Intra-articularly applied pulsed radiofrequency can reduce chronic knee pain in patients with osteoarthritis

Available online at Intra-articularly applied pulsed radiofrequency can reduce chronic knee pain in patients with osteoarthritis Haktan Karaman , Adnan Tu¨fek , Go¨nu¨l O a Department of Anesthesiology, Pain Management Center, Dicle University, Diyarbakir, Turkey b Department of Anesthesiology, Dicle University, Diyarbakir, Turkey c Diyarbakir Vocational Higher School, Department of Technique, Dicle University, Diyarbakir, Turkey d Department of Anesthesiology, Diyarbakir Education and Research Hospital, Diyarbakir, Turkey Received October 4, 2010; accepted February 19, 2011 Background: Osteoarthritis (OA) is the most widespread chronic joint disease worldwide. Symptomatic knee OA is observed in approximately12% of individuals more than 60 years of age. Conservative treatments models may not be effective always, and that some of them have seriousadverse effects that prompted the researchers to research different treatment methods. In this study, we investigated short- and mid-termeffectiveness of intra-articular pulsed radiofrequency (PRF) applied in patients with chronic knee pain due to OA.
Methods: This study was carried out in the pain management center of a university hospital between January 2009 and June 2009. The patientrecord files of 31 patients who received intra-articular PRF were retrospectively reviewed. The antero-lateral area of the knee, where theintervention would be applied, was anesthetized with 1% lidocaine. An introducer needle was placed intra-articularly. PRF was started as 42C at2 Hz for 15 minutes. The pain of the patients was evaluated by 10 cm Visual Analog Scale (VAS). Furthermore, the ages, the gender, thesymptom duration of the patients, the side of the knee on which the intervention was applied, and the complications were collected for statisticalevaluation.
Results: Although the mean initial VAS scores of the patients were 6.1 Æ 0.9 cm, it was found, respectively, to be 3.9 Æ 1.9 cm and 4.1 Æ 1.9 cmat the first- and sixth-month follow-ups. In general, a decrease of 32.8% in mean in the VAS scores was achieved in the last follow-up; whereasthe rate of patients reporting a minimum decrease of 2 points in the VAS scores was 64.5% and the rate of patients reporting a decrease of !50%in their pain was calculated as 35.5%.
Conclusion: PRF applied to the knee joint appears to be an effective and safe method.
Copyright Ó 2011 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.
Keywords: Knee; Osteoarthritis; Pain; Pulsed radiofrequency; Radiofrequency the most incurred joints in OA is the knee joint, which carriesthe heavy burden of the body.Knee OA is closely related Osteoarthritis (OA) is the most widespread chronic joint with increasing age and obesity. Symptomatic knee OA is disease worldwide. Its primary symptoms are pain, stiffness, observed in approximately 12% of individuals aged more than loss of function in the joints, and muscle atrophy.eOne of 60 years.The conservative treatment of OA usually includesphysical therapy, analgesics including nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular steroid andhyaluronan injectAlthough conservative management * Corresponding author. Dr. Haktan Karaman, Department of Anesthesiology, is effective in most OA patients, these treatments are not Pain Management Center, Dicle University, Diyarbakir 21280, Turkey.
effective in a small percentage of patients, and some of them 1726-4901/$ - see front matter Copyright Ó 2011 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.
doi: H. Karaman et al. / Journal of the Chinese Medical Association 74 (2011) 336e340 have serious adverse effects, prompting the investigators to manner. All patients who participated in the study were research different treatment methods.
informed in written and verbal on the intervention to be Minor and major surgical methods are also applied for applied before application, and their written consents accept- treatment of knee OA. The place of arthroscopy, which is ing the intervention were obtained. The study and all inter- one of these methods, is controversial. It was reported that ventions were carried out in the pain treatment center of arthroscopy would not be useful in cases where findings of a university hospital. The files of the patients, on whose knee a meniscal rupture or a recent trauma do not exist.Another joints PRF was applied between January 2009 and June 2009, method that can be applied for surgical treatment of OA is were reviewed independently by a physician who was not total knee replacement. Despite the successful results ach- ieved by total knee replacement, which is an option consid-ered for end-stage knee diseases, a significant percent of the patients continue suffering from pain despite total kneereplacement.
The following were used as the criteria for being included As a general concept, pain treatment by radiofrequency in the study: (1) patients with a diagnosis of knee OA (RF) energy has had wide coverage in the pain management according to The American College of Rheumatology practice for the past 30 yIn conventional radiofrequency criteria; (2) patients between Stage 1 and Stage 3 radiolog- thermocoagulation (CRFT) applications, an electrode emitting ically, according to the Kellgren-Lawrence classification; (3) RF currents is placed on the target nerve and the destruction patients who had continued to conservative treatment such of the nerve tissue is ensured by the heat producCRFT as physical therapy, analgesic drugs including NSAIDs or has many fields of application such as “denervation of the opioids, for at least six months, but could not respond to the medial branch innerving the zygapophycial joint”, “dorsal treatment sufficiently [<2-point improvement in pain severity root ganglionotomy”, “intradiscal applications”, “percutaneous cordotomy for treatment of malign pain”, and “trigeminal The following were used as the exclusion criteria for the radiofrequency ganglionotomy for treatment of trigeminal study: (1) patients at Stage 4 radiologically, according to the Kellgren-Lawrence classification; (2) existence of general Pulsed RF (PRF) application is a relatively new method that contraindications against application of invasive intervention has been developed as an alternative to CRFT. PRF has much (such as hemorrhagic diathesis, systemic infection, or local less (if any) neurodestructive characteristic. In PRF, the RF infection at the area to be intervened); (3) excessive use of energy is applied at high voltage (typically 45 V) and with 20 millisecond bursts followed by 480 millisecond silent pha-ses.Thus, because of the long silent phase, the tissue temperature will be spread and will not exceed 42C. So, notissue damage will develop because the tissue temperature will All procedures were carried out under local anesthesia, remain below 45e50C, which is considered as the irrevers- with blind technique, in the intervention room of the pain ible tissue damage threshold.PRF, which can be applied in treatment center. After the patients who would be intervened a similar manner to CRFT applications (such as facet medial were prepared according to the standard hunger protocol (6e8 nerve or trigeminal nerve applications), is distinguished hours of hunger), all of them had vascular access and were mainly by peripheral applications where CRFT is never given isotonic solution of 0.9%. Following the standard applied. PRF has been reported to be used successfully in monitorization (3-lead ECG, TA, pulsoxymetry), the patients treatment of disorders such as myofascial trigger were seated in a chair. After the area to be intervened was phantom limb occipital neuralgia,meralgia par- wiped with an iodine-based antiseptic solution, it was draped esthetand premature ejaculatOne of the fields according to the rules of sterility. The antero-lateral part of the where PRF was claimed to be effective is that of intra-articular knee was palpated, and the entry point was anesthetized with 1% lidocaine. An introducer needle with 22 G 100-mm Based on a study published by Sluijter et in 2008, we length and 10-mm active tip (Baylis Medical Inc., Montreal, have been applying intra-articular PRF for treatment of chronic Canada) was placed intra-articularly through the predefined pain developing due to knee OA in our pain management area. After satisfactory placement, the stylet in the introducer center. In this study, we intended to survey retrospectively the was removed and RF probe (Baylis Medical Inc., Montreal, cases where we applied intra-articular PRF, and to study the Canada) was placed through the introducer needle. Then, PRF was applied with 42C temperature and a pulse width of 20milliseconds, at 2 Hz for 15 minutes. Because the application was not painful, sedoanalgesia was not applied to any patientsduring the intervention. After the intervention was completed, a plaster was applied to the entry point and the patients weretransferred to the recovery room. The patients who stayed in This study was carried out with the approval of the Insti- this room for 30 minutes were monitored by the clinic nurse tutional Review Board and in a retrospective, noncontrolled for early complications and then discharged from hospital with H. Karaman et al. / Journal of the Chinese Medical Association 74 (2011) 336e340 suggestions to rest for the 1st day and then engage in their Demographic characteristics of study patients The pain of the patients was evaluated by a 10-cm VAS. In this scale, “0” identifies the situation where no pain exists and “10” identifies the most severe pain that can be imagined.
Because most of our patients did not experience pain unless movement, pain severity was assessed on motion.
Furthermore, the ages, the gender, the duration of symptom, and the side of the knee on which the intervention was applied (right or left) were collected for statistical evaluation.
applied before Analgesic drugs (NSAIDs and/or opioids) þ 15 (48.4) Additionally, if early or late complications developed, these physical therapyAnalgesic drugs (NSAIDs and/or opioids) þ 11 (35.5) physical therapy þ intra-articular injection(steroid or hyaluronan) NSAID ¼ nonsteroidal anti-inflammatory drugs; SD ¼ standard deviation.
From all patients who received knee PRF between January 2009 and June 2009, only those who received PRF due to OA and the follow-up notes of whom existed for the 1stmonth and 6th month after the intervention were included in Although the mean of the initial VAS scores of the patients was 6.1 Æ 0.9 cm, these values were found, respectively, to be The successful result criteria were determined as achieve- 3.9 Æ 1.9 cm and 4.1 Æ 1.9 cm at the 1st month and 6th month ment of a decrease of at least 2 points in VAS scores when the follow-ups Thus, a decrease of 2.0 Æ 1.4 cm in mean latest follow-ups were compared with the baseline.
was achieved when the latest follow-up scores were taken asreference in comparison with the baseline scores. Although this decrease in VAS scores was found as a statisticallysignificant difference, no statistically significant differences All data were analyzed using the Medcalc Version were found between the follow-up periods themselves ( (MedCalc Software, Mariakerke, Belgium) for Windows. We ). In general, a decrease of 32.8% in mean of the VAS used the paired samples t test with Bonferonni’s correction to scores was achieved at the last follow-up when compared with perform pairwise comparisons. We also used Spearman correlation coefficients to assess the effects of various factors The rate of the patients reporting at least 2 cm of decrease on the outcomes. p < 0.05 was considered statistically in VAS scores in comparison with the baseline scores, which we considered as success criteria, was found to be 64.5%. The The knee PRF application was performed on a total of 49 patients between January 2009 and June 2009. From thesepatients, those who received knee PRF for reasons other thanOA and those whose follow-up data are missing wereexcluded from the study. Thus, the remaining 31 patients weretaken into statistical evaluation. The mean age of the patientswas 62.8 Æ 9.3 years, and 71% of them were women. Themean symptom duration was 78.8 Æ 64.3 months. Twenty-three patients had bilateral knee OA, all of them underwentPRF application made bilaterally whereas 16.1% of thepatients took only analgesic drugs (NSAIDs and/or opioids)and 35.5% of them had been treated with analgesic drugs(NSAIDs and/or opioids) þ physical therapy þ intra-articular Fig. 1. Agraphic showing the change in time in VAS scores. ***p < 0.0001, injection (steroid or hyaluronan) before PRF applications.
statistically significant difference when comparing the baseline scores.
CI ¼ confidence interval; VAS ¼ Visual Analog Scale.
H. Karaman et al. / Journal of the Chinese Medical Association 74 (2011) 336e340 suggested that PRF shows its second effect (which explains the Pairwise comparisons of all-time VAS scores effectiveness observed particularly in large joint applications such as knee and shoulder joints, and emerging gradually) over the immune cells. According to this suggestion, the electric field affects the immune cells and thus affects production of proinflammatory cytokines such as interleukin-1b, tumor necrosis factor-a, and interleukin-6. Therefore, it is suggested that PRF affects the inter-cell communication by intermediary CI ¼ confidence interval; VAS ¼ Visual Analog Scale.
of these cytokines and triggers, rather than a limited effect,formation of possibly more generalized response.
Unlike CRFT, PRF can be applied to peripheral nerves rate of the patients reporting !50% decrease in their pain in because it does not cause neuronal damage, and to inside comparison with that of the last follow-up was calculated as joints because it does not cause tissue damage. However, studies on intra-articular application of PRF are scarce and, as The possible effects of various factors such as age, duration far as we know, there are only two articles in the literature in of symptom and gender on the final outcomes were studied by English. In a series of cases published by Sluijter et alin using Spearman’s coefficient of rank correlation ( 2008, PRF was applied to various joints (cervical facet, knee, Although there is no correlation between gender (p ¼ 0.9643) shoulder, sacroiliac, atlanto-axial, and radiocarpal joints) of and age (p ¼ 0.1878) and the outcomes, an inverse correlation six different patients who had arthrogenic pain. The authors was found between the pain duration of the patients have reported that they have obtained excellent results from all (p ¼ 0.0338) and amount of decrease in VAS scores.
application in mid and long term. In another studyHalimet al applied intra-articular PRF to atlanto-axial joints of 86 patients with cervicogenic headache. In this retrospectivestudy, the long-term effectiveness of PRF was studied, and the In none of the patients, on whom the application was per- rate of patients reporting !50% decrease in their pain scores formed, were found any major or minor complications in the 1 year after the application was reported as 44.2%.
early or late period. In other words, no patients developed The most important weakness of the present study is hemorrhage, infection, increase in their existing complaints, or that it was not a randomized controlled study, but only a study designed, retrospectively. Hence, generalization of theoutcomes of our study to the society may not be very accurate.
However, though our study was a retrospective one, it gives anencouraging view on the effectiveness of intra-articular PRF Although it is still not understood completely how PRF application. The placebo-controlled, randomized, and double- takes eflaboratory reports suggest a genuine blind studies to be planned in future may provide more neurobiological phenomenon altering the pain signaling, objective information on effectiveness of intra-articular PRF which has been described as neuromodulatory.Sluijter application. One shortcoming of our study is that it did not et alsuggested the hypothesis that PRF may have dual effect have a long follow-up period. We do not know whether or not in intra-articular applications. In the first effect on the nervous this effectiveness observed in PRF application in the short- to system, PRF causes suppression of the excitatory C-fiber mid-term follow-up period will also continue in the long term.
response and inhibition of the synaptic transm To find the answer to this question, studies with long follow-up This effect explains the immediate pain relief effect of PRF particularly observed in small joint applications. It is In conclusion, PRF, applied to knee joint of patients who suffer from chronic knee pain due to OA and do not respond tothe conservative treatment methods sufficiently, seems to be an effective and safe method. To discriminate it from placebo response, prospective, randomized, and placebo-controlled studies with long follow-up period are needed.
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