552082

research-article2014
CRE0010.1177/0269215514552082Clinical RehabilitationMelo et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

Effects of neuromuscular electrical 1­–11

© The Author(s) 2014
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DOI: 10.1177/0269215514552082

therapy on the muscle architecture cre.sagepub.com

and functional capacity in elderly

patients with knee osteoarthritis: a
randomized controlled trial

Mônica de Oliveira Melo1,2, Klauber Dalcero Pompeo1,

Guilherme Auler Brodt1,2, Bruno Manfredini Baroni1,5,
Danton Pereira da Silva Junior3 and Marco Aurélio
Vaz1,4

Abstract
Objectives: To determine the effects of low-level laser therapy in combination with neuromuscular
electrical stimulation on the muscle architecture and functional capacity of elderly patients with knee
osteoarthritis.
Design: A randomized, evaluator-blinded clinical trial with sequential allocation of patients to three
different treatment groups.
Setting: Exercise Research Laboratory.
Subjects: A total of 45 elderly females with knee osteoarthritis, 2-4 osteoarthritis degrees, aged 66–
75 years.
Intervention: Participants were randomized into one of the following three intervention groups:
electrical stimulation group (18–32 minutes of pulsed current, stimulation frequency of 80 Hz, pulse
duration of 200 μs and stimulation intensity fixed near the maximal tolerated), laser group (low-level laser
therapy dose of 4–6 J per point, six points at the knee joint) or combined group (electrical stimulation
and low-level laser therapy). All groups underwent a four-week control period (without intervention)
followed by an eight-week intervention period.
Main measures: The muscle thickness, pennation angle and fascicle length were assessed by
ultrasonography, and the functional capacity was assessed using the 6-minute walk test and the Timed Up
and Go Test.

1Exercise Research Laboratory, Federal University of Rio Corresponding author:

Grande do Sul, Porto Alegre, Brazil Mônica de Oliveira Melo, Exercise Research Laboratory,
2Núcleo de Pesquisa em Ciências e Arte do Movimento
School of Physical Education, Federal University of Rio
Humano, University of Caxias do Sul, Caxias do Sul, Brazil Grande do Sul, Porto Alegre, Ave Willy Eugênio Fleck 1500,
3Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
casa 1500, casa 187. Porto Alegre, 90150-180, Brazil.
4Physique Centre of Physical Therapy and Physical Fitness,
Email address: melo.monica@terra.com.br
Porto Alegre, Brazil
5Federal University of Ciências da Saúde de Porto Alegre
2 Clinical Rehabilitation 

Results: After intervention, only the electrical stimulation and combined groups exhibited significant
increases in the muscle thickness (27%–29%) and pennation angle (24%–34%) values. The three groups
exhibited increased performance on the walk test (5%–9%). However, no significant differences in terms
of functional improvements were observed between the groups.
Conclusions: Neuromuscular electrical stimulation reduced the deleterious effects of osteoarthritis on
the quadriceps structure. Low-level laser therapy did not potentiate the effects of electrical stimulation
on the evaluated parameters.

Keywords
Neuromuscular electrical stimulation, low-level laser therapy, knee osteoarthritis, elderly, vastus
lateralis muscle architecture, functional capacity

Received: 2 November 2013; accepted: 28 August 2014

Introduction
Knee osteoarthritis is a chronic degenerative disease
that presents clinical symptoms, such as morning
stiffness, reduced range of motion, chronic joint pain
and muscle weakness.1 Evidence also suggests that
muscle weakness is associated with negative changes
in the muscle architecture, such as a decrease in the
muscle thickness and fascicle length.2,3 These
changes in the muscle structure have a negative
impact on the patient’s functionality because a
reduced fascicle length is related to a serial sarcomere
loss and reflects the muscle’s reduced shortening
velocity.3–5 Furthermore, reduced muscle thickness is
associated with parallel sarcomere loss and ulti-
mately leads to a reduction in the maximum muscle
fibre strength capacity.3–6
Neuromuscular electrical stimulation has been
recommended for quadriceps strengthening when
chronic pain and joint stiffness prevent patients from
engaging in a voluntary exercise programme.7–9
Although previous studies found increases in quadri-
ceps strength and knee function,3,9 muscle architec-
ture adaptations from neuromuscular electrical
stimulation in patients with knee osteoarthritis have
not been completely described in randomized con-
trolled trials.
Low-level laser therapy has been considered effec-
tive for treating knee osteoarthritis because of its cell
bio-stimulating action10 and its regenerative,11,12 anal-
gesic,10 and anti-inflammatory effects.10,11 Because of
its effects on the release of neurotransmitters that are
associated with pain modulation and the release of
anti-inflammatory agents,10,11 low-level laser therapy
might improve the functionality of patients with knee
osteoarthritis.
The efficacy of low-level laser therapy, in com-
bination with neuromuscular electrical stimulation
to treat patients with knee osteoarthritis, has not
been previously studied. The aim of the present
study was to quantify the effects of neuromuscular
electrical stimulation and low-level laser therapy
on the muscle architecture parameters, pain and
functional capacity. Our main hypothesis was that
the combination of low-level laser therapy with
neuromuscular electrical stimulation should pro-
mote a greater decrease in pain and larger increases
in the functional capacity and muscle architecture
parameters than each therapy alone.
Methods
Trial design
This randomized, single-blinded, clinical trial
(ClinicalTrials.gov Identifier: NCT02067871) was
approved by the University’s Ethics in Research
Committee (Protocol number 20160). All patients
signed a written consent form prior to data
collection.
Melo et al. 3
Participants
Participants were recruited via advertisements in
disclosure media. The inclusion criteria included
Grade 2 or 3 knee osteoarthritis, diagnosed by a
traumatology–orthopaedics physician according to
the criteria proposed by Kellgren and Lawrence13;
age between 63 and 75 years; female gender; and
one or more episodes of knee pain in the past six
months. The following exclusion criteria were
observed: body mass index higher than 40 kg/m2;
hip, ankle or toe osteoarthritis diagnosis; the use of
crutches for locomotion; participation in a strength-
training programme or physiotherapy treatment for
knee osteoarthritis in the past six months; neurologi-
cal or cognitive disorders; rheumatoid arthritis; elec-
tronic implants; previous or upcoming surgery
(within three months); or any cardiorespiratory, neu-
romuscular or metabolic disease that could represent
an absolute contraindication or a contraindication to
the performance of maximum strength tests.
Randomization and blinding
A total of 45 participants who satisfied the inclusion
criteria were randomly assigned to one of three study
groups: Group 1 – the low-level laser therapy group;
Group 2 – the neuromuscular electrical stimulation
group; and Group 3 – the combined treatment group
(neuromuscular electrical stimulation plus low-level
laser therapy). Group allocation was randomized in
three blocks of 15 sealed envelopes without external
marks, which were mixed and numbered from 1 to
15, containing a piece of paper with the group alloca-
tion. As the fifth participant successfully completed
the study baseline evaluation, the researcher opened
the next envelope in the sequence in the presence of
a new patient. All participants received treatment and
had their results included in the data analysis. The
researchers responsible for data collection and data
analysis were blinded to the patients’ diagnosis or
intervention.
Evaluation protocol
All participants were assessed at three different
time points over a 12-week period. The first four
weeks were used as the control period, when no
intervention was performed. The intervention
period lasted for eight weeks. The evaluation pro-
tocol was performed before the control period (pre-
control), before the intervention period
(preintervention) and after the intervention period
(postintervention). The outcome measures were the
vastus lateralis muscle architecture parameters
(muscle thickness, fascicle length and pennation
angle), functional capacity and pain level, which
was measured during the functional tests.
The vastus lateralis architecture parameters
were assessed by an ultrasound system (SSD 4000,
51 Hz, ALOKA Inc., Japan) with a linear array
probe (60 mm, 7.5 mHz). Subjects were evaluated
at rest in the supine position with their knees and
thigh fully extended.14,15 Three ultrasound images
were captured with the probe positioned parallel to
the direction of the muscle fibres at a 50% distance
between the greater trochanter and the lateral femur
condyle.3,14,15 The muscle architecture was ana-
lysed with Image-J software (National Institute of
Health, USA) by a single researcher who was
blinded to the group allocation and data acquisition
using procedures previously described and vali-
dated in the literature14,15. The fascicle length was
normalised by the thigh length. The mean value of
each muscle architecture variable obtained from
the three recorded ultrasound images was consid-
ered for subsequent statistical analysis.
The functional capacity was evaluated via the
6-minute walk test and Timed Up and Go Test16.
For the Timed Up and Go Test, the subject was
instructed to initiate the test at a sitting position,
with the trunk in an erect posture, arms crossed
over the chest and feet on the floor.16 Each test was
performed three times with a one-minute interval
between trials. The mean value of the three trials
was used for the statistical analysis. Immediately
after the end of each test, pain was assessed using a
0 to 10 visual analogue pain scale, with 0 meaning
‘no pain’ and 10 meaning ‘excruciating pain’. After
the tests, subjects were instructed to mark their
subjective pain sensation on the visual analogue
pain scale. The functional and pain outcomes were
also analysed by a researcher who was blinded to
the group allocation and data acquisition.
4 Clinical Rehabilitation 
Intervention protocols
One researcher, experienced in the use of the
applied therapies and blinded to the data acquisition
and data analysis, applied the three intervention
protocols. Low-level laser therapy was adminis-
tered twice a week, with a minimum of 48 hours
between the sessions, over a period of eight weeks.
A THOR DD2 Control Unit, consisting of an infra-
red gallium–aluminium–arsenide (GaAlAs) diode
laser probe (λ = 810 nm, continuous wave, 200 mW
output power, 0.0364 cm2 spot size area and 0.218 J/
cm2 power density) (THOR®–London, UK) was
used for the laser application. The laser was applied
while the probe was held stationary and perpendic-
ular to the skin, and light pressure was applied to
three anteromedial and three anterolateral points
over the intercondylar notch.11,12
The low-level laser therapy programme was
based on the World Association for Laser Therapy
recommendations17 and on studies that obtained
positive results for the relief of osteoarthritic symp-
toms.11,12 During the first four intervention weeks,
laser therapy was administered for 30 seconds per
point, with a dose of 6 J per point (totalling 36 J),
to optimise the laser’s analgesic18 and anti-inflam-
matory19 effects. In the remaining four weeks, the
treatment focused on cartilage regeneration,20–21
for which an approximately 30% lower energy
dose was used, i.e. 20 seconds per point, resulting
in a dose of 4 J per point (totalling 24 J).
In the neuromuscular electrical stimulation
group, participants underwent supervised neuro-
muscular electrical stimulation sessions twice a
week, at 48-hour intervals, over an eight-week
period, with a progressive increase in the intensity
and volume. Electrical stimulation was adminis-
tered with portable, constant-voltage electrical
stimulation equipment that was developed espe-
cially for the present trial. All sessions were per-
formed at the same time of the day with participants
seated on a conventional chair, knees flexed to 90°
(0° = full extension) and the treated lower-limb
strapped to the chair with a band.
During electrical stimulation, two electrodes
(5 cm × 13 cm) were placed anteriorly on the par-
ticipants’ thighs. The proximal electrode was posi-
tioned over the quadriceps motor point, and the
distal electrode was placed perpendicular to the lon-
gitudinal thigh axis just above the patellar border.3
The quadriceps motor point was determined using
an electrical stimulator pen (KLD Biosistemas,
Brazil) with a faradic current, maximum frequency
of 30 Hz and sufficient intensity to produce a tetanic
contraction. A pulsed symmetric biphasic rectangu-
lar current, with a pulse frequency of 80 Hz, pulse
duration of 400 μs and an intensity adjusted to the
maximum level that subjects could tolerate, was
used during electrical stimulation.22 The individual
intensity and treatment volume were recorded by
the stimulator during all sessions and stored on a
computer following the intervention. Owing to the
maximum stimulator current limit (≈127 mV), fur-
ther treatment volume increases were reached by
gradually increasing the total stimulation time and
reducing the rest-time between contractions (Table
1, available online).
The combined treatment was administered
twice a week with at least 48 hours between ses-
sions over an eight-week period. Participants
received low-level laser therapy prior to electrical
stimulation, using the same parameters that were
used for the isolated electrical stimulation and laser
therapy groups.
Statistical analysis
Using muscle architecture variables as the main
outcome and estimating a minimum difference
equivalent to a standard deviation of 0.5 cm for
muscle thickness, 3° for the pennation angle, and
α = 0.05, a sample size of 14 subjects per group
achieved a calculated power of 0.80 (WinPepi 1.45
for Windows) and was used in the study. To deter-
mine the between-intervention effects, two-factor
(group X time) mixed-design analyses of variance
(ANOVA) with repeated measures of time were
performed. Major effects and significant interac-
tions were also investigated via multiple compari-
sons using the Bonferroni post hoc test. The
per cent variation between pre- and postinterven-
tion (the difference between the pre- and postinter-
vention scores, divided by the preintervention
score) was compared between the groups using
one-way ANOVA followed by a Bonferroni post
Melo et al. 5
Table 2.  Anthropometric and baseline clinical characteristics of the three experimental groups.
Laser (n = 15)
Age (years) 67.7 ±4.7
Height (m) 1.59 ±0.10
Mass (kg) 74.7 ±11.7
Thigh length (cm) 40.9 ±2.2
Systolic pressure (mmHg) 120.0 ±13.2
Diastolic pressure (mmHg) 77.3 ±6.8
BMI (kg/m2) 30 ±5
(% of Grade 2 OA) 46.66
(% of Grade 3 OA) 53.44
BMI: body mass index; OA: osteoarthritis.
hoc test. The effect size (the difference between the
pre- and postintervention scores, divided by the
standard deviation of the preintervention score)
was calculated and interpreted using the following
scale, which was proposed by Cohen23: trivial
effect (<0.10), small effect (0.30–0.10), medium
effect (0.50–0.30) and large effect (above 0.50).
The significance level was set to α < 0.05 for all
statistical analyses. All results are expressed as the
mean ± standard deviation.
Results
Overall, 45 of 193 eligible participants underwent
randomization, and 44 out of 45 completed postint-
ervention testing (Figure 1). No significant differ-
ences were found between the precontrol
anthropometric or clinical characteristics (p > 0.05;
Table 2).
Muscle architecture
The effect sizes were high for all architecture
parameters between the precontrol and preinter-
vention tests (pennation angle = 0.87; muscle thick-
ness = 0.96 and fascicle length = 0.93; p < 0.001).
No within-group differences were observed for the
architecture variables between the precontrol and
preintervention tests (p > 0.05). A significant inter-
action was observed between the time and group
for the pennation angle (p = 0.010) and muscle
thickness (p < 0.001). Only the neuromuscular
Neuromuscular electrical Combined (n = 14)
stimulation (n = 15)
69.3 ±5.5 69.6 ±4.7
1.52 ±0.10 1.55 ±0.05
77.5 ±13.7 70.9 ±8.9
39.3 ±2.5 38.2 ±2.9
136.4 ±15.4 129.2 ±11.0
75.0 ±19.2 70.8 ±18.6
33 ±6 29 ±4
53.44 57.14
46.66 42.86
electrical stimulation and combined groups showed
an increased pennation angle (p < 0.001) and mus-
cle thickness (p < 0.001) (Table 3) between the pre-
and postintervention tests. There were no
between-intervention effects on the fascicle length
(p = 0.67) (Table 3). Significant differences in the
muscle thickness (p = 0.003), but not in the penna-
tion angle (p > 0.05), were observed between
groups for the per cent variation between pre- and
postintervention. The neuromuscular electrical
stimulation and combined groups showed the high-
est increases in the per cent values of muscle thick-
ness (p = 0.003) after the eight-week intervention,
compared with the laser group (Table 3). Figure 2
illustrates the changes in the muscle architecture of
a representative subject from the neuromuscular
electrical stimulation group during the pre- and
postintervention tests. The increased thickness
after the eight-week electrical stimulation interven-
tion is visible. A similar increase was observed in
the combined group.
Functional capacity and pain scale
There were no within-group differences for the func-
tional or pain outcomes during the 6-minute walk test
or the Timed Up and Go Test between the precontrol
and preintervention tests (p > 0.05, Table 3).
All of the experimental groups decreased their
pain scales and increased their travelled distance
on the 6-minute walk test after eight weeks of
intervention (p < 0.001) (Table 3). However, there
6 Clinical Rehabilitation 
Figure 1.  Participants’ flow diagram.
BMI: body mass index.
were no between-group differences in terms of the
functional improvement or pain relief (p > 0.05)
(Table 3).
There was no time effect on the Timed Up and
Go Test performance (p > 0.05) (Table 3). All of
the experimental groups decreased their pain scales
during the Timed Up and Go Test (p < 0.001).
Again, there were no between-group differences in
terms of the functional improvement or pain relief
(p > 0.05) (Table 3).
Discussion
The main outcomes of this study were the follow-
ing: (1) neuromuscular electrical stimulation treat-
ment alone or in combination with low-level laser
therapy, results in increases in the pennation angle
and muscle thickness, but has no effect on the fas-
cicle length; (2) there were no between-group dif-
ferences in terms of the functional improvement or
pain relief; and (3) low-level laser therapy, when
Melo et al. 7

Table 3.  Time elapsed and pain scale during the Timed Up and Go Test, distance travelled and pain scale during
the 6-minute walk test and architectural variables during the study evaluation times.

Group Precontrol Preintervention Postintervention Δ% ES

TUG (s) Laser 9.8 ±2.2 9.7 ±2.7 9.7 ±3.3 0 0.01
  Neuromuscular electrical 9.2 ±1.5 9.0 ±1.5 8.8 ±1.4 –2 0.11
stimulation
  Combined 10.4 ±2.8 9.8 ±3.0 9.4 ±2.7 –4 0.13
  Laser 1.7 ±1.1 1.6 ±0.9 0.8 ±0.5* 50 0.88
Pain – TUG Neuromuscular electrical 2.2 ±1.3 2.1 ±1.7 0.8 ±0.6* 62 0.76
stimulation
  Combined 2,2 ±1.6 2.18 ±1.2 0.8 ±0.4* 63 1.15
6WT (m) Laser 440 ±70 430 ±80 470 ±80* 9 0.43
  Neuromuscular electrical 400 ±50 400 ±50 420 ±60* 5 0.51
stimulation
  Combined 370 ±70 380 ±70 410 ±80* 8 0.53
  Laser 2.3 ±1.1 2.3 ±1.3 1.6 ±0.8* 30 0.53
Pain – 6WT Neuromuscular electrical 3.5 ±1.9 3.4 ±2.1 0.9 ±0.5* 74 1.19
stimulation
  Combined 3.3 ±1.8 3.5 ±2.2 1.2 ±0.9* 66 1.04
Fascicle length (%) Laser 21.1 ±5.3 22.1 ±5.7 20.7 ±7.4 –6 <0.10
  Neuromuscular electrical 23.3 ±4.6 23.3 ±4.2 22.9 ±4.4 –2 <0.10
stimulation
  Combined 24.2 ±6.5 22.3 ±5.9 23.6 ±5.5 6 <0.10
Pennation angle (°) Laser 9.9 ±1.9 9.6 ±1.9 10.9 ±2.7 13 <0.10
  Neuromuscular electrical 9.3 ±2.3 9.8 ±2.8 12.2 ±2.7* 24 1.23
stimulation
  Combined 9.1 ±2.6 9.6 ±2.0 12.9 ±2.9* 34 1.21
Muscle thickness (cm) Laser 1.4 ±0.5 1.5 ±0.5 1.5 ±0.5 0 <0.10
  Neuromuscular electrical 1.4 ±0.3 1.5 ±0.3 1.9 ±0.3*,# 27 1.24
stimulation
  Combined 1.4 ±0.3 1.4 ±0.3 1.8 ±0.3*,# 29 0.75

Δ%: difference between the pre- and postintervention scores divided by the preintervention score; 6WT: 6-minute walk test; ES:
effect size; TUG: Timed Up and Go Test.
*Indicates significant differences between the pre- and postintervention tests (p < 0.01).
#Indicates significant differences between the neuromuscular electrical stimulation group or combined vs. the laser group in the
postintervention test (p < 0.001).

combined with neuromuscular electrical stimula- 12-week programme of neuromuscular electrical

tion, adds nothing to the muscle structure or func-
tional capacity gains.
Neuromuscular electrical stimulation alone and
in combination with low-level laser therapy, were
equally effective in restraining the deleterious
effects of osteoarthritis on the muscle thickness and
pennation angle. Both groups had a large effect for
these two parameters (Table 3). Similar results have
been reported by Suetta et al.,5 who found increases
in the muscle thickness and pennation angle after a
stimulation, plus voluntary lower limb exercise in
elderly individuals with hip osteoarthritis. Increases
in the muscle thickness and pennation angle have
been associated with increases in the parallel sar-
comeres (hypertrophy) and increased maximal
muscle force capacity.3,14,15
As neuromuscular adaptations are specific to
the type of overload on the musculoskeletal struc-
tures, the progressive increase in the neuromuscu-
lar electrical stimulation volume used in the
8 Clinical Rehabilitation 

Figure 2.  Ultrasonography images from a representative subject showing vastus lateralis muscles before
(preintervention) and after (postintervention) the neuromuscular electrical stimulation programme.
VI: vastus intermedius; VL: vastus lateralis.

present study was most likely responsible for the
increased fascicle pennation angle and muscle
thickness. A previous study from our group,3 using
an identical neuromuscular electrical stimulation
protocol, reported a similar increase in the muscle
thickness that was related to the increased fascicle
length but not to the pennation angle in 12 elderly
patients with knee osteoarthritis after eight weeks
of intervention. These results suggest that, despite
using the same electrical stimulation protocol, a
parallel increase in the number of sarcomeres was
responsible for the architectural changes in the
vastus lateralis in our study. However, in the study
by Vaz et al.,3 these changes were likely associated
with an increase in the number of serial sarcom-
eres. The reason for this different structural adap-
tation is yet unknown given that, with the exception
of the subject’s maximally tolerated stimulation
intensity, the neuromuscular electrical stimulation
parameters used during the interventions were the
same in both studies.
Future investigations will try to identify whether
the stimulation intensity is different between the
two groups of these studies, and whether this
variable can explain the observed differences in
parallel and serial hypertrophy. Nevertheless, the
results of both studies confirm that neuromuscular
electrical stimulation treatment is an effective strat-
egy for restraining (and/or postponing) the charac-
teristic muscle atrophy associated with knee
osteoarthritis. However, it is still unclear whether
neuromuscular electrical stimulation can change
the fascicle length or optimal angle for force pro-
duction, and these issues require further
investigation.
The neuromuscular electrical stimulation proto-
col is critical for the induction of quadriceps mor-
phological and functional changes. High-intensity
electrical stimulation has been recommended when
the training is aimed at improving the strength;24,25
a significant linear correlation between current
intensity, the number of activated motor units and,
consequently, the measured external force has
already been shown.26 However, progressive
increases in the intensity of neuromuscular electri-
cal stimulation are limited to the maximal discom-
fort tolerated by subjects, limiting our ability to
increase the mechanical overload on the muscle
Melo et al. 9
structures. The present study shows that, in addi-
tion to the electrical stimulation increase, when
aiming to promote muscle strengthening and to
minimise muscle atrophy, neuromuscular electrical
stimulation protocols should ideally provide
increases in the treatment volume.
The fact that no between-group differences in
terms of the functional and pain outcomes were
observed was unexpected, because our hypothesis
was that low-level laser therapy should potentiate
electrical stimulation effects owing to the anti-
inflammatory and analgesic effects at the knee
joint. As no within-group differences were
observed during the control period, postinterven-
tion improvements seem to be related to the real
effects caused by the tested therapies. The neuro-
muscular electrical stimulation findings, regarding
the functional and pain outcomes, are in accord-
ance with previous knee osteoarthritis studies per-
formed on elderly subjects.27,28. However, the
low-level laser therapy effect observed on the func-
tional capacity of the osteoarthritic patients was
reported for the first time.
The improvements in the 6-minute walk test
performance associated with pain relief, suggest
that reducing muscle weakness is not the only fac-
tor that produces functional improvement. The
reduction in joint inflammation and pain owing to
laser treatment might have been responsible for
this performance improvement. Furthermore, if
muscle weakness associated with muscle atrophy
has a unique influence on the progression of oste-
oarthritis,29 pain and inflammation at the initial
disease stages should accelerate the degenerative
process via muscle inhibition.30,31 Considering the
well-established analgesic effect of low-level
laser therapy,10–12,18 laser treatment most likely
blocked the vicious cycle of pain, thereby decreas-
ing muscle inhibition and increasing physical
activity that had been reduced as a strategy to
avoid pain. Ultimately, this will minimise muscle
weakness.
Our main hypothesis was that the combined use
of low-level laser therapy and neuromuscular elec-
trical stimulation should have additional improve-
ments on muscle structure and functional capacity,
because reduced pain and inflammation should
reduce muscle inhibition and muscle weakness,
amplifying the effects of electrical stimulation on
muscle strengthening. However, low-level laser
therapy did not potentiate the effects of neuromus-
cular electrical stimulation as had been initially
expected. Although one could posit that combined
neuromuscular electrical stimulation and low-level
laser treatment are not more effective than neuro-
muscular electrical stimulation therapy alone, it is
important to mention that pain is the main clinical
symptom used for assessing the severity of this
degenerative disease; therefore, low-level laser
therapy should be considered an important clinical
tool for treating osteoarthritic patients. One of the
possible limitations of this approach might be that
only six points were used for the laser therapy
treatment. Perhaps additional points, or even higher
doses, might be necessary to affect the structural
outcomes. Additionally, the fact that participants
were allowed to use analgesic or anti-inflammatory
drugs might have altered the effect of low-level
laser therapy.17
Another possibility is that the addition of low-
level laser therapy to neuromuscular electrical
stimulation generated a false negative effect (Type
II error), caused by the statistical test power
because the calculation used to determine the sam-
ple size considered a large effect size based on data
obtained from the use of neuromuscular electrical
stimulation alone in similar studies. However, even
if the above-stated possibilities are not confirmed,
it is important to note that the combined group
patients might have obtained additional clinical
benefits (not evaluated via ultrasound or functional
tests) that patients receiving the isolated therapy
did not obtain.
Despite the body of evidence on the positive
effects of low-level laser therapy on cartilage,20,21 a
placebo effect might have contributed to the
patients’ improved performance on the 6-minute
walk test. As an investigation of the real analge-
sic,19 anti-inflammatory11 and regenerative20,21
effects on cartilage is beyond the focus of the pre-
sent study, future studies could use magnetic reso-
nance imaging to evaluate the effect of low-level
laser therapy on cartilage structure and inflamma-
tory markers in osteoarthritic patients, and to assess
10 Clinical Rehabilitation 
the correlation of these effects with the clinical
findings of improved functionality.
Clinical messages
•• Neuromuscular electrical stimulation
with progressive volume and intensity
promotes incremental changes in the
muscle structure and function.
•• The combination of low-level laser ther-
apy and neuromuscular electrical stimula-
tion did not produce any additional
benefits in the muscle structure and
function.
Contributors
● MOM: Conception and design, training, data acqui-
sition and data analysis, drafting, revising and final
approval of the manuscript. BMB: Conception and
design, revising and final approval of the manu-
script. KP, GAB, DPSJ: Acquisition, analyses and
interpretation of data. MAV: Conception, design,
training and supervision, data analysis and interpre-
tation, English review and final approval of the
manuscript.
Acknowledgement
This work was supported by the Financiadora de
Estudos e Projetos Ministério da Ciência e Tecnologia
– FINEP [ 105074400], Fundação de Amparo e Ensino
à Pesquisa – PAPERGS [1015272 ] and Conselho
Nacional de Desenvolvimento Científico e Tecnológico
– CNPq [ 304039/2012-8].
Conflict of interest
The authors report no conflict of interest.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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