## 4 Discussion  
In this pilot study, we showed that US-guided RF ablation of genicular nerves combined with physical exercise might be effective in reducing pain in patients affected by KOA in the short-term period. These results are intriguing considering the heavy burden of chronic pain that affects different domains of HRQoL and functioning and the lack of rapid and effective treatment strategies [16,17]. We observed a significant reduction in pain, with mean NPRS almost halved compared to baseline (7.48 vs. 3.63; \(p<0.005\)) in just 2 weeks after the treatment. Moreover, our results are in line with those of [PERSON] et al. [17] that in a recent RCT showed that the short-term effects of RF were significantly better compared to intraarticular glucocorticoid joint injection in KOA patients. Furthermore, in the present study, there was a significant improvement in physical function and ADL, as assessed by the improvement in all the KOOS domains. However, RF did not significantly change the KOOS \"symptoms domain\", probably because it could not influence the pathophysiology of OA. On the other hand, our findings emphasize the positive effects of this combined RF and rehabilitative intervention in terms of pain, ADL, function, and quality of life subscales improvement and are in line with previous studies that assessed the positive role of RF on disability with similar outcome scales [16,31,32,33]. Lastly, this study confirmed that US-guided RF ablation of genicular nerves might be considered as a safe technique in KOA patients, as already assessed by previous studies [16,31]. In addition, our results reported for the first time the feasibility and the safety of a combined non-pharmacological treatment involving both US-guided RF geniculate ablation and physical exercise. Noticeably, it should be underlined that a US-guided cannula positioning is mandatory to perform a correct nerve ablation. A recent RCT [31] compared US-guided RF to fluoroscopy-guided RF  
Figure 2: Differences between baseline (T0) and 1 month (T1) in the outcome measures (\(n=47\)). Abbreviations: ADL: Activities of daily living; EQ-5D: EuroQoL. Five Dimensions; EQ-VAS: EuroQol Visual Analogue Scale; KOOS: Knee Injury and Osteoarthritis Outcome Score; NPRS: Numeric Pain Rating Scale; QoL: Quality of Life; T0: Baseline; T1: 1 Month after treatment. without finding any significant differences in terms of pain relief, functional improvement, and safety. US guidance could be considered as safer (no radiation exposure) and easy to use also in outpatient settings. Therefore, we confirmed the promising results previously described in the literature and support the US-guided RF as a useful and safe treatment for knee OA pain. To date, the efficacy of physical exercise interventions on muscle strength and functional improvement in patients suffering from KOA is debated [21, 22, 23, 24]. However, one of the most common factors negatively influencing physical exercise efficacy is knee pain that dramatically reduces the overall compliance to these interventions [25]. In the present study, US-guided RF treatment was proposed not only to reduce pain but also as a synergic and feasible intervention aiming at promoting physical exercise interventions in patients with KOA. To date, the European League Against Rheumatism and the ACR/Arthritis Foundation guidelines recommended lifestyle interventions to promote physical activity, involving multidisciplinary health professionals in a non-pharmacological approach [34, 35]. However, the optimal approach to promote adherence to physical activity in patients suffering from KOA remains unclear. In this scenario, our preliminary data showed promising results in reducing pain and improving functioning and HRQoL, suggesting that a comprehensive tailored approach focusing on early pain management could minimize the functional consequences of KOA, as previously reported in other chronic pain conditions [36, 37, 38].