64.8 ± 7.0	62.8 ± 7.6	12	12	TENS	US	3	VAS; WOMAC
Funda	2012	Turkey	RCT	61.9 ± 6.9	62.0 ± 7.9	37	31	TENS	IFC	3	VAS; WOMAC
Bruce-Brand	2012	Ireland	RCT	63.4 ± 5.9	65.2 ± 3.1	10	6	Land-EX	Sham	1.5	WOMAC
Adalberto	2012	Canada	RCT	62.6 ± 9.5	61.2 ± 11.5	13	13	US	Sham	2	WOMAC
Stephen	2011	Columbia	RCT	66.9 ± 4.9	65.9 ± 8.3	12	10	Land-EX	Sham	3	WOMAC
Müller-Rath	2011	Germany	RCT	49.8	57.4	13	10	Braces	Sham	1	VAS; WOMAC
Foroughi	2011	Australia	RCT	65	66	28	26	Land-EX	Sham	6	WOMAC
Bennell	2011	Australia	RCT	63.3 ± 8.1	65 ± 7.9	103	97	Insoles	Sham	12	VAS; WOMAC
Fukuda	2010	Brazil	RCT	63.0 ± 9.0	63.0 ± 8.0	25	22	LLLT	Sham	6	VNPS
Van Raaij	2010	Holland	RCT	54.9 ± 7.4	54.4 ± 7.0	46	45	Braces	Insoles	1.5	VAS
Salli	2010	Turkey	RCT	55.7 ± 8.2	57.1 ± 6.8	23	24	Land-EX	Sham	5	VAS; WOMAC
Akyol	2010	Turkey	RCT	57.8 ± 10.7	56.6 ± 8.1	20	20	SWD	Sham	1	VAS; WOMAC
Lim	2009	China	RCT	63.7 ± 8.2	61.6 ± 7.2	36	36	Land-EX	Sham	2	WOMAC
Barrios	2009	USA	RCT	62.0 ± 7.4	62.8 ± 9.6	35	31	Insoles	Sham	12	VAS; WOMAC
Priscilla	2008	Brazil	RCT	61.6 ± 11.4	61.9 ± 11.3	16	14	Insoles	Sham	8	VAS; WOMAC
Itoh	2008	Japan	RCT	62–83	62–83	6	6	TENS	Sham	2.5	VAS; WOMAC
Silva	2008	Brazil	RCT	59.0 ± 7.6	59.0 ± 6.1	32	32	Hydrotherapy	Land-EX	4.5	VAS
Yurtkuran	2007	Turkey	RCT	51.8 ± 6.8	53.5 ± 7.1	28	27	LLLT	Sham	3	VAS; WOMAC
Laufer	2005	Israel	RCT	72.7 + 6.4	74.8 + 6.6	32	38	SWD	Sham	3	WOMAC
Tascioglu	2004	Turkey	RCT	62.9 ± 7.3	64.3 ± 10.5	20	20	LLLT	Sham	6	WOMAC
Ali Gur	2003	Turkey	RCT	59.8 ± 8.0	60.5 ± 6.9	30	30	LLLT	Sham	3	VAS; WOMAC
Henrik	1998	Denmark	RCT	69.3 ± 8.2	73.0 ± 6.5	11	12	Land-EX	Sham	3	VAS

Network relationship diagram of the included studies.

Risk-of-bias analysis. (A) A summary of the risk of prejudice; the opinions expressed by the review writers about every risk associated with the topic of bias for each included study. (B) Present the authors' evaluations of each bias risk element as percentage values across all incorporated studies.

2.2

2.2 Inconsistency test

A total of 20 closed loops are involved in this study; that is, direct and indirect comparisons exist simultaneously. The consistency test results show that the IF ranges from 0 to 2.07. The 95 % CI lower limit of all the closed rings was 0, except for the two closed rings A and B, indicating good consistency between the results of the overall comparison and indirect comparison in this study, as shown in Fig. 4. Furthermore, all P values exceeded 0.05, demonstrating that the results of both direct and indirect comparisons across the different treatment methods were consistent.

Displays the assessment of inconsistency for both direct and indirect comparisons within the studies included in the network meta-analysis.

2.3

2.3 Meta-analysis results

The results of the network meta-analysis (NMA) are presented in Fig. 5. The effectiveness of the different treatment methods was ranked based on the SUCRA values. A higher SUCRA value reflects a better outcome score for the therapy, indicating greater treatment efficacy. According to the SUCRA rankings, the results revealed the following order of effectiveness: HILT > ESWT > hydrotherapy > land-EX > LLLT > braces > tDCS > US > IFCs > SWD > insoles > TENS (Fig. 6).

Illustrates the findings of the network meta-analysis.

Depicts the SUCRA probabilities for various surgical treatments, where SUCRA represents the surface under the cumulative ranking curve.

2.4

2.4 Publication bias

The funnel plot, generated using Stata 15.0 software, employs distinct colors to denote various surgical methods, with the number of data points corresponding to the number of trials. The outcome measures were symmetrically distributed along the vertical axis (X = 0), suggesting a low probability of publication bias and minimal small-sample effects (Fig. 7).

Comparison-adjusted funnel plot of multiple surgical treatments. A = Sham, B = LLLT, C = HILT, D = TENS, E = IFCs, F = SWD, G = Land-EX, H = US, I = Insoles, J = Braces, K = tDCS, L = ESWT, M = Hydrotherapy.

3 Discussion

KOA leads to discomfort and restricted mobility, and if it progresses, patients often enter a cycle of pain, inactivity, and weakness. A range of physical interventions are employed to alleviate discomfort and enhance functionality. This study represents the inaugural network meta-analysis examining twelve distinct physiotherapy approaches for KOA. The objective was to assess the efficacy of these therapeutic techniques.

Currently, there are no disease-modifying interventions specifically designed for KOA.⁷³ As a result, conservative approaches, including pharmacological treatments and rehabilitation exercises, are frequently combined with electrophysical agents to enhance therapeutic outcomes.⁷⁴ Among these agents are low-level laser therapy (LLLT), high-intensity laser therapy (HILT),⁷⁵ therapeutic ultrasound, and transcutaneous electrical nerve stimulation (TENS).⁷⁶ In recent years, photobiomodulation therapy, particularly LLLT and HILT, has gained prominence as a highly promising approach. Both methods have demonstrated the ability to alleviate pain and inflammation, promote tissue repair, enhance blood circulation, and improve physical function and overall performance.⁷⁷ This study revealed that HILT was superior to LLLT in reducing pain. Some scholars believe that HILT can rapidly reach peak amplitude and reduce heat accumulation during pulse intervals, thereby minimizing thermal damage and achieving effective tissue penetration with low risk.⁷⁸

Physical exercise is strongly recommended for individuals with KOA,⁷⁹^,⁸⁰ as it has been shown to reduce knee inflammation, albeit less effectively than NSAIDs and LLLT.⁸¹^,⁸² According to a rigorous methodological analysis by Bartholdy et al., strength training, as outlined by the American College of Sports Medicine (ACSM), proves more effective than other forms of exercise in improving leg extension strength for KOA patients.⁸³ The ACSM guidelines suggest engaging in strength training at least twice weekly, with each session comprising 2–4 sets of 8–12 repetitions.⁸⁴ Steinhilber et al. demonstrated that after 8 weeks of equal quadriceps exercise, muscle strength was significantly reduced, and knee pain was notably improved, indicating good safety and feasibility.⁸⁵ The study categorizes exercise therapy into land exercises and hydrotherapy, encompassing various forms of physical activity. Land exercises involve a range of concentric and eccentric movements performed in daily life, such as ascending and descending stairs, rising from a seated position, and sitting down. Additionally, they include simple isometric contractions of lower limb muscles and straight leg elevation exercises. Conversely, hydrotherapy refers to a systematic exercise regimen conducted in water. A systematic review by Anne-Kathrin indicated that a standardized exercise regimen can effectively alleviate pain and enhance knee function in patients with KOA inflammation.⁵⁸ In recent years, hydrotherapy has gained popularity as a treatment for knee osteoarthritis (OA) due to its distinctive properties, such as turbulence, viscosity, hydrostatic pressure, and buoyancy. These characteristics provide body support, decrease joint compression forces, and alleviate pain during exercise.⁸⁶

The International Osteoarthritis Society (OARSI), a globally influential professional organization in the field of KOA research, has recently published a series of clinical practice guidelines for the diagnosis and treatment of KOA.⁸⁷ The 2019 update to these rules stressed the strong suggestion for land-based exercise, weight management and strength training. For individuals with knee osteoarthritis and no additional health issues, recommended non-pharmacological include Aquatic exercise, gait aids, cognitive behavioral therapy that incorporates physical activity, and self-management initiatives.⁸⁸ The gait aids utilized in this study were knee braces and insoles, as recommended by the Guidelines. Notably, land exercise, hydrotherapy and braces demonstrated relatively high efficacy in pain relief for patients with KOA in this study. Conversely, ultrasound therapy was discouraged, whereas TENS was strongly opposed according to the guidelines. These two therapies also ranked low in terms of pain relief effectiveness for KOA patients in this study. The overall findings of this study align with the recommendations outlined in the OARSI Guidelines and encompass a broader range of physical therapy interventions for pain management in patients with KOA. The results of the study offer important information about the future development of pertinent clinical research.

A notable limitation of this review is the substantial heterogeneity observed in the results of the assessed variables. Although the factors contributing to this high heterogeneity or inconsistency could not be determined, they may have arisen from significant variability in demographic and clinical characteristics among the samples. The age range was wide (49–74 years), and the patients included had symptom durations ranging from one month to one year. Differences in outcome measurement methods might also lead to greater heterogeneity. Considering that knee osteoarthritis patients exhibit considerable individualization, their overall physical condition and various comorbidities potentially influence their perception of pain efficacy.

In summary, all 12 physical modalities reduced the pain associated with KOA of the knee, with HILT being the most effective. However, to fully assess their influence on quality of life, functional results, and patient contentment when used in conjunction with other treatments, as well as their potential to reduce the necessity for total knee replacement, additional long-term follow-up research is essential.

Availability of data and materials

The figures and/or tables of this paper contain the data produced in the current study.

Authors' contributions

XZ and ZD composed the manuscript and created the visual aids. YY and LC participated in data collection and analysis. JG and YY finalized the manuscript's revision. LC and XZ confirmed the accuracy of the initial data. All authors examined and approved the final draft.

Data availability

Data is availability through request to corresponding author.

Ethics approval and consent to participate

Not applicable.

Clinical trial number

Not applicable.

Funding

This study was supported by the Chongqing Natural Science Foundation, China (Chongqing Science and Technology Bureau project) (Grant No. cstc2021jcyj-msxmX0904), and the Project Supported by Scientific and Technological Research Program of Chongqing Municipal Education Commission (Grant Nos. KJQN202300106 and KJQN202400109).

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[27] Nazari A., Moezy A., Nejati P., et al . Efficacy of high-intensity laser therapy in comparison with conventional physiotherapy and exercise therapy on pain and function of patients with knee osteoarthritis: a randomized controlled trial with 12-week follow up. Laser Med Sci. 2019;34(3):505-516.
[Google Scholar]

[28] Thoumie P., Marty M., Avouac B., et al . Effect of unloading brace treatment on pain and function in patients with symptomatic knee osteoarthritis: the ROTOR randomized clinical trial. Sci Rep. 2018;8(1)
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[29] Lizis P., Kobza W., Manko G., . Extracorporeal shockwave therapy vs. kinesiotherapy for osteoarthritis of the knee: a pilot randomized controlled trial. J Back Musculoskelet Rehabil. 2017;30(5):1121-1128.
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[30] Alfredo P.P., Bjordal J.M., Junior W.S., et al . Long-term results of a randomized, controlled, double-blind study of low-level laser therapy before exercises in knee osteoarthritis: laser and exercises in knee osteoarthritis. Clin Rehabil. 2018;32(2):173-178.
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[31] Chang W.J., Bennell K.L., Hodges P.W., et al . Addition of transcranial direct current stimulation to quadriceps strengthening exercise in knee osteoarthritis: a pilot randomised controlled trial. PLoS One. 2017;12(6)
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[32] Yeğin T., Altan L., Kasapoğlu Aksoy M., . The effect of therapeutic ultrasound on pain and physical function in patients with knee osteoarthritis. Ultrasound Med Biol. 2017;43(1):187-194.
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[33] Dias J.M., Cisneros L., Dias R., et al . Hydrotherapy improves pain and function in older women with knee osteoarthritis: a randomized controlled trial. Braz J Phys Ther. 2017;21(6):449-456.
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[34] S G.N., Kamal W., George J., et al . Radiological and biochemical effects (CTX-II, MMP-3, 8, and 13) of low-level laser therapy (LLLT) in chronic osteoarthritis in Al-Kharj, Saudi Arabia. Laser Med Sci. 2017;32(2):297-303.
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[35] Lewinson R.T., Vallerand I.A., Collins K.H., et al . Reduced knee adduction moments for management of knee osteoarthritis:: a three month phase I/II randomized controlled trial. Gait Posture. 2016;50:60-68.
[Google Scholar]

[36] Cherian J.J., Harrison P.E., Benjamin S.A., et al . Do the effects of transcutaneous electrical nerve stimulation on knee osteoarthritis pain and function last? J Knee Surg. 2016;29(6):497-501.
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[37] Jia L., Wang Y., Chen J., et al . Efficacy of focused low-intensity pulsed ultrasound therapy for the management of knee osteoarthritis: a randomized, double blind, placebo-controlled trial. Sci Rep. 2016;6
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[38] Angelova A., Ilieva E.M., . Effectiveness of high intensity laser therapy for reduction of pain in knee osteoarthritis. Pain Res Manag. 2016;2016
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[39] Yu S.P., Williams M., Eyles J.P., et al . Effectiveness of knee bracing in osteoarthritis: pragmatic trial in a multidisciplinary clinic. Int J Rheum Dis. 2016;19(3):279-286.
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[40] Vance C.G., Rakel B.A., Blodgett N.P., et al . Effects of transcutaneous electrical nerve stimulation on pain, pain sensitivity, and function in people with knee osteoarthritis: a randomized controlled trial. Phys Ther. 2012;92(7):898-910.
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[41] Callaghan M.J., Parkes M.J., Hutchinson C.E., et al . A randomised trial of a brace for patellofemoral osteoarthritis targeting knee pain and bone marrow lesions. Ann Rheum Dis. 2015;74(6):1164-1170.
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[42] Yildiz S.K., Özkan F.Ü., Aktaş I., et al . The effectiveness of ultrasound treatment for the management of knee osteoarthritis: a randomized, placebo-controlled, double-blind study. Turk J Med Sci. 2015;45(6):1187-1191.
[Google Scholar]

[43] Kheshie A.R., Alayat M.S., Ali M.M., . High-intensity versus low-level laser therapy in the treatment of patients with knee osteoarthritis: a randomized controlled trial. Laser Med Sci. 2014;29(4):1371-1376.
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[44] Fukuda T.Y., Alves da Cunha R., Fukuda V.O., et al . Pulsed shortwave treatment in women with knee osteoarthritis: a multicenter, randomized, placebo-controlled clinical trial. Phys Ther. 2011;91(7):1009-1017.
[Google Scholar]

[45] Anwer S., Alghadir A., . Effect of isometric quadriceps exercise on muscle strength, pain, and function in patients with knee osteoarthritis: a randomized controlled study. J Phys Ther Sci. 2014;26(5):745-748.
[Google Scholar]

[46] Al Rashoud A.S., Abboud R.J., Wang W., et al . Efficacy of low-level laser therapy applied at acupuncture points in knee osteoarthritis: a randomised double-blind comparative trial. Physiotherapy. 2014;100(3):242-248.
[Google Scholar]

[47] Cakir S., Hepguler S., Ozturk C., et al . Efficacy of therapeutic ultrasound for the management of knee osteoarthritis: a randomized, controlled, and double-blind study. Am J Phys Med Rehabil. 2014;93(5):405-412.
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[48] Palmer S., Domaille M., Cramp F., et al . Transcutaneous electrical nerve stimulation as an adjunct to education and exercise for knee osteoarthritis: a randomized controlled trial. Arthritis Care Res. 2014;66(3):387-394.
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[49] Jones R.K., Nester C.J., Richards J.D., et al . A comparison of the biomechanical effects of valgus knee braces and lateral wedged insoles in patients with knee osteoarthritis. Gait Posture. 2013;37(3):368-372.
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[50] Alghadir A., Omar M.T., Al-Askar A.B., et al . Effect of low-level laser therapy in patients with chronic knee osteoarthritis: a single-blinded randomized clinical study. Laser Med Sci. 2014;29(2):749-755.
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[51] Mascarin N.C., Vancini R.L., Andrade M.L., et al . Effects of kinesiotherapy, ultrasound and electrotherapy in management of bilateral knee osteoarthritis: prospective clinical trial. BMC Muscoskelet Disord. 2012;13:182.
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[52] Atamaz F.C., Durmaz B., Baydar M., et al . Comparison of the efficacy of transcutaneous electrical nerve stimulation, interferential currents, and shortwave diathermy in knee osteoarthritis: a double-blind, randomized, controlled, multicenter study. Arch Phys Med Rehabil. 2012;93(5):748-756.
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[53] Bruce-Brand R.A., Walls R.J., Ong J.C., et al . Effects of home-based resistance training and neuromuscular electrical stimulation in knee osteoarthritis: a randomized controlled trial. BMC Muscoskelet Disord. 2012;13:118.
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[54] Loyola-Sánchez A., Richardson J., Beattie K.A., et al . Effect of low-intensity pulsed ultrasound on the cartilage repair in people with mild to moderate knee osteoarthritis: a double-blinded, randomized, placebo-controlled pilot study. Arch Phys Med Rehabil. 2012;93(1):35-42.
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[55] Sayers S.P., Gibson K., Cook C.R., . Effect of high-speed power training on muscle performance, function, and pain in older adults with knee osteoarthritis: a pilot investigation. Arthritis Care Res. 2012;64(1):46-53.
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[56] Müller-Rath R., Cho H.Y., Siebert C.H., et al . [Clinical and gait analytical investigation of valgus knee bracing in therapy for medial degenerative joint disease of the knee] Z Orthop Unfall. 2011;149(2):160-165.
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The effects of various physical modalities on pain in patients with knee osteoarthritis: A network meta-analysis

Abstract