Quadriceps strengthening exercises may not change pain and function in knee
osteoarthritis
PII: S1360-8592(17)30137-7
DOI: 10.1016/j.jbmt.2017.06.013
Reference: YJBMT 1560
Please cite this article as: Bokaeian, H.R., Bakhtiary, A.H., Mirmohammadkhani, M., Moghimi, J.,
Quadriceps strengthening exercises may not change pain and function in knee osteoarthritis, Journal of
Bodywork & Movement Therapies (2017), doi: 10.1016/j.jbmt.2017.06.013.
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osteoarthritis.
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Hamid Reza Bokaeian, M.Sc1, Amir Hoshang Bakhtiary, Ph.D1*, Majid Mirmohammadkhani, Ph.D2,
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1. Neuromuscular Rehabilitation Research Centre, Rehabilitation Faculty, Semnan University of
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Medical Sciences, Semnan, Iran.
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2. Research Center for Social Determinants of Health, School of Medicine, Semnan University
Semnan, Iran.
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Short running title: Quadriceps strengthening may not change pain and
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function.
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Scores of funding: This research did not receive any specific grant from
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ABSTRACT
It is believed that Quadriceps strength training may reduce pain and improve
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functional activity in patients with knee osteoarthritis (OA). This improvement
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is generally attributed to an increase in quadriceps strength. This study
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improving functional activity in knee OA. Twenty-four patients with knee OA
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participated in an 8-week treatment protocol including traditional physical
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therapy and strength training 3 sessions per week. Measurements were
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conducted before and after the intervention and included the peak torque of
quadriceps muscle, pain by visual analogue scale (VAS), short Western Ontario
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by 2 minutes walking test (2MWT) and time up & go test (TUGT). After the
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This study showed that reduction in pain and improvement in functional activity
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occurs independently from an increase in quadriceps muscle strength in knee
OA. It seems that increased quadriceps muscle strength may not be a cause of
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activity, correlation
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INTRODUCTION
prevalence increases with aging (Sun et al., 2017). It imposed large economic
costs (around 23.9 billion dollars direct and indirect) on Australia government
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in 2007 (Jones et al., 2007). Knee OA is the most prevalent joint disease
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(Abdalbary, 2016). Its main pathologic feature is progressive loss of articular
cartilage (Sun et al., 2017) which creates a variety of clinical symptoms such as
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pain, joint effusion, joint stiffness, weakness, progressive muscle atrophy, joint
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instability, muscle contracture and limitation of a range of motions (Kaya Mutlu
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et al., 2017; Porter, 2003).
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improvement of function and quality of life (Fauci AS, 2008). Exercise therapy
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activities and quality of life in knee OA (Bennell et al., 2014; Lin et al., 2009;
McQuade & de Oliveira, 2011). These have also been confirmed by some
systemic review studies (Lange et al., 2008). It has been claimed that the
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strength training may provide several beneficial effects to patients with knee
OA, including; facilitating endorphins that makes the patient more tolerant
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changes in biomechanics of knee (Thorstensson et al., 2007). In addition,
strength training may cause mental effects that directly affect knee joint
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performance (Bokaeian et al., 2016). Because excessive and unnatural forces
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may damage articular cartilage (Pearle et al., 2005), it is assumed that the
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beneficial effects of muscle strength in patients with knee OA may be due to
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increased joint stability and reduced joint stress (McQuade & de Oliveira,
2011).
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been confirmed. For example, Trans and his colleagues, treating patients with
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increased, the pain did not change (Trans et al., 2009). In addition, McQuade
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and his colleagues reported that the strength training improved pain and
function, but could not change muscle strength (McQuade & de Oliveira,
2011). Researchers have also reported that changes in the intensity of strength
training may not bring about any difference in the improvement of pain and
function (Zacharias et al., 2014). So, it seems that the improvement of pain and
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function may be due to increase in activity not increase in muscle strength. This
training, aerobic exercise (Golightly et al., 2012; Kudo et al., 2013), balance
training (Bennell et al., 2014; Chaipinyo & Karoonsupcharoen, 2009; Lin et al.,
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2009) and home management (Maurer et al., 1999; McKnight et al., 2010). This
has also been confirmed by systemic review study (Juhl et al., 2014; Roddy et
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al., 2005).
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Strength training is the main exercise that will be used in knee OA,
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however, Studies have reported conflicting results regarding the effect of
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strength training on this disease. All previous studies have evaluated the mean
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change and personal differences have ignored, this may be the reason for the
conflicting results. This study has been designed to investigate the correlation
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between muscle strength changes and pain and functional changes after
applying quadriceps muscle strength training protocols in the patients with knee
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OA.
METHOD
Medical Science No. 91/216810. From 56 patients with knee OA who have
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rheumatologist, 24 volunteers were eligible to participate in the study. The
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month and being able to walk with or without assistant devices (Bokaeian et al.,
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musculoskeletal, neuromuscular, cardiovascular, respiratory, etc., the use of
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injections or other invasive treatments (such as surgery) in the lower extremities
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during the last three months, having an artificial hip or knee joints, medication,
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history of trauma to knee joint during last week, performing regular professional
(TENS) (Cameron, 2003), hot pack (Di Domenica et al., 2005) and strength
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flexion and extension exercise of knee joint with the quadriceps chair. Before
starting exercise training, all subjects were asked to perform warm up exercise
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65% of 10 RM (Repetition Max) in the first set, 70 to 75% of 10 RM in the
second set and 80 to 85% of 10 RM in the third set. The amount of 10 RM was
assessed every week for each participant (McQuade & de Oliveira, 2011). If
the subjects reported pain during exercise (VAS> 5), the range of knee joint
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motion was reduced. If the pain remained, the load was reduced (Petersen et al.,
2011).
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Before and after the intervention, the examiner measured pain intensity,
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quality of life, functional activity and muscle strength. Pain intensity was
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assessed using visual analogue scale (VAS).
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Knee pain perception was measured by VAS, on which the patients could
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(no pain at all) to 10 (the most severe pain that I can imagine) (Carlsson, 1983).
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The short type of Western Ontario and McMaster Universities Arthritis Index
(WOMAC) was used to assess the quality of life. The scale consisted of 8 items
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question was assigned from zero (no problem) to 4 (severe problem). Higher
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2MWT: To complete 2MWT, individuals were free to use a walking aid.
The 2MWT was recorded indoors in a 25-m tiled hallway. Participants were
instructed to "walk as quickly and safely as they can for 2 minutes. The
recorded score was the total distance traveled during 2 minutes. All participants
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practiced walking in the test hallway before measurement began; however, to
prevent fatigue, the complete 2MWT was not practiced (Bohannon et al., 2015;
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Selman et al., 2014).
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TUGT: The patient was in the sitting position on a standard chair and we
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asked him to stand up from the chair and walk straightly for 3 meters, with
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maximum effort and then return the same way, and sit on the chair again. The
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elapsed time during the test was measured with a standard chronometer
(Model 4Pro) (Lund et al., 2005). The machine was initially calibrated just
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before the start of each test session. Subjects were positioned sitting with the
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backrest at an 85º angle and were instructed to grip the sides of the seat during
the testing. The thigh, pelvis, and trunk were stabilized with straps. An
adjustable lever arm was attached to the subject’s leg by a padded cuff just
proximal to the medial malleolus. The axis of rotation of the dynamometer arm
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were calculated by the computer software (Dvir, 2004). Conventional
was a maximal contraction. There was a 2-minute break between the warm up
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and test procedure. During concentric tests, the subjects were asked to
continuously push the lever arm of the dynamometer up and down through the
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range of motion between 10º and 90º of knee flexion. All subjects were
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encouraged verbally to exert maximal effort during the test. The participants
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performed 5 maximal continuous flexion-extension repetitions for angular
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velocity of 90°/sec in each leg (Snyder et al., 2011). Then, the machine
measured the peak torque of quadriceps and hamstring muscles during knee
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extension and flexion, respectively and values were normalized by dividing the
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STATISTICAL ANALYSIS
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After collecting data, Kolmogorov Smirnov test was used to assess normality of
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the data. In order to evaluate the effects of intervention, paired t-test was used to
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compare pre and posttest means. Correlation of the mean change of 2MWT,
TUGT, VAS and WOMAC with the mean change of muscle strength was
Results
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The study involved 24 volunteers with knee OA who completed 24 intervention
all variables before and after the intervention and the mean changes of all
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Place Table 1.
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Although the data analysis illustrated that the change in the quadriceps
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muscle strength significantly correlated with the changes in VAS (r2 = 0.310, p
= 0.005), WOMAC (r2 = 0.278, p = 0.008) and 2MWT (r2 = 0.275, p = 0.009),
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the correlation coefficient between these variables was very low. Analysis of the
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recorded parameters also showed that there was no correlation between the
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changes in quadriceps muscle strength and TGUT (r2 = 0.013, p = 0.599) (see
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figure 1). Similarly, comparisons of the values of the variables before and after
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TUGT and 2MWT by comparing before and after the intervention recordings (p
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Place figure 1.
Place Table 2.
Discussion
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OA is the most common degenerative joint disease (Lane et al., 2017).
Although there is no real cure for OA, exercise therapy is considered as one of
the most important treatments (Farr et al., 2008). A key component of most
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conflicting research considering this method superior to other exercise therapy
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other symptoms of knee OA. This study evaluated the correlation of increased
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quadriceps muscle strength with improved pain and function in knee OA.
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The results showed that there was a significant correlation between the
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changes in the quadriceps muscle strength and pain, however, the correlation
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was poor. The mean changes in quadriceps muscle strength and pain improved
are divided into the several major factors for the patients with OA including a
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impacts associated with the strengthening (Pearle et al., 2005) and joint stability
and reduced joint stress (McQuade & de Oliveira, 2011). This means that
exercise therapy may reduce pain without increasing muscle strength. For this
reason, the results showed that reduction of pain in strength training and other
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methods may not be accomplished with muscle strength improvement (Juhl et
al., 2014). On the other hand, increase in strength training intensity may
improve muscle strength, but it cannot reduce pain (Bokaeian et al., 2016).
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increase in quadriceps muscle strength and pain reduction. However, Trans and
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his colleagues showed that although strength training can increase muscle
strength, it may not reduce pain (Trans et al., 2009). On the contrary, McQuade
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and his colleagues reported that although strength training can reduce pain, it
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may not increase muscle strength (McQuade & de Oliveira, 2011). However,
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several studies showed that strength training can increase muscle strength and
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reduce pain at the same time although the correlation between changes in pain
and muscle strength have not been investigated in these studies (Bennell et al.,
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2014; Lange et al., 2008; van Baar et al., 2001). Our study also showed that
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strength training may increase muscle strength and reduce pain at the same
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time, but there was not an acceptable correlation between these changes.
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between changes in quadriceps muscle strength and 2MWT, this correlation was
quadriceps muscle strength and TUGT. Overall, these results showed that there
functional activity due to strength training in knee OA. Similarly, this study
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showed that the mean changes in quadriceps muscle strength and functional
strength and improving cardiovascular capacity (Brehm et al., 2009; Minor &
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Lane, 1996; van Baar et al., 1998). Furthermore, the improvement in muscle
power, proprioception and balance function may have great effects on the
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functional activity performance (Jan et al., 2008). In the meantime, improving
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functional activity by changing the joint dynamic is not impossible
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(Thorstensson et al., 2007). Nonetheless, it seems that pain reduction is the main
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factor directly and indirectly affecting the functional activity (Schilke et al.,
1996). These results suggest that there may not be need to increase muscle
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McQuade and his colleagues reported that although strength training may
improve functional activity, it may not increase muscle strength (McQuade &
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de Oliveira, 2011). However, several studies showed that strength training may
increase muscle strength and improve functional activity at the same time
(Fukumoto et al., 2014; Jan et al., 2008; Lange et al., 2008). Our study also
indicated that strength training may increase muscle strength and improve
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functional activity at the same time, but there was not an acceptable correlation
between them.
misinterpreting the information (Henseler et al., 2015; Wells et al., 2001). This
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is due to the dependence of mean changes to the sample size. On the other hand,
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evaluation of the mean changes may cause the loss of individual differences
which may create wrong conclusions (de Vet et al., 2006). Although no one has
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studied the shortcomings of the mean change in knee OA, the result of this
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study showed that evaluation of the mean change could be misinterpreted. It
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seems that linking between the improvements of knee OA symptoms to the
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The most important limitation of this study is the small sample size. The
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lack of a control group is another issue that limits these results. On the other
hand the relatively long time of treatment (8 weeks) increases the possibility of
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CONCLUSION
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This study indicated that there was not an acceptable correlation between
quadriceps muscle strength with pain and functional activity caused by strength
training protocol therapies in the patients with knee OA. It seems that one of the
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independent of the other results. The present study showed that muscle strength
may not be a major factor in exercise therapy in knee OA. Paying more
activation, etc.) and exercise therapy factors (eg, biomechanical factors, etc.) in
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the treatment of knee OA are proposed by authors.
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ACKNOWLEDGEMENT
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The study sponsor had no involvement in the study design, collection,
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submit the manuscript for publication. This study was supported by
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Neuromuscular Rehabilitation Research Centre, Semnan University of Medical
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Sciences.
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REFERENCES
Abdalbary SA 2016 Ultrasound with mineral water or aqua gel to reduce pain and improve the
WOMAC of knee osteoarthritis. Future Sci OA 2, FSO110.
Bennell KL, Hunt MA, Wrigley TV, Lim BW, Hinman RS 2008 Role of muscle in the genesis and
management of knee osteoarthritis. Rheumatic Diseases Clinics of North America 34, 731-754.
Bennell KL, Kyriakides M, Metcalf B, Egerton T, Wrigley TV, Hodges PW, Hunt MA, Roos EM, Forbes
A, Ageberg E, Hinman RS 2014 Neuromuscular versus quadriceps strengthening exercise in patients
with medial knee osteoarthritis and varus malalignment: a randomized controlled trial. Arthritis
PT
Rheumatol 66, 950-959.
Bilbao A, Quintana JM, Escobar A, Las Hayas C, Orive M 2011 Validation of a proposed WOMAC short
form for patients with hip osteoarthritis. Health Qual Life Outcomes 9, 75.
RI
Bohannon RW, Wang YC, Gershon RC 2015 Two-minute walk test performance by adults 18 to 85
years: normative values, reliability, and responsiveness. Archives of Physical Medicine and
Rehabilitation 96, 472-477.
SC
Bokaeian HR, Bakhtiary AH, Mirmohammadkhani M, Moghimi J 2016 The effect of adding whole
body vibration training to strengthening training in the treatment of knee osteoarthritis: A
randomized clinical trial. Journal of Bodywork and Movement Therapies 20, 334-340.
Brehm M, Picard F, Ebner P, Turan G, Bolke E, Kostering M, Schuller P, Fleissner T, Ilousis D, Augusta
U
K, Peiper M, Schannwell C, Strauer BE 2009 Effects of exercise training on mobilization and
functional activity of blood-derived progenitor cells in patients with acute myocardial infarction.
AN
European Journal of Medical Research 14, 393-405.
Cameron M 2003 Physical agents in rehabilitation from research to practice, 2 ed. Saunders, USA.
Carlsson AM 1983 Assessment of chronic pain. I. Aspects of the reliability and validity of the visual
analogue scale. Pain 16, 87-101.
M
de Vet HC, Terwee CB, Ostelo RW, Beckerman H, Knol DL, Bouter LM 2006 Minimal changes in health
status questionnaires: distinction between minimally detectable change and minimally important
TE
Dvir Z 2004 Isokinetics of the knee muscle. In: Isokinetics muscle testing, interpretation and clinical
application, 2 ed. Churchill Livingstone, China.
Farr JN, Going SB, Lohman TG, Rankin L, Kasle S, Cornett M, Cussler E 2008 Physical activity levels in
C
patients with early knee osteoarthritis measured by accelerometry. Arthritis and rheumatism 59,
1229-1236.
AC
Fauci AS KD, Longo DL 2008 HARRISSONS principle of INTERNAL MEDICINE, 17 th ed. McGraw-Hill
companie.
Fransen M 2004 When is physiotherapy appropriate? Best Practice & Research: Clinical
Rheumatology 18, 477-489.
Fukumoto Y, Tateuchi H, Ikezoe T, Tsukagoshi R, Akiyama H, So K, Kuroda Y, Ichihashi N 2014 Effects
of high-velocity resistance training on muscle function, muscle properties, and physical performance
in individuals with hip osteoarthritis: a randomized controlled trial. Clin Rehabil 28, 48-58.
Golightly YM, Allen KD, Caine DJ 2012 A comprehensive review of the effectiveness of different
exercise programs for patients with osteoarthritis. Phys Sportsmed 40, 52-65.
Henseler JF, Kolk A, van der Zwaal P, Nagels J, Vliet Vlieland TP, Nelissen RG 2015 The minimal
detectable change of the Constant score in impingement, full-thickness tears, and massive rotator
cuff tears. J Shoulder Elbow Surg 24, 376-381.
17
ACCEPTED MANUSCRIPT
Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells
G, Tugwell P 2012 American College of Rheumatology 2012 recommendations for the use of
nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis
Care Res (Hoboken) 64, 465-474.
Hyldahl RD, Evans A, Kwon S, Ridge ST, Robinson E, Hopkins JT, Seeley MK 2016 Running decreases
knee intra-articular cytokine and cartilage oligomeric matrix concentrations: a pilot study. European
Journal of Applied Physiology 116, 2305-2314.
Jan MH, Lin JJ, Liau JJ, Lin YF, Lin DH 2008 Investigation of clinical effects of high- and low-resistance
training for patients with knee osteoarthritis: a randomized controlled trial. Phys Ther 88, 427-436.
PT
Jenkinson CM, Doherty M, Avery AJ, Read A, Taylor MA, Sach TH, Silcocks P, Muir KR 2009 Effects of
dietary intervention and quadriceps strengthening exercises on pain and function in overweight
people with knee pain: randomised controlled trial. BMJ 339, b3170.
Jones G, Cahill A, McQuade J, Coleman S, Bennett J 2007 Painful Realities: The economic impact of
RI
arthritis in Australia in 2007. www.arthritisaustralia.com.au.
Juhl C, Christensen R, Roos EM, Zhang W, Lund H 2014 Impact of exercise type and dose on pain and
disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized
SC
controlled trials. Arthritis Rheumatol 66, 622-636.
Kaya Mutlu E, Mustafaoglu R, Birinci T, Razak Ozdincler A 2017 Does Kinesio Taping of the Knee
Improve Pain and Functionality in Patients with Knee Osteoarthritis?: A Randomized Controlled
U
Clinical Trial. American Journal of Physical Medicine and Rehabilitation 96, 25-33.
Kudo M, Watanabe K, Otsubo H, Kamiya T, Kaneko F, Katayose M, Yamashita T 2013 Analysis of
AN
effectiveness of therapeutic exercise for knee osteoarthritis and possible factors affecting outcome. J
Orthop Sci 18, 932-939.
Lane NE, Shidara K, Wise BL 2017 Osteoarthritis year in review 2016: clinical. Osteoarthritis and
Cartilage 25, 209-215.
M
Lange AK, Vanwanseele B, Fiatarone Singh MA 2008 Strength training for treatment of osteoarthritis
of the knee: a systematic review. Arthritis Rheum 59, 1488-1494.
Lin DH, Lin CH, Lin YF, Jan MH 2009 Efficacy of 2 non-weight-bearing interventions, proprioception
D
training versus strength training, for patients with knee osteoarthritis: a randomized clinical trial. J
Orthop Sports Phys Ther 39, 450-457.
TE
Maurer BT, Stern AG, Kinossian B, Cook KD, Schumacher HR, Jr. 1999 Osteoarthritis of the knee:
isokinetic quadriceps exercise versus an educational intervention. Arch Phys Med Rehabil 80, 1293-
1299.
C
McKnight PE, Kasle S, Going S, Villanueva I, Cornett M, Farr J, Wright J, Streeter C, Zautra A 2010 A
comparison of strength training, self-management, and the combination for early osteoarthritis of
AC
18
ACCEPTED MANUSCRIPT
Porter S 2003 Tidys Physiotherapy, 13 ed. Butterword:Hheinman.
Roddy E, Zhang W, Doherty M 2005 Aerobic walking or strengthening exercise for osteoarthritis of
the knee? A systematic review. Ann Rheum Dis 64, 544-548.
Schilke JM, Johnson GO, Housh TJ, O'Dell JR 1996 Effects of muscle-strength training on the
functional status of patients with osteoarthritis of the knee joint. Nurs Res 45, 68-72.
Selman JP, de Camargo AA, Santos J, Lanza FC, Dal Corso S 2014 Reference equation for the 2-minute
walk test in adults and the elderly. Respiratory Care 59, 525-530.
Snyder A, Colvin B, Gammack JK 2011 Pedometer use increases daily steps and functional status in
older adults. J Am Med Dir Assoc 12, 590-594.
PT
Stagg NJ, Mata HP, Ibrahim MM, Henriksen EJ, Porreca F, Vanderah TW, Philip Malan T, Jr. 2011
Regular exercise reverses sensory hypersensitivity in a rat neuropathic pain model: role of
endogenous opioids. Anesthesiology 114, 940-948.
Stratford PW, Kennedy DM, Woodhouse LJ 2006 Performance measures provide assessments of pain
RI
and function in people with advanced osteoarthritis of the hip or knee. Physical Therapy 86, 1489-
1496.
Sun MM, Beier F, Pest MA 2017 Recent developments in emerging therapeutic targets of
SC
osteoarthritis. Current Opinion in Rheumatology 29, 96-102.
Thorstensson CA, Henriksson M, von Porat A, Sjodahl C, Roos EM 2007 The effect of eight weeks of
exercise on knee adduction moment in early knee osteoarthritis--a pilot study. Osteoarthritis
U
Cartilage 15, 1163-1170.
Trans T, Aaboe J, Henriksen M, Christensen R, Bliddal H, Lund H 2009 Effect of whole body vibration
AN
exercise on muscle strength and proprioception in females with knee osteoarthritis. Knee 16, 256-
261.
van Baar ME, Dekker J, Oostendorp RA, Bijl D, Voorn TB, Bijlsma JW 2001 Effectiveness of exercise in
patients with osteoarthritis of hip or knee: nine months' follow up. Ann Rheum Dis 60, 1123-1130.
M
van Baar ME, Dekker J, Oostendorp RA, Bijl D, Voorn TB, Lemmens JA, Bijlsma JW 1998 The
effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized
clinical trial. J Rheumatol 25, 2432-2439.
D
Wells G, Beaton D, Shea B, Boers M, Simon L, Strand V, Brooks P, Tugwell P 2001 Minimal clinically
important differences: review of methods. J Rheumatol 28, 406-412.
TE
Zacharias A, Green RA, Semciw AI, Kingsley MI, Pizzari T 2014 Efficacy of rehabilitation programs for
improving muscle strength in people with hip or knee osteoarthritis: a systematic review with meta-
analysis. Osteoarthritis Cartilage 22, 1752-1773.
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QMS (Nm/Kg) 0.6 (0.25) 0.925
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Table 2: compare of mean (SD) of variable before and after treatment.
treatment
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WOMAC 16.5 (4)* 7.2 (5)* 0.000
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2MWT, m 122.4 (21.1)* 134.7 (19.5)* 0.000
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TUGT, s 11.6 (3.4)* 10 (2.8)* 0.000
*Significant difference
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SD= standard deviation, VAS= visual analogue scale, WOMAC= Western
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Figure 1: correlation of pain (VAS) difference, WOMAC difference, 2MWT
difference and TUGT difference with quadriceps muscle strength difference.
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