Accepted Manuscript

Quadriceps strengthening exercises may not change pain and function in knee
osteoarthritis

Hamid Reza Bokaeian, Amir Hoshang Bakhtiary, Majid Mirmohammadkhani, Jamileh

Moghimi

PII: S1360-8592(17)30137-7
DOI: 10.1016/j.jbmt.2017.06.013
Reference: YJBMT 1560

To appear in: Journal of Bodywork & Movement Therapies

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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 ACCEPTED MANUSCRIPT

Quadriceps strengthening exercises may not

change pain and function in knee

osteoarthritis.

PT
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Hamid Reza Bokaeian, M.Sc1, Amir Hoshang Bakhtiary, Ph.D1*, Majid Mirmohammadkhani, Ph.D2,

Jamileh Moghimi, M.D3.

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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

of Medical Sciences, Semnan, Iran.

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3. Internal Medicine Group, School of Medicine, Semnan University of Medical Sciences,

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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funding agencies in the public, commercial, or not-for-profit sectors.

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Conflict of interest: We certify that there is no conflict of interest with any

financial organization regarding the material discussed in the manuscript.

*Corresponding author: Amir Hoshang Bakhtiary, Ph.D.PT, Neuromuscular

Rehabilitation Research Center, Semnan University of Medical Sciences,

Semnan, Iran, 00989123311892, [email protected].

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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

investigated whether quadriceps muscle strength increases with decreasing pain,

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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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and McMaster Universities Arthritis Index (WOMAC) and functional activity

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by 2 minutes walking test (2MWT) and time up & go test (TUGT). After the
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intervention, analysis of data illustrated that changes in quadriceps muscle

strength correlated with changes in VAS (r2=0.310, p=0.005), WOMAC

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(r2<0.278, p<0.008) and 2MWT (r2<0.275, p<0.009) significantly, although the

correlation slope was negligible. No correlation was found between muscle

strength and TUGT. However, the strength training significantly improved

quadriceps muscle strength (p=0.013), pain and functional activity (p=0.000).

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

improvement in pain and functional activity in knee OA.

Key word: knee osteoarthritis, quadriceps muscle strength, pain, functional

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activity, correlation

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INTRODUCTION

Osteoarthritis is a joint disease affecting one in every three adults. Its

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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There are several ways to treating OA that non-pharmacologic

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conservative treatment is the key stone. The goals of treatments include

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reduction of pain, enhancement of muscle strength and endurance and

improvement of function and quality of life (Fauci AS, 2008). Exercise therapy
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plays an important role in the conservative treatment of knee OA (Hyldahl et

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al., 2016). The American College of Rheumatology (ACR) recommends

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strength training to manage symptoms of OA (Hochberg et al., 2012). Many

documents illustrate that strength training may improve pain, functional

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

(Stagg et al., 2011), reducing degree of disability (Hyldahl et al., 2016),

considerable reduction in weight (Jenkinson et al., 2009) and other mechanical

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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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Although improvement of pain and function by strength training has been

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attributed to increased muscle strength, these improvements have not always

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been confirmed. For example, Trans and his colleagues, treating patients with
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knee OA by strength training, found that although the muscle strength

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

possibility increased when researchers reported similar effects of strength

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. Accordingly, it is necessary to examine the effect of

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strengthening exercises separately in each patient to be able to explain the

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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

This study was approved by the Ethics Committee of Semnan University of

Medical Science No. 91/216810. From 56 patients with knee OA who have

been referred to the Neuromuscular Rehabilitation Research Center, by a

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rheumatologist, 24 volunteers were eligible to participate in the study. The

inclusion criteria included having mild to moderate chronic osteoarthritis of

unilaterally or bilaterally tibiofemoral joint according to the method of Kellgren

& Lawrance, age range of 35 to 76 years, a history of symptoms more than a

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month and being able to walk with or without assistant devices (Bokaeian et al.,

2016). Moreover, reporting other diseases such as: diabetes, diseases of

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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

exercise and extreme physical weakness were considered as exclusion criteria

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(Bokaeian et al., 2016).

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All patients received an educational leaflet (Fransen, 2004) and were

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treated with therapeutic interventions for 3 times a week in 8 weeks including,

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continued ultrasound therapy, transcutaneous electrical nerve stimulation

(TENS) (Cameron, 2003), hot pack (Di Domenica et al., 2005) and strength
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training protocol (Petersen et al., 2011). Strength training protocol included

flexion and extension exercise of knee joint with the quadriceps chair. Before

starting exercise training, all subjects were asked to perform warm up exercise

on an ergonomic bicycle for 5 minutes. Each exercise session included 3 sets

with 2-minute intervals. The load of exercise increased progressively from 60 to

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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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indicate their assessment of pain perception along a 10 cm line ranging from 0

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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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which determine patient’s own assessment of his physical performance. Each

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question was assigned from zero (no problem) to 4 (severe problem). Higher
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scores indicate poorer performance (Bilbao et al., 2011).

Functional activity was evaluated using a 2-minute walking test (2MWT)

and a timed up and go test (TUGT).

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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

(Stratford et al., 2006).

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Muscle performance evaluation: The isokinetic concentric quadriceps and

hamstring muscle peak torques were measured by Biodex isokinetic system

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(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

was adjusted to the lateral femoral epicondyle. Gravity corrections to torque

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were calculated by the computer software (Dvir, 2004). Conventional

concentric continuous isokinetic tests were used. Subjects were familiarized

with test procedures by performing 3 consecutive warm-up trials, one of which

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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patient's weight (Bennell et al., 2008).

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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

calculated by linear regression. SPSS 16 was used at significance level of 0.05

and 95% confidence interval.

Results

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The study involved 24 volunteers with knee OA who completed 24 intervention

sessions in 8 weeks. Results of Kolmogorov-Smirnov test showed the means of

all variables before and after the intervention and the mean changes of all

variables were normal (see Table 1).

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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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the intervention showed that quadriceps muscle strength increased significantly

(p = 0.013). Significant improvements were also found in the VAS, WOMAC,

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TUGT and 2MWT by comparing before and after the intervention recordings (p
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< 0.001) (see Table 2).

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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

exercise therapy protocols is strength training (Bokaeian et al., 2016). There is

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conflicting research considering this method superior to other exercise therapy

methods and correlation of increased muscle strength with improvement of

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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

significantly. As mentioned, the beneficial effects of exercise therapy on pain

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are divided into the several major factors for the patients with OA including a
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facilitation of endorphins which causes the patient to be more tolerant (Stagg et

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al., 2011), reduction of the degree of disability (Hyldahl et al., 2016), a

significant decrease in weight (Jenkinson et al., 2009), other mechanical

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changes on the biomechanics of knee (Thorstensson et al., 2007), mental

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).

To our knowledge, no study has investigated the correlation between the

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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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This study showed that although there was a significant correlation

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between changes in quadriceps muscle strength and 2MWT, this correlation was

poor. On the other hand, there was no correlation between changes in

quadriceps muscle strength and TUGT. Overall, these results showed that there

was not an acceptable correlation between changes in muscle strength and

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

activity improved significantly. Several studies suggested that exercise therapy

may reduce disability and improve functional activity by increasing muscle

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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strength to improve certain types of functional activity.

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Based on our records, there is no study investigating the correlation

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between changes in muscle strength and functional activity in knee OA.

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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.

Previous studies showed that evaluation of mean change may cause

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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increase of muscle strength is one of these misinterpretations.

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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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unanticipated events in patient’s personal lives.

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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

results of strength training in knee OA is increase in muscle strength which is

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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

attention to other muscle performance factors (eg, the pattern of muscle

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,

analysis and interpretation of data, writing of the manuscript and decision to

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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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Table 1: The mean (SD) of baseline variables.

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variable mean (SD) p-value

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VAS 6.9 (2.2) 0.734

WOMAC 16.5 (4) 0.788

2MWT (m) 122.4 (21.1) 0.674

TUGT (s) 11.6 (3.4) 0.449

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QMS (Nm/Kg) 0.6 (0.25) 0.925

SD= standard deviation, VAS= visual analogue scale, WOMAC= Western

Ontario and McMaster Universities Arthritis Index, 2MWT= 2 minute walking

test, TGUT= time up & go test, QMS= quadriceps muscle strength.

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Table 2: compare of mean (SD) of variable before and after treatment.

variable Before of After of treatment p-value

treatment

VAS 6.9 (2.2)* 3.4 (2.5)* 0.000

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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

QMS, Nm/Kg 0.6 (0.25)* 0.67 (0.27)* 0.013

*Significant difference
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SD= standard deviation, VAS= visual analogue scale, WOMAC= Western
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Ontario and McMaster Universities Arthritis Index, 2MWT= 2 minute walking

test, TGUT= time up & go test, QMS= quadriceps muscle strength.
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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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