Influnce of Dense Disperse Current Via Electro acupuncture on Knee Osteoarthrosis

Transcription

1 Med. J. Cairo Univ., Vol. 82, No. 1, September: , Influnce of Dense Disperse Current Via Electro acupuncture on Knee Osteoarthrosis MOHAMMAD F. ALI, Ph.D. 1; AKRAM M. HELMY, Ph.D 2 ; SHEREEN H. ELWARDANY, M.Sc. 3 and NORAN A. ELBEHARY, Ph.D. 4 The Departments of Orthopedic Physical Therapy, Faculty of Physical Therapy, October 6 University 1, Physical Therapy, College of Medical Rehabilitation, Qassim University, Saudi Arabia 2, El Kasr El Ainy, Cairo University Hospitals 3 and Basic Science, Faculty of Physical Therapy, Cairo University 4 Abstract Background: Osteoarthrosis (OA) of the knee is a leading cause of impaired mobility. Patients with knee OA have pain and limitations in the functions that prevent them from engaging in their usual functional activities. Purpose: This study was conducted to investigate the effect of combined dense disperse current through electroacupuncture with therapeutic exercises on pain, range of motion, and functional limitation in patients with knee OA. Subjects: Forty patients with knee OA their age ranged years with mean of (42.13 ±3.66) and their BMI below 30kg/m2 with mean of (26.23±2.48) were randomly distributed into two equal groups. Material and Methods: Single use stainless steel needles and EA device were used. The experimental group (A) received combined dense disperse current through electroacupuncture with therapeutic exercises. The control group (B) received the same exercises only. Pain was measured by modified visual analog scale (VAS), knee ROM was measured by Myrin goniometer, and functional activity level was determined by the WOMAC scale before and after 12 sessions. Results: There was a significant difference between the two groups in post treatment measurement; the experimental group had significant decrease in pain intensity level and the limitation of functional performance than the control group and significant increase in knee ROM; active and passive flexion and extension than the control group. Conclusion: Combined dense disperse current through with therapeutic exercises proved to be beneficial in improving perceived knee pain, range of motion and decreasing the limitation of functional performance more than therapeutic exercises only in patients with knee OA. Key Words: Dense disperse current Therapeutic exercises Knee osteoarthrosis. Introduction OSTEOARTHROSIS (OA) with common name of osteoarthritis is the most common form of ar- Correspondence to: Dr. Mohammad F. Ali, The Department of Orthopedic Physical Therapy, Faculty of Physical Therapy, October 6 University thritis and is a major cause of limitation of activity especially in elderly patients [1]. Knee OA increases in prevalence with age and is more common in women than in men [2]. It is associated with symptoms of pain and physical disability that arising from pain and loss of functional activity which reduces the quality of life [1,3]. Treatment of knee OA is focused on symptoms with both pharmacologic and non pharmacologic management to control pain and reduce functional limitation [4,5]. Non pharmacologic therapy is the preferred first line of treatment, which includes patient education, social support, physical and occupational therapy [5,6]. It is the cornerstone of a multidisciplinary approach to the management of osteoarthrosis while complementary or alternative medicine is another successful approach [6-8]. Dense disperse current through electroacupuncture means stimulation of acupuncture points via dense disperse electrical current where fine needles are inserted into specific points in the skin [6,7,9, 10]. After series of acupuncture treatments, knee pain, joint swelling, and range of motion were changed in patients suffered from knee OA [8]. Some previous studies [6,8,9] have suggested that denseand-disperse (D-D) mode through electroacupuncture elicited a more potent analgesic effect as compared to fixed-frequency EA stimulation [10]. The time period in which disperse frequency (2Hz) was alternated with dense frequency (1 5Hz or 1 00Hz) was set at 2, 4, 6, 8 and 10 seconds, respectively; maximal analgesic effect was obtained at 6 sec. per cycle. The intensity was set at 1, 2 and 3mA, respectively; maximal analgesic effect was obtained at 3mA. The analgesic effect induced by D-D mode (2/15Hz or 2/100Hz) stimulation was significantly higher than that induced by fixed-frequency stimulation (2, 15 and 100Hz) [10,11]. In recent years, there have been 543

2 544 Influnce of Dense Disperse Current Via Electroacupuncture numerous studies demonstrated the effectiveness of exercises for individuals with knee OA [12-14]. There is platinum level evidence that therapeutic exercises have benefits in reducing knee pain and improved physical function for patients with knee OA [3,15]. Therapeutic exercise was recommended as part of any treatment regimen for osteoarthritis [13,15]. Because muscle weakness is associated with pain and physical dysfunction and influences the progression of the disease in patients with OA of the knee muscle strengthening is a key component in cases of OA [16,17]. Therapeutic exercises in the form of strengthening, stretching and functional exercises are effective for patients with knee OA to reduce pain, disability and improve physical function, strength, and walking speed [13,18]. No studies compared between the effect of combined dense disperse current through electroacupuncture with therapeutic exercises and therapeutic exercises only so the current study was conducted to investigate the effect of combined dense disperse current through electroacupuncture with therapeutic exercises on pain, range of motion, and functional limitation in patients with knee OA. Subjects and Methods This study was conducted in Orthopedic Physical Therapy Outpatient Clinic of Cairo University Hospitals to investigate the effects of EA in patients with knee OA on pain level during rest, range of during motion of the knee joint and functional activities level. Forty subjects (10 males and 30 females) with moderate OA of the knees were selected from the orthopedic physical therapy outpatient clinic of El Kasr El Ainy Hospital. All patients signed informed consents before participating in this study. Their age ranged between 38 and 50 years with mean of (42.13 ±3.66) and their BMI below 30kg/m 2 with mean of (26.23 ±2.48). In case of bilateral knee OA, the most painful one was chosen in this study. They were randomly assigned into two equal groups, experimental and control group. Each group consisted of 20 participants. Subjects in the experimental group received combined dense disperse current through electroacupuncture (EA) in addition to therapeutic exercises program in the form of strengthening exercises for the quadriceps muscle and stretching exercises of the hamstrings and the calf muscles. The program was applied 3 times per week for a period of four weeks. Subjects in the control group received the same exercise program of the experimental group three times per week for a period of four weeks. Patients with previous knee operations, recent knee injury, presence of meniscus tear and collateral ligament injury were excluded. Assessment procedures: Pain severity level of the knee was assessed by modified VAS. The scale consists of a 10cm straight line with defined end-points divided into 10 degrees from 0 to ten. Each cm represents one degree, on which the patients were asked to mark their experienced pain. (Modified VAS; 0 = No pain; 10 = Intolerable pain). The modified VAS was considered to have a high degree of validity and reliability [19]. Myrin goniometer (Fig. 1) was used to measure active and passive knee flexion and extension. This procedure was repeated 3 times for the tested leg and an average of all 3 measures was recorded. Myrin goniometer is valid and reliable [20,21]. The patient was in supine lying position. The untested leg was extended and the tested leg was in 90 degrees flexion hip and 90 degrees flexion knee. The patient was asked to flex his lower leg while the examiner fixing his thigh then the reading of active knee flexion was reported and 90 degrees were added to the goniometer reading to record the active knee flexion then the assessor pressed downward on the lower leg to measure passive knee flexion. Active knee extension ROM was measured from the previous position when the assessor asked the patient to extend his lower leg then the assessor pressed upward on the lower leg to measure passive knee extension [22]. Functional performance of the patients was assessed by Western Ontario and Mc- Master Universities index (WOMAC) functional assessment scale. The WOMAC scale was used to asses patients with knee OA using 24 parameters which describe the presence and severity of pain in different activities of daily living, stiffness and physical function. The WOMAC scale is valid and reliable [23-25]. Lower scores indicate better subjective functional abilities. The response points were; None 0 Slight 1, Moderate 2, Severe 3 and Extreme 4. The minimal total possible score is 0 while the maximal total score is 96. Fig. (1): Myrin goniometer.

3 Mohammad F. Ali, et al. 545 Treatment instruments: 1- Acupuncture needles: Single use stainless steel needles of 15mm length and 0.25 gauge diameter filiform type. 2- Electroacupuncture device: Was connected to the acupuncture needles for getting dense disperse current treatment. An electroacupuncture device model KWD-808 made in china which provides biphasic square wave form was used. The chosen wave form was dense-disperse wave form which is slow then fast and alternating patterns of stimulation. Low frequency interspersed with periods at higher frequencies. Dense frequency was 100Hz, pulse duration was 0.5ms, disperse frequency ranged from (10±3) cycles/min to (50± 10) cycles /min and maximum output pulse amplitude (40± 10) volts [9]. Skin was cleaned with an alcohol swab. Sterile needles were inserted cun (10-15mm) into the acupuncture points. A de qi (a needle sensation of heaviness, numbness, soreness, or paresthesia) sensation was preferably sought before the electrical disperse current of frequancy100hz was connected to the needles via the EA device with pulse duration 0.5ms. The intensity was increased slowly up to a tolerable non painful sensation level [30]. The treatment session lasted for 20 minutes for each point and the intensity of the EA was readjusted, if necessary, after 5 minutes to maintain the desired sensation [10]. Medial-Xiyan (EX. 31) and Dubi (St.35) were connected together and Zusanli (St. 36) and Netting (St.44) were connected together shown in (Fig. 3). Treatment was given each other day for 12 sessions over 4 weeks period [8]. Treatment procedures: The acupuncture points for the most painful knee (in case of bilateral knee OA) were determined. These local points are: Heding (Ex.31) [11,26], Medial-Xiyan (Ex.32) [11,27] and Dubi (St. 35) also known as lateral-xiyan [11,28]. Zusanli (St.36): One cun lateral to lower end of tibial tubrosity [11,29]. Distal and analgesic points; Neitting (St.44) [27,29]. All acupuncture points location for knee OA used in the current study are shown in (Fig. 2). Heding (Ex. 31) Dubi (St. 35) Zusanli (St. 36) Neitting (St. 44) Medial- Xiyan (Ex. 32) Fig. (2): Acupuncture points for knee OA. Fig. (3): Electroacupuncture application. Therapeutic exercises: Straight leg raising exercise; the patient was asked to contract the quadriceps muscle and elevate the limb to 450 and hold for 6 seconds, slowly lower the limb and then relax for 6 seconds, 3 sets of 10 repetitions were done [12]. Strengthening of the quadriceps muscle: In the form active resisted straight leg raising exercise with lifting 2kg (sand bags) 3 sets of 6 repetitions. The SLR exercise was repeated at multiple knee angles drawn on a sheet beside the affected leg (300, 600, 900) degree respectively. Each exercise at each knee angle was followed by 10 seconds rest period [12,18]. Passive stretching of the calf muscles from supine position was done 3 times, 30 second each [12,13,18]. All patients were advised to do home program straight leg raising exercise 3 times a day in the form of elevating the limb to 450 and hold for 6 seconds, slowly lower the limb and then relax for 6 seconds, 3 sets of 10 repetitions [13]. After termination of the 4 week study period, all the participants of both groups stopped their programs and then were

4 546 Influnce of Dense Disperse Current Via Electroacupuncture re-evaluated as in the pre-study state. All data were recorded and statistically analyzed by using: 1- Descriptive statistics (mean and standard deviation) for the general characteristics of the subjects. 2- Paired t-test was used to analyze the differences within groups. 3- Unpaired t-test was used to analyze the differences between groups. The data were analyzed by using Statistical Package for the Social Sciences (SPSS) version 18. Results Group (A): Twenty patients were included in this group. The data in Table (1) represents their mean age (41.66±3.65) years, mean weight (71.8 ±7.44) ki- lograms (Kg), mean height ( ±4.92) centimeters (cm), and mean BMI (26.12 ±2.33) Kg/m 2. Group (B): Twenty patients were included in this group. The data in Table (1) represents their mean age (42.6±3.68) years, mean weight (73.33 ±8.82) kilograms (Kg), mean height (166.8 ±8.02) centimeters (cm), and mean BMI (26.35 ±2.64) Kg/m 2. There was no significant difference between both groups in their ages, weights, heights, and BMI where t and p-value were (0.69, 0.49), (0.51, 0.61), (0.43, 0.66), and (0.25, 0.8) respectively. There was no significant difference in pre treatment assessment between groups in pain intensity. WOMAC pain scale, WOMAC stiffness scale, WOMAC physical function scale, active flexion, passive flexion, active extension and passive extension as shown in Table (2). Table (1): Physical characteristics of patients in both groups (A & B). Items Group (A) Group (B) Comparison Mean ±SD Mean ±SD t-value p-value S Age (yrs) ± ± NS Weight (Kg) 71.8 ± ± NS Height (cm) ± ± NS BMI (Kg/m 2 ) ± ± NS Table (2): Difference between group (A & B) pre treatment. Group (A) Group (B) t p S Pain at rest pre treatment 7.40±(1.69) 7.13±(1.24) NS WOMAC pain pre treatment 3.8±(1.69) 3.5±(1.7) NS WOMAC stiffness pre treatment 4.4±(2.06) 4.05±(1.95) NS WOMAC physical function pre treatment 28±(10.11) 26.5±(9.38) NS Active flex pre treatment ±(14.3) 125.9±(7.13) NS Passive flex pre treatment 127.9±(12.5) ±(6.14) NS Active ext. pre treatment ±(13.2) ±(10.57) NS Passive ext. pre treatment ±(10.59) 138±(10.27) NS Within group difference: There was significant difference between pre treatment assessment and post treatment assessment of all dependant variables in groups (A&B) as shown in Tables (3,4). Between groups difference: There was significant difference between post treatment means of group (A) and post treatment means of group (B) (p-value <0.05) in favor of the first group as shown in Table (5).

5 Mohammad F. Ali, et al. 547 Table (3): Difference within group (A) pre and post treatment. Table (4): Difference within group (B) pre and post treatment. Group (A) t p-value Mean-±SD Group (B) t p-value Pain at rest (VAS) Pre 7.40±(1.69) 16.1 Post 3.5±(1.24) WOMAC pain Pre 3.8±(1.69) Post 1.6±(1.7) WOMAC stiffness Pre 4.4±(2.06) Post 1.3 ±(0.72) WOMAC physical Pre 2 8±( ) function Post 13 ±(10.11) 14.8 Active knee flex. Pre ±(14.3) Post 132.4±(9.9) Passive knee flex. Pre 127.9±(12.5) Post 136±(9.9) Active knee ext. Pre ±(13.2) Post ±(11.97) Passive knee ext. Pre ±(10.59) Post ±(1.91) 11.5 Pain at rest (VAS) Pre 7.25±(1.24) Post 5.4±(1.57) WOMAC pain Pre 3.5±(1.7) Post 2.7±(0.78) WOMAC stiffness Pre 4.05±(1.95) Post 3.7±(1.75) 10.5 WOMAC physical Pre 26.5±(9.3 8) function Post 19.5±(8.11) Active knee flex. Pre 120.9±(7.13) Post ±(6.29) Passive knee flex. Pre ±(6.14) Post 130.5±(5.5) Active knee ext. Pre ±(10.57) Post ±(10.06) Passive knee ext. Pre 138.0±(10.27) Post ±(2.17) Table (5): Difference between group (A & B) post treatment. group (A) post ttt group (B) post ttt t p-value Pain at rest 3.5±(1.24) 5.4±(1.57) (VAS) WOMAC pain WOMAC stiffness WOMAC physical function Active knee flex. Passive knee flex. Active knee ext. Passive knee ext. 1.6 ±(1.7) 2.7 ±(0.78) ±(0.72) 3.7 ±(1.75) ±( 10.11) 19.5±(8.11) ±(9.9) ±(6.29) ±(9.9) 130.5±(5.5) ±(11.97) ±(10.06) ±(1.91) ±(2.17) Discussion The aim of this study was to determine the effect of combined dense disperse current through electroacupuncture with therapeutic exercises on pain, range of motion, and functional limitation in patients with knee OA. Both combined dense disperse current through electroacupuncture with therapeutic exercises and only therapeutic exercises were statistically improved. Group (A) had significant improvement more than group (B). The difference in improvement in both groups may be attributed to the additional dense disperse current through electroacupuncture for group (A). There is evidence to suggest that dense disperse current through electroacupuncture is a safe treatment that can activate powerful opoid and non opoid analgesic mechanism [6]. Electroacupuncture activates serotonergic in the Nucleus Raphe Magnus (NRM) neurons that project to the spinal cord. electroacupuncture inhibits osteoarthritis-induced pain by enhancing spinal 5-hydroxytryptamine 2A/CT2 (5-H A/2C) [6,9]. These explanations are in consistent with the results of the current study [19]. In group (A) the use of biphasic wave was to avoid electrolysis at the needle end and to avoid chemical burn. The use of square wave was to produce optimal depolarization of nerve fiber as the initial deflection should be perpendicular. The use of pulse duration of 0.5ms was used because more than 0.5ms stimulates C fibers and cause pain and less than 0.05ms is insufficient to depolarize nerve endings and 0.5ms is the most commonly used pulse duration proved to be effective to depolarize nerve endings [5]. The improved range of motion might be due to the influence of stretching exercises which leads to increase muscle flexibility so minimize shortening which decrease pain and increase range of motion which is maintained by strengthening exercises leading to more practice and activities that

6 548 Influnce of Dense Disperse Current Via Electroacupuncture patient can do which improve functional performance. Recent best evidence summary of systematic reviews concluded that therapeutic exercises (strengthening, stretching and functional exercises) compared with no treatment is effective for patients with knee OA [17]. Reduction of pain may result from improvement of muscle strength. The improved range of motion leads to increase the liability to benefit of the strengthening exercises and improving pain level, patient s ability to interact with the home exercises program increases, patient s functional level or interaction with his daily living activities improves confidence is achieved [16]. The findings of this study were in agreement with the findings of Ahsin et al., [6] found that dense disperse current through Electro acupuncture (EA) appeared to raise patients blood levels of endorphins and lower their levels of the hormone cortisol, which tends to rise during physical or mental stress. So it s possible that these changes explain the greater pain relief, according to the researchers. Modern research has suggested that acupuncture may help ease pain by altering signals among nerve cells or affecting the release of various chemicals of the central nervous system, such as pain-killing endorphins. The findings of this study were in agreement with the findings of Selefe et al., [31] reviewed the English-language articles, indexed in MEDLINE or CINAHL, describing randomized, controlled trials of the effects of needle or electroacupuncture on knee osteoarthritis. Ten trials representing 1456 participants met the inclusion criteria and were analyzed. These studies provide evidence that acupuncture is an effective treatment for pain and physical dysfunction associated with osteoarthritis of the knee. The findings of this study are in agreement with Zhi and Zhao [32]. Who explained the pain relief effect of EA and manual acupuncture. In manual acupuncture, all types of afferent fibers (Aß, AS and C) are activated. In electrical acupuncture (EA), a stimulating current via the inserted needle is delivered to acupoints. Electrical current intense enough to excite Aß-and part of A S-fibers can induce an analgesic effect. Acupuncture signals ascend mainly through the spinal ventrolateral funiculus to the brain. The findings of this study are also in agreement with Zhu Y et al., [17] They investigated the effect of electroacupuncture and medications on hip osteoarthritis. Sixty patients were allocated to electroacupuncture or oral diclofenac. One month after treatment, Visual Analogue Scale (VAS) scores and Harris scores were compared between the group. Both the pain and Harris scores improved more with electroacupuncture than with the medication (p<0.05). They concluded that electroacupuncture can treat hip OA effectively, relieve joint pain and improve joint function, and is more effective than oral diclofenac. The findings of our study were not consistent with the findings of Casimiro et al., [33] They further concluded that acupuncture has no effect on ESR, CRP, pain, patient s global assessment, number of swollen joints, number of tender joints, general health, disease activity and reduction of analgesics. These conclusions are limited by methodological considerations such as the type of acupuncture (acupuncture versus electroacupuncture), the site of intervention, the low number of clinical trials and the small sample size of the included studies. The results of their study may be because of having different sample; the patients of Casimiro et al., [33] study had RA but the patients of the current study had OA study. Conclusion: Combined dense disperse current through (EA) with therapeutic exercises proved to be beneficial in improving perceived knee pain, range of motion and decreasing the limitation of functional performance more than therapeutic exercises only in patients with knee OA. References 1- REFERENCES DAVID T. and FELSON M.D.: Osteoarthritis of the Knee, N. Engl. J. Med., Vol. 35, No. 4, pp , SRIKANTH V.K., FRYER J.L., ZHAI G., WINZENBERG T.M., HOSMER D. and JONES G.: A meta-analysis of sex differences prevalence, incidence and severity of osteoarthritis. Osteoarthritis and Cartilage, Vol. 13 No. 9, pp , FRANSEN M., CROBIE J. and EDMONDS J.: Physical therapy is effective for patients with knee OA: Randomised controlled clinical trails J. Rheumatol., Vol. 28, pp , NAPADOW V., MAKRIS N.L., LIU K., KETTNER N.W., KWONG K.K. and HUI K.K.: Effects of electroacupuncture versus manual acupuncture on the human brain as measured by FMRI J. Human. Brain Mapp., Vol. 24, No. 3, pp , THOMAS J. HOOGEBOOM, MIRELLE J.P.M. STUKSTETTE1 and ROB A. De BIE: Nonpharrmacological care for patients with generalized osteoarthritis: J. Musculoskeletal Disorders, Vol. 11, No. 142, pp , 2010.

7 Mohammad F. Ali, et al AHSIN S., SALEEM S., BHATTI A.M., ILES R.K. and ASLAM M.: Clinical and endocrinological changes after electro-acupuncture treatment in patients with osteoarthritis of the knee J. Pain BMC Complement Altern Med. Dec., 15, Vol. 147, pp , MADSEN M.V., GØTZSCHE P.C. and HRÓBJARTSSON A.: Acupuncture treatment for pain: Systematic review of randomized clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. Vol. 33 No. 8, p, 3115, SANGDEE C., TEEKACHUNHATEAN S. and SANAN- PANICH K.: Electroacupuncture versus Diclofenac in symptomatic treatment of osteoarthritis of the knee: A Randomized Controlled Trial, pp , JUBB R.W., TUKMACHI E.S., JONES P.W., DEMPSEY E., WATERHOUSE L. and BRAILSFORD S.: A blinded randomised trial of acupuncture (manual and electroacupuncture) compared with a non-penetrating sham for the symptoms of osteoarthritis of the knee J. Acupuncture in Medicine, Vol. 26, No. 2, pp , LEUNG B., KHADIVI J.R. and DUANN Z.H.: The effect of Ting point (tendinomuscular meridians) electroacupuncture on thermal pain: A model for studying the neuronal mechanism of acupuncture analgesia, The Journal of Alternative and complementary Medicine, Vol. 11, No. 4, pp , BERMAN B., LAO L., LANGENBERG P., LEE W., GLIPIN A. and HOCHBERG M.: Effectiveness of acupuncture as adjunct therapy in osteoarthritis of the knee. Ann. Intern. Med., Vol. 141, No. 12, pp GAIL D., NANCY E., ROBERT L. and MICHAEL G.: Effectiveness of manual physical therapy & exercise in OA of the knee. J. Annals. Int. Med., Vol. 132 (3), pp , THOMAS K.S., MILLER P., DOHERTY M., MUIR K.R., JONES A.C. and O REILLY S.C.: Cost-effectiveness of a two-year home exercise program for the treatment of knee pain. J. Arthritis. Rheum., Vol. 53, pp , THOMAS K.S., MUIR K.R., DOHERTY M., JONES A.C. and O REILLY S.C.: Home based exercise programme for knee pain and knee osteoarthritis: Randomised controlled trial. Clin. J. Sport. Med., Vol. 13, pp , HOLDEN A.M., NICHOLLS E.E., HAY M.E. and FOS- TER E.N.: Physical therapists use of therapeutic exercise for patients with clinical knee osteoarthritis in the united kingdom: PT Journal, Vol. 88, No. 10, p , FITZGERALD G.K.: Therapeutic exercise for knee osteoarthritis:considering factors that may influence outcome. Eura. Medicophys, 41: , SMIDT, N.H.C.W. De VET, L.M. BOUTER and J. DEK- KER: Effectiveness of exercise therapy: A best evidence summary of systematic reviews. Aust. J. Phsio. Ther., 51: 71-85, FRANSEN M. and McCONNELL S.: Exercise for osteoarthritis of the knee Cochrane Database Syst. Rev., CD004376, pp , HARDING G., COYNE K., BARRETT R.J. and PIXTON G.C.: Modified visual analog scale symptom-intensity and overall-bother measures for the assessment of symp- toms in studies of pharmacologic stress agents J. Clinical Therapeutics, Vol. 31, No. 4, pp , BAKIRTZOGLOU P., IOANNOU P. and BAKIRTZO- GLOU F.: Evaluation of hamstring flexability by using two different measurement instruments, Sport Logia, Vol. 6, No. (2), pp , MALMSTRÖM E.M., KARLBERG M., MELANDER A. and MAGNUSSON M.: Zebris versus myrin: A comparative study between a three-dimensional ultrasound movement analysis and an inclinometer/compass method: Intradevice reliability, concurrent validity, intertester comparison, intratester reliability, and Intraindividual Variability J. Spine, Vol. 28, No. 21, pp , O SULLIVAN K., MURRAY E. and SAINSBURY D.: The effect of warm-up, static stretching and dynamic stretching on hamstring flexibility in previously injured subject, Musculoskeletal Disorders, Vol. 10, pp , GOODWIN J., CLARK C. and DEAKES J.: Clinical methods of goniometry: A Comparative Study, Vol. 14, No. 1, p , SOININEN J.V., PAAVOLAINEN P.O., GRONBLAD M.A. and KAAPA E.H.: Validation study of a finnish version of the western ontario and McMasters University Osteoarthritis Index, Vol. 18, No. 2, pp , WOO S.L., ABRAMOWITCH S.D. and KILGER R.: Biomechanics of knee ligaments: Injury, Healing, and Repair, Vol. 39, No. (1), pp. 1-20, WITT C., BRINKHAUS B. and JENA S.: Acupuncture in patients with osteoarthritis of the knee: A randomised trial. Lancet, Vol. 366, pp , TUKMACHI E., JUBB R., DEMPSEY E. and JONES P.: The effect of acupuncture on the symptoms of Knee Osteoarthritis J. Acupuncture Med., Vol. 22, No. 1, pp , NG M.M.L., LEUNG M.C.P. and POON D.M.Y.: The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: A randomized controlled trial with follow-up evaluation. J. Altern Complement Med., Vol. 9, pp , CASIMIRO L., BARNSLEY L., BROSSEAU L., MILNE S., WELCH V., TUGWELL P. and WELLS G.A.: Acupuncture and electroacupuncture for the treatment of Osteoarthritis of the Knee, Vol. 31, No.4, pp , XIE F., LI S.C. and GOEREE R.: Validation of western ontario and mcmaster universities osteoarthritis index (WOMAC) in patients scheduled for total knee replacement. Qual. Life Res., Vol. 17, No., , SELEFE H., TERRY KIT D.C. and TAYLOR D.: Acupuncture and osteoarthritis of the Knee: A review of randomized, Controlled Trials., pp , ZHI Q. and ZHAO: Neural mechanism underlying acupuncture analgesia Progress in Neurobiology, 85 (4): , CASIMIRO L., BARNSLEY L., BROSSEAU L. and MI- LNE S.: Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis. Cochrane Database Syst. Rev. Oct., 19; (4): CD003788, 2005.