Comparison of neuromuscular and quadriceps strengthening exercise in the treatment of varus malaligned knees with medial knee osteoarthritis: a randomised controlled trial protocol

Kim L Bennell, Thorlene Egerton, Tim V Wrigley, Paul W Hodges, Michael Hunt, Ewa M Roos, Mary Kyriakides, Ben Metcalf, Andrew Forbes, Eva Ageberg, Rana S Hinman, Kim L Bennell, Thorlene Egerton, Tim V Wrigley, Paul W Hodges, Michael Hunt, Ewa M Roos, Mary Kyriakides, Ben Metcalf, Andrew Forbes, Eva Ageberg, Rana S Hinman

Abstract

Background: Osteoarthritis of the knee involving predominantly the medial tibiofemoral compartment is common in older people, giving rise to pain and loss of function. Many people experience progressive worsening of the disease over time, particularly those with varus malalignment and increased medial knee joint load. Therefore, interventions that can reduce excessive medial knee loading may be beneficial in reducing the risk of structural progression. Traditional quadriceps strengthening can improve pain and function in people with knee osteoarthritis but does not appear to reduce medial knee load. A neuromuscular exercise program, emphasising optimal alignment of the trunk and lower limb joints relative to one another, as well as quality of movement performance, while dynamically and functionally strengthening the lower limb muscles, may be able to reduce medial knee load. Such a program may also be superior to traditional quadriceps strengthening with respect to improved pain and physical function because of the functional and dynamic nature. This randomised controlled trial will investigate the effect of a neuromuscular exercise program on medial knee joint loading, pain and function in individuals with medial knee joint osteoarthritis. We hypothesise that the neuromuscular program will reduce medial knee load as well as pain and functional limitations to a greater extent than a traditional quadriceps strengthening program.

Methods/design: 100 people with medial knee pain, radiographic medial compartment osteoarthritis and varus malalignment will be recruited and randomly allocated to one of two 12-week exercise programs: quadriceps strengthening or neuromuscular exercise. Each program will involve 14 supervised exercise sessions with a physiotherapist plus four unsupervised sessions per week at home. The primary outcomes are medial knee load during walking (the peak external knee adduction moment from 3D gait analysis), pain, and self-reported physical function measured at baseline and immediately following the program. Secondary outcomes include the external knee adduction moment angular impulse, electromyographic muscle activation patterns, knee and hip muscle strength, balance, functional ability, and quality-of-life.

Discussion: The findings will help determine whether neuromuscular exercise is superior to traditional quadriceps strengthening regarding effects on knee load, pain and physical function in people with medial knee osteoarthritis and varus malalignment.

Trial registration: Australian New Zealand Clinical Trials Registry reference: ACTRN12610000660088.

Figures

Figure 1
Figure 1
Flow diagram of study protocol.

References

    1. Salaffi F, Carotti M, Stancati A, Grassi W. Health-related quality of life in older adults with symptomatic hip and knee osteoarthritis: a comparison with matched healthy controls. Aging Clin Exp Res. 2005;12(4):255–263.
    1. Wright EA, Katz JN, Cisternas MG, Kessler CL, Wagenseller A, Losina E. Impact of knee osteoarthritis on health care resource utilization in a US population-based national sample. Med Care. 2010;12(9):785–791. doi: 10.1097/MLR.0b013e3181e419b1.
    1. Brooks PM. The burden of musculoskeletal disease--a global perspective. Clin Rheumatol. 2006;12(6):778–781. doi: 10.1007/s10067-006-0240-3.
    1. Bitton R. The economic burden of osteoarthritis. Am J Manag Care. 2009;12(8 Suppl):S230–235.
    1. Lachance L, Sowers MF, Jamadar D, Hochberg M. The natural history of emergent osteoarthritis of the knee in women. Osteoarthritis & Cartilage. 2002;12(11):849–854. doi: 10.1053/joca.2002.0840.
    1. Australian Orthopaedic Association. Hip and Knee Arthroplasty, Annual Report. Adelaide: Australian Orthopaedic Association, National Joint Replacement Registry; 2008.
    1. Ledingham J, Regan M, Jones A, Doherty M. Radiographic patterns and associations of osteoarthritis of the knee in patients referred to hospital. Ann Rheum Dis. 1993;12(7):520–526. doi: 10.1136/ard.52.7.520.
    1. Andriacchi TP. Dynamics of knee malalignment. Orthop Clin North Am. 1994;12(3):395–403.
    1. Cooke D, Scudamore A, Li J, Wyss U, Bryant T, Costigan P. Axial lower-limb alignment: comparison of knee geometry in normal volunteers and osteoarthritis patients. Osteoarthritis Cartilage. 1997;12(1):39–47. doi: 10.1016/S1063-4584(97)80030-1.
    1. Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD. The role of knee alignment in disease progression and functional decline in knee osteoarthritis. Jama. 2001;12(2):188–195. doi: 10.1001/jama.286.2.188.
    1. Brouwer GM, van Tol AW, Bergink AP, Belo JN, Bernsen RM, Reijman M, Pols HA, Bierma-Zeinstra SM. Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis Rheum. 2007;12(4):1204–1211. doi: 10.1002/art.22515.
    1. Lim BW, Hinman RS, Wrigley TV, Sharma L, Bennell KL. Does knee malalignment mediate the effects of quadriceps strengthening on knee adduction moment, pain, and function in medial knee osteoarthritis? A randomized controlled trial. Arthritis Rheum. 2008;12(7):943–951. doi: 10.1002/art.23823.
    1. Radin EL, Orr RB, Kelman JL, Paul IL, Rose RM. Effect of prolonged walking on concrete on the knees of sheep. J Biomech. 1982;12(7):487–492. doi: 10.1016/0021-9290(82)90002-1.
    1. Sharma L, Lou C, Cahue S, Dunlop DD. The mechanism of the effect of obesity in knee osteoarthritis: the mediating role of malalignment. Arthritis Rheum. 2000;12(3):568–575. doi: 10.1002/1529-0131(200003)43:3<568::AID-ANR13>;2-E.
    1. Muthuri SG, Hui M, Doherty M, Zhang W. What if we prevent obesity? Risk reduction in knee osteoarthritis estimated through a meta-analysis of observational studies. Arthritis Care Res (Hoboken) 2011;12(7):982–990. doi: 10.1002/acr.20464.
    1. Coggon D, Croft P, Kellingray S, Barrett D, McLaren M, Cooper C. Occupational physical activities and osteoarthritis of the knee. Arthritis Rheum. 2000;12(7):1443–1449. doi: 10.1002/1529-0131(200007)43:7<1443::AID-ANR5>;2-1.
    1. Zhao D, Banks SA, Mitchell KH, D'Lima DD, Colwell CW Jr, Fregly BJ. Correlation between the knee adduction torque and medial contact force for a variety of gait patterns. J Orthop Res. 2007;12(6):789–797. doi: 10.1002/jor.20379.
    1. Schipplein OD, Andriacchi TP. Interaction between active and passive knee stabilizers during level walking. J Orthop Res. 1991;12(1):113–119. doi: 10.1002/jor.1100090114.
    1. Baliunas AJ, Hurwitz DE, Ryals AB, Karrar A, Case JP, Block JA, Andriacchi TP. Increased knee joint loads during walking are present in subjects with knee osteoarthritis. Osteoarthritis Cartilage. 2002;12(7):573–579. doi: 10.1053/joca.2002.0797.
    1. Hurwitz DE, Ryals AB, Case JP, Block JA, Andriacchi TP. The knee adduction moment during gait in subjects with knee osteoarthritis is more closely correlated with static alignment than radiographic disease severity, toe out angle and pain. Journal of Orthopaedic Research. 2002;12(1):101–107. doi: 10.1016/S0736-0266(01)00081-X.
    1. Amin S, Luepongsak N, McGibbon CA, LaValley MP, Krebs DE, Felson DT. Knee adduction moment and development of chronic knee pain in elders. Arthritis Rheum. 2004;12(3):371–376. doi: 10.1002/art.20396.
    1. Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S. Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis. Annals of the Rheumatic Diseases. 2002;12(7):617–622. doi: 10.1136/ard.61.7.617.
    1. Simic M, Hinman RS, Wrigley TV, Bennell KL, Hunt MA. Gait modification strategies for altering medial knee joint load: A systematic review. Arthritis Care Res (Hoboken) 2010.
    1. Erhart JC, Mundermann A, Elspas B, Giori NJ, Andriacchi TP. Changes in knee adduction moment, pain, and functionality with a variable-stiffness walking shoe after 6 months. J Orthop Res. 2010;12(7):873–879.
    1. Kemp G, Crossley KM, Wrigley TV, Metcalf BR, Hinman RS. Reducing joint loading in medial knee osteoarthritis: shoes and canes. Arthritis Rheum. 2008;12(5):609–614. doi: 10.1002/art.23578.
    1. Thorstensson CA, Henriksson M, von Porat A, Sjodahl C, Roos EM. The effect of eight weeks of exercise on knee adduction moment in early knee osteoarthritis--a pilot study. Osteoarthritis Cartilage. 2007;12(10):1163–1170. doi: 10.1016/j.joca.2007.03.012.
    1. Pollo FE, Otis JC, Backus SI, Warren RF, Wickiewicz TL. Reduction of medial compartment loads with valgus bracing of the osteoarthritic knee. Am J Sports Med. 2002;12(3):414–421.
    1. Komistek RD, Dennis DA, Northcut EJ, Wood A, Parker AW, Traina SM. An in vivo analysis of the effectiveness of the osteoarthritic knee brace during heel-strike of gait. J Arthroplasty. 1999;12(6):738–742. doi: 10.1016/S0883-5403(99)90230-9.
    1. Giori NJ. Load-shifting brace treatment for osteoarthritis of the knee: a minimum 2 1/2-year follow-up study. J Rehabil Res Dev. 2004;12(2):187–194. doi: 10.1682/JRRD.2004.02.0187.
    1. Beaudreuil J, Bendaya S, Faucher M, Coudeyre E, Ribinik P, Revel M, Rannou F. Clinical practice guidelines for rest orthosis, knee sleeves, and unloading knee braces in knee osteoarthritis. Joint Bone Spine. 2009;12(6):629–636. doi: 10.1016/j.jbspin.2009.02.002.
    1. Zhang W, Doherty M, Peat G, Bierma-Zeinstra MA, Arden NK, Bresnihan B, Herrero-Beaumont G, Kirschner S, Leeb BF, Lohmander LS. et al.EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis. 2010;12(3):483–489. doi: 10.1136/ard.2009.113100.
    1. Conaghan PG, Dickson J, Grant RL. Care and management of osteoarthritis in adults: summary of NICE guidance. BMJ. 2008;12(7642):502–503. doi: 10.1136/.
    1. King LK, Birmingham TB, Kean CO, Jones IC, Bryant DM, Giffin JR. Resistance training for medial compartment knee osteoarthritis and malalignment. Med Sci Sports Exerc. 2008;12(8):1376–1384. doi: 10.1249/MSS.0b013e31816f1c4a.
    1. Bennell K, Hunt M, Wrigley T, Hunter D, McManus F, Hodges P, Li L, Hinman R. Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment: a randomised controlled trial. Osteoarthritis & Cartilage. 2010;12:621–628. doi: 10.1016/j.joca.2010.01.010.
    1. Cheing G, Hui-Chan C. The motor dysfunction of patients with knee osteoarthritis in a Chinese population. Arthritis Care & Research. 2001;12:62–68. doi: 10.1002/1529-0131(200102)45:1<62::AID-ANR85>;2-W.
    1. Diracoglu D, Aydin R, Baskent A, Celik A. Effects of kinesthesia and balance exercises in knee osteoarthritis. Journal of Clinical Rheumatology. 2005;12(6):303–310. doi: 10.1097/01.rhu.0000191213.37853.3d.
    1. Jan M-H, Lai J-S, Tsauo J-Y, Lien I-N. Isokinetic study of muscle strength in osteoarthritic knees of females. J Formosan Med Assoc. 1990;12:873–879.
    1. Liikavainio T, Lyytinen T, Tyrvainen E, Sipila S, Arokoski JP. Physical function and properties of quadriceps femoris muscle in men with knee osteoarthritis. Arch Phys Med Rehabil. 2008;12(11):2185–2194. doi: 10.1016/j.apmr.2008.04.012.
    1. Palmieri-Smith RM, Thomas AC, Karvonen-Gutierrez C, Sowers MF. Isometric quadriceps strength in women with mild, moderate, and severe knee osteoarthritis. Am J Phys Med Rehabil. 2010;12(7):541–548. doi: 10.1097/PHM.0b013e3181ddd5c3.
    1. Slemenda C, Brandt KD, Heilman DK, Mazzuca S, Braunstein EM, Katz BP, Wolinsky FD. Quadriceps weakness and osteoarthritis of the knee. Ann Intern Med. 1997;12(2):97–104.
    1. Messier SP, Loeser RF, Hoover JL, Semble EL, Wise CM. Osteoarthritis of the knee: effects on gait, strength, and flexibility. Arch Phys Med Rehabil. 1992;12(1):29–36.
    1. Slemenda C, Heilman DK, Brandt KD, Katz BP, Mazzuca SA, Braunstein EM, Byrd D. Reduced quadriceps strength relative to body weight: a risk factor for knee osteoarthritis in women? Arthritis Rheum. 1998;12(11):1951–1959. doi: 10.1002/1529-0131(199811)41:11<1951::AID-ART9>;2-9.
    1. Segal NA, Torner JC, Felson D, Niu J, Sharma L, Lewis CE, Nevitt M. Effect of thigh strength on incident radiographic and symptomatic knee osteoarthritis in a longitudinal cohort. Arthritis Rheum. 2009;12(9):1210–1217. doi: 10.1002/art.24541.
    1. Segal NA, Glass NA, Torner J, Yang M, Felson DT, Sharma L, Nevitt M, Lewis CE. Quadriceps weakness predicts risk for knee joint space narrowing in women in the MOST cohort. Osteoarthritis Cartilage. 2010;12(6):769–775. doi: 10.1016/j.joca.2010.02.002.
    1. Sharma L, Cahue S, Song J, Hayes K, Pai YC, Dunlop D. Physical functioning over three years in knee osteoarthritis: role of psychosocial, local mechanical, and neuromuscular factors. Arthritis Rheum. 2003;12(12):3359–3370. doi: 10.1002/art.11420.
    1. Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2009;12
    1. Pelland L, Brosseau L, Wells G, MacLeay L, Lambert J, Lamothe C, Robinson V, Tugwell P. Efficacy of strengthening exercises for osteoarthritis (Part I): A meta-analysis. Physical Therapy Reviews. 2004;12(2):77–108. doi: 10.1179/108331904225005052.
    1. Foroughi N, Smith RM, Lange AK, Baker MK, Fiatarone Singh MA, Vanwanseele B. Lower limb muscle strengthening does not change frontal plane moments in women with knee osteoarthritis: A randomized controlled trial. Clin Biomech (Bristol, Avon) 2010.
    1. McQuade KJ, de Oliveira AS. Effects of progressive resistance strength training on knee biomechanics during single leg step-up in persons with mild knee osteoarthritis. Clin Biomech (Bristol, Avon) 2011;12(7):741–748. doi: 10.1016/j.clinbiomech.2011.03.006.
    1. Hunt MA, Birmingham TB, Giffin JR, Jenkyn TR. Associations among knee adduction moment, frontal plane ground reaction force, and lever arm during walking in patients with knee osteoarthritis. Journal of Biomechanics. 2006;12(12):2213–2220. doi: 10.1016/j.jbiomech.2005.07.002.
    1. Yamada H, Koshino T, Sakai N, Saito T. Hip adductor muscle strength in patients with varus deformed knee. Clin Orthop Relat Res. 2001. pp. 179–185.
    1. Buchanan TS, Lloyd DG. Muscle activation at the human knee during isometric flexion-extension and varus-valgus loads. J Orthop Res. 1997;12(1):11–17. doi: 10.1002/jor.1100150103.
    1. Winby CR, Lloyd DG, Besier TF, Kirk TB. Muscle and external load contribution to knee joint contact loads during normal gait. J Biomech. 2009;12(14):2294–2300. doi: 10.1016/j.jbiomech.2009.06.019.
    1. Heiden TL, Lloyd DG, Ackland TR. Knee joint kinematics, kinetics and muscle co-contraction in knee osteoarthritis patient gait. Clin Biomech (Bristol, Avon) 2009;12(10):833–841. doi: 10.1016/j.clinbiomech.2009.08.005.
    1. Lloyd DG, Buchanan TS. Strategies of muscular support of varus and valgus isometric loads at the human knee. J Biomech. 2001;12(10):1257–1267. doi: 10.1016/S0021-9290(01)00095-1.
    1. Chang A, Hayes K, Dunlop D, Hurwitz D, Song J, Cahue S, Genge R, Sharma L. Thrust during ambulation and the progression of knee osteoarthritis. Arthritis Rheum. 2004;12(12):3897–3903. doi: 10.1002/art.20657.
    1. Zech A, Hubscher M, Vogt L, Banzer W, Hansel F, Pfeifer K. Neuromuscular training for rehabilitation of sports injuries: a systematic review. Med Sci Sports Exerc. 2009;12(10):1831–1841. doi: 10.1249/MSS.0b013e3181a3cf0d.
    1. Hubscher M, Zech A, Pfeifer K, Hansel F, Vogt L, Banzer W. Neuromuscular training for sports injury prevention: a systematic review. Med Sci Sports Exerc. 2010;12(3):413–421. doi: 10.1249/MSS.0b013e3181b88d37.
    1. Fitzgerald G, Childs J, Ridge T, Irrgang J. Agility and perturbation training for a physically active individual with knee osteoarthritis. Physical Therapy. 2002;12:372–382.
    1. Ageberg E, Link A, Roos EM. Feasibility of neuromuscular training in patients with severe hip or knee OA: the individualized goal-based NEMEX-TJR training program. BMC Musculoskelet Disord. 2010;12:126. doi: 10.1186/1471-2474-11-126.
    1. Fitzgerald GK, Piva SR, Gil AB, Wisniewski SR, Oddis CV, Irrgang JJ. Agility and perturbation training techniques in exercise therapy for reducing pain and improving function in people with knee osteoarthritis: a randomized clinical trial. Phys Ther. 2011;12(4):452–469. doi: 10.2522/ptj.20100188.
    1. Boutron I, Moher D, Altman DG, Schulz KF, Ravaud P. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Intern Med. 2008;12(4):295–309.
    1. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Annals of the Rheumatic Diseases. 1957;12(4):494–502. doi: 10.1136/ard.16.4.494.
    1. Altman RD, Gold GE. Atlas of individual radiographic features in osteoarthritis, revised. Osteoarthritis & Cartilage. 2007;12(Supplement A):A1–A56.
    1. Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am. 1987;12(5):745–749.
    1. Hinman RS, May RL, Crossley KM. Is there an alternative to the full-leg radiograph for determining knee joint alignment in osteoarthritis? Arthritis Rheum. 2006;12(2):306–313. doi: 10.1002/art.21836.
    1. Ericsson YB, Dahlberg LE, Roos EM. Effects of functional exercise training on performance and muscle strength after meniscectomy: a randomized trial. Scand J Med Sci Sports. 2009;12(2):156–165.
    1. Borg G, Ljunggren G, Ceci R. The increase of perceived exertion, aches and pain in the legs, heart rate and blood lactate during exercise on a bicycle ergometer. Eur J Appl Physiol Occup Physiol. 1985;12(4):343–349. doi: 10.1007/BF02337176.
    1. Besier TF, Sturnieks DL, Alderson JA, Lloyd DG. Repeatability of gait data using a functional hip joint centre and a mean helical knee axis. J Biomech. 2003;12(8):1159–1168. doi: 10.1016/S0021-9290(03)00087-3.
    1. Moisio KC, Sumner DR, Shott S, Hurwitz DE. Normalization of joint moments during gait: a comparison of two techniques. J Biomech. 2003;12(4):599–603. doi: 10.1016/S0021-9290(02)00433-5.
    1. Bellamy N. Osteoarthritis clinical trials: candidate variables and clinimetric properties. Journal of Rheumatology. 1997;12(4):768–778.
    1. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. Journal of Rheumatology. 1988;12(12):1833–1840.
    1. Jaeschke R, Singer J, Guyatt GH. Measurement of health status. Ascertaining the minimal clinically important difference. Control Clin Trials. 1989;12(4):407–415. doi: 10.1016/0197-2456(89)90005-6.
    1. ten Klooster PM, Drossaers-Bakker KW, Taal E, van de Laar MA. Patient-perceived satisfactory improvement (PPSI): interpreting meaningful change in pain from the patient's perspective. Pain. 2006;12(1-2):151–157. doi: 10.1016/j.pain.2005.12.021.
    1. Pua Y-H, Wrigley TW, Cowan SM, Bennell KL. Intrarater test-retest reliability of hip range of motion and hip muscle strength measurements in persons with hip osteoarthritis. Archives of Physical Medicine and Rehabilitation. 2008;12(6):1146. doi: 10.1016/j.apmr.2007.10.028.
    1. Franchignoni F, Horak F, Godi M, Nardone A, Giordano A. Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med. 2010;12(4):323–331.
    1. Hill KD, Bernhardt J, McGann AM, Maltese D, Berkovits D. A new test of dynamic standing balance for stroke patients: reliability, validity and comparison with healthy elderly. Physiotherapy Canada. 1996;12(4):257–262. doi: 10.3138/ptc.48.4.257.
    1. Hinman RS, Bennell KL, Metcalf BR, Crossley KM. Balance impairments in individuals with symptomatic knee osteoarthritis: a comparison with matched controls using clinical tests. Rheumatology (Oxford) 2002;12(12):1388–1394. doi: 10.1093/rheumatology/41.12.1388.
    1. Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch Phys Med Rehabil. 2002;12(11):1566–1571. doi: 10.1053/apmr.2002.35469.
    1. Rejeski WJ, Ettinger WH Jr, Schumaker S, James P, Burns R, Elam JT. Assessing performance-related disability in patients with knee osteoarthritis. Osteoarthritis Cartilage. 1995;12(3):157–167. doi: 10.1016/S1063-4584(05)80050-0.
    1. Csuka M, McCarty DJ. Simple method for measurement of lower extremity muscle strength. Am J Med. 1985;12(1):77–81.
    1. Whitfield K, Buchbinder R, Segal L, Osborne RH. Parsimonious and efficient assessment of health-related quality of life in osteoarthritis research: validation of the Assessment of Quality of Life (AQoL) instrument. Health Qual Life Outcomes. 2006;12:19. doi: 10.1186/1477-7525-4-19.
    1. Osborne RH, Hawthorne G, Lew EA, Gray LC. Quality of life assessment in the community-dwelling elderly: validation of the Assessment of Quality of Life (AQoL) Instrument and comparison with the SF-36. J Clin Epidemiol. 2003;12(2):138–147. doi: 10.1016/S0895-4356(02)00601-7.
    1. Hawthorne G, Osborne R. Population norms and meaningful differences for the Assessment of Quality of Life (AQoL) measure. Aust N Z J Public Health. 2005;12(2):136–142. doi: 10.1111/j.1467-842X.2005.tb00063.x.
    1. Martin KA, Rejeski WJ, Miller ME, James MK, Ettinger WH Jr, Messier SP. Validation of the PASE in older adults with knee pain and physical disability. Med Sci Sports Exerc. 1999;12(5):627–633. doi: 10.1097/00005768-199905000-00001.
    1. Washburn RA, Ficker JL. Physical Activity Scale for the Elderly (PASE): the relationship with activity measured by a portable accelerometer. J Sports Med Phys Fitness. 1999;12(4):336–340.
    1. Washburn RA, Smith KW, Jette AM, Janney CA. The Physical Activity Scale for the Elderly (PASE): development and evaluation. J Clin Epidemiol. 1993;12(2):153–162. doi: 10.1016/0895-4356(93)90053-4.
    1. Bellamy N, Kean WF, Buchanan WW, Gerecz-Simon E, Campbell J. Double blind randomized controlled trial of sodium meclofenamate (Meclomen) and diclofenac sodium (Voltaren): post validation reapplication of the WOMAC Osteoarthritis Index. J Rheumatol. 1992;12(1):153–159.
    1. Tubach F, Ravaud P, Baron G, Falissard B, Logeart I, Bellamy N, Bombardier C, Felson D, Hochberg M, van der Heijde D. et al.Evaluation of clinically relevant changes in patient reported outcomes in knee and hip osteoarthritis: the minimal clinically important improvement. Ann Rheum Dis. 2005;12(1):29–33. doi: 10.1136/ard.2004.022905.
    1. Little RJA, Rubin DB. Statistical analysis with missing data. New York: John Wiley; 1987.
    1. Pocock SJ, Assmann SE, Enos LE, Kasten LE. Subgroup analysis, covariate adjustment and baseline comparisons in clinical trial reporting: current practice and problems. Stat Med. 2002;12(19):2917–2930. doi: 10.1002/sim.1296.
    1. Portney LG, Watkins MP. Foundations of clinical research: applications to practice. 3. Upper Saddle River, N.J.: Pearson/Prentice Hall; 2009.
    1. Buckwalter JA, Stanish WD, Rosier RN, Schenck RC, Jr, Dennis DA, Coutts RD. The increasing need for nonoperative treatment of patients with osteoarthritis. Clin Orthop Relat Res. 2001. pp. 36–45.

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