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CRE0010.1177/0269215515610039Clinical RehabilitationLi et al.


Clinical Rehabilitation

The effects of resistance exercise 2016, Vol. 30(10) 947­–959

© The Author(s) 2015
Reprints and permissions:
in patients with knee
DOI: 10.1177/0269215515610039

osteoarthritis: a systematic

review and meta-analysis

Yanan Li, Youxin Su, Shaoqing Chen, Yingjie Zhang,

Ziyi Zhang, Changyan Liu, Meili Lu, Feiwen Liu, Shuzhen Li,
Zhen He, Yiru Wang, Lu Sheng, Wenting Wang,
Zhengxuan Zhan, Xu Wang and Naixi Zheng

Objective: To analyze the effectiveness of resistance exercise in the treatment of knee osteoarthritis on
pain, stiffness, and physical function.
Design: Systematic review and meta-analysis of randomized controlled trials.
Data sources: PubMed, Embase, Cochrane Central Register of Controlled Trials, the Web of Science,
and Chinese Biomedical Literature Database were searched from the date of inception to August 2015.
Methods: Trials comparing effects of resistance exercise intervention with either non-intervention or
psycho-educational intervention were selected by two reviewers independently. The risk of bias was
assessed and studies with similar outcomes were pooled using a fixed or random effects model.
Results: Data from 17 randomized clinical trials including 1705 patients were integrated. The main
source of methodological bias in the selected studies was lack of double blinding. The meta-analysis
results suggested that resistance exercise training relieved pain (standard mean difference [SMD]: -0.43;
95% confidence interval [CI]: -0.57 to -0.29; P < 0.001), alleviated stiffness (SMD: -0.31; 95%: CI -0.56 to
-0.05; P = 0.02), and improved physical function (SMD -0.53; 95% CI: -0.70 to -0.37; P < 0.001).
Conclusion: Resistance exercise is beneficial in terms of reducing pain, alleviating stiffness, and improving
physical function in patients with knee osteoarthritis.

Resistance exercise, knee osteoarthritis, pain, meta-analysis

Received: 6 May 2015; accepted: 5 September 2015

Department of Rehabilitation Medicine College, Fujian

Introduction University of Traditional Chinese Medicine, Fujian, China

Osteoarthritis is the most common age-related rheu- Corresponding author:

Youxin Su, Department of Rehabilitation Medicine College,
matic disease and a major cause of chronic pain and Fujian University of Traditional Chinese Medicine, 1 Qiuyang
disability worldwide,1 affecting approximately 52.5 Street, Shangjie, Fuzhou, Fujian, China.
million adults, or 22.7% of the population.2 Due to Email:

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948 Clinical Rehabilitation 30(10)

its predilection for the knee,3 patients with sympto- •• improve physical function in patients with knee
matic knee osteoarthritis often complain of intermit- osteoarthritis?
tent pain, limitation of joint movement, and difficulty
in daily activities. In light of the aging of the world’s
population, there is a large increase in the demand
for treatments of knee osteoarthritis.4 Inclusion and exclusion criteria for studies were
Therapeutic exercise is recommended in numerous based on study design, participants, interventions,
international guidelines as a nonpharmacologic treat- comparisons, and outcomes as follows. Available
ment for knee osteoarthritis.5–7 Resistance exercise human randomized controlled trials (RCTs) were
— defined as use the external resistance load (e.g. included. Observational studies were excluded.
body weight, resistance bands, machines) to force Participants who had been diagnosed with unilat-
skeletal muscles contract — may be successful in eral or bilateral knee osteoarthritis were consid-
normalizing muscle firing patterns and joint biome- ered. Age, sex, disease duration and severity were
chanics for knee osteoarthritis.8 Resistance exercise unrestricted. The diagnosis had to be made based
can be performed in a variety of ways, and numerous on the classification criteria of the American
studies have shown that it can reduce pain.9–11 College of Rheumatology.16, 17 Participants who
Several previous systematic reviews have out- had undergone a knee surgery or had history of
lined and shown the effectiveness of resistance exer- rheumatoid arthritis were excluded. Studies per-
cise for knee osteoarthritis.12–15 One of these reviews forming resistance exercise were included. Studies
included other interventions, such as aerobic exer- with multiple interventions (for example, resist-
cise, performance exercise, or mixed exercise.14 A ance exercise plus aerobic exercise, neuromuscular
review reported in 2005 focused on home based electrical stimulation, or ultrasound) were
quadriceps strengthening exercise, excluded other excluded. Studies comparing with no treatment or
types of resistance exercise.12 In addition, another educational interventions were included. The out-
review included a variety of the surgical patients and come measures pain, stiffness, or physical function
included studies comparing with active control were included.
group(e.g. paracetamol, short-wave diathermy treat- Original articles were searched in five elec-
ment, stretching exercise),15 variation in this review tronic databases: PubMed, Embase, Cochrane
may effects resistance exercise outcomes. A review Central Register of Controlled Trials (CENTRAL),
reported in 2013 meta analysed the effect of weight- the Web of Science, and Chinese Biomedical
bearing strengthening exercise and non-weight- Literature Database (CBM) from their inception
bearing strengthening exercise separately, and this to August 2015. The search strategies can be
study looked at pain only.13 Furthermore, none of found in the appendix, available online. Reference
them found evidence that resistance exercise ther- lists of retrieved RCTs and previous systematic
apy had a significant benefit on stiffness alleviating, reviews were also searched.
the evidence is still inconclusive. Because of the Two reviewers (ZYZ and CYL) independently
expansion of research in the area of resistance exer- screened titles and abstracts of retrieved studies to
cise in the past years, an updated systematic review exclude obviously irrelevant studies. Full texts of
and meta-analysis of research data in this area would the potential studies were reviewed to determine
be useful in informing clinical practice. eligible trials. Articles were considered relevant
The aims of this systematic review were to based on the inclusion and exclusion criteria.
answer the following questions. Should resistance Disagreements between reviewers were resolved
exercise be used to: by discussion.
Data from all eligible trials were extracted by two
•• reduce pain in patients with knee osteoarthritis? reviewer (MLL and FWL) independently. A special
•• alleviate stiffness in patients with knee standardised forms, developed for this review, was
osteoarthritis? used to record authors’ names, publication year,

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Li et al. 949

demographics of participants, content of interven- If data within any study were insufficient for
tion, outcome measures and other information. If pooling even after requesting details from the
the reported data were incomplete or ambiguous, authors, we excluded this study from meta-analyses
we requested additional information from corre- and described the result narratively.
sponding authors. Conflicts were resolved through
When a given study reported more than one
pain, stiffness, or physical function measure, we Study selection and characteristics
gave preference to the Western Ontario and
McMaster Universities Osteoarthritis Index Seventeen RCTs were included in this review,9–11, 22–35
(WOMAC) scale, which has been widely used and the flowchart of study selection is shown in
worldwide and employed in most trials.18 Figure 1. In total, 1705 patients with the mean age
Two reviewers (MLL and FWL) independently of 63.5 years were included, and characteristics of
assessed the quality of studies, and the Cochrane the included studies are shown in Table 1. Studies
Collaboration’s tool was used for assessing the risk were conducted in the United States,9, 24, 25, 27, 30, 34, 35
of bias.19 Recommended domains were considered England,26, 32 Australia,10, 23, 31, 33 Turkey,22 and
as following: selection bias, performance bias, China.11, 28, 29
detection bias, attrition bias, reporting bias, and The included studies varied substantially in deliv-
other bias. For the “other bias” item on the risk of ery mode, resistance load, duration, repetitions and
bias scale, we assessed the compliance acceptable frequency in resistance exercise program. Resistance
in all groups. We requested additional information exercise was delivered individually,22, 26, 27, 31, 32, 34
from corresponding authors if it is necessary, and in a class-based format,35 performed under supervi-
disagreements were resolved through discussion. sion in facility,11, 27–29 or at home.24, 26, 30–32 Resistance
For the continuous data, if studies used different loads varied from low resistance (10% 1RM) to high
scales to assess the same outcome, the standardized resistance (80% 1RM), and there is a periodic
mean difference (SMD) with 95% confidence increase. Intervention duration ranged from eight
intervals (CI) were calculated. If studies used same weeks to 24 months, and the most commonly utilized
scale to assess the same outcome, the mean differ- program was three days per week, with three sets at
ences (MD) with 95% CI were used. 8–12 repetitions per set.
Statistical heterogeneity among studies was Majority of the included studies used the self-
assessed using the Chi-square test or by calculating report WOMAC scale to measure pain, stiffness,
Higgins I2 values.20 The results were pooled using and physical function, while the Visual Analog
a fixed effect model if the I2 value was < 40%. Scale (VAS),22 Osteoarthritis Screening Index
Otherwise, a random effect model was applied. (OASI),27 Knee Pain Scale (KPS)35 were also used
However, if the I2 value was > 75%, the heteroge- to measure outcomes.
neity was regarded as substantial, and overall
meta-analysis was considered inappropriate. In Risk of bias in included studies
such cases, subgroup analysis was considered to
measure the pooled effect. Methodological quality scores are shown in
The Review Manager Software (version 5.3.5, Supplementary Figure 1 and 2. According to the
updated 2014 Cochrane Collaboration) was used Cochrane Collaboration, none of the RCTs received
for data analysis, and all P values were two-sided. the maximum quality score. In all of the included
Evaluation of overall effect size was based on RCTs, random sequences were generated by using a
Cohen’s categories: effect sizes of 0.2–0.5 was computer or random table, except one study used
considered small, effect sizes of 0.5–0.8 consid- pseudo-randomly.9 The most common source of
ered moderate, and effect sizes > 0.8 considered likely methodological bias was lack of double blind-
large effects.21 ing. Only two of the 17 included studies reported

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950 Clinical Rehabilitation 30(10)

Figure 1.  Flowchart of randomised controlled trials included in the systematic review.

blinding of both participants and outcomes asses- size (SMD: -0.43; 95% CI: -0.57 to -0.29; P <
sors.10, 33 However, in the item of blinding assess- 0.001) for pain relief (2030 subjects) and a moder-
ment, eight studies presented a low risk.11, 23, 28, 29, 31, ate effect size (SMD: -0.53; 95% CI: -0.70 to -0.37;
32, 34, 35 For the item intent-to-treat four studies pre- P < 0.001) for physical function improvement
sented a high risk9, 10, 33, 34 and 13 studies a low (2077 subjects). Pooling the data using a fixed
risk.11, 22-32, 35 The description of compliance was effect model revealed a small effect size (SMD:
generally insufficient in many studies. -0.31; 95% CI: -0.56 to -0.05; P = 0.02) for stiff-
ness alleviation (254 subjects). The study heteroge-
neity was calculated as I2 = 46%, 0%, and 58% for
Effect of intervention
pain, stiffness, and physical function, respectively.
The effect of resistance exercise is shown in The effect of high intensity and low intensity
Figure 2. Pooling of the data for resistance exercise resistance exercise on pain, stiffness, and physical
using a random effect model revealed a small effect function is shown in Figure 3. Both categories

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Table 1.  Characteristics of included studies.
Study Participants Intervention Frequency Outcome Outcome Outcome
Li et al.

(per week) (pain) (stiffness) (function)

Size I/C Age(y) Sex (F%) I/C BMI(kg/m2)
Schilke, 199627 10 / 10 64.5 ± NR 85.0 (in all NR 8 weeks of muscle- 3 days OASI OASI subscale AIMS physical
68.4 ± NR subjects) strength training vs. subscale activity
Ettinger,199735 146 / 149 68 ± 6.0 73 / 69 NR 18 months of 3 days KPS _ Self-report of
69 ± 6.0 resistance exercise Physical Disability
vs. health education
Maurer,199934 57 / 56 66.3 ± 8.8 43.4 / 35.7 NR 8 weeks of exercise vs. 3 days WOMAC _ WOMAC function
64.5 ± 8.4 education pain subscale
O’Reilly,199926 113 / 78 61.9 ± 10.0 NR NR 6 months of exercise 7 days WOMAC _ WOMAC function
62.3 ± 9.7 vs. control pain subscale
Baker, 200130 23 / 23 69.0 ± 6.0 73.9 / 82.6 31.0 ± 4.0 4 months of home 3 days WOMAC _ WOMAC function
68.0 ± 6.0 32.0 ± 5.0 based progressive pain subscale
resistance training vs. subscale
a nutrition education
Gür, 200222 9/8/6 55 ± 12.0 NR 32.1 ± NR 8 weeks of concentric 3 days VAS _ _
56 ± 12.0 31.6 ± NR vs. concentric-
57 ± 9.0 32.2 ± NR eccentric vs. control
Topp, 200224 32 / 35 / 35 63.5 ± 1.9 65.6/71.4/80.0 NR 16 weeks of isometric 3 days WOMAC WOMAC WOMAC function

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65.6 ± 1.8 exercise vs. dynamic pain stiffness subscale
60.9 ± 1.8 exercise vs. control subscale subscale
Thomas, 200232 235 / 78 61.5 ± 9.58 64.0 / 65.0 28.0 ± 4.18 24 months of exercise 7 days WOMAC WOMAC WOMAC function
61.9 ± 9.39 28.1 ± 4.81 vs. control pain stiffness subscale
subscale subscale
Jan, 200811 34 / 34 / 34 63.3 ± 6.6 79.4 /79.4/83.3 24.1 ± NR 8 weeks of high- 3 days WOMAC _ WOMAC function
31.8 ± 7.1 24.0 ± NR strength training vs. pain subscale
62.8 ± 6.3 24.1 ± NR low-strength training subscale
Table 1. (Continued)

Study Participants Intervention Frequency Outcome Outcome Outcome

(per week) (pain) (stiffness) (function)
Size I/C Age(y) Sex (F%) I/C BMI(kg/m2)
Lim, 200823 VM VM VM VM 12 weeks of home- 5 days WOMAC _ WOMAC function
26 / 26 67.2 ± 6..7 50.0 28.2 ± 3.7 based quadriceps pain subscale
NA 66.6 ± 8.9 46.2 30.3 ± 5.3 strengthening program subscale
27 / 28 NA NA NA vs. control
64.1 ± 9.3 62.9 29.0 ± 5.2
60.8 ± 7.8 60.7 28.4 ± 5.0
Jan, 200928 35 / 35 63.2 ± 6.8 71.4 / 68.6 25.1 ± NR 8 weeks of nonweight- 3 days _ _ WOMAC function
62.2 ± 6.7 24.9 ± NR bearing exercise vs. subscale
Lin, 200929 36 / 36 61.6 ± 61.6 66.7 / 72.2 23.7 ± NR 8 weeks of strength 3 days WOMAC _ WOMAC function
62.2 ± 6.7 24.7 ± NR training vs. control pain subscale
Bennell, 201031 45 / 44 64.5 ± 9.1 51.1 / 45.5 27.5 ± 4.7 12 weeks of hip 5 days WOMAC _ WOMAC function
64.6 ± 7.6 28.4 ± 4.1 strengthening exercises pain subscale
vs. control subscale
Foroughi, 201133 26 / 28 66.0 ± 8.0 NR 31.4 ± 5.4 6 months of exercise 3 days WOMAC WOMAC WOMAC function
65.0 ± 7.0 32.7 ± 8.4 vs. sham-exercise pain stiffness subscale
subscale subscale
Foroughi, 201135 26 / 28 64.0 ± 7.0 NR 31.9 ± 5.2 6 months of 3 days WOMAC WOMAC WOMAC function
64.0 ± 8.0 33.2 ± 8.1 progressive resistance pain stiffness subscale
training vs. sham subscale subscale

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Wortley, 20139 15 / 9 69.5 ± 6.7 69.2 / 66.7 30.5 ± 6.0 10 weeks of resistance 2 days WOMAC WOMAC WOMAC function
70.5 ± 5.0 30.0 ± 6.2 training program vs. pain stiffness subscale
control subscale subscale
Aaboe, 201425 15 / 15 57.1 ± 60.0 27.1 ± 12 weeks of quadriceps 3 days WOMAC WOMAC WOMAC function
7.7 (in all (in all subjects) 4.0 (in all strengthening group pain stiffness subscale
subjects) subjects) vs.control subscale subscale

F: Female; BMI: body mass index; I/C: intervention /control group; NR: not reported; OASI: the Osteoarthritis Screening Index; KPS: knee pain scale; VAS: visual analog scale;
WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index; VM: varus malalignment subjects; NA: neutral alignment subjects.
Clinical Rehabilitation 30(10)
Li et al. 953

Figure 2.  Forest plots for effects of resistance exercise (RE) on pain, stiffness, and physical function.

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954 Clinical Rehabilitation 30(10)

Figure 3.  Forest plots for effects of resistance exercise (RE) intensity on pain, stiffness, and physical function.

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Li et al. 955

achieved significant treatment benefits in terms of found improvement in muscle strength.10, 37 Only
pain and physical function. Pooling of the data for one included study addressed the role of hip mus-
high intensity resistance exercise revealed a large cles strengthening in the treatment of knee osteoar-
effect size for pain relief and physical function thritis,31 and majority of the studies highlight the
improvement. Meanwhile, pooling the data in low strengthening of the quadriceps and hamstrings
intensity resistance exercise revealed a small effect with a gradually increased load ignoring the fact
size. However, for both high intensity and low that individuals with knee osteoarthritis experience
intensity resistance exercise, there is no significant weakness in the hip muscles.38
treatment benefits in terms of stiffness. Previous reviews did not investigate the effect
The effect of resistance exercise duration on of resistance training on stiffness. Our study dem-
pain, stiffness, and physical function is shown in onstrated that resistance training resulted in allevi-
Figure 4 and Figure 5. Both categories achieved ating stiffness comprising with control group.
significant treatment benefits in terms of pain and However, the effect size was small (SMD: -0.31;
physical function. Pooling of the data for 12 or less 95% CI: -0.56 to -0.05), it may due to the small
weeks resistance exercise revealed a moderate sample size (254 subjects).
effect size on stiffness alleviation. However, there Components of a resistance exercise program
is no benefits for more than 12 weeks resistance include intensity, delivery mode, duration, and fre-
exercise. quency. Exercise intensity is commonly reported as
the percentage of 1RM (repetition maximum). Our
study demonstrated that both high intensity (6 to 8
Discussion repetitions at 80% of 1RM) and low intensity (12
According to the meta-analyses, outcomes showed to 15 repetitions at 60% of 1RM) resistance exer-
statistically significant results comparing resist- cise are benefit to pain and physical function, and
ance exercise with control group, and the resist- high intensity resistance exercise program seems
ance exercise is beneficial in terms of reducing more effective than low intensity. Resistance exer-
pain, alleviating stiffness, and improving physical cise can be performed under supervision in facil-
function. ity,11, 27–29 or at home.24, 26, 30–32 And a study reported
Knee osteoarthritis has been linked to decreased that the differences between the various forms of
muscular strength, increased ligament stiffness, exercise delivery were not statistically significant
and alterations in muscle activation patterns.36 for knee osteoarthritis,14 but encouraging patients
Resistance exercise may normalize muscle firing to maintain exercise programmes beyond a super-
patterns and joint biomechanics leading to reduc- vised period of instruction is a major challenge.
tions in pain and cartilage degradation, and restore There was considerable variation in the duration
muscle strength and joint mechanics while improv- of the exercise programme, length of intervention
ing physical function.8 ranged from eight weeks to 24 months. Although,
Our results support previous reviews which our results showed that there was no significant
reported improvements in pain and function with treatment benefits between within 12 weeks and
resistance exercise,12, 15 and showed a moderate more than 12 weeks duration for pain and physical
effect size (SMD: -0.53; 95% CI: -0.70 to -0.37) function, within 12 weeks duration is effective for
compared with Roddy’s review a small effect size stiffness alleviation. For the frequency of the resist-
(SMD: -0.32; 95% CI: -0.23 to -0.41) for physical ance exercise program, three days per week pro-
function improvement. This may be due to Roddy’s gram was used in majority of the studies. It may
review included only home-based quadriceps due to moderate weekly frequency could promote
strengthening trails which ignored hamstrings and marked gains on muscle hypertrophy and power
hip muscles strengthening trails. gains in elderly subjects.39
Previous studies involving hip abductor and There are also some important caveats to note
adductor strengthening and resistance exercises about resistance exercise. First of all, it concerns

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956 Clinical Rehabilitation 30(10)

Figure 4.  Forest plots for effects of resistance exercise (RE) duration on pain and stiffness.

the responsiveness of self-reported pain and physi- present. Secondly, it concerns the placebo effect
cal function. Exercise makes people feel better for knee osteoarthritis patients.
generally and in doing so may affect self-reported The most common source of methodological
outcome even if changes to function are not bias was lack of double blinding. Thus, the nature

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Li et al. 957

Figure 5.  Forest plots for effects of resistance exercise (RE) duration on physical function.

of the resistance exercise intervention, and the result. Third, since we excluded patients who had
awareness of being treated may lead to perfor- undergone a knee surgery, many severe knee oste-
mance bias. Consequently, we estimated the risk of oarthritis participants were not included in this
performance bias as high for all studies except two review, which may exaggerate the outcomes.
studies that utilized a sham exercise control group, Finally, the result of this study is lack of long-
whose patients trained on the same equipment as term effect and overall beneficial effect of resist-
the patients from the intervention group but did not ance exercise.
perform hip abduction and adduction.10, 33 However, Even though there are some limitations in this
the patients could easily identify the group they review, there are also some implications for prac-
were assigned to, and the authors did not report if tice. For knee osteoarthritis, benefits can be
their blinding approach was successful. Since the obtained with leg exercises, basic components of
sham exercise group was not a true sham control the prescription should include seated leg presses,
group, these studies received an “unclear” score in leg extensions and leg curls (with ankle cuff
the performance bias domain. weights to provide resistance). Inclusion of hip
There are several limitations in our study. First, adduction and abduction can help with improving
we may have missed some relevant studies pub- and maintaining appropriate knee mechanics.
lished in other languages other than English or Although, both high intensity and low intensity
Chinese. Second, our analysis was not according resistance exercise are benefit to pain and physical
to ITT (Intention-To-Treat) due to some studies function, high intensity program is more effective
did not reported ITT data, which may bias our than low intensity program. Moreover, within 12

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958 Clinical Rehabilitation 30(10)

weeks duration of resistance exercise program is 4. Cross M, Smith E, Hoy D, et al. The global burden of hip
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