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INTRODUCTION
Knee osteoarthritis (OA)
is a degenerative disease associated with pain and loss
of functional capacity. Physical disability arising
from pain and loss of functional capacity in the knee
reduces quality of life and increases the risk of further
morbidity and mortality (1). Pain and muscle strength
may particularly influence postural sway (2). Also,
if knee OA impairs quadriceps function this may impair
the patient's balance and gait, reducing their mobility
and function (3,4,5).
Both strength exercise and aerobic exercise are evidence-based
recommendations, which reduce pain and improve function
and health status in patients with knee OA (6).
Strengthening is an important factor in the performance
of daily activities, and an important part of a comprehensive
rehabilitation program for the elderly adult with OA.
Researchers have demonstrated that resistance training
reverses many age-related physiologic changes and can
improve function (7,8). Exercise has been recommended
by the American College of Rheumatology as a treatment
for knee osteoarthritis on the basis of several small
trials that demonstrated its efficacy for this condition
(9,10). In patients with light to moderate OA of the
knees, regular strength exercise is possible and leads
to improvement in muscle strength, endurance and speed
(11).
The classification of lower extremity strengthening
exercises is commonly referred to as either open kinetic
chain (OKC, non-weight-bearing) or closed kinetic chain
(CKC, weight-bearing) exercises. Exercises with the
distal segment of the limb fixed are referred to as
CKC, whereas exercises performed with the distal segment
of the limb movable are referred to as OKC (12). It
is not imperative that so-called OKC exercises have
more negative effects than CKC exercises. Depending
on the stage of rehabilitation, application of OKC and
CKC exercises have special importance which supports
a combination of the two forms. Both exercise modes
are necessary in rehabilitation to improve both proprioception
and function (13). Many randomized trials have demonstrated
the positive effect of regular exercise on older people's
muscle strength, flexibility, aerobic capacity, and
balance and on reducing the risk of falls and fractures
and preventing (coronary) disease (14). However, there
is no consensus regarding = OKC and CKC training programs
with elastic band for functional performance in women
with knee osteoarthritis, in Turkey.
The purpose of this study was to determine the effect
of closed kinetic chain and open kinetic chain strength
exercises with elastic band on functional performance
and pain in elderly women with knee OA.
METHODS
Setting and Participants
The study was conducted at the Education and Research
Hospital, Department of Physical Therapy and Rehabilitation
in Antalya, Turkey between August 2005 and August 2006.
Participants with OA, with a diagnosis based on clinical
and radiological criteria by the American College of
Rheumatology (15), were recruited. We informed participants
that we were studying the effects of two different types
of exercise training programs. All outcome measures
were measured and 12 weeks of training were conducted
in the Akdeniz University, Sports Sciences Research
and Application Center in Antalya, Turkey. Inclusion
criteria were being independent in daily activities,
volunteer and being between 50-74 years of age. Exclusion
criteria were being involved in regular physical activity
and physiotherapy, perception and cognition defect,
diabetes, using any assistive equipment, having a Standardized
Mini-Mental State Examination (SMMSE) score of 23 or
less (16).
Before randomization all participants were informed
about types of OA, risk factors and management of OA,
in a one hour educational session. All participants
were also informed about a random allocation to either
of the exercise groups or a control group. After written
informed consent, fifty two participants were randomized.
Seventeen participants were assigned to the control
group, whose members did not exercise, and eighteen
patients were assigned to the open kinetic chain group
and seventeen participants were assigned to the closed
kinetic chain group. Simple randomization was employed
using a computer generated table of random numbers by
a person external to the study and was managed by an
external department. Seven women in the control group
did not participate in the first measurements (no given
reason). In the second measurements period, two women
did not participate in the open kinetic chain group
(one because of a relative's death and because of a
grandchild), and in the seventh weeks of the training
period, one woman withdrew from the study in the closed
kinetic chain group (because of a move to another city).
The final analysis included 42 women who completed the
training program: 16 in the OK group, 16 in the CK group
and 10 in the C group. Data on demographics, medical
history, and drug use were collected directly from the
participants at the beginning of the study. All outcome
measures were measured before the initiation of strength
training (baseline) by five trained assistants blinded
to the participants treatment allocations and then measured
again at six weeks of training (mid-training) and at
12 weeks of training (post training) by the same researchers
from the Sports Sciences Research and Application Center
in Akdeniz University. Assessments and measurements
were performed under similar conditions (time of day,
temperature, setting) during the 12 weeks. Participants
were advised not to change the treatment for any chronic
condition and to immediately inform the research team
in the case of participation in other programs.
Click
here for Figure 1:Summary
data of study recruitment and completion
Outcome measure
Knee OA outcome measurements were by WOMAC pain, stiffness,
function, static (eyes open-eyes closed) and dynamic
balance, functional performance such as the chair-stand,
6-min walk, stairs descent and stairs climbing. A Turkish
version of WOMAC consists of three subscales including
pain, stiffness, and physical function, with higher
scores indicating disease severity (17). It has 3 subscales
that we analyzed separately: pain (score range 0-500),
stiffness (score range 0-200), and function (score range
0-1700), with higher scores indicating more severe disease.
Height was measured using a stadiometer (Britain Holtain
Limited Crymych Dyfed). Weight was measured using Tanita
body composition analyzer (model TBF-300). The chair-stand
test (measured in seconds) was used to assess lower
body strength. Participants sat in the middle of the
chair with the back straight and with a seat height
of 43.18cm, feet flat on the floor, and arms crossed
at the wrists and held against the chest. The participant
stood up, then returned to a fully seated position.
After a demonstration by the tester, a practice trial
of two numbers of stands executed correctly within 30
seconds was conducted. Support with the arms was not
allowed. A 6 minute walk test (measured in meters) was
used to assess aerobic endurance. The score was the
total distance walked in 6 minutes along a 45.72 m rectangular
course, marked every 4.57 m. Stairs climbing test was
used to assess functional capacity. The participant
stood at the bottom of a regular 10-step staircase (tread
height 15-cm) and was asked to ascend the stairs as
fast as possible on the command "Go." The
stopwatch was started on the command and was stopped
when participants put their feet on the top step of
stairs. Stairs descent test was used to assess functional
capacity. The participant stood at the top of the stair
described previously. The stopwatch was started on the
command and was stopped when the participant placed
their feet on the floor at the bottom of the stairs.
Patients were not allowed use of handrails. The KAT
balance system (KorebalanceTM Kinesthetic Ability Trainer
VISTA CA) was used to assess static and dynamic balance.
The KAT balance measure protocol was used to test stability
on a platform with adjustable settings measured in pounds
per square inch (increased psi increases platform stability).
Prior to the first test condition, stability was set
to 6.0 psi to replicate standing on a hard surface.
Participants removed their hands from the handrail upon
command and stood as quietly as possible and tried not
to grasp the handrail. The measure of balance was recorded
as the length of time the participant maintained platform
stability within ± 0.2 for a maximum of 30 seconds.
(18).
Training Program
A 12 week strength training program was supervised two
times per week by five trainers and one health technician.
Participants were informed of the details of the training
program, rules of safety, work stations and breathing
control, and using the elastic band during training.
The training program involved open kinetic chain and
closed kinetic chain exercises. Training sessions began
with a 15 minute warm-up and ended with a 10 minute
cool-down session. These sessions included slow walk,
low-impact calisthenics and slow, static stretching
exercises. Briefly, each of the 35 patients in the training
group had an individually planned program with respect
to their own physical capacity. The elastic bands were
used for resistance and the stiffness of the band was
increased according to the improvements in strength.
The program included progressive dynamic strength training
for low major muscle groups. In the first two weeks,
exercises with 10 repetitions in two sets were performed.
In the first two weeks exercises were performed without
elastic band. Two-minute rest intervals were allowed
between sets, and 1-minute rest between single exercises.
Exercises
The open kinetic chain exercises were organized as a
row of six exercise stations. The exercises included
hip adduction and abduction (standing position), external
rotation and internal rotation (in a sitting position),
knee flexion (lying position) and extension (in a sitting
position). The closed kinetic chain exercises included
hip adduction and abduction (received chair support)
external rotation and internal rotation (in sitting
position on a chair), knee flexion and extension and
squat (received chair support).
Intensity
Intensity of the strength training program was expressed
as a percentage of 20 RM (Repetition Maximum). Low loads
of 50 % of 20 RM were used during the second 2 weeks.
The intensity of beginning was determined according
to Borg scale for each participant. The participant
was applied to 20 RM with low resistance elastic band
(yellow) and when the participant could easily complete
20 repetitions (14 of Borg scale) of an exercise, they
were encouraged to use a band of higher resistance,
with progression from yellow to red to green to blue
bands. The intensity of training was applied during
two weeks. At the beginning, the participants completed
two sets of 10 repetitions for each leg. The volume
of training was increased to 14 repetitions. Progression
application of the overload principle as adaptation
depends on the individual's response to training. The
resistance (band colour) was increased according to
the improvements in strength, individually.
Data Analysis
All data analysis was performed using SPSS for Windows,
version 11.5 (SPSS, Chicago, IL). The mean ±
standard deviation was calculated for each variable.
The data were assessed for normality by calculating
values for kurtosis and skewness, as well as via the
Kolmogorov-Smirnov test of normality. One way analysis
of variance and Kruskal Wallis tests were used to compare
differences of baseline measurements among the three
groups. The level of significance was set at 0.05. Multiple
3 3 (group time) analysis of variance (ANOVA) was performed
to identify significant changes over time. A post hoc
Bonferroni test was used to compare the main time and
group effects with confidence interval adjustment.
Ethics
The experimental protocol was in accordance with ethical
standards on human experimentation and the Helsinki
Declaration of 1975 as revised in 1983, and was approved
by the Akdeniz University, Faculty of Medicine Research
and Ethics Committee. (12.07.2005 date, number 189 and
project number of this research: 2006.03.0122.001) and
each participant gave signed informed consent.
RESULTS
Between August 2005 and
August 2006, 218 individuals were contacted at the Education
and Research Hospital, Department of Physical Therapy
and Rehabilitation in Antalya, Turkey and screened by
telephone and 93 were identified for evaluation. Fifty
two participants were found eligible and were randomized
to the training program or control group. The remaining
participants were excluded for a variety of reasons
(Figure 1). Baseline data: Table 1 shows the baseline
data of 52 participants before the training program.
The groups did not differ in age, SMMSE, height, weight,
the chair-stand, 6 minute walk, chair-stand, stairs
descent and stairs climbing, and pain, functional, stiffness
of WOMAC scores and static-dynamic balance at the baseline
(p>0.05, Table2). The results of the outcome measurements
at the baseline, mid-training, and post-training times
are presented in Table 2 for all groups.
SMMSE, Standardized Mini-Mental State Examination; OKG,
open kinetic chain group; CKG,
closed kinetic chain group; CG, control group; * F value,
p<0.05, significant baseline difference, one-way
ANOVA; † 2 value, p<0.05, significant baseline
difference, Kruskal-Wallis test.
Table 1: Age, height and weight
characteristics of Women (M ± SD)
Click
here for Table 2: Physical performance and quality of
life characteristics of women (M ± SD)
Attendance for the training
was 88% for the open kinetic chain group and 94 % for
the closed kinetic chain group and 100% for the control
group over 12 weeks.
There was a significant group effect for the chair stand,
stairs descent, static balance (eyes open), WOMAC pain,
stiffness, and function scores (p<0.05). But, the
groups did not differ significantly on stairs climbing,
6 minute walk, static balance (eyes closed), and dynamic
balance (p>0.05). The chair stand, stairs descent,
static balance (eyes open) performances increased (p<0.001,
p=0.046, and p<0.001, respectively) and WOMAC pain,
stiffness and function scores decreased in OKG with
respect to CG (p<0.001, p<0.001, and p<0.001,
respectively). The chair stand, stairs descent, static
balance (eyes open) performances increased (p<0.001,
p=0.044, and p<0.001, respectively) and WOMAC pain,
and function scores decreased in CKG when compared with
the CG (p<0.001 and p<0.001, respectively). However
there were no differences in the chair stand, stairs
descent, static balance (eyes open), and WOMAC pain,
stiffness, and function scores between the OKG and the
CKG (p>0.05) (Table 2).
None of the test scores had changed in the CG compared
with baseline scores, except WOMAC function score which
increased (p=0.028). The difference between baseline
and post-training values in the OKG and CKG was significant
for stairs climbing (p=0.010 and p=0.007, respectively),
and WOMAC pain score (p<0.001 and p=0.021, respectively),
stiffness score (p=0.006 and p=0.048, respectively),
and function score (p<0.001 and p=0.002, respectively).
Additionally, the chair stand test, static balance (eyes
open), and dynamic balance performances increased in
the CKG at post-training with respect to baseline (p=0.003,
p<0.001, and p=0.041, respectively, Table 2).
Click
here for Table 3: Functional performance and WOMAC changes
over time between groups
DISCUSSION
This study indicated that
elderly women with knee osteoarthritis may improve their
functional performance, balance and may decrease pain
after OK and CK strength training with elastic band
for 12 weeks. In patients with severe OA, strenuous
strength exercise programs could not be applied, presumably
on the assumption that they might be harmful to the
knee. Another concern might be that pain could limit
the outcome of such programs. Another study investigated
physical function and pain in patients with severe knee
OA (19). They used a rehabilitation program including
general fitness, balance, coordination, stretching and
lower-extremity muscle strength exercises twice a week
for 3 months. The rising from chair was found to be
unaltered in their study. However, Gilsenan et al.,
(20) have demonstrated significant improvement in quadriceps
strength between pre and post-exercise programs. Our
results supported previous reports that indicated that
elastic-bands were effective to improve physical strength
and functional ability in older-adults (21). However,
there is no consensus regarding the optimal OK and CK
training program with elastic band for functional performance
in women with knee osteoarthritis. In our study, chair-stand
performance was significantly increased in CKG at the
post-training period. Although there was no significant
improvement in chair stand results between periods in
OKG, it was found to be improved when compared with
CG.
Safely ascending and descending stairs are essential
daily living activities that are often difficult to
perform for a patient with knee osteoarthritis (22).
Physical therapists must routinely determine a patient's
readiness to perform functional tasks such as stairs
descent and stairs climbing which has a comparatively
greater injury risk, particularly when patients initially
attempt stairs descent (23, 24). In our study, stairs
climbing time was improved between baseline and post-training
period in OKG and CKG. The stairs descent performance
was significantly improved in OK and CK groups when
compared with CG.
After strength training, although we found increased
walk distance and toleration to walk in women with knee
OA, this did not reach statistical significance. Improvement
of muscle strength is associated with time, intensity
and volume of strength training. On the other hand,
to our knowledge, aerobic capacity can improve in training
sessions that consist of aerobic exercises. Researchers
have demonstrated that a combined training program (strength
and walking training) had greater effect on aerobic
capacity in knee OA patients (25, 26). Declining balance,
gait disorders, strength deficits, difficultly standing
from a chair, and other impairments increase the risk
of falls for older adults (27). Jones et al. (28) found
reduced quadriceps strength and increased postural sway
in patients with self-reported OA compared with controls.
We used the equipment-based assessment of balance in
our study and we observed decreased postural sway after
training in patients with knee OA. Osteoarthritis of
the knee may be risk factor for falls in older adults.
Wegener et al. (29) hypothesized that the accelerated
deterioration of strength and proprioception in knee
OA patients may result in increased body sway and impaired
balance. Using measures of static and dynamic balance,
they found significantly greater body sway in 11 subjects
with knee OA compared with a similar aged group of healthy
adults.
Strength training of the lower extremities with elastic
resistance also may improve balance and proprioception.
A more direct method of balance training involves closed-chain
strengthening, in which the lower extremity is challenged
to maintain postural stability (30). We found that patients
with knee OA improved in dynamic and static balance
(open eyes) after 12 weeks strength training in CKG.
There was no significant difference in dynamic and static
(open eyes) balance between OKG and CKG. Static balance
(open eyes) was significantly different in OKG and CKG
when compared with CG. The other study suggested that
long term weight training and aerobic walking programs
significantly improved postural sway in elders. Our
study shows that OK and CK strength training with elastic
band can give rise to significant reductions in knee
pain when compared with the control group. This effect
was not observed between baseline and the post-training
period in CG. No significant differences were found
between the OK and CK groups. In addition to improvements
in pain, strength training also produced significant
improvements in knee stiffness and physical function.
The findings are consistent with previous investigators
who have reported that exercise can reduce pain and
increase the perceived and actual functional abilities
of OA patients (31). Topp et al. (32) investigated pain
and physical function in patients with knee OA. They
used lower-extremity strength exercise with elastic
band and isometric exercise 3 times a week for 16 weeks.
Although Topp et al. used a different training program
than used in our study, they also found significant
improvement in pain and physical function after training.
In conclusion, although there was no significant difference
between OK and CK groups, the strength training program
resulted in significant improvement in the chair stand,
stairs descent, and static balance performances and
WOMAC pain, stiffness, and function scores in the training
groups when compared to the CG.
Acknowledgements
This study was supported
by Akdeniz University Research Foundation (2006.03.0122.001).
We would like to thank Dr. Asuman Doseyen at Antalya
Education and Research Hospital, Department of Physical
Therapy and Rehabilitation for evaluating the patients
who had knee OA, Prof. Kamil Ozer for providing training
areas, Assoc. Prof. Y. Gul Ozkaya for supporting writing,
and very special thanks to all patients who volunteered
for this study.
REFERENCES
1- Jordan KM., Arden NK.,
Doherty M, Bannwarth B, Bijlsma JWJ, Dieppe P &
et al.. EULAR Recommendations: An evidence based approach
to the management of knee osteoarthritis: report of
a task force of the standing committee for international
clinical studies including therapeutic trials (ESCISIT).
Ann Rheum Dis 2003; 62, 1145-55.
2- Hassan B, Mockett S& Doherty M. Static postural
sway, proprioception, and maximal voluntary quadriceps
contraction in patients with knee osteoarthritis and
normal control subjects. Ann Rheum Dis 2001; 60, 612-18.
3- Hurley MV, Scott DL, Rees J & Newham DJ. Sensorimotor
changes and functional performance in patients with
knee osteoarthritis. Ann Rheum Dis 1997; 56, 641-48.
4- Sturnieks DL, Tiedemann A, Chapman K, Bridget M,
Murray SM & Lord SR. Physiological risk factors
for falls in older people with lower limb arthritis.
J Rheumatol 2004; 31, 2272-79.
5- Hinman RS, Bennell KL, Metcalf BR & Crossley
KM. Balance impairments in individuals with symptomatic
knee osteoarthritis: a comparison with matched controls
using clinical tests. J Rheumatol 2002; 41, 1388-94.
6- Roddy E, Zhang W, Arden DN, Barlow J, Birrell F,
Carr A& et al. Evidence-based recommendations for
the role of exercise in the management of osteoarthritis
of the hip or knee-the move consensus. Rheumatology
2005; 44, 67-73.
7- Hurley, M.V. & Scott, D.L. Improvements in quadriceps
sensorimotor function and disability of patients with
knee osteoarthritis following a clinically practicable
exercise regime. Br J Rheumatol 1998; 37, 1181-87.
8- Gur H, Cakin N, Akova B, Okay E & Kucukoglu S.
Concentric versus combined concentric-eccentric isokinetic
training: effects on functional capacity and symptoms
in patients with osteoarthrosis of the knee.Arch Phys
Med Rehab 2002; 83, 308-16.
9- Bearne LM, Scott DL & Hurley MV. Exercise can
reverse quadriceps sensorimotor dysfunction that is
associated with rheumatoid arthritis without excerbating
disease activity. Rheumatology 2002; 41, 157-166.
10- Geffen SJ. Rehabilitation principles for treating
chronic musculoskeletal injuries. MJA 2003; 78, 238-42.
11- Fisher NM, Pendergast DR, Gresham GE & Calkins
E. Muscle rehabilitation: Its effect on muscular and
functional performance of patients with knee osteoarthritis.
Arch Phys Med Rehab 1991; 72, 367-74.
12- Risberg MA, Lewek M & Snyder-Mackler L. A systematic
review of evidence for anterior cruciate ligament rehabilitation:
how much and what type? Physical Therapy in Sports 2004;
5(3), 125-145.
13- Seto JL & Brewster CE. Treatment approaches
following foot and ankle injury. Clin J Sport Med 1994;
13, 695-718.
14- Lord SR, Ward JA, Williams P & et al. The effect
of a 12-month exercise trial on balance, strength, and
falls in older women: A randomized controlled trial.
J Am Geriatr Soc 1995; 43:1198-1206.
15- Altman R, Asch E, Bloch D, Bole G, Borenstein D,
Brandt K & et al. Development of criteria of the
classification and reporting of osteoarthritis. Classification
of osteoarthritis of the knee. Diagnostic and therapeutic
criteria committee of American Rheumatism Association.
Arth Rheum 1986; 29(8), 1039-49.
16- Gungen C, Ertan E, Eker E, Yasar R & Engin F.
The standardized mini mental state examination in Turkish.
proceeding of the ninth congress of the International
Psychogeriatric Association. August, Vancouver, Canada
1999; 78.
17- Tuzun EH, Eker L, Aytar A, Da?kapan A & Bayramo?lu
M. Acceptability, reliability, validity and responsiveness
of the Turkish version of WOMAC osteoarthritis index.
Osteoarthr Cartilage 2005; 13, 28-33.
18- Rezmovitz J, Taunton JE, Rhodes E, Martin A &
Zumbo B. The effects of a lower body resistance-training
program on static balance and well-being in older adult
women. BCM J, 2003; 45(9), 449-55.
19- Rogind H, Nielsen BB, Jensen B, Moller HC, Moller
HF& Bliddal H. The effects of physical training
on patients with osteoartritis of the knees. Arch Phys
Med Rehab 1998; 79, 1421-27.
20- Gilsenan C, Keoghen F, O'Connell P & Blake C.
Efficacy of open and closed kinetic chain strengthening
exercises in subjects with osteoarthritis of knee: A
prospective, Randomised trial. Physical Therapy Reviews
2006; 11, 205-28.
21- Takeshima N, Islam M.N & Rogers ME. Benefits
of resistance exercise for older adults: using elastic
bands for training. World Leisure Asia Conference, Shangai,
Chinai, April 2001; 24-29.
22- Guccione AA, Felson DT, Anderson JJ, Anthony JM,
Zhang Z, Wilson PW & et al. The effects of specific
medical conditions on the functional limitations of
elders in the framingham study. Am J Public Health 1994;
84(3), 351-58.
23- Nagata H. Occupational accidents while walking on
stairs. Safety Sci 1991; 14, 199-211.
24- Nyland J, Frost K, Quesada P, Angeli C, Swank A,
Topp R & et al. Self-reported chair-rise ability
relates to stair-climbing readiness of total knee arthroplasty
patients: a pilot study. J Rehabil Res Dev 2007; 44(5),
751-60.
25- Bammert C, O'Connell S, Miskevics S, Collins E &
Budiman-Mak E. Increased mobility in obese elderly with
knee osteoarthritis-a home-based walking and strength
program. ACSM 2006; 38(5), 419-420.
26- Schilke JM, Johnson GD, Housh TJ & et al. Effects
of muscle-strength training on the functional status
of patients with osteoarthritis of the knee joint. Nurs
Res 1996; 45,68-72.
27- Rogers ME, Sherwood HS, Rogers NL & Bohlken
RM. Effects of dumbbell and elastic band training on
physical function in older inner-city African-American
women. Women& Health 2002; 36(4), 33-41.
28- Jones G, Nguyen T, Sambrook PN, Lord SR, Kelly PJ
& Eisman JA. Osteoarthritis, bone density, postural
stability and osteoporotic fractures: a population based
study. J Rheumatol 1995; 22, 921-5.
29- Wegener L, Kisner C & Nichols D. Static and
dynamic balance responses in persons with bilateral
knee osteoarthritis. J Orthop Sport Phys 1997; 25,13-18.
30- Page P & Ellenbecker TS. The scientific and
clinical application of elastic resistance. Human Kinetics.
2003
31- Aglam?s A, Toraman NF, Yaman H. Change of quality
of life due to exercise training in knee osteoarthritis:
SF-36 and WOMAC . J Back Musculoskelet 2009 22 (1).43-44.
32- Topp R, Woolley S, Hornyak J, Khuder S & Kahaleh
B. The effect of dynamic versus isometric resistance
training on pain and functioning among adults with osteoarthritis
of the knee. Arch Phys Med Rehab 2002 83, 1187-95.
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