Effects of resistance training on gait velocity and knee adduction moment in knee osteoarthritis patients: a systematic review and meta-analysis

Comparative Efficacy of Various Exercise Therapies and Combined Treatments on Inflammatory Biomarkers and Morphological Measures of Skeletal Muscle among Older Adults with Knee Osteoarthritis: A Network Meta-Analysis

Osteoarthritis is associated with high risks of sarcopenia in older populations. Exercise interventions are promising treatments for musculoskeletal impairments in knee osteoarthritis (KOA). The purpose of this study was to identify the comparative effects of exercise monotherapy and its adjunct treatments on muscle volume and serum inflammation for older individuals with KOA. A literature search in the electronic databases was comprehensively performed from this study's inception until April 2024 to identify relevant randomized controlled trials (RCTs) that reported muscle morphology and inflammation outcomes after exercise. The included RCTs were analyzed through a frequentist network meta-analysis (NMA). The standard mean difference (SMD) with a 95% confidence interval was estimated for treatment effects on muscle morphology and inflammation biomarkers. The relative effects on each main outcome among all treatment arms were compared using surface under the cumulative ranking (SUCRA) scores. The certainty of evidence (CoE) was assessed by the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) ranking system. Probable moderators of the treatment efficacy were investigated by network meta-regression analysis. This study included 52 RCTs (4255 patients) for NMA. Among the 27 identified treatment arms, isokinetic training plus physical modality as well as low-load resistance training plus blood-flow restriction yielded the most optimal treatment for inflammation reduction (-1.89; SUCRA = 0.97; CoE = high) and muscle hypertrophy (SMD = 1.28; SUCRA = 0.94; CoE = high). The patient's age (β = -0.73), the intervention time (β = -0.45), and the follow-up duration (β = -0.47) were identified as significant determinants of treatment efficacy on muscle hypertrophy. Exercise therapy in combination with noninvasive agents exert additional effects on inflammation reduction and muscle hypertrophy compared to its corresponding monotherapies for the KOA population. However, such treatment efficacy is likely moderated by the patient's age, the intervention time, and the follow-up duration.

Effect of strength training on knee proprioception in patients with knee osteoarthritis: A systematic review and meta-analysis

Proprioception is significantly impaired in knee osteoarthritis (KOA), contributing to reduced functionality. Strength training (ST) is essential in KOA by improving muscle strength, although it may also be effective in improving proprioception. The purpose was to determine the effect of ST on knee proprioception in KOA patients. Pubmed, CINAHL, Scopus, WOS, and PEDro were searched for randomized controlled trials (RCTs) (inception to March 2023). Comparisons for ST were physical exercise different from ST, non-exercise-based interventions, and no intervention. Methodological quality was assessed using the PEDro scale, and risk of bias (RoB) using the Cochrane tool. Meta-analyses were performed by comparison groups using the standardized mean difference (SMD) (Hedge's g) with random effects models, also considering subgroups by proprioception tests. Finally, six RCTs were included. The mean PEDro score was 6.3, and the highest proportion of biases corresponds to performance, selection, and detection. The meta-analysis indicated that only when compared with non-intervention, ST significantly improved knee proprioception for the joint position sense (JPS) (active + passive), JPS (passive), and threshold to detect passive motion (TTDPM) subgroups (g ​= ​-1.33 [-2.33, -0.32], g = ​-2.29 [-2.82, -1.75] and g ​= ​-2.40 [-4.23, -0.58], respectively). However, in the knee JPS (active) subgroup, ST was not significant (g ​= ​-0.72 [-1.84, 0.40]). In conclusion, ST improves knee proprioception compared to non-intervention. However, due to the paucity of studies and diversity of interventions, more evidence is needed to support the effectiveness of ST. Future RCTs may address the limitations of this review to advance knowledge about proprioceptive responses to ST and contribute to clinical practice.

The impact of digital healthcare systems on pain and body function in patients with knee joint pain: a systematic review and meta-analysis

The digital healthcare (DH) system has recently emerged as an advanced rehabilitation approach that promotes rehabilitation training based on virtual reality (VR) and augmented reality (AR). The purpose of this meta-analysis study is to review and assess the impact of DH systems on pain and physical function among patients diagnosed with knee joint pain. Between January 2003 and September 2023, studies that met the listed inclusion criteria were gathered from Scopus, PubMed, Web of Science, and EBSCO databases. The analysis of standardized mean difference (SMD) was carried out with 95% confidence interval (95% CI) (PROSPERO registration number: CRD42023462538). Eight research papers were selected, which collectively involved 194 males and 279 females. The meta-analysis outcomes revealed that DH intervention significantly improved balance (SMD, 0.41 [0.12, 0.69], p < 0.05) and pain level (SMD, - 1.10 [- 2.02, - 0.18], p < 0.05). The subgroup analysis of the pain level showed varied outcomes for the TKA (SMD, - 0.22 [- 0.49, 0.04], p = 0.10) or OA patients (SMD, - 2.80 [- 3.83, - 1.78], p < 0.05) Next, this study found no significant effect of DH intervention on knee joint range of motion (ROM) (SMD, 0.00 [- 0.76, 0.76], p = 1.00) and walking velocity (SMD, 0.04 [- 0.22, 0.29], p = 0.77) in patients with knee joint pain. The meta-analysis review conducted in this study revealed that DH intervention may potentially improve balance among the patients with knee joint pain. It may also alleviate the pain level particularly among OA patients.

Can exercise interventions reduce external knee adduction moment during gait? A systematic review and meta-analysis

BACKGROUND

An increased external knee adduction moment has been identified as a factor contributing to the progression of medial knee osteoarthritis. Interventions that reduce knee adduction moment may help prevent knee osteoarthritis onset and progression. While exercise interventions have been commonly used to treat knee osteoarthritis, whether exercises can modulate knee adduction moment in knee osteoarthritis patients remains unknown. This systematic review and meta-analysis aimed to determine if exercise interventions are effective in reducing knee adduction moment during gait.

METHODS

Study reports published through May 2023 were screened for pre-specified inclusion/exclusion criteria. Nine studies met the eligibility criteria and yielded 24 effect sizes comparing the reduction in knee adduction moment of the exercise intervention groups to the control groups. Moderator/experimental variables concerning characteristics of the exercise interventions and included subjects (e.g., sex, BMI, type of exercise, muscle group targeted, training volume, physical therapist supervision) that may contribute to variation among studies were explored through subgroup analysis and meta-regression.

FINDINGS

The effect of exercise intervention on modulating knee adduction moment during gait was no better than control (ES = -0.004, P = 0.946). Sub-group analysis revealed that the effect sizes of studies containing only females (positive exercise effect) were significantly greater than studies containing both males and females.

INTERPRETATION

Exercise may not be effective in reducing knee adduction moment during gait. Clinicians aiming to decrease knee adduction moment in patients with medial knee osteoarthritis should consider alternative treatment options. Exploring the underlying mechanism(s) regarding a more positive response to exercises in females may help design more effective exercise interventions.

The Effects of Combined Exercise with Citrulline Supplementation on Body Composition and Lower Limb Function of Overweight Older Adults: A Systematic Review and Meta-Analysis

The combined exercise with citrulline (CIT) supplementation is a potential adjuvant treatment approach to address the declining body composition and lower limb function of overweight older adults. However, research on this approach is limited. Thus, this study performed a meta-analysis review to explore the effects of combined exercise with CIT supplementation on body composition and lower limb function among overweight older adults. The search strategy and manuscript development of this study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Eligible studies were first searched through four databases (Web of Science, Scopus, PubMed, and EBSCO) from January 2003 until April 2023, followed by screening. The main inclusion criteria for the article selection are as follows: 1) Randomized Controlled Trial studies; 2) Participants aged over 55; 3) Studies involved exercise with CIT supplementation for the experimental group and exercise with Placebo (PLA) supplementation for the control group; 4) Body composition and lower limb function were measured at pre- and post-intervention. Subsequently, the Cochrane risk of bias assessment tool was utilized to evaluate the selected studies' quality. The Standardized Mean Difference (SMD) was chosen as the suitable effect scale index, and the mean differences of the data from the selected articles were analyzed using Revman 5.4 software with a 95% Confidence Interval (CI). A total of seven studies fulfilled the inclusion criteria and were selected for the meta-analysis. The included studies involved 105 males and 198 females, where 157 belonged to the PLA group and 146 from the CIT group. Significant improvements were observed among overweight older adults with CIT supplementation in 6-Minute Walking Test (6MWT) (P = 0.04, I2 = 4%), SMD (95% CI) = -0.28 (-0.54, -0.01), and Lower Limb Strength (LLS) (P < 0.01, I2 = 30%), SMD (95% CI) = -0.38 (-0.65, -0.12) compared to those with PLA supplementation. Combined exercise with CIT supplementation could be an effective non-pharmaceutical intervention to improve the physical function of overweight older adults by increasing their muscle strength.

Effects of Protein Supplementation Combined with Resistance Exercise Training on Walking Speed Recovery in Older Adults with Knee Osteoarthritis and Sarcopenia

Knee osteoarthritis (KOA) is closely associated with sarcopenia, sharing the common characteristics of muscle weakness and low physical performance. Resistance exercise training (RET), protein supplementation (PS), and PS+RET have promise as treatments for both sarcopenia and KOA. However, whether PS+RET exerts any effect on time to recovery to normal walking speed (WS) in older adults with sarcopenia and KOA remains unclear. This study investigated the treatment efficiency of PS+RET on WS recovery among individuals with KOA and sarcopenia. A total of 108 older adults aged ≥ 60 years who had a diagnosis of radiographic KOA and sarcopenia were enrolled in this prospective cohort study. Sarcopenia was defined on the basis of the cutoff values of the appendicular skeletal muscle mass index for Asian people and a slow WS less than 1.0 m/s. The patients were equally distributed to three groups: PS+RET, RET alone, and usual care. The weekly assessment was performed during a 12-week intervention and a subsequent 36-week follow-up period. A cutoff of 1.0 m/s was used to identify successful recovery to normal WS. Kaplan-Meier analysis was performed to measure the survival time to normal WS among the study groups. Multivariate Cox proportional-hazards regression (CPHR) models were established to calculate the hazard ratios (HRs) of successful WS recovery and determine its potential moderators. After the 3-month intervention, PS+RET as well as RET obtained greater changes in WS by an adjusted mean difference of 0.18 m/s (p < 0.0001) and 0.08 (p < 0.05) m/s, respectively, compared to usual care. Kaplan-Meier analysis results showed both RET and PS+RET interventions yielded high probabilities of achieving normal WS over the 12-month follow-up period. Multivariate CPHR results revealed that PS+RET (adjusted HR = 5.48; p < 0.001), as well as RET (adjusted HR = 2.21; p < 0.05), independently exerted significant effects on WS recovery. PS+RET may accelerate normal WS recovery by approximately 3 months compared with RET. Sex and initial WS may influence the treatment efficiency. For patients with KOA who suffer sarcopenia, 12-week RET alone exerts significant effects on WS recovery, whereas additional PS further augments the treatment effects of RET by speeding up the recovery time of WS toward a level ≥ 1.0 m/s, which facilitates the patients to diminish the disease severity or even free from sarcopenia.

Exploring the modification factors of exercise therapy on biomechanical load in patients with knee osteoarthritis: a systematic review and meta-analysis

The objective of this systematic review and meta-analysis is to clarify the effect of exercise therapy on the first peak knee adduction moment (KAM), as well as other biomechanical loads in patients with knee osteoarthritis (OA), and identify physical characteristics that influence differences in biomechanical load after exercise therapy. The data sources are PubMed, PEDro, and CINAHL, from study inception to May 2021. The eligibility criteria include studies evaluating the first peak (KAM), peak knee flexion moment (KFM), maximal knee joint compression force (KCF), or co-contraction during walking before and after exercise therapy in patients with knee OA. The risk of bias was independently assessed by two reviewers using PEDro and NIH scales. Among 11 RCTs and nine non-RCTs, 1119 patients with knee OA were included (average age: 63.7 years). As the results of meta-analysis, exercise therapy tended to increase the first peak KAM (SMD 0.11; 95% CI: -0.03-0.24), peak KFM (SMD 0.13; 95% CI: -0.03-0.29), and maximal KCF (SMD 0.09; 95% CI -0.05-0.22). An increased first peak KAM was significantly associated with a larger improvement in knee muscle strength and WOMAC pain. However, the quality of evidence regarding the biomechanical loads was low-to-moderate according to the GRADE approach. The improvement in pain and knee muscle strength may mediate the increase in first peak KAM, suggesting difficulty in balancing symptom relief and biomechanical load reduction. Therefore, exercise therapy may satisfy both aspects simultaneously when combined with biomechanical interventions, such as a valgus knee brace or insoles. Registration: PROSPERO (CRD42021230966).

Elevated hip adduction angles and abduction moments in the gait of adolescents with recurrent patellar dislocation

INTRODUCTION

Impaired hip kinematics and kinetics may incite patellar instability. This study tested the hypothesis that hip adduction and internal rotation angles during gait are higher in adolescents with recurrent patellar dislocations compared to healthy controls.

MATERIAL AND METHODS

Case-control study. Eighty-eight knees (67 patients) with recurrent patellar dislocation (mean age 14.8 years ± 2.8 SD) were compared to 54 healthy knees (27 individuals, 14.9 years ± 2.4 SD). Peak hip, knee and pelvis kinematics and kinetics were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, Plug-in-Gait, two force plates) and compared between the two groups. One cycle (100%) consisted of 51 data points. The mean of six trials was computed.

RESULTS

Peak hip adduction angles and abduction moments were significantly higher in patients with recurrent patellar dislocation compared to the control group (p < 0.001 and 0.002, respectively). Peak internal hip rotation did not differ significantly.

CONCLUSION

Elevated hip adduction angles and higher hip abduction moments in gait of adolescents with recurrent patellar dislocation may indicate an impaired function of hip abductors that contributes to patellar instability.

Compensatory Responses During Slip-Induced Perturbation in Patients With Knee Osteoarthritis Compared With Healthy Older Adults: An Increased Risk of Falls?

Background: Functional impairment of the knee joint affected by osteoarthritis and loss of muscle strength leads to a significant increase in the number of falls. Nevertheless, little is known about strategies for coping with gait perturbations in patients with knee osteoarthritis (KOA). Thus, this study aimed to examine the compensatory strategies of patients with KOA in response to a backward slip perturbation compared with healthy older adults.

Methods: An automated perturbation program was developed by using D-Flow software based on the Gait Real-time Analysis Interactive Lab, and an induced backward slip perturbation was implemented on nine patients with severe KOA (68.89 ± 3.59 years) and 15 age-matched healthy older adults (68.33 ± 3.29 years). Step length, gait speed, range of motion, vertical ground reaction forces, lower extremity joint angles, and joint moments were computed and analyzed.

Results: Compared with older adults, patients with KOA had significantly lower step length, gait speed, and vertical ground reaction forces in both normal walking and the first recovery step following backward slip perturbations. Inadequate flexion and extension of joint angles and insufficient generation of joint moments predispose patients with KOA to fall. Hip extension angle and flexion moment, knee range of motion, and vertical ground reaction forces are key monitoring variables.

Conclusion: The risk of falls for patients with KOA in response to backward slip perturbations is higher. Patients with KOA should focus not only on quadriceps muscle strength related to knee range of motion but also on improving hip extensor strength and activation through specific exercises. Targeted resistance training and perturbation-based gait training could be better options.

Comparison of the open kinetic chain and closed kinetic chain strengthening exercises on pain perception and lower limb biomechanics of patients with mild knee osteoarthritis: a randomized controlled trial protocol

Background

Clinical recommendations suggest exercises as the main treatment modality for patients with knee osteoarthritis (OA). This study aimed to compare the effects of two different exercise interventions, i.e., open kinetic chain (OKC) and closed kinetic chain (CKC) exercises, on the pain and lower limb biomechanics of patients with mild knee OA.

Method

A total of 66 individuals with painful early knee OA, aged 50 years and above, with body mass index (BMI) between 18.9kg/m2 and 29.9 kg/m2 in Kelantan, Malaysia, will be recruited in this study. Participants will be randomly allocated into three different groups, either the OKC, CKC, or control groups. All three groups will attend an individual session with a physiotherapist. The participants in the OKC and CKC groups will perform the exercises three times weekly for 8 weeks at their home. The control group will receive education about clinical manifestations, risk factors, diagnosis, treatment, and nursing care for knee via printed materials. The primary outcomes include self-reported pain scores (visual analog scale), disability scores (Western Ontario and McMaster Universities Arthritis Index), and quality of life scores (Osteoarthritis Knee and Hip Quality of Life). Secondary outcomes include lower limb biomechanics during gait and sit-to-stand as well as isokinetic knee strength. The outcomes will be measured before and after the intervention.

Discussion

The present study will compare the effects of two different home-based exercise intervention programs among patients with mild knee OA. The study findings will provide vital information that can be used to design an effective exercise program that aims at delaying the OA progression.

Trial registration

The protocol was registered on 22 December 2020 at ClinicalTrials.gov (registration number: NCT04678609).

Protection against Osteoarthritis Symptoms by Aerobic Exercise with a High-Protein Diet by Reducing Inflammation in a Testosterone-Deficient Animal Model

A testosterone deficiency potentially increases osteoarthritis (OA) symptoms, and dietary protein and exercise affect them. However, their efficacy and their interactions are still unclear. We hypothesized that a high-protein diet (HPD) and regular exercise modulated OA symptoms in testosterone-deficient rats, and it was examined in bilateral orchidectomized (ORX) and monoiodoacetate (MIA)-injected rats. The ORX rats were given a 30 energy percent (En%) protein (HPD) or 17.5 En% protein (CD). Both groups had 39 En% fat in the diet. Non-ORX-CD rats (sham-operation of ORX) were given the CD and no exercise (normal control). After an eight-week intervention, all rats had an injection of MIA into the left knee, and the treatments were continued for an additional four weeks. The non-ORX-CD rats showed a significant increase in body weight compared to the ORX rats, but the ORX rats had elevated fat mass. ORX exacerbated the glucose tolerance by lowering the serum insulin concentrations and increasing insulin resistance. ORX exacerbated the OA symptoms more than the non-ORX-CD. The HPD and exercise improved bone mineral density and glucose metabolism without changing serum testosterone concentrations, while only exercise increased the lean body mass and decreased fat mass, lipid peroxide, and inflammation. Exercise, but not HPD, reduced the OA symptoms, the weight distribution in the left leg, and running velocity and provided better relief than the non-ORX-CD rats. Exercise with HPD improved the histology of the knee joint in the left leg. Exercise reduced lipid peroxide contents and TNF-α and IL-1β mRNA expression in the articular cartilage, while exercise with HPD decreased MMP-3 and MMP-13 mRNA expression as much as in the non-ORX-CD group. In conclusion, moderate aerobic exercise with HPD alleviated OA symptoms and articular cartilage degradation in a similar way in the non-ORX rats with OA by alleviating inflammation and oxidative stress.