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  • 1.
    Thorstensson, Carina
    Spenshult Hospital for Rheumatic Diseases, Oskarström, Sweden & Lund University, Lund, Sweden.
    Exercise and Functional Performance in Middle-aged Patients with Knee Osteoarthritis2005Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The overall purpose of this thesis was to explore the impact of exercise and functional performance on development and treatment of knee osteoarthritis in the middle aged.

    In this thesis, I have studied a population based cohort of middle-aged subjects (35-54 years, 42 % women) with chronic knee pain at baseline, to evaluate the longitudinal effect of muscle weakness on knee osteoarthritis development, the relationship between muscle function and joint load and the effects of exercise on joint load. I have also studied the effect of exercise on pain and function in another middle-aged cohort (36-65 years, 51 % women) with moderate to severe knee osteoarthritis, and explored their conceptions of exercise as treatment. In the first study, 148 subjects with chronic knee pain underwent radiographic examination and tests of functional performance at baseline. 94 of them had no radiographic signs of knee osteoarthritis. Five years later they had new radiographs taken and 41/94 (44 %) had developed incident knee osteoarthritis. I found that reduced functional performance, assessed by maximum number of one-leg rises from a stool, predicted knee osteoarthritis development. The result was controlled for the previously known risk factors of age, BMI and pain.

    In the second study, I used 3-dimensional motion analysis to explore the possibility of altering joint load by exercise. The medial compartment joint load (peak adduction moment) during maximum number of one-leg rises was assessed in 13 subjects with early radiographic signs of knee osteoarthritis from the cohort in study one, before and after 8 weeks of exercise. Two subjects were lost to follow up for reasons not related to the knee. The peak adduction moment could be reduced by exercise, and a high maximum number of one-leg rises was associated with lower levels of peak adduction moment.

    The third study included 61 subjects with moderate to severe radiographic knee osteoarthritis. They were randomized to 6 weeks of intensive exercise or to a control group. The effects of exercise were assessed using questionnaires. No effects were seen on pain or self estimated function, however, the quality of life improved. The individual response to exercise ranged from clinically significant improvement to clinically significant worsening.

    As an attempt to understand this large inter individual response to exercise, I designed the fourth study, where I interviewed 16 of the 30 patients in the exercise group about their conceptions of exercise as treatment. The interviews were analysed using qualitative methodology, and it was revealed that all patients were aware of the general health benefits of exercise, but had doubts about exercise as treatment of osteoarthritis even if they had perceived pain relief and improvement in physical function from the exercise intervention. The pain experienced during exercise caused the patients to believe that exercise was harmful to their knees, and some of them would prefer not to exercise at all. They thought that exercise should be introduced early during the course of the disease, and all of them expressed the need of continuous encouragement and support to adhere to exercise.

    From this thesis I conclude that reduced muscle function is a risk factor of knee osteoarthritis development among middle aged subjects with knee pain. Reduced muscle function is associated with increased joint load, which seem to be modifiable by exercise. Initial pain when starting exercise, or occasional pain from exercise, should be treated by combining exercise with pain relief such as analgesics or acupuncture. Pain contributes to the difficulty patients have determining the degree of benefit or damage related to exercise, and thus causes feelings of anxiety and helplessness (paper IV). Pain also seems to interfere with the possibility of achieving increased functional performance (paper II, III, IV).

  • 2.
    Thorstensson, Carina A.
    et al.
    Spenshult Hospital for Rheumatic Diseases, Halmstad, Sweden & Lund University, Lund, Sweden.
    Henriksson, M.
    Karolinska Institutet, Stockholm, Sweden.
    von Porat, A.
    Lund University, Lund, Sweden.
    Roos, E. M.
    Spenshult Hospital for Rheumatic Diseases, Halmstad, Sweden & Lund University, Lund, Sweden.
    Eight weeks of exercise reduced knee adduction moment during one-leg rise in patients with early knee osteoarthritisManuscript (preprint) (Other academic)
    Abstract [en]

    Background

    Reduced functional performance is a risk factor for development of knee osteoarthritis, and peak knee adduction moment is associated with radiographic progression. Knee adduction moment can be reduced by high tibial osteotomy. The effect of dynamic stabilization through increased muscle performance is not known.

    Aims

    To study the effect from exercise on external peak knee adduction moment during one-leg rise, and the relationship between peak knee adduction moment during one-leg rise and maximum number of one-leg rise.

    Methods

    13 patients, aged 48–63, with mild to moderate knee osteoarthritis underwent 8 weeks of supervised exercise, aiming at increasing neuromuscular control and lower extremity strength. The maximum number of one-leg rise from a stool (48 cm), 3-dimensional gait analysis and self-estimated knee symptoms were assessed before and after exercise intervention. Peak external knee adduction moment during one-leg rise and gait was calculated using a Vicon system. The Knee injury and Osteoarthritis Outcome Score (KOOS) was used as assessment of knee symptoms. Patients defined their most symptomatic knee as index knee.

    Results

    Peak knee adduction moment during one-leg rise was reduced for the index knee from 0.57 Nm/kg at baseline to 0.51 after 8 weeks of exercise (p=0.04). The change for the opposite knee was not significant (from 0.58 to 0.56 Nm/kg, p=0.23). No significant changes were seen for index or opposite knees in peak adduction moment during gait (p>0.40). A higher maximum number of one-leg rise was correlated to a lower peak adduction moment for the index knee at baseline (rs =-0.35, p=0.24) and follow up (rs = -0.65, p=0.03). For the opposite knee the correlation was similar at baseline (rs= -0.47, p=0.10), and no correlation was seen at follow up (rs = 0.13, p=0.70). Correlations for change over time were poor (-0.43 to -0.03) and not significant (p>0.20). Patients with symptomatic knee osteoarthritis had higher peak adduction moment in their opposite knee, than patients without symptoms at baseline (0.72 (0.09) vs. 0.50 (0.11), p=0.01) and follow-up (0.66 (0.14) vs. 0.51 (0.07), p=0.04). The differences for the index knee pointed in the same direction, however not significant (p>0.28).

    Conclusion

    Peak knee adduction moment in the most symptomatic knee of middle-aged patients with early signs of knee osteoarthritis can be reduced by exercise. Improved muscular performance might reduce the risk of radiographic progression of knee osteoarthritis. It seem of importance to reduce pain prior to starting exercising. A lower maximum number of one-leg rise is associated with higher peak knee adduction moment and has the potential to serve as a surrogate in studies where 3-dimensional analysis is not feasible.

  • 3.
    Thorstensson, Carina A.
    et al.
    Spenshult Hospital for Rheumatic Diseases, Oskarström, Sweden.
    Petersson, I. F.
    Spenshult Hospital for Rheumatic Diseases, Oskarström, Sweden.
    Jacobsson, L. T. H.
    Spenshult Hospital for Rheumatic Diseases, Oskarström, Sweden & Department of Rheumatology, Malmö University Hospital, Malmö, Sweden.
    Boegård, T. L.
    Spenshult Hospital for Rheumatic Diseases, Oskarström, Sweden & Department of Radiology, County Hospital, Helsingborg, Sweden.
    Roos, E. M.
    Spenshult Hospital for Rheumatic Diseases, Oskarström, Sweden & Department of Orthopaedics, Lund University Hospital, Lund, Sweden.
    Reduced functional performance in the lower extremity predicted radiographic knee osteoarthritis five years later2004In: Annals of the Rheumatic Diseases, ISSN 0003-4967, E-ISSN 1468-2060, Vol. 63, no 4, p. 402-407Article in journal (Refereed)
    Abstract [en]

    Background: Reduced quadriceps strength is an early finding in subjects with knee osteoarthritis, but it is not clear whether it is a cause or a consequence of knee osteoarthritis.

    Objective: To determine whether reduced functional performance in the lower extremity predicts the incidence or progression of radiographic knee osteoarthritis.

    Design: Prospective, epidemiological, population based cohort study.

    Patients: 148 subjects (62 women), aged 35–54 (mean 44.8), with chronic knee pain from a population based cohort.

    Measurements: Predictors analysed were age, sex, body mass index, baseline knee pain, and three tests of lower extremity functional performance: maximum number of one-leg rises from sitting, time spent walking 300 m, and timed standing on one leg. Weightbearing tibiofemoral knee radiographs were obtained at baseline and after 5 years (median 5.1, range 4.2–6.1), and classified according to Kellgren and Lawrence as no osteoarthritis (Kellgren and Lawrence = 0, n = 94) or prevalent osteoarthritis (Kellgren and Lawrence ⩾1, n = 54).

    Results: Fewer one-leg rises (median 17 v 25) predicted incident radiographic osteoarthritis five years later (OR 2.6, 95% CI 1.1 to 6.0). The association remained significant after controlling for age, sex, body mass index, and pain. No significant predictor of radiographic progression in the group with prevalent osteoarthritis was found.

    Conclusion: Reduced functional performance in the lower extremity predicted development of radiographic knee osteoarthritis 5 years later among people aged 35–55 with chronic knee pain and normal radiographs at baseline. These findings suggest that a test of one-leg rises may be useful, and interventions aimed at improving functional performance may be protective against development of knee osteoarthritis.

  • 4.
    Thorstensson, Carina A.
    et al.
    Spenshult Hospital for Rheumatic Diseases, Halmstad, Sweden.
    Roos, Ewa M.
    Spenshult Hospital for Rheumatic Diseases, Halmstad, Sweden.
    Petersson, Ingemar F.
    Spenshult Hospital for Rheumatic Diseases, Halmstad, Sweden.
    Arvidsson, Barbro
    Halmstad University, School of Health and Welfare, Centre of Research on Welfare, Health and Sport (CVHI).
    How do middle-aged patients conceive exercise as a form of treatment for knee osteoarthritis?2006In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 28, no 1, p. 51-59Article in journal (Refereed)
    Abstract [en]

    Purpose. To describe conceptions, as registered by a semi-structured interview, of exercise as treatment among sixteen middle-aged patients with moderate to severe knee osteoarthritis.

    Method. Sixteen patients (aged 39 – 64) with symptomatic, radiographic knee osteoarthritis and previous participants in an exercise intervention, were interviewed. The qualitative data obtained were analysed using phenomenographic approach.

    Results. Four descriptive categories containing 13 conceptions emerged: Category 1) To gain health included five conceptions; to experience coherence, to experience well-being, to be in control, to experience improved physical functioning, to experience symptom relief; 2) To become motivated included three conceptions; to experience inspiration, to be prepared to persevere, to experience the need to exercise; 3) To experience the need for support included three conceptions; to have structure, to receive guidance, to devote time; 4) To experience resistance included two conceptions; to hesitate, to deprecate.

    Conclusion. Patients with knee osteoarthritis and knee pain, previously participating in exercise intervention, are aware of the health benefits of exercise, but have many doubts and concerns about exercise as treatment. These aspects should be considered when designing patient information and treatment programmes. Furthermore, a hesitative and resistive perception of exercise as a concept could have major influences on the implementation of health programmes. © 2006 Taylor & Francis.

  • 5.
    Thorstensson, Carina A.
    et al.
    Spenshult Hospital for Rheumatic Diseases, Halmstad, Sweden & Dept. of Rheumatology, Lund University, Lund, Sweden.
    Roos, Ewa M.
    Spenshult Hospital for Rheumatic Diseases, Halmstad, Sweden & Dept. of Orthopedics, Lund University, Lund, Sweden.
    Petersson, Ingemar F.
    Spenshult Hospital for Rheumatic Diseases, Halmstad, Sweden & Dept. of Orthopedics, Lund University, Lund, Sweden.
    Ekdahl, Charlotte
    Dept. of Physical Therapy, Lund University, Lund, Sweden.
    Six-week high-intensity exercise program for middle-aged patients with knee osteoarthritis: a randomized controlled trial [ISRCTN20244858]2005In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 6, article id 27Article in journal (Refereed)
    Abstract [en]

    Background: Studies on exercise in knee osteoarthritis (OA) have focused on elderly subjects. Subjects in this study were middle-aged with symptomatic and definite radiographic knee osteoarthritis. The aim was to test the effects of a short-term, high-intensity exercise program on self-reported pain, function and quality of life. Methods: Patients aged 36-65, with OA grade III (Kellgren & Lawrence) were recruited. They had been referred for radiographic examination due to knee pain and had no history of major knee injury. They were randomized to a twice weekly supervised one hour exercise intervention for six weeks, or to a non-intervention control group. Exercise was performed at ≥ 60% of maximum heart rate (HR max). The primary outcome measure was the Knee injury and Osteoarthritis Outcome Score (KOOS). Follow-up occurred at 6 weeks and 6 months. Results: Sixty-one subjects (mean age 56 (SD 6), 51 % women, mean BMI 29.5 (SD 4.8)) were randomly assigned to intervention (n = 30) or control group (n = 31). No significant differences in the KOOS subscales assessing pain, other symptoms, or function in daily life or in sport and recreation were seen at any time point between exercisers and controls. In the exercise group, an improvement was seen at 6 weeks in the KOOS subscale quality of life compared to the control group (mean change 4.0 vs. -0.7, p = 0.05). The difference between groups was still persistent at 6 months (p = 0.02). Conclusion: A six-week high-intensive exercise program had no effect on pain or function in middle-aged patients with moderate to severe radiographic knee OA. Some effect was seen on quality of life in the exercise group compared to the control group. © 2005 Thorstensson et al; licensee BioMed Central Ltd.

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