Ultrasound in Med. & Biol., Vol. 35, No. 1, pp.

44 49, 2009
Copyright 2008 World Federation for Ultrasound in Medicine & Biology
Printed in the USA. All rights reserved
0301-5629/09/$see front matter

doi:10.1016/j.ultrasmedbio.2008.07.009

Original Contribution

A DOUBLE-BLIND TRIAL OF CLINICAL EFFECTS OF THERAPEUTIC

ULTRASOUND IN KNEE OSTEOARTHRITIS

LEVENT ZGNENEL, EBRU AYTEKIN, and GULIS DURMUSOGLU

Department of Physical Medicine & Rehabilitation, S.B. Istanbul Education and Research Hospital, Istanbul, Turkey

(Received 6 December 2007; revised 20 June 2008; in final form 24 July 2008)

AbstractA randomized double blind clinical trial was conducted to determine the effectiveness of ultrasound
(US) therapy in knee osteoarthritis (OA). Sixty-seven patients (mean age 54.8 7) were randomized to receive
either 1 MHz frequency or 1 watt/cm2 power continuous ultrasound for 5 min (n 34) or sham US (n 33) as
a placebo. Ten sessions of treatment were applied to the target knee of the patient. A blinded evaluation at
baseline and after treatment was made. Primary outcome was pain on movement assessed by visual analog scale
(VAS). Secondary outcomes consisted of the Western Ontario and McMaster Universities Osteoarthritis Index
(WOMAC) scores and 50 meters walking time. Both groups showed significant improvements in knee pain on
movement. In the treatment group, the improvement in VAS score was statistically and significantly higher (p <
0.001) and more pronounced than in the placebo group. Pain reduction averaged 47.76% in the treatment group
(p 0.013). Secondary outcomes improved in both groups but reached statistical significance only in the
treatment group: p 0.006 for the mean change in total WOMAC scores and p 0.041 for 50 meters walking
time. Results suggest that therapeutic US is safe and effective treatment modality in pain relief and improvement
of functions in patients with knee OA. (E-mail: levento26@yahoo.com) 2008 World Federation for Ultra-
sound in Medicine & Biology.

Key Words: Therapeutic ultrasound, Knee, Osteoarthritis.

INTRODUCTION content such as bone and connective tissue (Falconer et

The treatment of osteoarthritis (OA) is oriented primarily
to relieve the pain and preserve joint function and in-
cludes both pharmacologic and nonpharmacologic treat-
ment modalities. Therapeutic ultrasound (US) is one of
the nonpharmacological management options in patients
with OA of the knee.
Therapeutic US is a deep heating agent that con-
verts mechanical energy into form of sound waves. This
is accomplished by passing an electrical current through
a crystal. The electric current causes the crystal to ex-
pand and contract, transforming electrical energy into
mechanical energy in the form of sound waves piezo-
electric effect. The resulting mechanical sonic energy is
absorbed in the target tissue and converted once again
into thermal energy, which results in heating of the
deeper tissues (Hooper 1996). The temperature can be
elevated by as high as 5C in the joint structure at depths
of 8 cm and is absorbed by tissues with high protein
Address correspondence to: Levent zgnenel, Darssafaka ma-
hallesi, Maslak 89 Sitesi,C-2 blok Daire:16,34450 Maslak- Istinye,
Istanbul, Turkey. E-mail: levento26@yahoo.com
al. 1992). These thermal changes are translated into
myriad physiological effects, including augmentation of
blood flow, increased capillary permeability and tissue
metabolism, enhancement of fibrous tissue extensibility,
elevation of pain threshold and alteration of neuromus-
cular activity leading to muscle relaxation.
Heat is not the sole effect of ultrasound therapy on
tissues, however, and other nonthermal changes (chem-
ical, biologic, mechanic and acoustic streaming effects)
contribute to its analgesic effect. These nonthermal ef-
fects include increased rate of chemical activity; alter-
ation in permeability of cell membranes; expansion of
gas-filled bubbles and an increase in fluid flow. The
acoustic streaming effect accounts for unidirectional
movement in tissue that alters cell permeability and
stimulates cell activity (Hooper 1996).
Although therapeutic US has been widely used as a
thermal modality in pain relief and treatment of muscu-
loskeletal disorders, scientific data for the effectiveness
of therapeutic US is limited. Its physiological effects
seem effective in the treatment of knee OA (Downing
and Weinstein 1986). In this double-blind placebo con-

44
 Effects of therapeutic ultrasound in knee osteoarthritis L. ZGNENEL et al.
trolled randomized study, we assessed the effectiveness
of therapeutic US in knee OA.
PATIENTS AND METHODS
The study was conducted at the Department of
Physical Medicine and Rehabilitation of Istanbul Re-
search and Education Hospital from August 2005 to
January 2006. The study was approved by the local
ethics committee and informed consent was obtained
from patients.
The study participants were recruited from among
patients with newly diagnosed osteoarthritis of the knee.
Selection criteria were based on the clinical and radio-
logical criteria defined by the American College of
Rheumatology for knee osteoarthritis (Altman et al.
1986). Patients were included if they were between 45
and 65 y, they had knee pain and limitation on most days
of the past 6 months and had Kellgren-Lawrence (Kell-
gren and Lawrence 1957) scores II-III on radiological
evaluation (Ravaud et al. 1996). Patients were excluded
from study if they had any systemic illness or abnormal
laboratory test result, any contraindication for physical
therapy, any knee operation, lower limb arthroplasty or
had been on any physiotherapy program before or re-
ceived intra-articular knee injections or ultrasound ther-
apy in the preceding year. Prior analgesic use was not an
exclusion criterion.
All participants were initially screened over the
phone with regard to selection criteria and participants
who fulfilled criteria of study design were invited to join
the study. Patients were assessed by one of the three
authors by history and detailed physical examination. All
patients were initially questioned about age, sex, weight,
height, duration of knee pain and the target knee (the
more symptomatic or painful knee). In patients in whom
both knees were symptomatic, the more painful knee, or
when symptoms were similar bilaterally, the right knee
was chosen as the target knee. Patients were closely
questioned on past and present medication. Laboratory
analyses, including complete blood count, erythrocyte
sedimentation rate, C-reactive protein, rheumatoid fac-
tor, hepatic enzyme tests and renal function tests were
performed to rule out secondary causes of OA and other
diseases.
Primary outcome was knee pain on movement over
the past week assessed by visual analogue scale (VAS)
numbered in 1 cm intervals. Secondary outcomes were
Western Ontario and McMaster Universities Osteoarthri-
tis Index (WOMAC) scores and 50 meters walking time.
The time required to walk a distance 50 meters as fast
as possible measured with a stopwatch and recorded in
seconds.
45
Table 1. Demographic characteristics of patients
Characteristics Placebo Ultrasound
Age (y) 56.2 8.0 53.6 6.9
Height (m) 159.9 8.0 159.0 10.7
Weight (kg) 81.2 14.6 79.6 11.6
Sex Male 7 (21.2%) Male 6 (17.6%)
Female 26 (78.8%) Female 28 (82.4%)
Target knee Right 17 (51.5%) Right 18 (52.9%)
Left 16 (48.5%) Left 16 (47.1%)
Severity on X-ray Grade 2: 16 (48.5%) Grade 2: 15 (44.1%)
Grade 3: 17(51.6%) Grade 3: 19 (55.9%)
Age, height and weight parameters are represented as mean
standard deviation.
The WOMAC scores test pain, stiffness and phys-
ical functioning (Bellamy et al. 1988) and consist of 24
items: Five determine subjective global assessment of
pain, two assess joint stiffness and 17 assess physical
functioning. WOMAC scores were recorded on a Likert
scale of 0-4, where 0 no pain/limitation; 1 mild
pain/limitation; 2 moderate pain/ limitation; 3 se-
vere pain/ limitation and 4 very severe pain / limita-
tion.
Study design and assessment
Following baseline assessment, participants were
randomized to receive either therapeutic ultrasound or
placebo (sham ultrasound). An independent researcher
not involved in the data assessment randomized the sub-
jects.
Patients were not permitted to use any analgesics 10
days before and during physiotherapy program (wash-
out-period). The physiotherapy program was conducted
five times a week for 2 wk, excluding weekends for a
total of 10 sessions. Both the therapeutic US and the
sham US application were performed by the same ther-
apist and patients were assessed by three blinded re-
searchers before and at the end of therapy program.
Interventions
No physiotherapy was prescribed prior to ultra-
sound treatment to either of the groups. In the treatment
group, US was applied using an aqueous gel as a cou-
pling medium in circular movements with the probe at
right angles. The treatment area was 25 cm2 and ex-
tended to both patellofemoral and tibiofemoral borders
of the target knee on both the lateral and medial margins,
avoiding the patella. Continuous ultrasonic waves with 1
MHz frequency and 1 watt/cm2 power were applied with
a 4 cm diameter applicator (Petson .250 ultrasound
equipment, Petas, Turkey) for 5 min in each session. To
avoid the immediate effects of heat application, the out-
come data evaluation was performed 2 days after com-
pletion of the last session.
46 Ultrasound in Medicine and Biology Volume 35, Number 1, 2009

Table 2. Pre-treatment and post-treatment VAS
measurements in the placebo and treatment groups are given
as mean standard deviation
Placebo Treatment group
Pre-treatment VAS measurements 5.1 2.3 6.7 1.8
Post-treatment VAS measurements 4.0 2.6 3.9 2.0
p* 0.022 p* 0.001
Mean change from baseline 20.6% 45.9% 42.8% 23.1%
p 0.05 p 0.013
VAS visual analog scale.
* Significance level when pre-treatment and post-treatment mea-
surements are compared
In the placebo group, sham ultrasound (an applica-
tor disconnected from the back to working ultrasound
machine) was applied to the target knee in the same
manner described above, using the same acoustic gel, 5
min per session. Patients were not able to see whether the
cable was disconnected or not.
Statistical analysis
SPSS 10.0 for Windows package program was used
for statistical analysis. For nonparametric variables, i.e.,
WOMAC and VAS scores, Mann-Whitney U test was
employed to compare outcome scores among treatment
groups and Wilcoxon signed-rank test was used to com-
pare post-therapy scores to baseline. The improvement in
WOMAC scores was also assessed as percent change
from baseline and compared between treatment groups
using one-way analysis of variance. For parametric vari-
ables, i.e., knee ROM measurements, paired t-test was
employed to compare outcome scores among treatment
groups and to compare post-therapy scores to baseline. P
values 0.05 were considered significant. Mean change
in scores within groups and differences in change scores
between groups were calculated with 95% confidence
interval. The minimum number of subjects per group was
estimated to be 26 to attain an 80% probability of being
able to detect a treatment effect (alpha 0.05).
RESULTS
The number of patients enrolled into the treatment
group and the placebo group were 34 and 33, respec-
tively, which was sufficiently powered. The mean age of
the patients in the placebo group and the treatment group
were 56.2 8.0 y and 53.6 6.9 y, respectively. The
majority of patients were female in both groups (78.8%
in the placebo and 82.4% in the treatment groups). The
demographic data and baseline characteristics of the pa-
tients are summarized in Table 1.
Primary outcomes
Both groups showed reduced knee pain on move-
ment following intervention. The VAS measurements
improved significantly both in the placebo group and the
treatment group patients (p 0.0022 and p 0.001,
respectively). Pain reduction averaged 20.6% in the pla-
cebo group (p 0.05) and 42.8% in the treatment group
(p 0.013) (Table 2).
Secondary outcomes
WOMAC scores improved in all domains in the
treatment group at a significant level. Although an over-
all improvement was noticeable in all parameters in the
placebo-treated group, only the total WOMAC scores
and those for the physical function domain showed sta-
tistically significant changes (Table 3). Change in 50
meters walking time showed a statistically significant
improvement only in the treatment group (Table 4).
Adverse events
There were no adverse events during and after in-
terventions. In the placebo group, two patients used

Table 3. Pre-treatment and post-treatment WOMAC measurements in the placebo and treatment groups are given as
mean standard deviation
Placebo group Treatment group

WOMAC: Pain Pre-treatment 9.4 3.6 10.4 3.0

Post-treatment 8.4 4.2 p* 0.057 6.9 3.6 p* 0.001
Mean change 11.0% 36.9% p 0.05 35.1% 27.8% p 0.003
WOMAC: Physical function Pre-treatment 30.6 511.4 33.4 11.2
Post-treatment 27.1 14.0 p* 0.007 23.6 11.6 p* 0.001
Mean change 17.0% 31.1% p 0.05 28.9% 26.8% p 0.022
WOMAC: Stiffness Pre-treatment 3.3 2.3 3.4 1.6
Post-treatment 3.0 1.9 p* 0.297 2.9 1.5 p* 0.001
Mean change 15.5% 44.2% p 0.05 21.9% 39.4% p 0.536
WOMAC: Total Pre-treatment 43.2 16.1 47.8 14.4
Post-treatment 38.5 15.2 p* 0.007 33.3 15.5 p* 0.001
Mean change 14.8% 28.6% p 0.05 30.8% 24.7% p 0.006

WOMAC Western Ontario and McMaster Universities Osteoarthritis Index.

* Significance level when pre-treatment and post-treatment measurements are compared.
 Effects of therapeutic ultrasound in knee osteoarthritis L. ZGNENEL et al.
Table 4. Walking time measurements in the placebo and
treatment groups are given as mean standard deviation
Placebo Treatment
Pre-treatment 40.9 9.8s 40.9 13.5s
Post-treatment 36.4 7.6s 35.5 6.7 s
p* 0.809 p* 0.041
* Significance level when pre-treatment and post-treatment mea-
surements are compared.
analgesics because of increased pain and were thus
dropped out of the study.
DISCUSSION
In this report, we present the findings of a random-
ized double blind placebo controlled trial of US therapy
in knee OA. Both pain and joint function improved after
10 sessions of therapy spanning over 2 wk with either the
real US or the sham US. Patients receiving the actual US
treatment showed statistically significant improvement in
all pain measurements (VAS and WOMAC) and 50
meter walking time, whereas the patients enrolled in the
sham US group showed improvement only in some pain
scores (VAS) and function. Based on these results, we
conclude that US therapy has been superior over placebo
in the treatment of OA of the knee.
Analgesia induced by therapeutic US may be due to
both thermal and nonthermal mechanisms. The reduction
of soft tissue pain by US could result from increased
capillary permeability and tissue metabolism, enhance-
ment of fibrous tissue extensibility and elevation of pain
threshold by thermal mechanism. However, nonthermal
mechanisms may act in pain relief by stimulating tissue
regeneration, changing cell membrane permeability and
increasing intracellular calcium in the nervous system
(Baker et al. 2001). It is hypothesized that therapeutic US
may block pain transmission in nociceptive fibers.
Mardiman and Wessel (1995) applied 5 min of continu-
ous 1.1 MHz ultrasound at 1 W/cm2 on the dorsal aspect
of one forearm and sham US to the other arm as a control
group in healthy subjects. They measured pain threshold
with a dolorimeter on treated and untreated areas before
and after interventions and concluded that US could raise
the pain threshold.
US application may also decrease pain by modulat-
ing nociceptive neurons. Nitric oxide, a transmitter of
nociception in the spinal cord, is produced in the nitric
oxide synthase-like neurons, which can be induced with
peripheral inflammation. In rats with peripheral inflam-
matory arthritis, US treatment significantly suppressed
nitric oxide synthase-like neurons in spinal cord (Hsieh
2005).
47
The improvement in stiffness and ROM of knee and
walking time may depend on the healing and thermal
effects of US on periarticular structures of knee joint.
Deep heating with US can produce a temporary increase
in the extensibility of highly collagenous structures such
as tendons, ligaments and joint capsule. Besides its ther-
mal effects, nonthermal effects of US can modulate cell
diffusion, fibroblast production, collagen synthesis, alter
extracellular matrix arrangement, break down adhesion
and accelerate healing (Ng et al. 2003). Enwemeka
(1989) showed that daily application of 1 MHz therapeu-
tic ultrasound at intensity of 1W/cm2 for 5 min in the
continuous mode for 10 d augments the tensile strength
and energy absorption capacity of rabbit Achilles ten-
dons. He reported that therapeutic US may have bio-
chemical effects on healing tendon. Daily application of
1 MHz therapeutic US either at 1W/cm2 or 2W/cm2 to
hemitransected Achilles tendons of rats accelerates the
healing process of the ruptured tendon (Ng et al. 2003).
In a recent study, Kozanoglu et al. (2003) reported
comparing the effectiveness of ibuprofen phonophoresis
with conventional US therapy in knee OA. Continuous
ultrasonic waves of 1 MHz frequency and 1 Watt/cm2
power applied for 5 min to target knee for 10 sessions.
Pain scores, knee ROM degrees, walking time and
WOMAC scores improved significantly in both groups.
The method and results of this study are similar and
consistent with our study. In a study by Huang et al.
(2005), US treatment (1 MHz, 1.5 W/cm2 for 5 min)
increased the effectiveness of isokinetic exercise for
functional improvement for knee OA. In this study, pa-
tients had better compliance than those in the group with
only exercise therapy, which supports analgesic effect of
US.
Despite the popularity of US therapy in the treat-
ment of musculoskeletal disorders, its clinical efficacy is
controversial. In a review of 35 randomized controlled
trials of therapeutic US published between 1975 and
1999 (Robertson and Baker 2001), only 10 studies were
judged to have acceptable methods, and of these, in only
two (Ebenbicher et al. 1998, 1999) US proved to be more
effective than placebo in treating clinical musculoskele-
tal problems. Similarly two meta-analyses (Gam and
Johannsen 1995; van der Windt et al. 1999) have con-
cluded that there is poor evidence to support the use of
therapeutic US in the treatment of musculoskeletal dis-
orders. A recent Cochrane (Welch et al. 2001) review
about therapeutic US for knee OA found no benefit over
placebo for patients with knee OA for pain relief, range
of motion or functional status. Briefly, all reviewers
reported finding little evidence that therapeutic US was
more effective than placebo in treating people with pain
or a range of musculoskeletal injuries or in promoting
soft tissue healing.
48 Ultrasound in Medicine and Biology
A study judged to have acceptable methodological
quality according to the above-mentioned Cochrane re-
view (Falconer et al. 1992), tested the efficacy of thera-
peutic US followed by exercise treatment when con-
trolled with placebo. US therapy did not demonstrate any
superiority over placebo in this report; however, patients
in this study had chronic knee contracture and eight
patients had total knee replacement. In our study, our
patients had no knee contracture and the patients with
any knee operation were excluded from the study. The
patients in Falconers study were older than our subjects
(mean age 67.5 y versus 54.8 y, respectively). This
suggests that a subset of patients with knee OA free of
contractures may respond better to US treatment. In
Falconers study, knees were sonated for 3 min and
intensity of the US was not constant. Additionally, in our
study, continuous ultrasonic waves with constant fre-
quency (1 MHz) and intensity (1 W/cm2) were applied
for 5 min.
We observed improvement in pain and function in
placebo group. The mechanism of the placebo effect is
not quite clear, although there is evidence that placebo
induced analgesia is mediated by the release of endoge-
nous opioid peptides (Levine et al. 1978). A placebo
response is strongly associated with attention to patient,
concern by the doctor and the strength of doctor-patient
relationship. The trip to the hospital to receive treatment
may in itself be considered an exercise activity and may
have contributed to the improvement seen in both
groups. With intense monitoring during a study patients
may expect greater treatment effects. There are studies
about knee OA with high improvements with placebo,
ranging from 16% to 40% (Bennell et al. 2005). The
average pain reduction was 20% in the placebo group of
our study.
Limitations
Lack of a pure control group that did not receive
any treatment at all may be considered a limitation of this
study; however, double-blind placebo-controlled ran-
domization design renders it unfeasible to allocate a
group of subjects into a nonintervention group. What is
more, for most patients presenting with knee OA, non-
intervention may be an unacceptable option and may
lead to drop-outs. A nonintervention group may not even
be necessary as double-blind randomization minimizes
bias and statistical analysis attempts to ascertain to what
degree the changes seen in study samples could be as-
cribed to random change alone.
The fact that both treatment and placebo groups
showed improvement casts doubt on the clinical signif-
icance of the statistical significance of our results. In
small study samples (n 100) investigating pain relief,
the placebo effect may be responsible up to 50% of the
Volume 35, Number 1, 2009
response to treatment (McQuay and Moore 2005). In
larger samples, this effect dwindles. Therefore, this prob-
lem should be addressed in future studies by increasing
the sample size.
Because of a lack of an objective tool to assess
musculoskeletal pain and function, the scientific commu-
nity depends on subjective assessment tools (WOMAC
and VAS scores) that we employed in our study. The
validity of these scoring systems have been well estab-
lished (Whitehouse et al. 2008; Wassell et al. 2008) and
the results are reproducible. The Likert scales that we
have used to quantify WOMAC indices can be biased,
however, as the respondents may avoid using extreme
scores.
Long-term effectiveness of US should also be as-
sessed in a continuing study. Other dosages and appli-
cation forms of therapeutic US also need to be investi-
gated.
In conclusion, we suggest that therapeutic US is a
safe and effective treatment modality in pain relief and
improvement of function in patients with knee OA.
REFERENCES
Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, Christy
W, Cooke TD, Greenwald R, Hochberg M. Development of criteria
for the classification and reporting of osteoarthritis. Classification
of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria
Committee of the American Rheumatism Association. Arthritis
Rheum 1986;29:1039 1049.
Baker KG,Robertson VJ, Duck FA. A review of therapeutic ultrasound:
Biophysical effects. Phys Ther 2001;81:13511358.
Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW.
Validation study of WOMAC: A health status instrument for mea-
suring clinically important patient relevant outcomes to antirheu-
matic drug therapy in patients with osteoarthritis of the hip or knee.
J Rheumatol 1988;15:18331840.
Bennell KL, Hinman RS, Metcalf BR, Buchbinder R, McConnell J,
McColl G, Green S, Crossley KM. Efficacy of physiotherapy man-
agement of knee joint osteoarthritis: A randomised, double blind,
placebo controlled trial. Ann Rheum Dis 2005;64:906 912.
Downing DS, Weinstein A. Ultrasound therapy of subacromial bursitis:
A double trial. Phys Ther 1986;66:194 199.
Ebenbichler GR, Erdogmus CB, Resch KL, Funovics MA, Kainberger
F, Barisani G, Aringer M, Nicolakis P, Wiesinger GF, Baghestanian
M, Preisinger E, Fialka-Moser V. Ultrasound therapy for calcific
tendinitis of the shoulder. N Engl J Med 1999;340:1533.
Ebenbichler GR, Resch KL, Nicolakis P, Wiesinger GF, Uhl F, Gha-
nem AH, Fialka V. Ultrasound treatment for treating the carpal
tunnel syndrome: Randomised sham controlled trial. BMJ 1998;
316:731735.
Enwemeka CS. The effects of therapeutic ultrasound on tendon heal-
ing: A biomechanical study. Am J phys Med Rehabil 1989;68.283
287.
Falconer J, Hayes KW, Chang RW. Effect of ultrasound on mobility in
osteoarthritis of the knee. A randomised clinical trial. Arthritis Care
Res 1992;5:29 35.
Gam AN, Johannsen F. Ultrasound therapy in musculoskeletal disor-
ders: A meta-analysis. Pain 1995;63:8591.
Hooper PD. Physical modalities. A primer for chiropractic students. In
Hooper PD, eds. Deep Heating Modalities. 1st edition. Baltimore,
USA: William & Wilkins, 1996:85 86.
 Effects of therapeutic ultrasound in knee osteoarthritis L. ZGNENEL et al.
Hsieh YL.Reduction in induced pain by ultrasound may be caused by
altered expression of spinal neuronal nitric oxide synthase-produc-
ing neurons. Arch Phys Med Rehabil 2005;86:13111317.
Huang MH,Lin YS, Lee CL, Yang RC. Use of ultrasound to increase
effectiveness of isokinetic exercise for knee osteoarthritis. Arch
Phys Med Rehabil 2005;86:15451551.
Kozanoglu E, Basaran S, Guzel R, Guler-Uysal F. Short term efficacy
of ibuprofen phonophoresis versus continuous ultrasound therapy
in knee osteoarthritis. Swiss Med Wkly 2003;133:333338.
Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis.
Ann Rheum Dis 1957;16:494 502.
Levine JD, Gordon NC, Fields HL. The mechanism of placebo anal-
gesia. Lancet 1978;2:654 657.
Mardiman S, Wessel J,Fisher B. The effect of ultrasound on the
mechanical pain threshold of healthy subjects. Physiotherapy 1995;
81:718 723.
McQuay HJ, Moore RA. Placebo. Postgrad Med J 2005;81:155160.
Ng CO, Ng GY, See EK, Leung MC. Therapeutic ultrasound improves
strength of Achilles tendon repair in rats. Ultrasound Med Biol
2003;29:15011506.
49
Ravaud P, Auleley GR, Giraudeau B, Royant V, Amor B, Genant HK,
Dougados M. Assessment of joint space width in patients with
osteoarthritis of the knee: A comparison of four measuring instru-
ments. J Rheumatol 1996;23:1749 1755.
Robertson VJ, Baker KG. A review of therapeutic ultrasound: Effec-
tiveness studies. Phys Ther 2001;81:1339 1350.
Van der Windt D, van der Heijden GJ, van den Berg SG, ter Riet G, de
Winter AF, Bouter LM. Ultrasound for musculoskeletal disorders:
A systematic review. Pain 1999;81:257271.
Wassell RW, Moufti MA, Meechan JG, Steen IN, Steele JG. A method
for clinically defining improvers in chronic pain studies. J Orofac
Pain 2008;22:30 40.
Welch V, Brosseau L, Peterson J, Shea B, Tugwell P, Wells G.
Therapeutic ultrasound for osteoarthritis of the knee. Cochrane
Database Syst Rev 2001;(3)CD003132.
Whitehouse SL, Crawford RW, Learmonth ID. Validation for the
reduced Western Ontario and McMaster Universities Osteoar-
thritis Index function scale. J Orthop Surg (Hong Kong). 2008;
16:50 53.