J Orthop Sci (2013) 18:932939

DOI 10.1007/s00776-013-0443-9

Analysis of effectiveness of therapeutic exercise for knee

osteoarthritis and possible factors affecting outcome
Miki Kudo Kota Watanabe Hidenori Otsubo Tomoaki Kamiya Fuminari Kaneko Masaki
Katayose Toshihiko Yamashita

Received: 4 April 2012/Accepted: 9 July 2013/Published online: 2 October 2013

The Japanese Orthopaedic Association 2013 mass index, knee range of motion (ROM), the femorotibial
angle from radiographs, OA severity from Kellgren
Abstract Lawrence grade, and meniscus abnormality and subchondral
bone marrow lesions from MRI findings were statistically
Background There are numerous reports and evidences to
analyzed as factors that may affect exercise therapy. Results
suggest that exercise therapy is effective for knee
A significantly greater improvement in WOMAC was
osteoarthritis (knee OA). However, there is a lack of
observed in the subjects of group exercise (81 subjects) as
sufficient research concerning the factors influencing its
compared with the subjects of home exercise (122 subjects).
application and effectiveness. The purposes of this study
There was a significantly high proportion of subjects with
were to evaluate effects of the mode of treatment delivery on
knee flexion contracture among the subjects participating in
the improvement of symptoms in knee OA, and to analyze
group exercise that showed only minor symptom
potential risk factors affecting improvement after exercise
improvement (p\0.05). In addition, exercise therapy proved
therapies.
to be highly effective for subjects with limited quadriceps
Methods The 209 women applicants diagnosed with knee
muscle strength (p\0.05). Conclusions When prescribing
OA were randomly allocated into either a group performing
exercise therapy for knee OA, evaluation of a subjects
group exercise in a class or a group performing home
ROM and muscle strength is important in deciding whether
exercise. The 90 min exercise program was performed under
to commence exercise therapy and what type of exercise
the guidance of physiotherapists as a group exercise therapy.
therapy to apply; it is also important in predicting the effect
The Western Ontario and McMaster Universities
of exercise therapy.
Osteoarthritis Index (WOMAC) of the subjects of both
groups before and after intervention was compared to
examine the effect of exercise therapy. In addition, body
Introduction

Technology, 1-3-1 Kasumigaseki, Chiyoda-ku, Tokyo 100-

M. Kudo (&) K. Watanabe H. Otsubo T. Kamiya
T. Yamashita
Department of Orthopaedic Surgery, Sapporo Medical
University School of Medicine, South-1, West-16, Chuo-ku,
Sapporo, Hokkaido 060-8543, Japan e-mail:
miky_ku@yahoo.co.jp
F. Kaneko M. Katayose
Department of Physical Therapy, Sapporo Medical University
School of Health Science, Sapporo, Japan
F. Kaneko
National Institute of Advanced Industrial Science and
8921, Japan
Knee osteoarthritis (knee OA) is a condition often seen in
the elderly; thus, the number of affected individuals has
consequently been increasing along with the aging of
society. It is imperative to systematize the treatment of this
condition, and it is clear that conservative treatment is
particularly important from a medical-economic
perspective. Four items are listed as intervention strategies
for knee OA in the National Strategy for OA 2010
published by the US Centers for Disease Control and
Prevention (CDC) and Arthritis Foundation [1]: (1) self-
management education, (2) exercise therapy, (3) injury

123
Therapeutic exercise for knee OA
prevention, and (4) weight management. In particular,
exercise therapy is viewed as being important in the
treatment of knee OA. In addition, randomized
prospective studies and the Osteoarthritis Research
Society International (OARSI) guidelines regard
exercise therapy as a non-drug therapy backed by a
significant amount of evidence [24].
However, few reports have examined the factors
influencing the application and effectiveness of
exercise therapy in detail. Age, gender, obesity, leg
alignment, leg strength, joint distension, and a history
of injury are cited as risk factors for knee OA and are
believed to be involved in its onset and progression.
Moreover, these factors may influence the effect of
exercise therapy on knee OA.
Exercise therapy for knee OA can be divided into
muscle isolation strength training, range of motion
(ROM) exercises, and weight training. In addition,
although muscle isolation strength training is given as
a single category, many variations of muscle isolation
strength training exist. Its content can range from
straight leg raises and other bodyweight exercises to
training using specialized equipment. Furthermore, the
muscles trained can either be limited to the quadriceps
only or expanded to include muscles around the hip as
well as the trunk. Moreover, the form of exercise
intervention can be divided into exercise therapy
performed under the direct guidance of a
physiotherapist (either in a class or individually) and
exercise performed by the patient at home. Questions
regarding the differences in the effects of exercise
therapy as a consequence of the intervention format
still persist.
The main focus of this study was to analyze
potential factors affecting improvement after exercise
therapy for patients with knee OA. This study tested
the following hypotheses: (1) exercise therapy is an
effective treatment for knee OA, and group-guided
therapy has a greater effect than home therapy, and (2)
factors influencing the effectiveness of exercise
therapy exist, and they vary according to the method
of exercise therapy employed.
Materials and methods
Trial participants were invited with local newspapers
to participate in classes to test the effectiveness of
exercise therapy on knee OA. The conditions required
for the participants were females with knee pain aged
between 55 and 75 years. In total, 495 females
933
responded during the 20062008 invitation period. These
495 applicants were examined by orthopedic specialists and
underwent imaging before a decision was made to include
them in the trial. The exclusion criteria for participation in
the trial included the following: applicants with a Japanese
Orthopaedic Association score [5] of\65 points or a score of
100 points, or a the Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC) score [6] of
more than or equal to 96 points, applicants who had
difficulty in walking, cases where the applicants pain
worsened acutely, applicants with motion-limiting
conditions other than knee OA, and applicants adjudged as
KellgrenLawrence grade (KL grade) 0 [7] from simple
knee X-ray imaging of an anteriorposterior view with full
extension in weight-bearing. Ultimately, 209 applicants
were included in this study. The participants were informed
that data from the case would be submitted for publication
and gave their consent, and this study was given approval by
the institutional review board (IRB) of our facility.
Subjects were randomly allocated into either a group
performing group exercise therapy conducted in a class
(group exercise) or a group performing home exercise
therapy (home exercise) by drawing lots. The number of
participants in the group exercise was limited to 81, because
there was a limit of a room and equipment for exercise. The
group that waited for 3 months before commencing home
exercisewasdesignatedthecontrolgroup(control).There
were81subjectsinthegroupexercisegroup,withanaverage age
of 63.8 years, average height of 152.6 cm, average weight of
55.1 kg, and average body mass index (BMI) of 23.8; there
were 128 subjects in the control group, with an average age
of 65.6 years, average height of 152.4 cm, average weight of
55.3 kg, and average BMI of 23.8. This control group
subsequently performed home exercise therapy, with 122
subjects ultimately completing the program (the home
exercise group). There were no statistically significant
differences in age, height, weight, or BMI between the group
exercise and control/home exercise groups (Table 1).
The test items included simple front upright radiographs
and MRIs of the subjects knees in addition to their height,
weight, ROM, and muscle strength. In addition, the
WOMAC score were used as an index of clinical symptoms.
Table 1 Characteristics of participants at baseline
Group exercise (n = 81) Control (n = 128)
Age, years 63.8 5.9 65.6 5.8
Height, cm 152.6 4.9 152.4 5.1
Body weight, kg 55.1 7.3 55.3 7.3
934 M. Kudo et al.
BMI, kg/m 2
23.8 2.9 23.8 3.0 week for 3 months. A workshop was held for the home
exercise group, both prior to intervention and during
KL grade, no. (%)
intervention,inwhichguidancewasgivenconcerningtheconte
Grade 1 24 (29.6) 31 (24.2)
nt of the program. The home exercise group was provided
Grade 2 26 (32.1) 49 (38.3) with self-check sheets having attached photographs
Grade 3 27 (33.3) 42 (32.8) explaining each of the stretching, muscle strengthening, and
stabilization exercises (similar to those performed by the
Grade 4 4 (4.9) 6 (4.7)
group exercise group); this group was recommended to
Mink grade, no. (%) exercise at least twice a week for 3 months. The subjects did
Grade 0 8 (9.9) 29 (22.7) not have any other conservative treatments such as
Grade 1 22 (27.2) 33 (25.8) medication during the participating period of the program.
Age, BMI, ROM, quadriceps muscle strength, leg
Grade 2 24 (29.6) 34 (26.6)
alignment, severity of knee OA (from KL grade), and
Grade 3 27 (33.3) 32 (25.0) findings of meniscus abnormality and subchondral bone
Values are the mean standard deviation unless otherwise marrow lesions from MRI were analyzed as factors that may
indicated affect exercise therapy. Subjects were divided into two
This index (raw score out of 96) was normalized by groups according to the median age (65 years), and based on
multiplying it by 100/96, and the improvement in the their degree of obesity: a group with a BMI of\25 and a
normalized indexpre-intervention normalized group with a BMI of more than or equal to 25. In terms of
WOMAC subtracted by post-intervention normalized ROM, subjects whose knee extension was limited by 5 or
WOMAC was used as an indicator of clinical more were defined as having flexion contracture.
improvement. This calculated value was defined as W0 Quadriceps muscle strength was measured using a muscle
in this study. strength measurement instrument (Kenkonice, Hulia Co.
Knee OA severity was classified using KL grade. Ltd., Tokyo). Maximum voluntary isometric force of the
WOMAC was assessed both prior to commencement quadriceps muscle was measured while holding maximum
of the exercise program and 3 months after output for 3 s at 60 knee flexion in sitting position. This
commencement. The group exercise therapy was measurement was repeated twice and the higher value was
performed under the direct guidance of chosen as a representative value. Then, the weight ratio
physiotherapists. The 90 min program included calculated from the values obtained, and the subjects divided
stretching (warm up), followed by riding an exercise into two groups based on the median value.
bike, and muscle strength and stabilization exercises The femorotibial angle (FTA) was measured from simple
(focusing on the knee joint and incorporating pelvic front upright knee radiographs as an index of leg alignment,
and trunk areas), and subjects were subsequently divided into a group with an
followedbymorestretching(cooldown).Openkineticch FTAof\178andagroupwithanFTAofmorethanorequal to 178
ain exercises and a combination of isotonic contraction which was the median in the subjects. Subjects were divided
and isometric contraction of the muscle were firstly into a KL grade 1 and 2 group and KL grade 3 and 4 group
performed to the muscles around the knee, the trunk, based on the severity of knee OA; they were divided into a
the hip, and the ankle as the muscle strength exercises. Mink grade 02 and grade 3 group on the basis of meniscal
The time and the repetition number of the exercises MRI findings [8]. Mink grade 3 is considered as meniscal
were gradually increased, and then closed kinetic tear [8]. The degree of extension of an area of
chain exercises were added to the program including a abnormallowintensityonthefemoralcondylewasclassified
squat and a calf raise. The physical therapists into four types by sagittal proton-density MRI [9]: normal,
werepayingattentiontopainandsymptomsofthesubjects no abnormal low intensity area; spot, an area of abnormal
to prevent those deterioration during the exercises. low intensity is shown as a single spot on the subchondral
Riding an exercise bike was started from the exercise bone; moderate, the abnormal low intensity area is extended
intensity for 20 min to be around 5565 % of the fromthesubchondralbonetotheproximalbonemarrow,and
predicted maximum heart rate, and carried out for 40 extension is less than one-third of the femoral condyle; and
min in the end. The balance ball and balance cushion large, the extension of the abnormal low intensity area is
were used in stabilization exercise to improve the more than one-third of the femoral condyle. MRI imaging
balance in the standing posture and trunk muscle was performed using a 1.5-T system (General Electric
strength. Subjects participated in this program twice a Medical Systems, USA). Sagittal and coronal images were

123
Therapeutic exercise for knee OA
acquired with proton density-weighted images (TR/
TE = 1900/31.7; flip angle 90) and T2-weighted
images (TR/TE = 3800/102; flip angle 90). Each image
was obtained using a 160 mm, 320 9 256 matrix with
3 mm slices. All radiographs and MR images were
analyzed by an experienced orthopaedic surgeon.
Firstly, W0 was compared between pre- and post-
intervention in the groups of control, group exercise,
and home exercise. Statistical analysis was performed
using paired t test with statistical significance set at
p\0.05 level. Then, the groups of home exercise and
group exercise were divided into more effective group
and less effective group respectively according to the
value of W0, and relationship was analyzed between
the effectiveness of therapeutic exercise and the
various factors mentioned previously. Unpaired t test
was used for statistical analysis of W0 and the factors
of BMI, quadriceps strength, and FTA, and Mann
Whitney U test was used for flexion contracture, KL
grade, Mink grade, and subchondral bone marrow
lesion analysis with statistical significance set at
p\0.05 level. Finally, subjects of group exercise were
divided into two groups according to the factors
described above, and then W0 was compared between
the two groups. Statistical analysis was performed
using MannWhitney U test with statistical
significance set at p\0.05 level.
Results
Eighty-one subjects in the group exercise group and
122 in the home exercise group completed their
exercise programs ultimately. No significant change in
the WOMAC score of the control group was observed
before and after the 3 month waiting period according
to paired t test. However, W0 improved by an average
of 10.2 points in the group exercise (SD, 10.3)a
statistically significant improvement from the
beginning of exercise and compared with the control
(p\0.05). Although W0 improved by an average of 3.2
points in the home exercise (SD, 8.7), it was not
recognized as a statistically significant improvement
from the beginning of exercise according to paired t
test. The group exercise showed significantly higher
W0 improvement than the home exercise according to
935
unpaired t test (p\0.05). Figure 1 shows changes of
normalized WOMAC before and after intervention in the
home exercise and the group exercise.
Next, the factors obtained from physical, radiographical,
and MRI findings were compared between the group whose
symptoms improved with exercise (more effective group)
and the group where there was minimal improvement of
symptoms (less effective group) (Table 2). Subjects whose
W0 improved by 6 points or more were allocated to the more
effective group, and the subjects whose W 0 improved by\6
points were allocated to the less effective group. The results
of this comparison showed that there was a significantly
high proportion of subjects with flexion contracture of the
knee in the less effective group (p\0.05) and quadriceps
strength was significantly lower in the more effective group
(p\0.05).
Figure 2 shows whether each factor affected improvement
in WOMAC scores in group exercise. The WOMAC scores
of the group of subjects with quadriceps strength lower than
the median value improved significantly (p\0.05). Besides
this, no other factor was observed to significantly affect
improvement in WOMAC scores in group exercise.
Discussion
The first item examined in the study was a comparison of the
effects of group exercise and home exercise. The result
indicated that group exercise was superior to home exercise
for the treatment of knee OA. There were several factors
which might influence effects of exercise therapies on
patients with knee OA. In the group exercise, the subjects
performed their exercises with other subjects under the
guidance of therapists in a class. They could use exercise
machines such as an exercise bike. These factors might
improve not only quality of the exercise but also motivation
and compliance of the subjects. We thought that these
differences between two groups might lead to superior
results of the group exercise therapy in this study. Roddy et
al. [10] performed a systematic literature review and
provided 10 evidence-based recommendations for the role
of exercise in the management of OA of the hip or knee,
known as the MOVE consensus. One of the 10 recom-
936 M. Kudo et al.

Fig. 1 Improvements of normalized WOMAC pre- and post-exercise

in the home exercise and the group exercise. Normalized WOMAC =
(raw score out of 96) 9 100/96 Statistical analysis was performed using
paired t test (* p\0.05)
mendations was group exercise and home exercise are
equally effective, and patient preference should be
considered. Another meta-analysis [11] showed that the
mode of treatment delivery (individual treatments, exercise
classes, and home programs) was not significantly
associated with the magnitude of treatment benefit. They
analyzed supervision occasions and found that programs
providing fewer than 12 direct supervision occasions
demonstrated only small mean benefits for pain reduction
and physical function. In this study, direct supervision was
provided on 24 occasions over 3 months in the group
exercise program. However, direct supervision was only
provided once during the 3 month home exercise therapy
period, and there may have been limited opportunities to
check and re-teach the exercise method. In any event, it was
clear that the group exercise program adopted in this study
was effective.
Of the factors possibly influencing the effectiveness of
exercise therapy on knee OA, this study suggested that
flexion contracture and quadriceps strength affected group
exercise. Because a significant improvement in the
WOMAC score was not observed after the home exercise in
this study, we analyzed these factors in the group exercise

123
Therapeutic exercise for knee OA 937
Table 2 Relationship between the effectiveness of therapeutic exercise and various factors
Group exercise (n = 81) Home exercise (n = 122)
Less effective
(n = 35) More effective Less effective More effective p value
(n = 46) (n = 81) (n = 41)
p value
W0 1.4 2.8 16.9 8.7 \0.001 -1.4 6.1 12.1 5.8 \0.001

BMI, kg/m2 23.5 2.7 24.0 2.9 0.473 23.7 2.8 24.0 3.5 0.554

Flexion contracture, no. (%) 19 (54.3) 20 (43.5) 0.045 25 (30.9) 17 (41.5) 0.268
Quadriceps strength, Nm/kg 1.53 0.51 1.29 0.49 0.044 1.38 0.52 1.38 0.48 0.978
FTA, degrees 177.8 4.0 178.1 3.6 0.775 178.2 3.6 178.1 3.9 0.825

KL grade, no. (%) 0.172 0.458

Grade 1,2 19 (54.3) 31 (67.4) 53 (65.4) 24 (58.5)

Grade 3,4 16 (45.7) 15 (32.6) 28 (34.6) 17 (41.5)

Mink grade, no. (%) 0.455 0.856

Grade 02 20 (57.1) 34 (73.9) 58 (71.6) 30 (73.2)

Grade 3 15 (42.9) 12 (26.1) 23 (28.4) 11 (26.8)

Subchondral bone marrow lesion, 0.271 0.346

no. (%)
Normal 12 (34.3) 18 (39.1) 33 (40.7) 13

Spot 12 (34.3) 17 (37.0) 34 (42.0) 19

Moderate 11 (31.4) 10 (21.7) 12 (14.8) 9

Large 0 (0) 1 (2.2) 2 (2.5) 0

More effective: Group where W0 improved by 6 points or more Less

effective: Group where W0 improved by less than 6 points
W0: pre-intervention normalized WOMAC subtracted by post-intervention normalized WOMAC
Normalized WOMAC = (raw score out of 96) 9 100/96
Unpaired t test was used for statistical analysis of W 0 and the factors of BMI, quadriceps strength, and FTA, and MannWhitney U test was used
for flexion contracture, KL grade, Mink grade, and subchondral bone marrow lesion analysis
group. Subjects with low quadriceps strength experienced radiographic OA grading, or initial muscle strength. Only
superior symptomatic relief as a result of group exercise. In patients\70 years of age who had initially displayed
a study on the relationship between muscle strength prior to quadriceps muscle strength below median value
the commencement of an exercise program and symptomatic demonstrated a high incidence of pain relief. Torii [13]
improvement, Irie et al. [12] evaluated the efficacy of reported the results of 9 weeks of intervention to increase
quadriceps setting exercise programs for relieving pain in muscle strength around the knee and hip joints for middle-
knee OA and investigated background factors influencing or advanced-aged women with knee OA, and analyzed the
efficacy. Fifty-three knees of 43 patients were evaluated characteristics of the group whose pain improved. In the
until 12 months after initial examination. Pain was relieved groups that showed improvement, body weight was heavier,
at a mean of 2.3 months in half of the patients. No and the values of muscle strength per body weight were
association was identified between pain relief and age, BMI,
938 M. Kudo et al.
lower at baseline. Thus, it is thought that patients with low
muscle strength prior to the commencement of an
exercise program can more easily enhance their muscular
strength as a result of muscle strength exercises; therefore, it
is easier for them to obtain symptomatic relief.
A few reports examined knee ROM as a possible
predictor of treatment responsiveness of exercise therapy
[14, 15]. This factor did not reveal trends in treatment
effectiveness in those studies. However, flexion contracture
is one of major symptoms of patients with knee OA,
especially in advanced stages. Quadriceps muscle power or
contractile function of this muscle should be deteriorated in
near extended knee position in patients with flexion
contracture. From the results of this study, we believe that
flexion contracture and quadriceps strength are the possible
factors affecting improvement. We also think that further
study is needed to investigate effects of a specially modified
exercise program to reduce knee flexion contracture on
patients with knee OA.
Although several other factors such as those examined in
this study may influence the effect of exercise therapy on
knee OA, a consensus has not yet been reached. For
example, some reports indicate that symptomatic relief is
less in cases of severe knee OA; some dismiss any
correlation between symptomatic relief and OA severity.

123
Therapeutic exercise for knee OA
Fig. 2 Effects of various factors on the efficacy of therapeutic exercise
in subjects of group exercise. a Age, b BMI, c flexion contracture, d
quadriceps strength, e FTA, f KL grade g Mink grade, h subchondral
According to the aforementioned the MOVE consensus
by Roddy et al. [10], one of the 10 propositions was the
effectiveness of exercise is independent of the presence or
severity of radiographic findings. They did not find any
direct evidence to support this proposition except one
randomized controlled trial (RCT) performed by Fransen et
al. [14]. This study stratified subjects according to medial
939
bone marrow lesion W0: pre-intervention normalized WOMAC
subtracted by post-intervention normalized WOMAC. Statistical
analysis was performed using MannWhitney U test (* p\0.05)
knee joint space width and demonstrated significantly
greater improvement in pain and function in subjects with
less severe loss of medial joint space. In this study, 126
patients were randomized into one of 3 allocation arms:
individual treatments, small group format program, and
waiting list control. Assessments included both selfreporting
measures (WOMAC, SF-36) and objective measures of
940
physical performance (gait analysis and muscle strength).
Both physical therapy treatment allocations resulted in
significant improvements in pain, physical function, and
health-related quality of life above the control group.
The alignment of lower extremities assessed by FTA was
not correlated with the effectiveness of exercise therapy in
the current study. In a report that examined the connection
between muscle exercise and knee alignment, Lim et al. [15]
performed a RCT to examine whether the effects of 12
weeks of quadriceps strengthening on the knee adduction
moment, pain, and function in people with medial knee OA
differed in those with and without varus malalignment. The
benefits of quadriceps strengthening on pain were more
evident in those with more neutral alignment. They
concluded that knee alignment represented a local
mechanical factor that could mediate the symptomatic
outcome from exercise interventions in knee OA. The knee
OA severity of the participants in our study was between KL
grade 1 and 3. Few participants showed severe varus
malalignment. We thought that this factor might influence
our result of FTA analysis.
The present study also examined whether abnormal MRI
findings influenced the effects of exercise therapy. There
were few reports investigating MRI findings as a possible
factor of exercise treatment responsiveness. Several studies
investigated the relationship between abnormal MRI
findings and pain in knee OA. Link et al. [16] evaluated
whether knee symptoms assessed by WOMAC correlated
with abnormal MRI findings including cartilage lesions,
bone marrow edema, and ligamentous and meniscal lesions
in 50 patients. Significant differences between WOMAC
scores were found only for the grades of cartilage lesions.
While Felson et al. [17] reported that bone marrow lesions
on MRI were strongly associated with the presence of pain
in knee OA. No correlation was observed between the
presence of femoral subchondral bone or meniscal
abnormalities in MRI findings and the improvement of
symptoms from the results of the current study. Further
study of the relationship between knee pain from OA and
abnormalities in MRI findings is considered necessary.
The present study had limitations in that the participants
actually applied to participate in the exercise therapy for
knee OA, and therefore, may have had strong motivation to
exercise. Therefore, these results may not necessarily be
reflected in subjects in routine medical practice. However,
similar to previous studies, this study clarified that group
exercise under the guidance of a physical therapist familiar
with exercise therapy is extremely effective. Therapeutic
exercise should be encouraged for patients with quadriceps
muscle weakness. Moreover, exercise may be less effective
in providing symptomatic relief in cases where flexion
123
M. Kudo et al.
contracture is observed. Programs to improve joint
contracture warrant consideration in such cases. In
summary, flexion contracture of the knee and muscle
strength should be checked in patients with knee OA, and
therapeutic exercise is recommended as a treatment option.
Acknowledgments We sincerely thank Drs.Tsuyoshi Minowa, Kenji
Tateda, and Ima Kosukegawa for their help.
Conflict of interest The authors declare that they have no conflict of
interest.
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