ORIGINAL RESEARCH ARTICLE

Concentric and Eccentric Resistance Training Comparison

on Physical Function and Functional Pain Outcomes
in Knee Osteoarthritis
A Randomized Controlled Trial
Kevin R. Vincent, MD, PhD, and Heather K. Vincent, PhD, FACSM

Objective: The aim of the study was to compare the effectiveness of con-
centrically focused resistance training to eccentrically focused resistance What Is Known
training on physical function and functional pain in knee osteoarthritis. • Resistance exercise training can promote pain relief in
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKbH4TTImqenVDezntqwKeJGZ4+/XhAcDTkEls0QFq/TRiKcEmtjpuEMkkBwv/+O3EQ= on 09/19/2020

Design: This is a randomized, single-blinded controlled 4-mo trial. persons with knee osteoarthritis, but effects of this ex-
Older adults with knee osteoarthritis (N = 88; 68.3 ± 6.4 yrs, ercise on physical function performance are mixed.
30.4 ± 6.9 kg/m2, and 67.4% women) were randomized to eccentri- What Is New
cally focused resistance training, concentrically focused resistance
training, or no-exercise control. Main outcomes included chair rise • This study tested whether muscle actions type (eccen-
tric vs. concentric) provides different benefits on knee
time, stair climb time, 6-min walk test distance, temporal-spatial pa-
pain and functional ability among older adults with
rameters of gait, community ambulation, and functional pain.
knee osteoarthritis. The two muscle action types in-
Results: Leg muscle strength improved in both training groups com-
creased leg strength but did not differentially improve
pared with no-exercise control. There were no significant group  functional performance. Only concentric exercise re-
time interactions for any functional performance score (chair rise time, duced ambulatory pain. Clinically, any resistance ex-
stair climb time, 6-min walk test distance, gait parameters, community ercise can be used to manage knee osteoarthritis
ambulation). Compared with no-exercise control, functional pain pain but concentric actions may provide additional
scores were reduced for chair rise (−38.6% concentrically focused re- pain relief during walking.
sistance training, −50.3% eccentrically focused resistance training vs.
+10.0%) and stair climb (−51.6% concentrically focused resistance
training, −41.3% eccentrically focused resistance training vs. +80.7%; hysical activity is a key strategy to manage pain, improve
all P < 0.05). Pain scores were reduced during the 6-min walk and in
early recovery with concentrically focused resistance training compared
P physical function, and increase mobility among individuals
with knee osteoarthritis (OA). The evidence-based consensus
with the remaining two groups (P < 0.05). guidelines provided by the Osteoarthritis Research Society In-
Conclusions: Either resistance exercise type improves activity-related ternational (OARSI) for nonsurgical management of knee OA
knee osteoarthritis pain, but concentrically focused resistance training include resistance exercise training (RT) as a core treatment.1
more effectively reduced severity of ambulatory pain and pain upon Meta-analyses show that RT in general can have a positive
walking cessation. effect on pain relief and physical function and that greater
Key Words: Knee, Osteoarthritis, Resistance Exercise, improvements in pain tend to be associated with higher func-
Physical Function tional levels.2 Systematic reviews report that nonweight-
bearing RT is more effective for pain relief compared with
(Am J Phys Med Rehabil 2020;99:932–940) weight-bearing RT or aerobic exercise.3
For the last few years, federal research programs have fo-
cused on determining the mechanisms underlying the health
From the Divisions of Physical Medicine and Rehabilitation, Sports Medicine and
Research, Department of Orthopaedics and Rehabilitation, University of Florida, benefits of exercise and physical activity mediation of disease
Gainesville, Florida. states. What is known from the mechanistic perspective is that
All correspondence should be addressed to: Heather K. Vincent, PhD, FACSM, Division
of Research, Department of Orthopedics and Rehabilitation, UF Orthopaedics and
RT exercises involve muscle actions that are concentric and
Sports Medicine Institute, PO Box 112727, Gainesville, FL 32611. eccentric. Eccentric actions are essential in daily activities,
This work was supported by a grant from the National Institute of Arthritis and such as stair descent, squatting, or sitting into a chair. Concen-
Musculoskeletal and Skin Diseases of the National Institutes of Health (NIH)
Award Number AR059786 and K Award AR061146-01A1. tric actions are vital in stair ascent, standing up, and rising from
Portions of these data have been presented in various posters at the annual meetings a chair. Although RT is widely used to manage knee OA, the
of American Academy of Physical Medicine and Rehabilitation (AAPMR), role of RT muscle actions on OA functional pain symptoms4
November 16, 2012, Atlanta, GA and at the American College of Sports
Medicine (ACSM), June 1, 2018, Minneapolis, MN. and translation to gains in physical functions are not known.
Financial disclosure statements have been obtained, and no conflicts of interest have been This information could advance the knowledge of potential
reported by the authors or by any individuals in control of the content of this article.
Supplemental digital content is available for this article. Direct URL citations appear
mechanical mechanisms underlying changes in OA symptoms
in the printed text and are provided in the HTML and PDF versions of this article and functional gains and could guide the development of per-
on the journal’s Web site (www.ajpmr.com). sonalized RT programs. Eccentric exercise actions are charac-
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115 terized low energy cost, high force production, hypertrophic
DOI: 10.1097/PHM.0000000000001450 impact, and favorable effect on fall risk and physical function

932 www.ajpmr.com American Journal of Physical Medicine & Rehabilitation • Volume 99, Number 10, October 2020

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Volume 99, Number 10, October 2020 Concentric and Eccentric Exercise for Osteoarthritis

and mobility.5,6 Eccentric resistance training may also increase Participants and Screening
volitional drive and reduce corticospinal inhibition to muscle Older adults with knee OA were recruited from the
more than concentric training in OA.7 In theory, these neural Gainesville area using the UF Orthopedics Clinics, the Clinical
output features may improve functionality in activities, such Trials Register, and a mailing list provided by the UF Claude
as stair climb or ambulation. Most resistance exercise interven- Pepper Aging Center from November 2010 to December
tions for knee OA therefore have overloaded muscle and 2012. The inclusion criteria were as follows: adults aged
progressed concentric actions but understimulated muscle dur- 60–85 yrs; presence of tibiofemoral knee OA for 6 mos or lon-
ing the eccentric actions.8 Two promising studies have shown ger (defined using American College of Rheumatology criteria);
reductions in knee OA functional pain and accentuated im- bilateral standing anterior-posterior radiograph demonstrating
provements in physical function when eccentric muscle actions Kellgren and Lawrence OA grade 2 or 3 of 4; free from other
were added to manual RT or to isokinetic machine training pro- musculoskeletal limitations that would impede participation in
grams.9,10 These RT training methods, however, were not de- exercise; and free of abnormal cardiovascular responses during
signed to enable direct comparison of the two muscle action the screening graded maximal walk test. The exclusion criteria
types on OA outcomes. were as follows: surgery to either knee within the last 12 mos;
Therefore, the purpose of this study was to address this ev- lumbar radiculopathy; vascular claudication; knee pain due to
idence gap by directly comparing the effects of concentrically isolated patellofemoral syndrome or chondromalacia; received
focused resistance training (CNCRT) and eccentrically focused corticosteroid or hyaluronic acid injections within last 3 mos;
resistance training (ECCRT) on functional pain and physical and have added new over-the-counter or prescription pain med-
functional performance among individuals with knee OA. We ication within 2 mos of study participation. Eligibility criteria
hypothesized that ECCRT would elicit greater improvements were reviewed by the study coordinator and the study physician
in functional pain and several performance measures compared to ensure that the appropriate participants were enrolled. This
with CNCRT. study was approved by the University of Florida Institutional
Review Board. All procedures on human subjects were per-
formed in accordance with the Helsinki Declaration of 1975,
METHODS as revised in 1983. All participants provided written informed
consent to participate. Figure 1 depicts the Consolidated Stan-
Design dards of Reporting Trials study flow diagram.
This was a secondary analysis of a randomized, controlled, After determining eligibility, all enrolled participants
single-blinded parallel study. This study adhered to the Consoli- completed a progressive walking symptom-limited Naughton
dated Standards of Reporting Trials 2010 guidelines for reporting exercise test in an academic research laboratory for screening
parallel group randomized trials and reports the required in- to continue in the program. The testing sessions followed the
formation accordingly (see Supplemental Checklist, Supple- American College of Sports Medicine guidelines with electro-
mental Digital Content 1, http://links.lww.com/PHM/A997). cardiogram heart monitoring and blood pressure measures.
The registration number for this study on ClinicalTrials.gov Open-circuit spirometry was used to determine the rate of ox-
was NCT01245283. ygen use and carbon dioxide production using a metabolic cart

FIGURE 1. Consolidated Standards of Reporting Trials diagram.

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Vincent and Vincent Volume 99, Number 10, October 2020

(VIASYS; CareFusion Corp, San Diego, CA). All tests were machine was adjusted to equalize the work performed be-
supervised and reviewed by the study physician. Sample size tween the study groups.
was determined based on knee pain subscore improvements Participants randomized to the CON group continued per-
(on the Western Ontario and McMaster Universities Osteoar- forming their normal activities for 4 mos. Offers were made to
thritis Index [WOMAC]) with resistance exercise as described each individual in the group to complete either the CNCRT or
in our previous analysis.11 ECCRT program after the control period. Weekly telephone
contact was made to help encourage adherence to the healthy
behaviors guidelines and to provide attention to this group.
Testing Schedule
Once cleared for further participation, participants com- Functional Pain Ratings
pleted two additional laboratory visits at baseline for functional Pain symptoms were collected during each trial of each
performance testing and quality of life measures. At month 4, functional assessment using the 11-point Numerical Pain Rat-
participants returned to the laboratory three times for repeat ing scale (NRSpain; where 0 = no pain and 10 = worst imagin-
aerobic fitness testing and physical functional testing. able pain). Functional pain score was the primary outcome of
the study. The NRSpain has good psychometric properties, sim-
Randomization and Blinding ilar to the WOMAC function scale, is valid in knee OA and has
Participants were randomly and equally assigned to one of moderate to large responsiveness with treatments.12 A 1-point
three study groups in blocks of two: a CNCRT, an ECCRT, and reduction in pain or reduction by 15% represents a minimal
nonexercise, wait-list control group (CON). A computer- clinically important difference, with reductions of 30%–36%
generated list and hidden sequencing of the individual as- considered meaningful reduction in pain severity.
signment were used for randomization and provided to the
participants by one coordinator. This was a single-blinded de- Physical Function Assessments
sign as the PI, coordinators, and exercise physiologists who Four physical function performance test secondary mea-
collected measures did not know the group allocation of each sures were administered at baseline and month 4. These tests
participant. Group assignments were placed in opaque, num- are part of the recommended set of performance-based mea-
bered sealed envelopes and each new enrolled participant sures reflecting typical activities important to persons with
opened an envelope to receive the group assignment. Training knee or hip OA by the Osteoarthritis Research Society Interna-
was supervised by another co-investigator and performed by tional.13 These included the chair rise test, stair climb test,
exercise physiologists. walking gait test, and 6-min walking test. Strength was
assessed using the 1RM method. One-repetition maximum
values were determined using the following method: for each
Resistance Exercise Interventions and Control machine exercise, a warm up of five repetitions at a low weight
Group was followed by three repetitions at a higher weight. Single lifts
The two resistance training groups trained on MedX clin- were performed at progressively higher loads until the exercise
ical resistance exercise machines using the general guidelines could not be performed or performed with good form. Rest pe-
described by the American College of Sports Medicine. All riods between each lift for each exercise were 60 secs.
participants received an informational packet of healthy behav-
iors (Centers for Disease Control Physical Activity for Every- Chair Rise Time and Stair Climb Time
one and Nutrition for Everyone; American Heart Association Chair rise time was measured as the time required for the
Physical Activity in Daily Life). Participants in the CNCRT participant to move from a sitting to a full standing position.
group performed two resistance exercise sessions per week. Participants sat in an armless, straight-backed chair (42.5-cm
One set of each of the following exercises was completed dur- seat height, 45-cm seat depth) and had their arms folded in
ing each session: leg press, knee flexion, knee extension, calf front of their chests. On a standard countdown cue, participants
press, chest press, seated row, shoulder press, and biceps curl. rose from the chair as quickly as possible. This transitional ac-
For each set, 12 repetitions were performed at a resistance load tivity is common in daily life and may reflect muscle strength
of 60% of the one-repetition maximum (1RM) for that exer- and dynamic balance. Stair climb time was measured by hav-
cise.11 The effort of performing the exercise set was subjec- ing the participants walk up one standard flight of stairs as
tively rated using a 6- to 20-point rating of perceived exertion quickly as possible (12 stairs; 18 cm high, 30.5 cm deep).
scale. As the participant adapted, the effort felt less, and the One handrail was permitted, but the use of the legs alone
resistance load was raised for the set to keep the rating of per- was encouraged. The chair rise test and stair climb tests
ceived exertion value at approximately 17–18 of 20 points for are used in older adults with knee OA and are reliable
each exercise over the study duration. (intraclass coefficient values range = 0.94–0.96).14 Both
Participants in the ECCRT group also trained on modified tests were repeated three times, and the trial times were aver-
MedX machines. Enhanced eccentric training continually aged for data analysis.
performs the eccentric muscle action with the equivalent of
the 1RM and to sequentially reduce the load to 60% of Gait Parameters at Self-Selected Speed
1RM for the concentric muscle action. Rating of perceived ef- Participants walked on an 8-meter-long gait mat at a self-
fort was used in this group, and progressive loading was as selected speed (GaitRite; CIRSystems Inc, Havertown, PA).
described for CNCRT. The repetition structure on the eccen- The participants performed three acclimation trials to reduce
tric exercise machine and comparative concentric exercise the learning effect. The temporal-spatial parameters collected

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Volume 99, Number 10, October 2020 Concentric and Eccentric Exercise for Osteoarthritis

included velocity, cadence (steps per minute), step length, step after randomization).18 For both approaches, data were ana-
width, and single support times (when only 1 foot was making lyzed using general linear models. These models included time
contact with ground). The coefficient of variation CV (percent) (pretraining, posttraining) and study group (CON, CNCRT,
of specific measures reflect relative gait variability, and coeffi- ECCRT) as main effects, with an interaction model between
cient of variation = within person standard deviation of the time and group. Covariates in the models included age, dura-
measure / mean over the gait cycle.15 Increased variability of tion of pain symptoms, and body mass index. A significant
gait parameters is linked to decreased gait stability, complexity, time  group interaction would indicate that change in out-
and increased risk of falling.16 Given that the variability of come from pretraining to posttraining differed among groups.
most gait parameters described by the coefficient of variation Changes in functional pain scores are reported in raw numbers
is speed dependent, the most reliable and reproducible gait pat- and as a percent change from pretraining to posttraining. Par-
terns occur near the self-selected walking speeds.15 Walks were tial η2 was used to estimate effect size, with values of 0.02
repeated three times, and the scores were averaged and re- (small), 0.13 (medium), and 0.26 (large). For the intent-to-
ported. These were secondary measures. treat analysis, if participants began but did not finish the study,
the last data observations were carried forward.19 An α level
Six-Minute Walk Test was considered statistically significant if less than 0.05. Given
Each participant performed a 6-min walk test in the that there were no major differences in the overall results based
laboratory’s 24-meter hallway according to Osteoarthritis Re- on approach type, we present the per-protocol outcomes in the
search Society International standards. Distance was marked results and the modified intent-to-treat results as supplemen-
at 3-meter intervals. Participants were instructed as follows: tary tables.
“Cover as much ground as fast as you can, but do not push
yourself to a point of overexertion or beyond what you think RESULTS
is safe for you. You may rest or sit if needed in the test.” Regu-
lar, standardized encouragement was provided by the coordina- Participant Characteristics
tors flanking each side of the ends of the hallway (“Keep up the
Baseline characteristics of the three study groups are
good work, you are doing really well”). The NRSpain scale was
shown in Table 1. The study groups were well matched with re-
used to capture the knee pain severity scores at rest, at 1-min
spect to several demographics. However, the ECCRT group
intervals during the test and to 5-min posttest. No assistive de-
had 16.6%–27.7% fewer participants with obesity compared
vices were used for this test. The measures captured here were
with the two other groups (P = 0.005). This same group had
secondary outcomes.
an average of 5-yr longer duration of knee pain symptoms than
the other groups (P = 0.009).
Community Ambulation
All participants were provided a StepWatch step activity Exercise-Induced Strength Improvements
monitor (SAM; Cyma, Seattle, WA) by the study team to wear There were significant group  time interactions for all
during all nonsleeping hours as an estimate of physical activity muscle 1RM strength measures (all P < 0.05), which demon-
level and return after use. This is an accurate, dual-axis accel- strated efficacy of the training programs. For the leg muscula-
erometer devised to count steps in individuals with disabilities, ture, the mean relative strength gains for the CNCRT, ECCRT,
abnormal or slow gaits, or lower limb prostheses. This watch
has coefficients of 3.0%–51.3% with higher variation for short
periods of 1–2 days.17 Thus, a 7-day tracking period was com- TABLE 1. Participant characteristics at baseline
pleted by each participant to optimize reliability of the
StepWatch output. CON CNCRT ECCRT
(n = 17) (n = 17) (n = 19) P (Sig)
Statistics Age, yr 68.6 ± 7.1 69.5 ± 6.5 66.8 ± 5.4 0.079
Statistics were conducted in IBM SPSS Version 25.0 Height, cm 167.9 ± 13.0 164.7 ± 9.9 168.5 ± 11.1 0.163
(Armonk, NY). Differences in baseline categorical measures Weight, kg 91.6 ± 43.2 88.6 ± 19.4 81.9 ± 21.2 0.205
across concentric (CNCRT), eccentric (ECCRT), and control BMI, kg/m2 32.8 ± 18.2 32.8 ± 7.3 28.7 ± 6.6 0.107
(CON) groups were assessed using χ2 tests. Differences in Women, % 65.6 66.7 70.0 0.866
baseline continuous measures across study groups were Race, %
assessed with analysis of variance, using the Tukey-Kramer White 81.3 85.2 93.3
test for pairwise comparisons, which also adjusted for multiple African-American 6.3 11.1 6.7
comparisons using the Bonferroni method. Before analyses, Other 12.4 3.7 0.0 0.105
nonnormal measures were log transformed. Baseline values Comorbidities, %
for all outcome variables were conducted using a one-way anal- Diabetes mellitus 15.2 14.8 3.3 0.064
ysis of variance with a Tukey post hoc test. For the functional Hypertension 39.4 59.3 40.0 0.055
and pain outcomes, two analytical approaches were used: per- Low back pain 27.3 25.9 40.0 0.190
protocol analysis (inclusion of participants who did not have Obesity 33.3 44.4 16.7 0.005
any violations to the study protocol) and the modified intent- Duration of pain, yr 7.9 ± 8.1 7.8 ± 8.1 12.8 ± 11.9 0.009
to-treat concept (inclusion of all participations who were ran- Values are means ± SD or percent of the group.
domized to the study minus those who were deemed ineligible

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Vincent and Vincent Volume 99, Number 10, October 2020

and CON from pretraining to posttraining were as follows: leg baseline group differences in any gait measure. There were
press (33.5%, 32.8%, and −2.2%, respectively), knee extension no significant group  time interactions for any gait variable
(29.1%, 20.2%, and −7.4%, respectively), and knee flexion (partial η2 range = 0.005–0.092, small effect). However,
(20.8%, 19.1%, and −0.5%, respectively). main effects existed for group, where the CNCRT group
had slower velocities, cadence, step length, wider steps,
and less single leg support time than the remaining groups
Gait Measures (P < 0.05). The intent-to-treat analysis did detect any signif-
Temporal-spatial measures and variability of gait during icant interactions or main effects of group or time (Supple-
walking at a self-selected speed at baseline and month 4 are mental Table 1, Supplemental Digital Content 2, http://
presented in Table 2 (per-protocol analysis). There were no links.lww.com/PHM/A998).

TABLE 2. Temporal-spatial parameters of gait at a self-selected speed

CON (n = 17) CNCRT (n = 17) ECCRT (n = 19) Time Group Group  Time Partial η2
Velocity, m/sec
Baseline 120.8 ± 27.8 116.2 ± 23.4 130.2 ± 26.7
Month 4 129.1 ± 23.1 112.9 ± 21.0 131.4 ± 25.8 0.559 0.005 0.458 0.035
Change 8.9 ± 24.4 −3.2 ± 18.3 1.2 ± 30.4
Cadence, step/min
Baseline 108 ± 14 108 ± 10 114 ± 13
Month 4 112 ± 9 108 ± 8 114 ± 10 0.541 0.035 0.657 0.019
Change 3.7 ± 13.2 −0.5 ± 9.8 −1.2 ± 16.5
Step length, cm
Baseline 65.9 ± 8.7 64.5 ± 10.0 66.6 ± 10.0
Month 4 68.5 ± 10.4 62.8 ± 9.6 69.3 ± 10.6 0.782 0.026 0.172 0.077
Change 3.0 ± 5.9 −1.7 ± 5.8 2.6 ± 7.7
Step width, cm
Baseline 10.8 ± 3.8 11.5 ± 3.5 9.3 ± 3.4
Month 4 11.3 ± 2.9 11.5 ± 3.7 9.9 ± 2.9 0.923 0.025 0.887 0.005
Change 0.4 ± 3.3 −0.04 ± 2.2 0.6 ± 2.2
Single leg support, %GC
Baseline 35.2 ± 2.2 34.0 ± 2.8 35.9 ± 2.0
Month 4 35.7 ± 1.6 33.9 ± 2.6 36.4 ± 1.8 0.681 0.015 0.352 0.046
Change 0.4 ± 1.1 −0.1 ± 1.5 0.5 ± 1.5
Coefficient of variability, %
Stride velocity
Baseline 0.78 ± 0.21 0.79 ± 0.33 1.13 ± 0.42
Month 4 0.99 ± 0.23 0.98 ± 0.51 1.02 ± 0.33 0.774 0.250 0.121 0.092
Change 0.21 ± 0.27 0.19 ± 0.56 −0.11 ± 0.50
Stride time
Baseline 0.74 ± 0.37 0.88 ± 0.47 0.81 ± 0.36
Month 4 0.96 ± 0.40 1.00 ± 0.46 0.88 ± 0.31 0.721 0.759 0.555 0.057
Change 0.23 ± 0.44 0.12 ± 0.53 0.07 ± 0.50
Stride length
Baseline 0.96 ± 0.41 0.83 ± 0.19 0.98 ± 0.31
Month 4 0.94 ± 0.26 1.07 ± 0.36 1.01 ± 0.28 0.916 0.540 0.356 0.046
Change −0.01 ± 0.43 0.24 ± 0.46 0.02 ± 0.42
Swing time
Baseline 0.94 ± 0.44 0.87 ± 0.31 0.80 ± 0.14
Month 4 0.96 ± 0.27 1.21 ± 0.51 0.85 ± 0.20 0.891 0.789 0.168 0.078
Change 0.02 ± 0.40 0.34 ± 0.64 0.04 ± 0.25
Double support
Baseline 0.92 ± 0.62 0.92 ± 0.48 0.88 ± 0.42
Month 4 0.96 ± 0.58 1.24 ± 0.89 0.82 ± 0.31 0.360 0.895 0.286 0.055
Change 0.04 ± 0.75 0.32 ± 1.08 −0.06 ± 0.43
Values are means ± SD.
GC, gait cycle; variability % = coefficient of variability.

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Volume 99, Number 10, October 2020 Concentric and Eccentric Exercise for Osteoarthritis

Physical Function Performance Measures

Baseline 6-min walk test distance was lowest in the
CNCRT group compared with the other two groups. The per-
protocol analysis results of the functional tests of chair rise,
stair climb, and the 6-min walk are shown in Table 3. There
were no significant group  time interactions for any of the
timed scores of the performance tests (partial η2 range =
0.040–0.078, small effect). The intent-to-treat analysis also
did not detect significant interactions for these outcomes, but
a significant main effect for group was found, where the
CNCRT group demonstrated shorter walking distances during
the 6-min walk test (Supplemental Table 2, Supplemental Dig-
ital Content 3, http://links.lww.com/PHM/A999; P = 0.05).

Functional Pain Scores

Baseline chair rise pain scores were lowest in the CON
group compared with the other two groups. Pain scores during
the physical function tests are shown in Figures 2 and 3, re-
spectively. Intent-to-treat analyses revealed that mean chair rise
NRSpain scores increased for the CON and decreased for the
CNCRT and ECCRT groups by month 4 (partial η2 = 0.044;
Fig. 2A; P < 0.05, small effect). Mean stair climb NRSpain
scores increased for the CON and decreased for the CNCRT
and ECCRT groups by month 4 (partial η2 = 0.044; Fig. 2B,
small effect). Intent-to-treat analysis revealed a significantly
greater reduction in chair pain scores in the CNCRT compared
with the CON and ECCRT groups (Supplementary Table 2,
Supplemental Digital Content 3, http://links.lww.com/PHM/
A999; P = 0.008). FIGURE 2. A, 11-point NRSpain (where 0 = no pain and 10 = worst
Figures 3A–C provide the per-protocol NRSpain scores imaginable pain) values during the chair rise test. B, NRSpain values
before, during, and after the 6-min walk test. By month 4, during the stair climb test. Values are means ± SD. Partial η2 values for
chair rise and stair climb were 0.044 and 0.087, respectively.
the CNCRT group demonstrated significant reductions in
pain severity at minutes 2, 4, 5, 6, and at minute 1 of recov-
ery that ranged from 1.1 to 1.4 points on the NRSpain scale Community Ambulation
(B; all P < 0.05). The ECCRT group averaged 0.1- to 0.71- The StepWatch results from baseline to month 4 are pre-
point NRSpain reductions at these same time intervals. sented in Table 4. Baseline differences existed in the daily steps
Intent-to-treat analyses revealed the same pain responses per day, with the CNCRT group walking fewer steps than the
among the three groups at the same time points as the per- remaining groups. No significant group  time interactions
protocol analysis. were found for average daily steps taken or the daily minutes

TABLE 3. Chair rise, stair climb, and 6-min walk test performance measures

CON (n = 17) CNCRT (n = 17) ECCRT (n = 19) Time Group Group  Time Partial η2
Chair rise time, sec
Baseline 1.14 ± 0.62 1.66 ± 1.27 1.24 ± 0.64
Month 4 0.77 ± 0.31 0.76 ± 0.29 1.63 ± 3.9 0.207 0.524 0.301 0.054
Change −0.31 ± 0.52 −0.90 ± 1.21 0.39 ± 0.99
Stair climb time, sec
Baseline 5.04 ± 2.81 6.22 ± 2.87 4.33 ± 1.49
Month 4 5.04 ± 1.71 7.34 ± 3.53 5.12 ± 1.77 0.850 0.401 0.168 0.078
Change 0.07 ± 2.27 1.12 ± 1.83 0.79 ± 0.98
6-min walk distance, m
Baseline 491.6 ± 431.6 431.6 ± 78.9 490.4 ± 86.8
Month 4 512.0 ± 34.5 427.3 ± 83.8 510.5 ± 93.6 0.900 0.287 0.977 0.040
Change 20.3 ± 50.6 −4.3 ± 26.7 19.9 ± 82.4
Average changes from pretraining to posttraining are also shown. Values are means ± SD.

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Vincent and Vincent Volume 99, Number 10, October 2020

of walking at high to low intensities using per-protocol or

intent-to-treat approaches (partial η2 range = 0.002–0.033;
small effect). We did find a consistent main effect of group for
daily moderate-intensity walking time, where the CNCRT group
accumulated fewer minutes of walking at moderate intensities
during the day compared with the remaining two groups at both
time points (Supplementary Table 3, Supplemental Digital
Content 4, http://links.lww.com/PHM/A1000; P < 0.05).

DISCUSSION
The key findings of this study were that ECCRT did not
produce greater changes in functional test scores, gait perfor-
mance, or functional pain for stair climb or chair rise than
CNCRT. However, CNCRT group experienced lower pain sever-
ity than the other two groups during the 6-min walk test after
training. Thus, resistance training muscle action type did not seem
to be a strong mechanism modulating knee pain change or consis-
tent translation to better physical function outcomes tested here.
Comparative evidence of eccentric versus concentric muscle
actions on physical function tasks and functional pain outcomes
in knee OA is very limited. The existing data are discrepant,
potentially because of heterogeneity among interventions.
Some investigations that used concentric-focused leg exercise
(including leg extension, leg press, hip adduction/abduction,
lunge or straight leg raise with multiple sets)20,21 produced im-
provements in WOMAC pain subscores,16,20–22 and functional
ability (walking velocity, stair climb).16,22 One study of home
functional strengthening exercise (step-ups, squats, and ankle
weight resistance for knee flexion-extension, hip flexion-
FIGURE 3. A–C, 11-point NRSpain scores before, during, and after the extension), produced changes in WOMAC pain subscores
6-min walk test for the control group (A), the CNCRT group (B), and the
ECCRT group (C). Values are means ± SD. *Significantly different among
and faster stair climb times and faster time to complete chair
the three groups at P < 0.05. Partial η2 values for minute-by-minute pain stands.23 Topp et al.16 subjected individuals to either dynamic
scores ranged from 0.014 to 0.188. or isometric leg exercise with Therabands. After 4 mos,

TABLE 4. Daily ambulation (steps per day) and intensity of walking activity

CON (n = 17) CNCRT (n = 17) ECCRT (n = 19) Time Group Group  Time Partial η2
Average daily ambulation, steps
Baseline 5090 ± 2163 3600 ± 1181 4652 ± 1520
Month 4 4977 ± 1715 3496 ± 1308 4643 ± 1127 0.365 0.110 0.882 0.006
Change −5 ± 79 −36 ± 74 −48 ± 54
High-intensity walking, min
Baseline 14.4 ± 11.5 10.3 ± 10.4 18.4 ± 12.9
Month 4 13.4 ± 9.4 9.5 ± 9.6 18.3 ± 10.1 0.104 0.702 0.623 0.002
Change 1±8 1±6 1±9
Moderate-intensity walking, min
Baseline 119.7 ± 54.4 72.6 ± 29.6 101.7 ± 34.1
Month 4 118.7 ± 45.5 78.5 ± 26.4 99.9 ± 31.8 0.987 0.043 0.976 0.001
Change 2 ± 55 4 ± 24 2 ± 29
Low-intensity walking, min
Baseline 212.0 ± 70.8 179.8 ± 51.9 215.6 ± 65.1
Month 4 220.1 ± 68.6 179.0 ± 61.6 200.2 ± 58.2 0.756 0.512 0.479 0.032
Change −3 ± 60 1 ± 43 15 ± 43
Sedentary time, min
Baseline 1026.9 ± 97.9 1086.6 ± 95.1 1057.0 ± 108.2
Month 4 1046.4 ± 88.8 1137.6 ± 81.8 1069.7 ± 94.9 0.319 0.138 0.531 0.028
Change −28 ± 113 −51 ± 101 −12 ± 122
Average changes from pretraining to posttraining are also shown. Values are means ± SD.

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Volume 99, Number 10, October 2020 Concentric and Eccentric Exercise for Osteoarthritis

Topp et al.16 reported that functional pain was reduced by because they felt that exercise could help with symptom man-
42%–58.5% with both exercise types and that pain during stair agement. Despite rigorous control and measurement, the gen-
climb and descent was reduced by 28.2%–42.5% compared eralizability of the findings to all knee OA may not be
with controls. In another study, Foroughi et al.24 reported that possible. We provided per-protocol and intent-to-treat analyses
6 mos of RT on pneumatic machines reduced pain more than to reduce this bias. This study was previously powered to detect
sham exercise (32.1% vs. 21.4%), but this group difference differences in subjective average resting pain not for all the var-
was not significant over time. We found large reductions in iables in this analysis, which may explain the small training in-
functional pain with both resistance training types but addi- tervention effects observed in most of the functional variables.
tional protection against pain during the 6-min walk test with Importantly, there was considerable interindividual variation in
CNCRT. These collective data provide support that regular responsiveness to the interventions, and eight of the control par-
strengthening, irrespective of muscle action type, can reduce ticipants maintained or improved their strength. The 4-month
pain with load-bearing movements. changes in leg extension strength ranged from −1.6% loss to
Compared with other published regimens, our training did +140% in the CNCRT and from −59% to +47% in the ECCRT,
not emulate movements of daily living irrespective of muscle which could contribute to variation to changes in functional
action type.16,23 Thus, leg strength gains achieved by ECCRT performance. Thus, discrepant conclusions may exist based
or CNCRT did not directly translate to gait performance. on participant responsiveness. We may have missed potential
Sitting while exercising may not sufficiently challenge the functional and pain benefits with ECCRT as this study did
neuromotor system to translate to gains in functional outcomes not include functional performance tasks that specifically
and pain. Investigators used a combination of seated machines stressed eccentric capacity of the knee. Inclusion of activities,
(leg press), squats, and walking with dumbbells over stable and such as stair descent, multiple chair rise, or lowering oneself
unstable surfaces.25 Our data show that ECCRT of CNCRT did to the floor, may be useful in future investigation to assess
not differentially change temporal spatial parameters of gait ECCRT translation to daily function. Future resistance training
and gait variability. Machine-based resistance training, irre- protocols should consider this stability element in the design.
spective of muscle action type, may not facilitate improve- In addition, our participants with varying severity of knee
ments in motor exploration and reduction in variance during OA my not have had substantial gait variability at the onset
walking. Normal walking variability contains some random of the study.
and periodic components,26 which may reflect pain avoidance
strategies or pathology-related changes to the joint. Recent evi- CONCLUSIONS
dence suggests that inclusion of resistance exercise performed
Both resistance exercise types conferred benefit to func-
on a unstable surface (performed on foam pads and BoSUballs)
tional pain during chair rise and stair climb. Concentrically fo-
may increase motor adaptability, motor output, and better
cused resistance training reduced severity of ambulatory pain
responses to environmental conditions during walking.25 Our
and persistence of pain upon walking cessation. However, the
seated machine intervention was more similarly aligned with
ultimate selection of which type to use is dependent on several
the pneumatic machines used by Foroughi et al.24 This investi-
factors including equipment availability, pain at the knee or
gation did not detect group by time interactions for pain or func-
other joints, and the comfort level of the patient. The typical
tional scores despite leg muscle strength gains. Potentially,
concentrically focused program may improve comfort during
higher speeds of more functional resistive movement at lower
walking. The most important message is that patients with
percentage of 1RM may be more functionally useful for the
knee OA should participate in resistance training to help de-
knee OA population.27 For example, after 8 wks of resistance
crease pain during physical activity. Future research should ex-
training (sit-to-stand, squat, calf raises using vest weight starting
amine mechanisms of responsiveness to ECCRT and CNCRT
at 20% 1RM), participants demonstrated significant improve-
and protocols that include load-bearing movements emphasiz-
ments in timed-up-and-go, sit-to-stand repetitions accomplished
ing different muscle actions.
in 30 secs and stair climb power than in controls.27
Community ambulation did not change over time among
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