ORIGINAL RESEARCH| Volume 103, ISSUE 9, P1707-1714, September 2022

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Effect of Neuromuscular Electrical Stimulation During Walking on Pain Sensitivity in Women With Obesity With Knee Pain: A Randomized Controlled Trial

Published:March 22, 2022DOI:


      • The combination of voluntary contractions with electrical stimulation is effective for reducing peripheral pain sensitivity locally at the knee in women with obesity with knee osteoarthritis.
      • Walking combined with electrical stimulation improves symptomatic knee pain and quality of life.
      • Walking combined with electrical stimulation would be a simple and easy-to-implement means of reducing peripheral sensitivity.



      To assess the extent to which pain sensitivity is altered in women with obesity with frequent knee symptoms who walk with either a hybrid training system (HTS) that provides antagonist muscle electrical stimulation vs sensory transcutaneous electrical nerve stimulation (TENS).


      Randomized, double-blinded, controlled trial.


      University-based fitness center.


      Twenty-eight women (N=28) with obesity, aged 40-70 years, with daily knee symptoms.


      Participants were randomized to 12 weeks of biweekly 30-minute walking exercise with either HTS (HTSW group) or sensory TENS (control group).

      Main Outcome Measures

      Pressure pain thresholds (PPTs) at the more symptomatic knee (local PPT) and PPT at the ipsilateral pain-free wrist (remote PPT).


      After adjustment for preintervention values and body mass index (BMI), there was a statistically significant improvement in local PPT in the HTSW group compared with the control group (P=.039). After adjustment for pretraining value, age, and BMI, changes in remote PPT when comparing groups did not reach statistical significance, although the HTS group tended to demonstrate increased remote PPT (P=.052) compared with the control group. Moreover, after adjustment for pretraining value, knee pain, and quality of life, comparing groups did not reach statistical significance, although the HTS group tended to demonstrate decreased knee pain (P=.069) compared with the control group.


      Augmentation of walking exercise with HTS was more effective than application of sensory TENS in improving local pain sensitivity at the knee but not at the wrist in women with obesity with frequent knee symptoms.


      List of abbreviations:

      BMI (body mass index), ES (electrical stimulation), HTS (hybrid training system), HTSW (hybrid training system during walking), KOA (knee osteoarthritis), KOOS (Knee Injury and Osteoarthritis Outcome Score), PPT (pressure pain threshold), TENS (transcutaneous electrical nerve stimulation), VAS (visual analog scale), VC (volitional contraction)
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        • Blagojevic M
        • Jinks C
        • Jeffery A
        • Jordan KP.
        Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis.
        Osteoarthritis Cartilage. 2010; 18: 24-33
        • Stone AA
        • Broderick JE.
        Obesity and pain are associated in the United States.
        Obesity (Silver Spring). 2012; 20: 1491-1495
        • Sylwander C
        • Larsson I
        • Haglund E
        • Bergman S
        • Andersson MLE.
        Pressure pain thresholds in individuals with knee pain: a cross-sectional study.
        BMC Musculoskelet Disord. 2021; 22: 516
        • Nguyen US
        • Zhang Y
        • Zhu Y
        • Niu J
        • Zhang B
        • Felson DT.
        Increasing prevalence of knee pain and symptomatic knee osteoarthritis: survey and cohort data.
        Ann Intern Med. 2011; 155: 725-732
        • Carlesso LC
        • Segal NA
        • Frey-Law L
        • et al.
        Pain susceptibility phenotypes in those free of knee pain with or at risk of knee osteoarthritis: the Multicenter Osteoarthritis Study.
        Arthritis Rheumatol. 2019; 71: 542-549
        • Schaible HG.
        Mechanisms of chronic pain in osteoarthritis.
        Curr Rheumatol Rep. 2012; 14: 549-556
        • Fingleton C
        • Smart K
        • Moloney N
        • Fullen BM
        • Doody C.
        Pain sensitization in people with knee osteoarthritis: a systematic review and meta-analysis.
        Osteoarthritis Cartilage. 2015; 23: 1043-1056
        • Wang Y
        • Teichtahl AJ
        • Abram F
        • et al.
        Knee pain as a predictor of structural progression over 4 years: data from the Osteoarthritis Initiative, a prospective cohort study.
        Arthritis Res Ther. 2018; 20: 250
        • Donnelly JE
        • Smith B
        • Jacobsen DJ
        • et al.
        The role of exercise for weight loss and maintenance.
        Best Pract Res Clin Gastroenterol. 2004; 18: 1009-1029
        • Barrow DR
        • Abbate LM
        • Paquette MR
        • et al.
        Exercise prescription for weight management in obese adults at risk for osteoarthritis: synthesis from a systematic review.
        BMC Musculoskelet Disord. 2019; 20: 610
        • Henriksen M
        • Klokker L
        • Graven-Nielsen T
        • et al.
        Association of exercise therapy and reduction of pain sensitivity in patients with knee osteoarthritis: a randomized controlled trial.
        Arthritis Care Res (Hoboken). 2014; 66: 1836-1843
        • Fingleton C
        • Smart KM
        • Doody CM.
        Exercise-induced hypoalgesia in people with knee osteoarthritis with normal and abnormal conditioned pain modulation.
        Clin J Pain. 2017; 33: 395-404
        • Lima LV
        • Abner TSS
        • Sluka KA.
        Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena.
        J Physiol. 2017; 595: 4141-4150
        • Juhl C
        • Christensen R
        • Roos EM
        • Zhang W
        • Lund H.
        Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials.
        Arthritis Rheumatol. 2014; 66: 622-636
        • Stolzman S
        • Danduran M
        • Hunter SK
        • Bement MH.
        Pain response after maximal aerobic exercise in adolescents across weight status.
        Med Sci Sports Exerc. 2015; 47: 2431-2440
        • Marks R.
        Knee osteoarthritis and exercise adherence: a review.
        Curr Aging Sci. 2012; 5: 72-83
        • Poirier P
        • Despres JP.
        Exercise in weight management of obesity.
        Cardiol Clin. 2001; 19: 459-470
        • Stemberger R
        • Kerschan-Schindl K.
        Osteoarthritis: physical medicine and rehabilitation–nonpharmacological management.
        Wien Med Wochenschr. 2013; 163: 228-235
        • Rutjes AW
        • Nuesch E
        • Sterchi R
        • et al.
        Transcutaneous electrostimulation for osteoarthritis of the knee.
        Cochrane Database Syst Rev. 2009; 4CD002823
        • Paillard T.
        Combined application of neuromuscular electrical stimulation and voluntary muscular contractions.
        Sports Med. 2008; 38: 161-177
        • Yanagi T
        • Shiba N
        • Maeda T
        • et al.
        Agonist contractions against electrically stimulated antagonists.
        Arch Phys Med Rehabil. 2003; 84: 843-848
      1. N Shiba, T Maeda, Y Tagawa, et al. inventors; Kurume University, assignee. Apparatus for strengthening muscles. U.S. patent 6,456,885. 09/24/2002.

        • Matsuse H
        • Hashida R
        • Takano Y
        • et al.
        Walking exercise simultaneously combined with neuromuscular electrical stimulation of antagonists resistance improved muscle strength, physical function, and knee pain in symptomatic knee osteoarthritis: a single-arm study.
        J Strength Cond Res. 2017; 31: 171-180
        • Matsuse H
        • Segal NA
        • Rabe KG
        • Shiba N.
        The effect of neuromuscular electrical stimulation during walking on muscle strength and knee pain in obese women with knee pain: a randomized controlled trial.
        Am J Phys Med Rehabil. 2020; 99: 56-64
        • Bennell KL
        • Hall M
        • Hinman RS.
        Osteoarthritis year in review 2015: rehabilitation and outcomes.
        Osteoarthritis Cartilage. 2016; 24: 58-70
        • Roos EM
        • Roos HP
        • Lohmander LS
        • Ekdahl C
        • Beynnon BD.
        Knee Injury and Osteoarthritis Outcome Score (KOOS)–development of a self-administered outcome measure.
        J Orthop Sports Phys Ther. 1998; 28: 88-96
        • Collins NJ
        • Prinsen CA
        • Christensen R
        • Bartels EM
        • Terwee CB
        • Roos EM.
        Knee Injury and Osteoarthritis Outcome Score (KOOS): systematic review and meta-analysis of measurement properties.
        Osteoarthritis Cartilage. 2016; 24: 1317-1329
        • Takano Y
        • Haneda Y
        • Maeda T
        • et al.
        Increasing muscle strength and mass of thigh in elderly people with the hybrid-training method of electrical stimulation and volitional contraction.
        Tohoku J Exp Med. 2010; 221: 77-85
        • Rabe KG
        • Matsuse H
        • Jackson A
        • Segal NA.
        Evaluation of the combined application of neuromuscular electrical stimulation and volitional contractions on thigh muscle strength, knee pain, and physical performance in women at risk for knee osteoarthritis: a randomized controlled trial.
        PM R. 2018; 10: 1301-1310
        • Mutlu EK
        • Ozdincler AR.
        Reliability and responsiveness of algometry for measuring pressure pain threshold in patients with knee osteoarthritis.
        J Phys Ther Sci. 2015; 27: 1961-1965
        • Graven-Nielsen T
        • Arendt-Nielsen L.
        Assessment of mechanisms in localized and widespread musculoskeletal pain.
        Nat Rev Rheumatol. 2010; 6: 599-606
        • Bergman S
        • Thorstensson C
        • Andersson MLE.
        Chronic widespread pain and its associations with quality of life and function at a 20- year follow-up of individuals with chronic knee pain at inclusion.
        BMC Musculoskelet Disord. 2019; 20: 592
        • Carlesso LC
        • Segal NA
        • Curtis JR
        • et al.
        Knee pain and structural damage as risk factors for incident widespread pain: data from the Multicenter Osteoarthritis Study.
        Arthritis Care Res (Hoboken). 2017; 69: 826-832
        • Torgen M
        • Swerup C.
        Individual factors and physical work load in relation to sensory thresholds in a middle-aged general population sample.
        Eur J Appl Physiol. 2002; 86: 418-427
        • Swift DL
        • Johannsen NM
        • Lavie CJ
        • Earnest CP
        • Church TS.
        The role of exercise and physical activity in weight loss and maintenance.
        Prog Cardiovasc Dis. 2014; 56: 441-447
        • Nijs J
        • Malfliet A
        • Ickmans K
        • Baert I
        • Meeus M.
        Treatment of central sensitization in patients with 'unexplained' chronic pain: an update.
        Expert Opin Pharmacother. 2014; 15: 1671-1683
        • Belavy DL
        • Van Oosterwijck J
        • Clarkson M
        • et al.
        Pain sensitivity is reduced by exercise training: evidence from a systematic review and meta-analysis.
        Neurosci Biobehav Rev. 2021; 120: 100-108
        • Eckstein F
        • Lemberger B
        • Gratzke C
        • et al.
        In vivo cartilage deformation after different types of activity and its dependence on physical training status.
        Ann Rheum Dis. 2005; 64: 291-295
        • Matsuse H
        • Shiba N
        • Takano Y
        • Yamada S
        • Ohshima H
        • Tagawa Y.
        Cycling exercise to resist electrically stimulated antagonist increases oxygen uptake in males: pilot study.
        J Rehabil Res Dev. 2013; 50: 545-554
        • Gibson W
        • Wand BM
        • Meads C
        • Catley MJ
        • NE O'Connell
        Transcutaneous electrical nerve stimulation (TENS) for chronic pain - an overview of Cochrane Reviews.
        Cochrane Database Syst Rev. 2019; 4CD011890
        • Moran F
        • Leonard T
        • Hawthorne S
        • et al.
        Hypoalgesia in response to transcutaneous electrical nerve stimulation (TENS) depends on stimulation intensity.
        J Pain. 2011; 12: 929-935
        • Iwanaga S
        • Hashida R
        • Takano Y
        • et al.
        Hybrid training system improves insulin resistance in patients with nonalcoholic fatty liver disease: a randomized controlled pilot study.
        Tohoku J Exp Med. 2020; 252: 23-32
        • Naugle KM
        • Fillingim RB
        • Riley 3rd, JL
        A meta-analytic review of the hypoalgesic effects of exercise.
        J Pain. 2012; 13: 1139-1150
        • Omoto M
        • Matsuse H
        • Takano Y
        • et al.
        Oxygen uptake during aerobic cycling exercise simultaneously combined with neuromuscular electrical stimulation of antagonists.
        J Nov Physiother. 2013; 3: 185
        • Ote Karaca S
        • Demirsoy N
        • Gunendi Z
        Effects of aerobic exercise on pain sensitivity, heart rate recovery, and health-related quality of life in patients with chronic musculoskeletal pain.
        Int J Rehabil Res. 2017; 40: 164-170
        • Karelis AD
        • Fontaine J
        • Messier V
        • et al.
        Psychosocial correlates of cardiorespiratory fitness and muscle strength in overweight and obese post-menopausal women: a MONET study.
        J Sports Sci. 2008; 26: 935-940
        • Kuni B
        • Wang H
        • Rickert M
        • Ewerbeck V
        • Schiltenwolf M.
        Pain threshold correlates with functional scores in osteoarthritis patients.
        Acta Orthop. 2015; 86: 215-219
        • Roos EM
        • Arden NK.
        Strategies for the prevention of knee osteoarthritis.
        Nat Rev Rheumatol. 2016; 12: 92-101
        • Kosek E
        • Roos EM
        • Ageberg E
        • Nilsdotter A.
        Increased pain sensitivity but normal function of exercise induced analgesia in hip and knee osteoarthritis–treatment effects of neuromuscular exercise and total joint replacement.
        Osteoarthritis Cartilage. 2013; 21: 1299-1307
        • Ylinen J
        • Takala EP
        • Kautiainen H
        • et al.
        Effect of long-term neck muscle training on pressure pain threshold: a randomized controlled trial.
        Eur J Pain. 2005; 9: 673-681
        • Hashida R
        • Takano Y
        • Matsuse H
        • et al.
        Electrical stimulation of the antagonist muscle during cycling exercise interval training improves oxygen uptake and muscle strength.
        J Strength Cond Res. 2021; 35: 111-117
        • Vance CG
        • Rakel BA
        • Blodgett NP
        • et al.
        Effects of transcutaneous electrical nerve stimulation on pain, pain sensitivity, and function in people with knee osteoarthritis: a randomized controlled trial.
        Phys Ther. 2012; 92: 898-910