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International Journal of
Therapies and Rehabilitation Research [E-ISSN: 2278-0343]
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IJTRR 2015, 4: 4 I doi: 10.5455/ijtrr.00000079
Original Article
Open Access
Effects of combined isotonic exercises protocol on unilateral
symptomatic osteoarthritis knee
Madhusudan Tiwari
ARTICLE INFO
Introduction:
____________________________
Article History:
Received: July 1, 2015
Accepted: July 29, 2015
Published: July 29, 2015
Knee Osteoarthritis is the leading cause of chronic disability in
older person1. Osteoarthritis commonly affects hands, feet,
spine and large weight bearing joints such as hip and knees.
Osteoarthritis is the 2nd most common rheumatic problem and
is most frequent joint disease with prevalence of 22% to 39% in
India2. Symptomatic knee osteoarthritis affects=6% of the adult
population3. Pain is frequently the first symptom and is often
associated with swelling. Crepitus can often be detected and
muscle atrophy is seen secondary to disuse4. According to a
Davis et al prevalence study in 1989, bilateral osteoarthritis is
more prevalent (5%) than unilateral osteoarthritis (2%).Bilateral
osteoarthritis is twice as prevalent in women as in men5.
____________________________
AUTHORS AFFILIATIONS
Associate Professor and Dean, Faculty of Physiotherapy,
Mahatma Gandhi University of Medical Sciences and
Technology, Jaipur, Rajasthan, India
10 key recommendations for the diagnosis of knee OA have
been produced based both on expert consensus and a
systematic literature review. A confident diagnosis may be
made according to three symptoms (knee pain, short-lived
morning stiffness and functional limitation) and determination
of three signs on examination (crepitus, restricted movement
and bony enlargement) without a requirement for imaging6.
The femorotibial joint and Patellofemoral joint are the target
sites for osteoarthritis of the knee joint7.Muscles perform an
important protective function for its by maintaining normal
alignment, they serve as excellent shock absorbers when
function normally. Loading stress that is not absorbed by
surrounding weak muscles, tendons and ligaments, impacts on
opposing articular cartilages and their underlying trabecular
bone8.
Much of the disabilities associated with knee osteoarthritis is
attributed to muscular weakness and pain rather than
radiographic changes9,10,11,12. Many risk factors and their
association with knee osteoarthritis have been reported in
several cross-sectional and retrospective studies. Well
recognized factors associated with knee osteoarthritis include
femoral preponderance and the effect of obesity and age 13.
Knee flexor muscle groups are subjected to hypertrophy and
loss of strength, as well as the knee extensors in osteoarthritis
of the knee joint. It has been documented that dynamic stability
of the knee joint depends on the appropriate strength ratio of
Quadriceps and Hamstrings14.
Tiwari M et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (4): 132-137
There is no permanent cure for osteoarthritis, thus conservative
treatment aim is to reduce pain and limit functional
impairment. Inexpensive intervention with minimal side effects
is desirable15.
Purpose of the study
It is commonly seen that therapists use to teach and instruct
the quadriceps exercises in osteoarthritis knee patients,
whereas studies state that decrease in strength takes place in
quadriceps as well as hamstrings. The purpose of this study is to
see whether combined isotonic strength training of quadriceps
and hamstring is better than isolated quadriceps strength
training.
Aims and objective
To find out the effect of combined isotonic strength training on
pain and function in patients with symptomatic osteoarthritis
knee.
Methodology:Sample
A sample of convenience of 30 subjects (both male and female)
age ranged between 40 to 60 years and diagnosed with
symptomatic Osteoarthritis knee were recruited from
department of Physiotherapy, of Mahatma Gandhi Hospital,
Jaipur & Maharshi Balmiki Hospital, New Delhi. Those who
fulfilled the inclusion criteria were asked to sign an informed
consent form.
Design of study: - An experimental design, different subject
group was used in the study. Thirty short listed patients were
randomly assigned to the two different groups.
Group A (Experimental Group) – Combined (Quads. & Hamst.)
isotonic muscle strength training group.








Symptoms or signs of synovitis.
Acute or chronic ligamentous insufficiency.
Any history of recent injury to knee joint.
Any history of knee surgery.
Low back disorders.
Hip joint disorders.
Any systemic illness.
Any history of doing prescribed exercises of knee
osteoarthritis.
Instruments used:- Goniometer, stopwatch, stairs, plinth,
weight cuff(1/2 kg and 1 kg), Measuring tape.
Variables
Dependent variables: Pain on VAS, Walking speed test, & Step
test.
Independent Variables: Combined (quadriceps and hamstrings)
isotonic muscle strengthening Exercises.
Procedure
Group A subjects were instructed to carry out four exercises
(two for hamstrings and two for quadriceps), while Group B
subjects were instructed to carry out only two exercises for
quadriceps strengthening.
The exercises for group A were carried out as follows:
(Weight cuff were tied at end of the leg in all the
exercises)
1.
2.
3.
Group B (Control Group) - Isolated quadriceps muscles isotonic
strength training group.
Inclusion criteria




Age group: 40-60 years.
Symptomatic Osteoarthritis knee.
Minimum available range of 0-90 degrees knee
flexion.
Body weight: 40-60
4.
Patient lying supine, two pillows beneath his
exercising knee. Patients were told to lift the leg
maximally up without raising his /her thigh (Short Arc
Knee extension Exercise.)
Patient at high sitting position over plinth, hand
crossed at chest. Patients were told to take the leg
maximally up without moving the body forward or
backward.
Patient prone lying, foot at the edge of the bed.
Patients were told to move the leg as to try touching
the thigh. Simultaneously Patients were instructed to
keep thigh in contact with the plinth.
Patient in standing position. Patients were told to
stand on the uninvolved limb and to move the
exercising leg in to flexion (knee flexion).In case of
fear of fall or discomfort patients were allowed to
take support of any object from both hands.
The exercises for Group B were carried out as follows:
(Weight cuff were tied at end of the leg in all
Exclusion criteria
the exercises)
Tiwari M et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (4): 132-137
1.
Patient lying supine, two pillow beneath his
exercising knee. Patients were told to lift the leg
maximally up without raising his /her thigh (Short Arc
Knee extension exercise).
2. Patient at high sitting position, hand crossed at chest.
Patients were told to take the leg maximally up
without moving the body forward or backward.
Patients of both the groups were instructed to report thrice a
week on alternate day basis. Treatment module was limited to
5 weeks duration. For the first 3 weeks all the exercises were
carried out using 1kg weight and for the next 2 weeks exercises
were carried out using 1.5kg weight. Patients were instructed to
do each exercise Twenty five to thirty repetitions in one set and
single set is done by patient in one treatment session. Patients
were allowed to take break if they complain of tiredness or
discomfort. For both the groups precautions like not to squat,
not to sit low, and not to sit crossed leg were advised.
Method of data collection:
Preliminary measurements were taken at baseline prior to
beginning of the study, which included Walking speed test, Step
test, Pain on VAS scale.
Data was collected on 0 day (pre test), at the end of 3rd week,
and at the end of 5th week for measurements of walking speed,
step test and pain on VAS scale.
Results
In the present study student’s t test was done for all the three
variables, namely VAS, Step test and walking speed. The
variables with respect to the subjects recorded were clearly
insignificant at Day 0 (pre test) when compared against each
other namely Group A (Experimental group) and Group B
(Control group).
VAS
Intergroup analysis
The intergroup analysis with respect to the variable VAS is
reflected in (table1. figure- 1).
The overall data which was analyzed revealed significant
improvement on the effective variable in both the groups.
There was an insignificant difference between Group A and
Group B at 0 Day (Pre-Test) with t value=0.326699, p<0.05.
There was a significant difference between Group A and Group
B at Week 3 ((table1. figure- 1.) with t value=2.82137, p<0.05.
There was a significant difference between Group A and Group
B at Week 5 ((table1. figure- 1.) with t value=9.88929, p<0.05.
Table- 1. Comparison of V (variable) between Group A and
Group B
VAS
GROUP A (
N=15)
MEAN
S.D
GROUP B (N=15)
t-VALUE
MEAN
S.D
0.326699
6.666667
1.046536
6.8
0.676123404
0 DAY
(Pre-Test)
2.82137**
Testing Procedure:
Walking speed test- This was a 5 meter walking time.
Subjects were asked to walk for a total of 8 meters in
order to minimize the influence of acceleration and
deceleration at the onset and conclusion of task, the 5
meter time was recorded during the middle of 8
meter16.

Step test-In this test subjects were asked to stand on
the osteoarthritic limb, while opposite knee was kept
over the stool of height 15 cm. subjects stood on the
osteoarthritic limb, while steeping the opposite foot
on and off the step as many times a possible over 15
sec. The number of repetitions were taken the
participants could place the foot on the step and
return it to the floor was noted17.

Pain was evaluated using a 10cm horizontal VAS.
Result were scored from 0-10 cm.(Appendix D).
Data Analysis
Statistically the characteristics of the subjects and results were
analyzed using student t- test.
Data were managed on a Excel spread sheet SPSS statistical
software was used for data analysis.
4.066667
0.883715
6.066667
0.703732
3 WEEK
9.88929**
5 WEEK
1.533333
3.6
0.63994
0.910259
** Significant <0.05 level, V= Visual analogue scale.
PAIN PERCEPTION
9
8
7
6
VAS (c.m)

5
GROUP A
4
GROUP B
3
2
1
0
0 DAY
3 WEEK
5 WEEK
Fig: 1. - Comparison of VAS scale between Group A and Group B
Tiwari M et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (4): 132-137
GROUP B (N=15)
MEAN
MEAN
3 WEEK
3.923077
0.493548
2.5854**
5 WEEK
4.769231
0.438529
6.615385
0.50637
** Significant at <0.05 level, S = Step test
Walking speed Test - Intergroup analysis
The intergroup analysis with respect to the variable, walking
speed is reflected in (table 3. figure 3.). The overall data which
was analyzed revealed significant improvement on the effective
variable in both the groups. There was an insignificant
difference between Group A and Group B at 0 Day (Pre-Test)
with t value=0.145, p<0.05. There was insignificant difference
between Group A and Group B at Week 3 (table 3. figure 3.)
with t value=0.02, p<0.05. There was significant difference
between Group A and Group B at Week 5(table 3. figure 3.)
with t value=4.68, p<0.05.
Table: 3. Comparison of W (variable) between Group A and Group B
Walking speed
GROUP A (
N=15)
MEAN
S.D
GROUP B (N=15)
5.26
1.032
5.60
0.91
4.20
1.01
4.93
0.70
MEAN
t-VALUE
S.D
0.145
0
DAY
0.02
3
WEEK
4. 68*
5
4.33
WEEK
0.48
* Significant at < 0.05 level, W = Walking Speed
0.25
4
Group A
3
Group B
2
1
1
2
3
Discussion
0 DAY
0.000447
3.06
5
S.D
3.307692308
0.480384461
4.538462
0.518875
6
t-VALUE
0.168525
3.461538
0.518875
7
0
Step test
GROUP A ( N=15)
S.D
Comparison of Walking Speed between Group A
and Group B
Time in Second
Step Test- Intergroup analysis:- The inter group analysis with
respect to the variable step test is reflected in (Table 2., figure
2.). The overall data which was analyzed revealed significant
improvement on the effective variable in both the groups.
There was an insignificant difference between Group A and
Group B at 0 Day (Pre-Test.) with t value=0.168525, p<0.05.
There was insignificant difference between Group A and Group
B at Week 3 (table 2. figure 2.) with t value=0.000447, p<0.05.
There was a significant difference between Group A and Group
B at Week 5 (table 2. figure 2.) with t value=2.5854, p<0.05.
Table: 2. Comparison of S (variable) between Group A and
Group B
There are many studies which states that exercises has effect
on pain and function in knee pain18. In various studies on
strengthening & strength training has been found to decrease
pain and improve function in subjects with neck pain19,20 and in
general also, the effect of exercises in a variety of
musculoskeletal pain syndromes is established beyond doubt21.
Research has suggested that coordinated activity of the trunk
muscle is essential for maintaining Lumbar spine stability. It has
further shown that the central nervous system deals with the
stabilization of spine by contraction of the abdominal and
multifidus muscles22.
The research on mechanisms of pain reduction by exercise is
also very conclusive. The increase in endorphins that occurs
after training and better neuromuscular control may decrease
activity related pain. Strong muscle contractions activate
muscle ergoreceptors (stretch receptors). The afferent from
these receptors cause endogenous opiates to be released and
also cause the release of beta endorphins from the pituitary
gland. These secretions may cause both peripheral and central
pain to be blocked23.
In this study, reduction in pain and improvement in function
were noted which was greatly significant after 5th week of
treatment in both the groups. No doubt in the Group A which
was experimental group it was better in comparison to Group B
as there are many studies on lumbar musculature which
explains proper stabilization function if both abdominal muscles
and spinal extensors are strengthened.
Campbell14 1982 documented that dynamic stability of the
knee joint depends on the appropriate strength ratio of
quadriceps and hamstrings. It is a measure of relationship
between strengths of Hamstring and Quadriceps muscle group
around the knee joint. The ratio of strengths of antagonist to
agonist is used for determining muscle imbalance. Steindler
(1955) cited in study of Coombs et al24(i) stated that at the knee
H (concentric)/Q(concentric) value of 0.66 is accepted as
normal during low speed, with it approaching 1.0 at high
Tiwari M et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (4): 132-137
speed24(ii).Values ranging from 0.43 to 0.90 have been
reported. Although, it is depend on angular velocity, test
position, use of gravity, compensation and population group.
The degenerative disease decreases the strength of all the
groups across the joint and hence better recovery found in
Group A is well supported. Stability of knee joint is governed by
both hamstrings and quadriceps and decreased stability might
be a factor for pain and decreased functional performance (i.e.
step test and walking speed).
Study done by Rejeski et al25 states that exercise treatments
increased self efficacy for stair climbing in comparison to the
health education programme which is supporting the result of
our study.
The decision to choose weight training to reduce pain and
improving function was supported by Chamberlain 198226. Sibel
eyigor2003 did study on isokinetic against PRE in OA knee
patients and found that both programs are equally effective in
decreasing pain and improvement in function (walking time)
and no statistically significant differences could be found in two
groups. The PRE program, as it is cheaper, more easily
performed and efficient, may be preferable for the treatment of
knee OA which is again supporting our decision to choose PRE
asr treatment program in our study. 27
One study done by Hsieh FL et. al concluded that Exercise for
endurance is important for osteoarthritis patients, as they have
been shown to have diminished local muscle endurance28 as
well as diminished over all cardiovascular endurance29. Both
isotonic and isokinetic muscle contraction can increase local
muscle endurance.
In prescribing an exercise regimen for arthritis, the use of low
resistance and high repetition ( to fatigue) in a motion arc that
does not irritate the joint is preferred to high-load, low
repetition routines in which increased joint loading may cause
joint inflammation30. In general, start with low enough weight
to allow approximately three sets of 10 repetitions, with rest
between sets and no resulting joint pain or swelling. The
patient should gradually increase it to 30 repetitions without
rest and without symptom exacerbation and then increase the
resistance and start the protocol.
De Lorme method is not advocated for arthritis patients,
because of increasing weight requirement and the long lever
arm, progressively increased forces are placed across the joint.
Another method, De Lateur method, utilizes lower weight and
repetitions just to the point of fatigue. Because of the lower
weight less force is generated across the joint31. To further
decrease the forces across the joint; we recommend the De
Lateur method for patients with arthritis who don’t have any
joint inflammation or ligamentous laxity. Two to five ponds may
be used. Use of the Nautilus type machines implies isotonic
exercise, and these can be used with low weights and a short
arch of motion in Osteoarthritis patients.
Typically Physiotherapy programs don’t emphasized training at
different muscle lengths, especially the longer ones. These
lengths may have some clinical relevance, because they affect
posture rising from a chair, climbing stairs, and eventually,
walking. If the musculature is not sufficiently strong fatigue
resistant at these length reductions in function would be
expected32. The Exercise protocol of this study is isotonic
where strengthening is at different length which supports our
finding that improvement in function was noted.
Conclusion
The result of this study shows that combined (Quadriceps and
Hamstrings) isotonic Exercises are better than isolated
Quadriceps isotonic Exercises in terms of pain reduction as
measured by Visual Analogue Scale and improvement in
function as measured by Step Test and Walking speed. It is
generally seen in many clinical set ups for treatment of OA
knee that exercises are often prescribed only for strengthening
of quadriceps but rarely for hamstrings so this study will help to
design exercises to strengthen hamstrings also and help to
improve function in better way.
Conflict of Interest: None
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