Electromagnetic Field Therapy: A Rehabilitative Perspective in the Management of Musculoskeletal Pain – A Systematic Review

Figures & data

Figure 1 Flowchart of the included studies in the review according to the PRISMA 2009 guidelines.

Table 1 PEDro Score Values and Other Characteristics of the Included Studies

Author (Year Published) ^[Ref.]	Diagnosis	N (M/F) Mean± SD Age (Years)	Study	N TG (Mean± SD Age) CG (Mean± SD Age)	Intervention	Outcome Parameters	Evaluation Time	Conclusions	PEDro Score
Ay et al (2009)^Citation31	OA	N=55 (15/40)	RCT	TG=30 (58,9±8,8) CG=25 (57,7±6,5)	TG: PEMF, hot pack, TENS and exercise program; CG: sham-PEMF, hot pack, TENS and exercise program	VAS: pain; Likert pain scale: pain; LI: function	T0: baseline T1: 3 weeks	VAS: TG=CG LI: TG=CG	6/10
Bagnato et al (2016)^Citation30	OA	N=60 (43/17) y=67,7±10,9	RCT	TG=30 (68,6±11,9) CG=30 (66,9±10)	TG: PRFE CG: placebo	VAS: pain; WOMAC: function, pain, disability SF-36: QoL	T0: baseline T1: 1 month	VAS, WOMAC: TG>CG SF-36:TG=CG	9/10
Brook et al (2012)^Citation42	PF	N=70 (18/52)	RCT	TG=42 (53,2±14,7) CG=28 (49,7±15,2)	TG: PRFE CG: sham-PRFE	VAS: pain	T0: baseline T1: 1 day T2: 2 days T3: 3 days T4: after 4 days T5: 5 days T6: 6 days T7: 7 days	VAS: TG>CG	8/10
Dündar et al (2016)^Citation34	OA	N=40 (11/29)	RCT	TG= 20 (56.8±14.5) CG= 20 (57.6±13.8)	TG: hot pack, ultrasound, TENS, isometric knee exercise and PEMF CG: hot pack, ultrasound, TENS, isometric knee exercise and sham-PEMF	VAS: pain WOMAC: function, pain Ultrasonographic effusion of the knee Serum YKL-40 a novel biomarker of osteoarthritis	T0: before treatment T1: 1 month	WOMAC: TG=CG VAS: TG=CG	5/10
Galace de Freitas et al (2014)^Citation35	SIS	N=56 (20/36) y=50,5±8,9	RCT	TG=26 (50,1±8,2) CG=30 (50,8±9,6)	TG: PEMF and exercises; CG: placebo and exercises	VAS: pain; CMS: function; UCLA: function; Handheld dynamometry: strength	T0: baseline T1: 3 weeks T2: 9 weeks T3: 3 months	VAS, UCLA, CMS, Dynamometry: TG>CG	9/10
Giombini et al (2013)^Citation37	CNP	N=45 (14/31)	Prospective RCT	TG=15 (44.0±9.6) CG1=15 (40.5±7.4) CG2=15 (43.0±9.4)	TG: PEMF CG1: neck balance system CG2: neck balance system with negligible balancing	VAS: pain NDI: disability NPDS: QoL	T0: baseline; T1: end of 8 week T2: after follow-up 12 weeks	VAS: CG1>TG>CG2 NDI: CG1>TG>CG2 NPDS: CG1> CG2 > TG	8/10
Gökşen et al (2016)^Citation32	OA	N=97	RCT	TG=49 (54.02±6.79) CG= 48 (54.92±7.5)	TG: magnetic treatment CG: sham-magnetic treatment	VAS: pain WOMAC: function, pain, disability SF-36: QoL	T0: baseline; T1: end of 2 week T2: follow-up after 12 weeks	VAS, WOMAC, SF-36: TG=CG	9/10
Kanat et al (2013)^Citation43	HO	N= 50	RCT	TG= 25 (64±2.6) CG= 25 (62±2.4)	TG: PEMF + exercise CG: sham PEMF + exercise	Likert scale: pain at rest, pain at motion, joint stiffness SF-36: QoL Duruöz: function AUSCAN: pain, stiffness and disability HG and PG: strength	T0: baseline T1: after treatment T3: follow-up one month after treatment	SF-36: TG>CG Duruöz: TG>CG AUSCAN: TG>CG HG: TG=CG, PG: TG=CG	7/10
Klüter et al (2018)^Citation36	SIS	N=86 (41/45)	RCT	TG=44 (50,21±8,5) CG=42 (49,21±7,3)	TG: EMTT/ESWT; CG: sham-EMTT/ESWT	VAS: pain; CMS: function	T0: baseline T1: 6 weeks T2: 12 weeks T3: 24 weeks	VAS: TG>CG CMS: TG>CG	9/10
Krammer et al (2015)^Citation39	LBP	N=40 (20/20)	RCT	TG=20 (35,7) CG=20 (30,2)	TG: PEMF and physiotherapy treatment; CG: sham -PEMF and physiotherapy treatment	NRS: pain ODI: disability PSFS: function	T0: baseline T1: 1 week T2: 4 weeks	NRS, ODI, PSFS: TG=CG	8/10
Külcü et al (2009)^Citation33	OA	N=45	RCT	TG =15 (65.8±10.3) TG1 = 15 (63.1±13.6) CG =15 (62.0±6.0)	TG: PEMF TG1: US CG: control	VAS: pain WOMAC: function, pain, stiffness	T0: baseline T1: end of three weeks	VAS, WOMAC: TG, TG1>CG	5/10
Multanen et al (2018)^Citation17	FM	N=108 y=47±10	RCT (cross-over)	TG=57 CG=51	TC: PEMF CG: sham-PEMF	VAS: pain, stiffness FIQ: QoL and disability	T0: baseline T1: end of 12 week T2: after washout 16 week T3: end of 28 week	VAS: TG= CG FIQ: TG= CG	10/10
Nelson et al (2013)^Citation27	OA	N=34	RCT	TG=15 (55.5±2.5) CG= 19 (58.4±2.5)	TG: PEMF CG: Sham-PEMF	VAS: pain	T0: baseline T1: end of day 3 T2: end of day 14 T3: end of day 29 T4: end of day 42	VAS: TG>CG	10/10
Oke et al (2013)^Citation38	BP	N=16 (9/7) y= 26.00 ± 8.62	RCT	TG=8 CG=8	TG: PEMF + FANS CG: FANS	NRS: pain Functional Activity Scale	T0: baseline T1: end of treatment (after 5–9 days)	NRS, Functional Activity Scale: TG>CG	4/10
Omar et al (2012)^Citation14	LBP (Unilateral Radicular Pain)	N=40	RCT	TG=20 (37.5±8.5) CG= 20 (40.0±8.3)	TG: PEMF CG: sham-PEMF	VAS: pain OSW: disability SSEPs: nerve conduction	T0: baseline T1: end of 8 week T2: after follow-up 12 weeks	VAS, OSW, SSEPs: TG>CG	5/10
Özgüçlü et al (2010)^Citation28	OA	N=40	RCT	TG=20 (60.55±7.7) CG= 20 (62.15±8.1)	TG: isometric knee+ hot pack+ therapeutic ultrasound+ PEMF exercise CG: isometric knee+ hot pack+ therapeutic ultrasound+ sham PEMF	VAS: pain WOMAC: function, pain, disability	T0: baseline T1: end of 2 week	VAS, WOMAC: TG=CG	6/10
Paolucci et al (2016)^Citation18	FM	N=37 (F) y=50.33±10.94	RCT (cross-over)	TG1=16 (49.5±9.38) TG2 =17 (51.12±12.47)	TG1: ELF/sham-ELF TG2: sham-ELF/ELF	VAS: pain FAS: pain, fatigue and quality of sleep FIQ: QoL and disability HAQ: QoL and daily activities	T0: baseline; T1: end of 1 treatment cycle T2: beginning of 2 treatment cycle (after a 1-month washout) T3: end of 2 treatment cycle T4: follow-up after 1 month	VAS, FAS: T1:TG1<TG2 T3:TG2<TG1 FIQ, HAQ: T1: TG1<TG2 T3: TG2<TG1	8/10
Park et al (2014)^Citation16	LM (Lumbar Myalgia)	N= 38 (11/27) y=31.95±12.30	RCT	TG=19 (33.00±11.06) CG=19 (30.89±13.66)	TG: PEMF CG: placebo	VAS: pain ODI: function SF-36, EQ-5D: QoL BDI: depression RMDQ: disability	T0: baseline T1: after the 6^th treatment T2: follow-up after 1 week	VAS, RMDQ: TG>CG ODI, SF-36, EQ-5D, BDI: TG=CG	9/10
Servodio Iammarrone et al (2016)^Citation41	PFP	N= 31 y=22.5	RCT	TG: 13 (21±7) CG: 17 (24±8)	TG: PEMF, Home exercise program CG: Home exercise program	VAS: pain VISA: pain, functional mobility, QoL	T0: baseline T1: 2 months T2: 6 months T3: 12 months	VISA T1: TG=CG VISA T2-T3: TG>CG VAS: TG<CG	6/10
Sutbeyaz et al (2009)^Citation40	FM	N=56	RCT	TG=28 (42.96±9.57) CG=28 (40.89±6.88)	TG: PEMF CG: sham-PEMF	VAS: pain FIQ: QoL and disability BDI: depression SF-36: QoL PGART: patient’s global assessment	T0: baseline; T1: end of 3week T2: follow-up after 12 weeks	VAS: TG>CG FIQ, SF-36: TG >CG BDI: CG>TG PGART: debated	8/10
Wuschech et al (2015)^Citation29	OA	N=57	RCT	TG=44 (63.4±12.1) CG=13 (55.5±10.8)	TG: PEMF CG: placebo	VAS: pain WOMAC: function, pain, disability	T0: baseline; T1: end of 18 days	VAS, WOMAC: TG>CG	9/10

Abbreviations: OA, knee osteoarthritis; PF, plantar fasciitis; SIS, shoulder impingement syndrome; CNP, chronic mechanical neck pain; HO, hand osteoarthritis; LBP, low back pain; FM, fibromyalgia; BP, back pain; LM, lumbar myalgia; PFP, patellofemoral pain; PPS, parallel prospective study; RCT, randomized controlled trial; TG, treatment group; CG, control group; PEMF, pulsed electromagnetic fields; PRFE, pulsed radiofrequency electromagnetic field therapy; US, therapeutic ultrasound; EMTT/ESWT, electromagnetic transduction therapy/extracorporeal shockwave therapy; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; RMS, Roles–Maudsley score; CMS, Constant–Murley scale; UCLA, University of California/Los Angeles; SF-36, Short-Form 36 version-2; NDI, Neck Disability Index; NRS, numerical rating scale; LI, Lequesne algofunctional index; FIQ, Fibromyalgia Impact Questionnaire; FAS, Fibromyalgia Assessment Scale; HAQ, Health Assessment Questionnaire; BDI, Beck Depression Inventory; PGART, patient’s global assessment rating scale; NPDS, neck pain disability scale; OSW, Modified Oswestry Low Back Pain Disability Questionnaire; SSEPs, somatosensory evoked potentials; FSS, Fatigue Severity Scale; MFIS, Modified Fatigue Impact Scale; ROM, range of motion; VISA, Victorian Institute of Sport Assessment score; AUSCAN, Australian Canadian Osteoarthritis Hand Index; Duruöz, Duruöz Hand Index; HG, hand grip; PG, pinch grip; ODI, Oswestry Disability Index; EQ-5D, EuroQol-5 Dimension; RMDQ, Roland-Morris Disability Questionnaire; PSFS, Patient Specific Functional Scale.

Table 2 Type of Magnetic Field and Parameters Used in the Included Studies

Author (Year Published) ^[Ref.]	Diagnosis	Magnetic Fields	Frequency	Intensity	Duty Cycle	Wave’s Type	Duration of Singles Session/Number of Sessions of Treatment Group
Ay et al (2009)^Citation31	OA	PEMF	50 Hz	105 µT	NA	NA	30 min/5 per week/3 weeks
Bagnato et al (2016)^Citation30	OA	PRFE	27,12 MHz (pulse rate of 1000 Hz and a 100 µs burst width)	NA	NA	NA	Nightly/11,3± 0, 8 h/day/4 weeks
Brook et al (2012)^Citation42	PF	PRFE	27,12 MHz (pulse rate of 1000 Hz and a 100 µs burst width)	NA	NA	NA	Nightly for 7 days
Dündar et al (2016)^Citation34	OA	PEMF	50 Hz	100 µT	NA	NA	20min/5 per week/4 weeks
Galace de Freitas et al (2014)^Citation35	SIS	PEMF	50 Hz	20 mT	NA	NA	30 min/3 per week/3 weeks
Giombini et al (2013)^Citation37	CNP	PEMF whole body	5–25 Hz	5–70 µT	NA	Sinusoidal wave	2 hours/twice a day/8weeks
Gökşen et al (2016)^Citation32	OA	Magnetic Treatment	17–85 kHz	NA	NA	NA	1 hour/5 per week/2weeks
Kanat et al (2013)^Citation43	HO	PEMF	NA	3.5–25 mT	NA	NA	20 min/once a day for 10 days
Klüter et al (2018)^Citation36	SIS	EMTT	3 Hz	80 µT	NA	NA	20 min/2 per week/4 weeks
Krammer et al (2015)^Citation39	LBP	PEME	27.12 MHz (1000 pulses/s)	0.03 mT	NA	NA	For 7 days
Külcü et al (2009)^Citation33	OA	PEMF	2–100–25 Hz consecutively	2–10 mT	NA	NA	35 min/5 per week/3 weeks
Multanen et al (2018)^Citation17	FM	PEMF whole body	33,3Hz	0–150µT	NA	Sinusoidal half-wave	8 min twice a day/12weeks
Nelson et al (2013)^Citation27	OA	PEMF	6.8 MHz	NA	NA	Sinusoidal wave	15 min/twice a day/2 weeks
Oke et al (2013)^Citation38	BP	PEMF	NA	NA	NA	NA	2 hours per session; 4 per day for 5–9 days
Omar et al (2012)^Citation14	LBP (Unilateral Radicular Pain)	PEMF	7–4000 Hz	5–15 G	NA	NA	20min/once a day/3 weeks
Özgüçlü et al (2010)^Citation28	OA	PEMF	50 Hz	30 G	90-s interval	NA	30min/5 per week/2 weeks
Paolucci et al (2016)^Citation18	FM	ELF-MF whole body	1–80Hz	100 µT	NA	NA	30 min/3 per week/4 weeks
Park et al (2014)^Citation16	LM (Lumbar Myalgia)	PEMF	8.56 kHz	820 mT	NA	NA	10 min/3 per week/2 weeks
Servodio Iammarrone et al (2016)^Citation41	PFP	PEMF	75 Hz	1.5 mT	10%	Square waveform	4 h per day/6 weeks
Sutbeyaz et al (2009)^Citation40	FM	PEMF whole body	0.1–64Hz	40 µT	NA	NA	30 min/twice a day/3 weeks
Wuschech et al (2015)^Citation29	OA	PEMF	4–12 Hz	105 mT	NA	NA	5 min/twice a day/18 days

Abbreviations: OA, knee osteoarthritis; PF, plantar fasciitis; SIS, shoulder impingement syndrome; CNP, chronic mechanical neck pain; HO, hand osteoarthritis; LBP, low back pain; FM, fibromyalgia; BP, back pain; LM, lumbar myalgia; PFP, patellofemoral pain; PEMF, pulsed electromagnetic field; PRFE, pulsed radiofrequency electromagnetic field; ELF-MF, extremely low-frequency magnetic field; EMTT, electromagnetic transduction therapy; PEME, pulsed electromagnetic energy.

Table 3 Risk of Bias Summary of 21 Included Studies

		Random Sequence Generation	Allocation Concealment	Blinding of Participants and Personnel	Blinding of Outcome Assessment	Incomplete Outcome Data	Selective Reporting	Other Bias
Ay et al (2009)^Citation31	High	−	?	−	+	+	−	−
Bagnato et al (2016)^Citation30	Low	+	+	+	+	+	−	?
Brook et al (2012)^Citation42	Low	+	+	+	+	+	+	?
Dündar et al (2016)^Citation34	High	?	−	−	+	−	+	?
Galace de Freitas et al (2014)^Citation35	Low	+	+	+	+	+	+	?
Giombini et al (2013)^Citation37	Low	+	+	−	−	+	+	?
Gökşen et al (2016)^Citation32	Low	+	+	+	+	+	+	?
Kanat et al (2013)^Citation43	Unclear	?	?	+	−	+	−	?
Klüter et al (2018)^Citation36	Low	+	+	–	+	+	+	?
Krammer et al (2015)^Citation39	Low	+	+	+	+	−	−	?
Külcü et al (2009)^Citation33	High	+	−	−	−	−	+	?
Multanen et al (2018)^Citation17	Low	+	+	+	+	+	+	−
Nelson et al (2013)^Citation27	Low	+	?	+	+	+	−	?
Oke et al (2013)^Citation38	High	?	−	−	−	−	+	?
Omar et al (2012)^Citation14	Unclear	?	−	?	?	−	+	?
Özgüçlü et al (2010)^Citation28	Low	+	−	+	?	−	+	?
Paolucci et al (2016)^Citation18	Low	+	+	+	+	−	+	−
Park et al (2014)^Citation16	Low	+	+	+	+	+	+	?
Servodio Iammarrone et al (2016)^Citation41	Low	+	+	+	−	−	?	?
Sutbeyaz et al (2009)^Citation40	Low	+	+	+	+	+	+	?
Wuschech et al (2015)^Citation29	Low	?	+	+	+	−	?	?

Notes: The “+” means low risk of bias; the “−” means high risk of bias; the “?” means unknown risk of bias. Trials involving three or more high risks of bias were considered as poor methodological quality.

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