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Pan J, Fu W, Lv J, Tang H, Huang Z, Zou Y, Zhang X, Liao B. Biomechanics of the lower limb in patients with mild knee osteoarthritis during the sit-to-stand task. BMC Musculoskelet Disord 2024; 25:268. [PMID: 38582828 PMCID: PMC10998381 DOI: 10.1186/s12891-024-07388-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/27/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Knee osteoarthritis (KOA) is a prevalent and debilitating condition that markedly affects the sit-to-stand (STS) activity of patients, a prerequisite for daily activities. Biomechanical recognition of movements in patients with mild KOA is currently attracting attention. However, limited studies have been conducted solely on the observed differences in sagittal plane movement and muscle activation. AIM This study aimed to identify three-dimensional biomechanical and muscle activation characteristics of the STS activity in patients with mild KOA. METHODS A cross-sectional study was conducted to observe the differences between patients with mild KOA and a control group (CG). It was conducted to observe the differences in muscle activation, including root mean square (RMS%) and integrated electromyography (items), kinematic parameters like range of motion (ROM) and maximum angular velocity, as well as dynamic parameters such as joint moment and vertical ground reaction force (vGRF). RESULTS Patients with mild KOA had a higher body mass index and longer task duration. In the sagittal plane, patients with KOA showed an increased ROM of the pelvic region, reduced ROM of the hip-knee-ankle joint, and diminished maximum angular velocity of the knee-ankle joint. Furthermore, patients with KOA displayed increased knee-ankle joint ROM in the coronal plane and decreased ankle joint ROM in the horizontal plane. Integrated vGRF was higher in both lower limbs, whereas the vGRF of the affected side was lower. Furthermore, patients showed a decreased peak adduction moment (PADM) and increased peak external rotation moment in the knee joint and smaller PADM and peak internal rotation moment in the ankle joint. The affected side exhibited decreased RMS% and iEMG values of the gluteus medius, vastus medialis, and vastus lateralis muscles, as well as a decreased RMS% of the rectus femoris muscle. Conversely, RMS% and iEMG values of the biceps femoris, lateral gastrocnemius, and medial gastrocnemius muscles were higher. CONCLUSION The unbalanced activation characteristics of the anterior and posterior muscle groups, combined with changes in joint moment in the three-dimensional plane of the affected joint, may pose a potential risk of injury to the irritated articular cartilage.
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Affiliation(s)
- Jing Pan
- Department of Sports Medicine, Guangzhou Sport University, Guangzhou, 510000, China
| | - Wei Fu
- Department of Sports Medicine, Guangzhou Sport University, Guangzhou, 510000, China
| | - Jinmiao Lv
- Department of Sports Medicine, Guangzhou Sport University, Guangzhou, 510000, China
| | - Huiyi Tang
- Department of Sports Medicine, Guangzhou Sport University, Guangzhou, 510000, China
| | - Zhiguan Huang
- School of Sports and Health, Guangzhou Sport University, Guangzhou, 510000, China
| | - Yu Zou
- Department of Sports Medicine, Guangzhou Sport University, Guangzhou, 510000, China
| | - Xiaohui Zhang
- Department of Sports Medicine, Guangzhou Sport University, Guangzhou, 510000, China.
| | - Bagen Liao
- Department of Sports Medicine, Guangzhou Sport University, Guangzhou, 510000, China.
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da Silva LSL, Gonçalves LDS, Abdalla PP, Benjamim CJR, Tasinafo MF, Venturini ACR, Bohn L, Mota J, Marcos-Pardo PJ, Kemmler W, dos Santos AP, Machado DRL. Characteristics of resistance training-based protocols in older adults with sarcopenic obesity: a scoping review of training procedure recommendations. Front Nutr 2023; 10:1179832. [PMID: 37234555 PMCID: PMC10206023 DOI: 10.3389/fnut.2023.1179832] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 04/03/2023] [Indexed: 05/28/2023] Open
Abstract
Background Sarcopenic obesity (SO) is a clinical and functional disease characterized by the coexistence of obesity and sarcopenia. Resistance training (RT) characteristics for older adults with sarcopenia or obesity are already well established in the scientific literature. Nonetheless, we still do not know how detailed the RT protocols are described for older adults with SO. Therefore, we aimed to analyze the characteristics of RT programs, including each of their variables, recommended for older adults with SO. Methods This is a scoping review study that was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews. The search was carried out until November 2022 in PubMed/MEDLINE, EMBASE, Cochrane Library, Web of Science, Scopus, LILACS, Google Scholar, and medRxiv databases. The studies included SO diagnosis and RT as an intervention strategy. The RT variables analyzed were as follows: exercise selection, the volume of sets, the intensity of load, repetition cadence, rest interval between sets, and weekly frequency. Results A total of 1,693 studies were identified. After applying the exclusion criteria, 15 studies were included in the final analysis. The duration of the RT intervention ranged from 8 to 24 weeks. All studies included full-body routines, with single/multi-joint exercises. Regarding the volume of sets, some studies fixed it in three sets, whereas others varied between one and three sets. The load was reported by repetition range and the weight lifted, elastic-band color/resistance, percentage of one repetition maximum, or perceived exertion scale. Repetition cadence was fixed in some studies, while it was self-selected between concentric and eccentric phases in others. The interval between sets of rest varied from 30 to 180 s. All studies reported progression overload during the interventions. Not all studies reported how the exercise selection, repetition cadence, and rest interval were made. Conclusion The characteristics of RT protocols and their variables prescribed in the literature for older adults with SO were mapped. The lack of detail on some training variables (i.e., exercise selection, repetition cadence, and rest interval) was identified. RT protocols are heterogeneous and described only partially among studies. The recommendations for RT prescription details in older adults with SO are provided for future studies. Systematic review registration https://osf.io/wzk3d/.
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Affiliation(s)
- Leonardo Santos Lopes da Silva
- School of Physical Education and Sport of Ribeirão Preto (EEFERP/USP), University of São Paulo, Ribeirão Preto, Brazil
- Study and Research Group in Anthropometry, Training, and Sport (GEPEATE), School of Physical Education and Sport of Ribeirao Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Leonardo da Silva Gonçalves
- School of Physical Education and Sport of Ribeirão Preto (EEFERP/USP), University of São Paulo, Ribeirão Preto, Brazil
| | - Pedro Pugliesi Abdalla
- Study and Research Group in Anthropometry, Training, and Sport (GEPEATE), School of Physical Education and Sport of Ribeirao Preto, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Márcio Fernando Tasinafo
- School of Physical Education and Sport of Ribeirão Preto (EEFERP/USP), University of São Paulo, Ribeirão Preto, Brazil
- Study and Research Group in Anthropometry, Training, and Sport (GEPEATE), School of Physical Education and Sport of Ribeirao Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Ana Cláudia Rossini Venturini
- Study and Research Group in Anthropometry, Training, and Sport (GEPEATE), School of Physical Education and Sport of Ribeirao Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Lucimere Bohn
- Faculty of Psychology, Education and Sport, Lusófona University, Porto, Portugal
- Research Center in Physical Activity, Health and Leisure (CIAFEL), Faculty of Sports, University of Porto, Porto, Portugal
- Faculty of Sports, University of Porto, Porto, Portugal
| | - Jorge Mota
- Research Center in Physical Activity, Health and Leisure (CIAFEL), Faculty of Sports, University of Porto, Porto, Portugal
- Faculty of Sports, University of Porto, Porto, Portugal
| | - Pablo Jorge Marcos-Pardo
- Neuropsychological Evaluation and Rehabilitation (CERNEP) Research Centre, Scientific Projects Organization and Research Training (SPORT) Research Group (CTS-1024), Department of Education, Faculty of Education Sciences, University of Almería, Almería, Spain
- Active Aging, Exercise and Health/HEALTHY-AGE Network, Consejo Superior de Deportes, Ministry of Culture and Sport of Spain, Madrid, Spain
| | - Wolfgang Kemmler
- Institute of Medical Physics, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
- Institute of Radiology, University Hospital Erlangen, Erlangen, Germany
| | - André Pereira dos Santos
- School of Physical Education and Sport of Ribeirão Preto (EEFERP/USP), University of São Paulo, Ribeirão Preto, Brazil
- Study and Research Group in Anthropometry, Training, and Sport (GEPEATE), School of Physical Education and Sport of Ribeirao Preto, University of São Paulo, Ribeirão Preto, Brazil
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, Brazil
| | - Dalmo Roberto Lopes Machado
- School of Physical Education and Sport of Ribeirão Preto (EEFERP/USP), University of São Paulo, Ribeirão Preto, Brazil
- Study and Research Group in Anthropometry, Training, and Sport (GEPEATE), School of Physical Education and Sport of Ribeirao Preto, University of São Paulo, Ribeirão Preto, Brazil
- Research Center in Physical Activity, Health and Leisure (CIAFEL), Faculty of Sports, University of Porto, Porto, Portugal
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, Brazil
- Escola Superior de Educação e Comunicação, Campus da Penha, University of Algarve, Faro, Portugal
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Wang J, Liu W, Fu H. Effects of traditional Chinese herb hot compress combined with therapeutic exercise on pain, proprioception, and functional performance among older adults with knee osteoarthritis: A randomized controlled trial. Front Physiol 2022; 13:1070754. [PMID: 36589446 PMCID: PMC9794567 DOI: 10.3389/fphys.2022.1070754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Background: Knee osteoarthritis (KOA) is one of the most common chronic progressive diseases with degenerative destruction of articular cartilage and bone, leading to knee pain, impaired proprioception, and reduced functional performance. This study was to investigate the effects of an 8-week Traditional Chinese herb hot compress (TCHHC) combined with therapeutic exercise (TE) on pain, proprioception, and functional performance among older adults with KOA. Methods: Twenty-seven older adults with KOA were recruited and randomly assigned to the TCHHC + TE or TE groups. Thirteen participants received TCHHC + TE, and fourteen received TE. At pre- (week 0) and post-intervention (week 9), their pain, joint proprioception, and functional performance were measured. Two-way ANOVA with repeated measures was adopted to analyze the data. Results: Compared with week 0, the pain score, proprioception thresholds of knee extension and ankle plantarflexion, and the times of TUG and 20-m walk tests decreased more significantly in the TCHHC + TE group than in the TE group at week 9. Conclusion: Compared with TE, the 8-week TCHHC + TE was superior in relieving pain, recovering proprioception, and improving functional performance among older adults with KOA. It is recommended that TCHHC should be adopted prior to TE to enhance the effects of KOA rehabilitation.
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Affiliation(s)
- Jingwen Wang
- College of Sports and Health, Shandong Sport University, Jinan, China
| | - Wei Liu
- Department of Rehabilitation, Neck Shoulder Back and Leg Pain Hospital, Shandong First Medical University, Jinan, China
| | - Haitao Fu
- Athletic Training Division, Shandong Sport University, Jinan, China,*Correspondence: Haitao Fu,
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Harper SA, Thompson BJ. Interaction between age and fatigue on antagonist muscle coactivation during an acute post-fatigue recovery phase. FRONTIERS IN AGING 2022; 3:1005080. [PMID: 36263146 PMCID: PMC9574075 DOI: 10.3389/fragi.2022.1005080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/14/2022] [Indexed: 11/30/2022]
Abstract
This study investigated the age-related changes in antagonist muscle coactivation of the biceps femoris (BF) during an acute recovery period following a leg extensor fatiguing protocol. Twenty-three young (mean ± SD: age = 25.1 ± 3.0 years) and twenty-three old men (age = 71.5 ± 3.9 years) participated. Surface electromyography (sEMG) was recorded from the BF muscles for antagonist muscle coactivation. Testing involved participants performing leg extension isometric maximal voluntary contractions (MVCs) and isokinetic MVCs at 240°·s-1 at baseline (Pre) and again after the fatigue protocol at 0 (Post0), 7 (Post7), 15 (Post15), and 30 (Post30) minutes post fatigue. Root mean square (RMS) values were computed from the BF sEMG and were calculated as the first 200 ms from onset for the isometric (IsomCoact200ms) and dynamic isokinetic 240°·s-1 (DynCoact200ms) MVCs, and for the final 10° of the leg extension (DynCoact10°) on the isokinetic 240°·s-1 MVCs. Two-way ANOVAs [age group (young vs. old) × time (Pre vs. Post0 vs. Post7 vs. Post15 vs. Post30)] showed that DynCoact200ms had an effect for time (p = 0.018), with greater antagonist coactivation in Pre than Post0 (p = 0.009) and recovering by Post7 (p = 0.011) with no group differences. DynCoact10° had no age × time interaction (p = 0.070), but had a main effect for time (p = 0.020) with the Post0 being lower than the Pre. However, for this variable the young group showed a more severe Pre to Post0 fatigue decline (-45.9%) than the old group (-6.7%) indicating this may be a more sensitive variable for capturing age-related antagonist coactivation post-fatigue responses. Leg extensor fatigue affects some BF coactivation sEMG variables more than others, and any altered post-fatigue coactivation response recovers rapidly (<7 min) from baseline levels.
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Affiliation(s)
- Sara A. Harper
- Department of Kinesiology and Health Science, Utah State University, Logan, UT, United States,Sorenson Legacy Foundation Center for Clinical Excellence, Dennis Dolny Movement Research Clinic, Utah State University, Logan, UT, United States
| | - Brennan J. Thompson
- Department of Kinesiology and Health Science, Utah State University, Logan, UT, United States,Sorenson Legacy Foundation Center for Clinical Excellence, Dennis Dolny Movement Research Clinic, Utah State University, Logan, UT, United States,*Correspondence: Brennan J. Thompson,
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Bowen W, Frazer AK, Tallent J, Pearce AJ, Kidgell DJ. Unilateral Strength Training Imparts a Cross-Education Effect in Unilateral Knee Osteoarthritis Patients. J Funct Morphol Kinesiol 2022; 7:jfmk7040077. [PMID: 36278738 PMCID: PMC9589957 DOI: 10.3390/jfmk7040077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Worldwide, 86 million individuals over the age of 20 were diagnosed with knee osteoarthritis (KOA) in 2020. Hallmark features of KOA are the loss in knee extensor strength, increasing knee pain severity, and deficits in functional performance. There is a critical need for the investigation into potential cost-effective therapeutic interventions in the treatment of KOA. A potential therapeutic option is the cross-education phenomenon. Methods: This was a non-blinded randomized control trial, with a 4-week intervention, with a pre, post and follow-up assessment (3 months post intervention). Outcome measures of isometric knee extensor strength, rectus femoris muscle thickness and neuromuscular activation were assessed at all-time points. Results: Compared to age-matched KOA controls, 4 weeks of unilateral strength training in end-stage KOA patients increased strength of the untrained affected KOA limb by 20% (p < 0.05) and reduced bilateral hamstring co-activation in the KOA intervention group compared to the KOA control group (p < 0.05). Conclusions: A 4-week-long knee extensor strength training intervention of the contralateral limb in a cohort with diagnosed unilateral KOA resulted in significant improvements to knee extensor strength and improved neuromuscular function of the KOA limb. Importantly, these results were maintained for 3 months following the intervention.
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Affiliation(s)
- Warren Bowen
- School of Exercise and Nutrition Sciences, Deakin University, Melbourne 3125, Australia
- College of Science, Health and Engineering, La Trobe University, Melbourne 3086, Australia
| | - Ashlyn K. Frazer
- Monash Exercise Neuroplasticity Research Unit, Department of Physiotherapy, Monash University, Melbourne 3800, Australia
| | - Jamie Tallent
- Monash Exercise Neuroplasticity Research Unit, Department of Physiotherapy, Monash University, Melbourne 3800, Australia
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester CO4 3SQ, UK
| | - Alan J. Pearce
- College of Science, Health and Engineering, La Trobe University, Melbourne 3086, Australia
| | - Dawson J. Kidgell
- Monash Exercise Neuroplasticity Research Unit, Department of Physiotherapy, Monash University, Melbourne 3800, Australia
- Correspondence: ; Tel.: +61-3-9904-4119
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Li Y, Sun J, Hou Y, Wei J, Chai Y, Zhu X, Wang R. Gastrocnemius Muscle Injury Is the Condition to Induce Cartilage Degeneration of the Rabbit Tibiofemoral Joint: A New Perspective. BIOMED RESEARCH INTERNATIONAL 2022; 2022:7532434. [PMID: 36093403 PMCID: PMC9462983 DOI: 10.1155/2022/7532434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/20/2022] [Indexed: 11/17/2022]
Abstract
The knee osteoarthritis is a common joint disease that causes pain and inconvenience. Clinically, patients with knee osteoarthritis often have response points on the gastrocnemius. Gastrocnemius plays an essential role in stabilizing joints and changing gait and pace, which also has a close relationship with the knee joint. The objective of this study is to determine changes in the tibiofemoral joint after medial and lateral gastrocnemius injury. Rabbits were divided into a medial gastrocnemius injury group, a lateral gastrocnemius injury group, and a control group with two intervals: 6 and 8 weeks after modeling of the semisevered gastrocnemius. The gastrocnemius was weighed and sectioned for histology. The joint space and subchondral bone were observed using X-ray and microcomputed tomography. The cartilage was observed histologically using Safranin O fast green and Masson and immunohistochemically using antibodies to collagen type II, matrix metalloproteinase 13, and integrin beta1. Results showed muscle fiber atrophy, and fibrotic changes occurred after gastrocnemius semidissociation. After gastrocnemius injury, the femoral condyle of the tibiofemoral joint produced abnormal sclerosis and bone degeneration. The pathological changes of cartilage included disordered or reduced cell alignment, cartilage matrix loss, and collagen loss due to decreased collagen type II and increased matrix metalloproteinase 13 activity. The increase of integrin beta1 in the injured group may be related to mechanical conduction process. The results suggest that gastrocnemius injury is an essential factor in tibiofemoral arthritis.
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Affiliation(s)
- Yuanyuan Li
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Fangshan District, Beijing, China
| | - Jiwei Sun
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Fangshan District, Beijing, China
| | - Yimin Hou
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Fangshan District, Beijing, China
| | - Jiabi Wei
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Fangshan District, Beijing, China
| | - Yuzhuo Chai
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Fangshan District, Beijing, China
| | - Xiangyu Zhu
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Fangshan District, Beijing, China
| | - Rongguo Wang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Fangshan District, Beijing, China
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Murphy MT, Wang N, Felson DT, Nevitt MC, Lewis CE, Frey-Law L, Guermazi A, Segal NA. Association between hamstring coactivation during isokinetic quadriceps strength testing and knee cartilage worsening over 24 months. Osteoarthritis Cartilage 2022; 30:823-831. [PMID: 35307535 PMCID: PMC9450915 DOI: 10.1016/j.joca.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 02/24/2022] [Accepted: 03/07/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study aimed to determine longitudinal associations, including sex-specific differences, between greater knee flexor antagonist coactivation and worsening cartilage morphology in knees with or at risk for osteoarthritis (OA). DESIGN Baseline measurements were collected at the 60-month visit of a longitudinal osteoarthritis study following community-dwelling participants (MOST). Knee flexor and extensor muscle activity were measured with surface electromyography during a maximal isokinetic knee extension task. MRI analyzed knee cartilage morphology at baseline and 24-month follow-up. Multivariable adjusted logistic regression models were used to assess associations between coactivation level and cartilage morphology worsening. RESULTS Analysis of 373 women (mean ± SD age 67.4 ± 7.3 years and BMI 29.7 ± 5.0 kg/m2) and 240 men (66.5 ± 7.8 years and 29.9 ± 4.5 kg/m2) revealed that women had greater medial (P < 0.001), lateral (P < 0.001), and combined (P < 0.001) hamstring coactivation than men. In both sexes, combined hamstring coactivation was associated with patellofemoral cartilage morphology worsening [1.23 (1.02, 1.49)] and to a less significant degree with whole knee cartilage morphology worsening [1.21 (0.98, 1.49)]. In men, greater combined hamstring coactivation was associated with increased risk for whole knee [1.59 (1.06, 2.39)] and patellofemoral [1.38 (1.01, 1.88)] cartilage morphology worsening and point estimates suggested association between medial hamstring coactivation and medial tibiofemoral cartilage morphology worsening. No significant associations were detected between greater hamstring coactivation and cartilage morphology worsening in women. CONCLUSIONS These findings suggest a longitudinal relationship between antagonist hamstring coactivation during isokinetic knee extensor testing and worsening of cartilage morphology over 24 months in men with or at risk for knee OA.
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Affiliation(s)
- M T Murphy
- Department of Rehabilitation Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 1046, Kansas City, KS, 66160, USA.
| | - N Wang
- Department of Biostatistics and Epidemiology, Boston University, Boston, MA, USA.
| | - D T Felson
- Department of Epidemiology, Boston University, Boston, MA, USA.
| | - M C Nevitt
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA, USA.
| | - C E Lewis
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - L Frey-Law
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA.
| | - A Guermazi
- Department of Radiology, Boston University, Boston, MA, USA.
| | - N A Segal
- Department of Rehabilitation Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 1046, Kansas City, KS, 66160, USA.
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