Isokinetic testing of muscle strength in older adults with knee osteoarthritis: An integrative review
Abstract
BACKGROUND:
Knee osteoarthritis (OA) is common among older adults and associated with impaired knee strength.
OBJECTIVE:
Describe isokinetic testing procedures and clinimetric findings associated with the testing of knee strength in the presence of knee OA.
METHODS:
Relevant articles were identified by an electronic search of PubMed using the search string “isokinet
RESULTS:
One-hundred and twenty-nine relevant articles were found. The articles support the validity and reliability of isokinetic strength testing for patients with knee OA. The responsiveness to various therapeutic interventions has been reported.
CONCLUSIONS:
Isokinetic dynamometry is a valid and reliable measure of muscle strength in knee OA.
1.Introduction
Knee osteoarthritis (OA) is a common musculoskeletal condition that is responsible for approximately 80% of the global burden related to osteoarthritis at all sites within the body [1]. The individual and societal burden of knee OA is negatively associated with physical activity, disability, morbidity, and mortality levels [2, 3]. Muscle strength has been implicated in disease severity and highlighted as a target for therapeutic rehabilitation [4, 5, 6, 7]. There are several options for assessing lower extremity muscle strength in the presence of knee OA including manual muscle testing, hand-held dynamometry, and isokinetic dynamometry. The purpose of this review was to highlight procedures and results of isokinetic testing utilized for the measurement of knee strength in the presence of knee OA.
Table 1
Authorship (year) | Participants | Isokinetic procedures | Findings |
---|---|---|---|
Aily (2019) [8] | Brazilians with knee OA ( | Biodex System 3 Pro dynamometer measured knee extensor strength (PT & body weight normalized PT) @ 60 | Validity: knee extensor strength in middle-aged without knee OA SGNF |
Akyol et al. (2010) [9] | Turkish females with bilateral knee OA assigned to isokinetic strength training with short-wave diathermy ( | Cybex Human Norm dynamometer measured concentric flexor & extensor strength (PT) @ 60, 120, & 180 | Responsiveness: no difference in knee strength between groups at 4 weeks. 3-month improvements in right knee flexor strength @ 60 |
Alencar et al. (2007) [10] | Brazilians with knee OA with a history of falling ( | Biodex System 3 measured concentric knee flexor & extensor strength (body weight adjusted PT, work, & power) @ 60, 120, & 180 | Validity: No difference in concentric knee flexor or extensor strength between groups. |
Alkatan et al. (2015) [11] | Americans with knee OA assigned to receive cycling ( | Biodex dynamometer measured knee flexor & extensor strength (PT) @ 60 & 120 | Reliability: test-retest reliability in knee strength measurement (ICC |
Almosnino et al. (2012) [12] | Canadians with knee OA ( | Biodex System 3 dynamometer measured concentric knee extensor strength (bodyweight adjusted PT) @ 60, 90, & 120 | Validity: concentric knee extensor strength @ 60 |
Altubasi et al. (2018) [13] | Jordanians with knee OA ( | Biodex System 3 measured isokinetic knee extensor strength (PT) @ 60 | Validity: height, weight, age, gender, & isometric knee extensor strength partially explained variability in Get Up and Go Test ( |
Amin et al. (2009) [14] | Americans with knee OA ( | Cybex dynamometer measured isokinetic knee extensor strength (bodyweight adjusted PT) @ 60 | Responsiveness: no relationship between knee extensor strength & cartilage loss. Highest tertile of knee extensor strength had SGNF |
An et al. (2008) [15] | Chinese females with knee OA assigned to Baduanjin- traditional Chinese exercise ( | Biodex System 3 measured isokinetic knee extensor strength (PT) @ 60 | Responsiveness: SGNF |
An et al. (2013) [16] | Chinese with knee OA ( | Biodex System 3 Pro dynamometer measured knee flexor & extensor strength (PT) @ 60 | Responsiveness: SGNF |
Anandkumar (2014) [17] | Indians with knee OA assigned to receive kinesiotape with tension ( | Cybex Humac NORM dynamometer measured concentric & eccentric knee extensor strength (PT) @ 90 & 120 | Reliability: test-retest concentric knee extensor strength (ICC |
Table 1, continued | |||
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Authorship (year) | Participants | Isokinetic procedures | Findings |
Bacon et al. (2018) [18] | Americans with knee OA ( | Cybex 350 dynamometer measured knee extensor strength (PT & bodyweight adjusted PT) @ 60 | Validity: knee extensor strength females SGNF |
Baert et al. (2013) [19] | Belgians with established knee OA ( | Biodex System 3 Pro dynamometer measured knee flexor & extensor strength (body weight adjusted PT) @ 60 & 240 | Validity: knee extensor strength in OA groups was SGNF |
Baert et al. (2014) [20] | Belgian females (mean age | Biodex System 3 Pro dynamometer measured knee extensor strength (body weight adjusted PT) @ 60 & 240 | Validity: High correlation between all strength measures ( |
Baert et al. (2017) [21] | Belgian females with knee OA ( | Biodex System 3 measured isometric flexor & extensor strength (bodyweight adjusted PT) @ 60 & 90 | Validity: knee strength (all measures) in knee OA SGNF |
Barker (2018) [22] | Americans with knee OA ( | Biodex System 4 dynamometer measured concentric flexor & extensor strength (bodyweight adjusted PT) @ 60 | Validity: SGNF correlation of knee strength on limb with knee OA & superoxide dismutase but not cytokines. |
Batista et al. (2018) [23] | Brazilian females with knee OA ( | Biodex System 4 measured knee flexor & extensor strength (bodyweight adjusted PT) @ 90 & 240 | Validity: OA group knee extensor strength @ 90 & 240 |
Bayramoğlu et al. (2003) [24] | Turks with knee OA assigned to physiotherapy ( | Cybex 770 Norm dynamometer measured flexor & extensor strength (PT) @ 60 & 90 | Responsiveness: no difference in isokinetic strength within or between groups over time. |
Bayramoglu et al. (2007) [25] | Turks with bilateral knee OA ( | Cybex 770 Norm dynamometer measured isometric flexor & extensor strength (PT) @ 90 | Validity: OA group isometric knee flexor & extensor strength SGNF |
Bily (2019) [26] | Austrians with knee OA ( | S2P dynamometer measured isometric knee extensor strength (PT) @ 60 | Validity: SGNF inverse correlation of isometric knee extension strength with Timed Up and Go Test ( |
Table 1, continued | |||
---|---|---|---|
Authorship (year) | Participants | Isokinetic procedures | Findings |
Bokaeian et al. (2016) [27] | Iranians with knee OA assigned to strength training with whole body vibration ( | Biodex System 4 Pro dynamometer measured concentric knee flexor & extensor strength (PT, power, & work) @ 90 & 120 | Responsiveness: |
Börjesson et al. (1996) [28] | Swedes with knee OA assigned to physiotherapy ( | Cybex II dynamometer measured isokinetic flexor & extensor strength (PT) at 30 | Responsiveness: no difference in knee extensor or flexor strength after physiotherapy compared to control. |
Brandt et al. (1999) [29] | Americans with knee OA ( | KIN-COM 500H dynamometer measured knee flexor & extensor strength (body weight adjusted PT) @ 60 & 120 | Validity: no difference in knee flexor & extensor strength between females with progressive or stable knee OA. Body weight adjusted knee extensor strength was inversely correlated with body weight ( |
Brandt et al. (2000) [30] | Americans with radiographic knee OA ( | KIN-COM 500H dynamometer measured knee flexor & extensor strength (PT & bodyweight adjusted PT) @ 60 | Validity: knee extensor strength with knee OA SGNF |
Bülow et al. (1994) [31] | Danes with knee OA (median age | Kin-Com dynamometer measured knee extensor strength (PT) @ 60 | Responsiveness: no between group differences in knee extensor strength. |
Carpenter et al. (2006) [32] | Americans with mild knee OA ( | Biodex Multi-joint System B2000 measured extensor & flexor isokinetic strength (bodyweight adjusted PT, work, power, & fatigue) @ 60 & 180 | Reliability: test-retest isometric strength (ICC |
Cavanellas et al. (2018) [33] | Brazilians with mild knee OA ( | CSMI dynamometer measured maximal knee flexion & extension strength (bodyweight adjusted PT) @ 60 | Validity: severe knee OA or post-TKA knee extensor & flexor strength SGNF |
Table 1, continued | |||
---|---|---|---|
Authorship (year) | Participants | Isokinetic procedures | Findings |
Cetin et al. (2008) [34] | Turks with bilateral knee OA assigned to isokinetic exercise with receive short- wave diathermy & hot packs ( | Cybex 770 Norm measured concentric knee flexor & extensor strength (PT) @ 60, 120, & 180 | Responsiveness: knee extensor strength SGNF |
Chen et al. (2008) [35] | Taiwanese with mild to moderate knee OA assigned to wear magnetic knee wrap ( | Biodex System 3 measured concentric knee extensor strength (bodyweight adjusted PT) @ 30 & 60 | Responsiveness: knee extensor strength SGNF |
Cherian et al. (2015) [36] | Americans with knee OA ( | Biodex dynamometer measured knee flexor & extensor strength (PT & body weight normalized PT) @ 60 | Responsiveness: no difference in knee strength. |
Cherian et al. (2015) [37] | Americans with knee OA assigned to standard care ( | Biodex dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT) @ 60 | Responsiveness: SGNF |
Conroy et al. (2012) [38] | Americans with knee OA ( | Kin-Com dynamometer measured concentric knee extensor strength PT) @ 60 | Validity: no difference in knee extensor strength with or without radiographic knee OA & with or without pain. Radiographic knee OA group knee extensor strength per unit of muscle area SGNF |
Cornish and Peeler (2018) [39] | Canadians with knee OA with creatine supplementation ( | Biodex System 3 measured isometric knee flexor & extensor strength (PT) @ 0, 45, & 90 | Responsiveness: SGNF |
Cudejko et al. (2017) [40] | Dutch with knee OA ( | EnKnee isokinetic dynamometer measured isokinetic knee flexor & extensor strength(bodyweight adjusted PT) @ 60 | Validity: SGNF association of muscle strength with proprioception ( |
de Zwart et al. (2015) [41] | Dutch with knee OA ( | EnKnee dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT) @ 60 | Validity: knee flexor & extensor strength in those reporting falls within previous 3 months SGNF |
Table 1, continued | |||
---|---|---|---|
Authorship (year) | Participants | Isokinetic procedures | Findings |
Dias et al. (2017) [42] | Brazilian females with knee OA assigned to hydrotherapy ( | Biodex System 3 measured isokinetic flexor & extensor strength (bodyweight adjusted PT), power, & fatigue index at 180 | Responsiveness: SGNF |
Diracoglu et al. (2005) [43] | Turkish females with knee OA assigned to strength training with kinesthesia/ balance exercises ( | Biodex System 3 measured knee flexor & extensor strength (bodyweight adjusted PT) @ 60, 180, & 240 | Responsiveness: SGNF |
Diracoglu et al. (2009) [44] | Turks with knee OA assigned to hyaluronan injection ( | Biodex System 3 Pro measured knee flexor & extensor strength (PT, & agonist/antagonist ratio) @ 60, 180, & 240 | Responsiveness: |
Diraçoglu et al. (2009) [45] | Turks with bilateral knee OA ( | Biodex System 3 Pro measured knee flexor & extensor strength (bodyweight adjusted PT) @ 60, 180, & 240 | Validity: knee flexor & extensor strength in OA group @ all speeds SGNF |
Edelaar et al. (2017) [46] | Dutch with knee OA ( | EnKnee isokinetic dynamometer measured flexor & extensor strength (PT & bodyweight adjusted PT) @ 60 | Validity: SGNF correlation of knee strength between sides ( |
Eyigör et al. (2004) [47] | Turks with bilateral knee OA assigned to isokinetic exercise ( | Cybex Norm Dynamometer measured knee flexor & extensor strength @ 60, 90, 120, & 180 | Responsiveness: SGNF |
Germanou et al. (2013) [48] | Greeks with knee OA ( | Cybex 6000 dynamometer measured concentric flexor & extensor (PT) @ 90, 120, & 150 | Validity: knee flexor & extensor strength in knee OA group SGNF |
Gkrilias et al. (2018) [49] | Greeks with knee OA ( | Biodex System 3 measured isokinetic flexor & extensor strength (bodyweight adjusted PT) @ 120 & 180 | Validity: SGNF correlation between isokinetic flexor & extensor strength @ both speeds with 6 minute Walk Test ( |
Glass et al. (2013) [50] | Americans with knee OA or risk factors for knee OA ( | Cybex 350 dynamometer measured knee flexor & extensor strength (PT) @ 60 | Validity: knee strength in males SGNF |
Gökçen et al. (2016) [51] | Turks with knee OA ( | NORM 6000 dynamometer measured knee flexor & extensor strength (PT) @ @ 60 | Validity: Female knee strength SGNF |
Table 1, continued | |||
---|---|---|---|
Authorship (year) | Participants | Isokinetic procedures | Findings |
Gur et al. (2002) [52] | Turks with knee OA assigned to concentric ( | Cybex 6000 dynamometer measured concentric & eccentric flexor & extensor strength (PT) @ 60, 120, & 180 | Responsiveness: SGNF |
Gur and Cakin (2003) [53] | Turkish females with bilateral knee OA ( | Cybex 6000 dynamometer measured concentric & eccentric flexor & extensor strength (PT) @ 60, 120, & 180 | Validity: eccentric strength for knee flexors & extensors SGNF |
Ha et al. (2018) [54] | Korean females with knee OA assigned to aquatic therapy ( | Biodex System 3 measured isokinetic knee flexor & extensor strength (bodyweight adjusted PT) @ 60 | Responsiveness: SGNF |
Hall et al. (2018) [55] | Australians with knee OA assigned to exercise ( | KinCom 125-AP measured isometric knee extensor strength (bodyweight adjusted PT) @ 60 | Responsiveness: knee extensor strength in exercise group SGNF |
Harper (2019) [56] | Americans with knee OA assigned to moderate intensity ( | Biodex system measured knee extensor isokinetic strength (PT) @ 60 | Responsiveness: SGNF |
Huang et al. (2003) [57] | Taiwanese with bilateral knee OA (mean age | Kin-Com 505 dynamometer measured eccentric & concentric flexor & extensor strength (PT) @ 60 & 180 | Responsiveness: SGNF |
Table 1, continued | |||
---|---|---|---|
Authorship (year) | Participants | Isokinetic procedures | Findings |
Huang et al. (2005) [58] | Taiwanese with bilateral knee OA (mean age | Kin-Com 505 dynamometer measured concentric & eccentric flexor & extensor strength (PT) @ 60 & 180 | Responsiveness: SGNF |
Huang et al. (2005) [59] | Taiwanese with knee OA ( | Kin-Com 505 dynamometer measured concentric & eccentric knee flexion & extension strength (PT) @ 60 & 180 | Responsiveness: SGNF |
Hurley and Newham (1993) [60] | British with knee OA ( | Cybex System II | Validity: isometric knee extensor strength in knee OA SGNF |
Jadelis et al. (2001) [61] | Americans with knee OA ( | Kin-Com 125E dynamometer measured concentric & eccentric knee flexor & extensor strength (PT) @ 30% velocity. | Validity: correlation of knee flexor & extensor strength ( |
Kean et al. (2010) [62] | Canadians with knee OA ( | Biodex System 3 dynamometer measured concentric knee extensor strength (bodyweight adjusted PT & body size adjusted PT) @ 60 | Reliability: test-retest isokinetic knee extensor strength (ICC |
Kim et al. (2018) [63] | Taiwanese females with bilateral knee OA & no swelling ( | CSMI isokinetic dynamometer measured maximal knee flexion & extension strength (PT) @ 60 & 180 | Validity: knee extensor strength in painful knees SGNF |
King et al. (2008) [64] | Canadians with knee OA & varus malalignment ( | Biodex System 3 measured concentric knee flexor & extensor strength (PT & work) @ 60, 90, 120, & 180 | Validity: knee strength in affected limb SGNF |
Koeckhoven et al. (2016) [65] | Dutch with knee OA ( | En-Knee dynamometer measured knee flexor & extensor strength (body weight adjusted PT) @ 60 | Validity: SGNF correlation between right & left limb strength ( |
Table 1, continued | |||
---|---|---|---|
Authorship (year) | Participants | Isokinetic procedures | Findings |
Kumar et al. (2014) [66] | Americans with radiographic knee OA ( | Primus RS dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT) @ 120 | Validity: knee extensor strength in knee OA group SGNF |
Lankhorst et al. (1985) [67] | Dutch with knee OA ( | Cybex System II dynamometer measured knee flexor & extensor strength (PT) @ 30, 60, 120, & 180 | Validity: knee strength on affected knee SGNF |
Lee et al. (2015) [68] | Koreans with knee OA ( | Biodex System 4 dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT & work) @ 60 & 180 | Validity: SGNF correlation of knee flexor ( |
Levinger et al. (2018) [69] | Australians with knee OA ( | Biodex System 2 measured isokinetic knee extensor strength (bodyweight & height adjusted PT) @ 90 & 180 | Validity: individuals with multiple stepping strategy after induced forward fall had SGNF |
Lim et al. (2010) [70] | Obese Koreans with knee OA assigned to aquatic exercise ( | Biodex dynamometer measured knee flexor & extensor strength (PT) @ 60 | Responsiveness: No change in knee strength for any group. |
Lim et al. (2015) [71] | Koreans with knee OA ( | Primus RS dynamometer measured isometric extensor strength (bodyweight adjusted PT) @ 60 | Validity: no difference in isometric knee extension strength by radiographic knee alignment. |
Madsen et al. (1996) [72] | Danish with knee OA awaiting knee arthroplasty ( | Cybex 6000 dynamometer measured knee flexor & extensor strength (PT) @ 30 & 120 | Validity: knee extensor strength SGNF |
Malas et al. (2013) [73] | Turks with knee OA assigned to isokinetic ( | Biodex System 3 dynamometer measured concentric flexor & extensor strength (body weight adjusted PT) @ 60 | Responsiveness: SGNF |
Maly et al. (2006) [74] | Canadians with knee OA ( | Biodex System 3 measured concentric flexor & extensor strength (PT) @ 60 | Validity: SGNF correlation of Functional Self Efficacy scores with knee extensor strength ( |
Maly et al. (2008) [75] | Canadians with knee OA ( | Biodex System 3 measured knee extensor strength (PT) @ 60 | Validity: muscle strength did not contribute to explanation of pain variability. |
Matsuno et al. (1997) [76] | Japanese with knee OA ( | KIN-500-HX dynamometer measured knee extensor strength (PT) @ 30 | Responsiveness: SGNF |
Table 1, continued | |||
---|---|---|---|
Authorship (year) | Participants | Isokinetic procedures | Findings |
Matsuse et al. (2017) [77] | Japanese with knee OA ( | Biodex System 3 measured isokinetic knee flexor & extensor strength (bodyweight adjusted PT) @ 60 | Responsiveness: SGNF |
Maurer et al. (1999) [78] | Americans with knee OA assigned to an educational intervention ( | Biodex dynamometer measured knee extensor strength (PT) @ 90 & 120 | Responsiveness: SGNF |
Messier et al. (1992) [79] | Americans with knee OA ( | Cybex II | Validity: knee flexor & extensor strength in OA group SGNF |
Messier et al. (2000) [80] | Obese Americans with knee OA assigned to exercise & diet ( | Kin-Com 125E isokinetic dynamometer measured flexor & extensor strength (mean torque) @ 30 | Responsiveness: SGNF |
Messier et al. (2002) [81] | Older Americans with knee OA ( | Kin-Com 125E dynamometer measured concentric & eccentric knee flexor & extensor strength (PT) @ 30 | Validity: SGNF association between knee & ankle strength @ baseline. Responsiveness: SGNF |
Mikesky et al. (2006) [82] | Older Americans assigned to strength training ( | Kin-Com III dynamometer measured concentric flexor & extensor strength (PT) @ 60 & 120 | Validity: knee extensor strength in males without knee OA SGNF |
Miltner et al. (2002) [83] | Germans with bilateral knee OA ( | Cybex 6000 dynamometer measured flexor & extensor strength (PT & work) @ 60, 90, 120, 150, & 180 | Responsiveness: SGNF |
Öğüt (2018) [84] | Turk females with knee OA assigned to Kinesiology Taping ( | Humac Norm isokinetic dynamometer measured knee extensor strength (PT) @ 60 & 180 | Responsiveness: SGNF |
Park et al. (2013) [85] | Korean females with knee OA assigned to home based exercise with whole body vibration ( | Biodex 900-240 dynamometer measured knee extensor isokinetic strength (PT) @ 60 | Responsiveness: no difference in strength change between groups. SGNF |
Patsika et al. (2014) [86] | Greek females with knee OA ( | Cybex dynamometer measured concentric & eccentric knee flexor & extensor strength (flexor/extensor ratio) @ 60, 120, & 150 | Validity: females with knee OA flexor/extensor ratio SGNF |
Table 1, continued | |||
---|---|---|---|
Authorship (year) | Participants | Isokinetic procedures | Findings |
Peeler and Ripat (2018) [87] | Canadians with knee OA ( | Biodex System 3 measured maximal isokinetic knee extensor strength (bodyweight adjusted PT) @ 60, 180, & 240 | Validity: no difference in strength between affected & unaffected limbs at baseline. Responsiveness: females had SGNF |
Peixoto et al. (2011) [88] | Older Brazilian females with unilateral or bilateral knee OA ( | Biodex System 3 Pro dynamometer measured concentric knee flexor & extensor strength (bodyweight adjusted PT) @ 60 & 180 | Validity: SGNF inverse correlation of knee extensor strength @ 180 |
Pelletier et al. (2013) [89] | Canadian females with knee OA ( | Biodex System 3 dynamometer measured knee extensor strength (power & work) @ 180 | Responsiveness: SGNF |
Peloquin et al. (1999) [90] | Canadians with knee OA assigned an exercise program ( | Isokinetic dynamometer measured knee flexor & extensor strength (PT) @ 30 & 90 | Responsiveness: improvement in isometric knee extensor, & isokinetic & isometric knee flexor strength in exercise group was SGNF |
Petrella et al. (2017) [91] | Brazilians with knee OA ( | Biodex System 3 measured concentric & eccentric knee extensor strength (bodyweight adjusted PT) @ 90 | Validity: knee OA group eccentric knee extensor strength |
Pua et al. (2011) [92] | Singaporeans with knee OA awaiting total knee replacement ( | Biodex dynamometer measured isometric knee extensor strength (body weight adjusted PT) @ 75 | Validity: variation in SF36 physical function & gait speed were partially explained ( |
Pua et al. (2013) [93] | Singaporeans with knee OA awaiting total knee replacement ( | Biodex dynamometer measured isometric knee extensor strength (body weight adjusted PT) @ 75 | Validity: individuals with slower gait speeds ( |
Robbins et al. (2011) [94] | Canadians with symptomatic knee OA of medial compartment ( | Biodex System 3 Pro dynamometer measured concentric knee extensor strength (PT) @ 60 | Validity: SGNF correlation of knee extensor strength with KOOS pain score ( |
Rodrigues-da-Silva et al. (2017) [95] | Brazilians with knee OA ( | Biodex System 3 measured flexor & extensor isokinetic strength (PT, body weight adjusted PT, total work, coefficient of variation, & agonist-antagonist ratio) @ 60 | Responsiveness: SGNF |
Rodrigues da Silva (2019) [96] | Brazilians with knee OA ( | Biodex System 3 dynamometer measured concentric knee flexor & extensor strength (PT, bodyweight adjusted PT, total work, coefficient of variation, & agonist-antagonist ratio) @ 60 | Responsiveness: SGNF |
Røgind et al. (1998) [97] | Danes with knee OA assigned to exercise ( | Cybex 6000 dynamometer measured knee flexor & extensor strength (PT) @ 30, 60, 90 & 120 | Responsiveness: SGNF |
Samut et al. (2015) [98] | Turks with knee OA assigned to isokinetic exercise ( | Biodex System 3 Pro dynamometer measured concentric knee flexor & extensor strength (bodyweight adjusted PT) @ 60 & 180 | Responsiveness: SGNF |
Table 1, continued | |||
---|---|---|---|
Authorship (year) | Participants | Isokinetic procedures | Findings |
Sanchez-Ramirez et al. (2013) [99] | Dutch with knee OA ( | EnKnee dynamometer measured knee flexor & extensor strength (body weight adjusted PT) @ 60 | Validity: SGNF association in one leg stance time ( |
Sanchez-Ramirez et al. (2013) [100] | Dutch with knee OA ( | EnKnee dynamometer measured knee flexor & extensor strength (body weight adjusted PT) @ 60 | Validity: SGNF association of lower muscle strength with elevated C-reactive protein ( |
Sanchez-Ramirez et al. (2014) [101] | Dutch with knee OA ( | EnKnee dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT) @ 60 | Responsiveness: group with elevated c-reactive protein @ baseline & 2y had SGNF |
Sanchez-Ramirez et al. (2015) [102] | Dutch with knee OA ( | EnKnee dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT) @ 60 | Responsiveness: SGNF |
Santos et al. (2011) [103] | Brazilian females with knee OA ( | Biodex System 3 Pro dynamometer measured concentric knee flexor & extensor strength (bodyweight adjusted PT) 60 & 180 | Validity: SGNF inverse correlation of Interleukin-6 with knee flexor strength ( |
Schilke et al. (1996) [104] | Americans with knee OA assigned to isokinetic exercise ( | Cybex II dynamometer measured flexor & extensor strength (PT) @ 90 | Responsiveness: SGNF |
Segal et al. (2009) [105] | Americans (mean age | Cybex 350 dynamometer measured concentric knee flexor & extensor strength (PT) @ 60 | Validity: knee extensor strength in males SGNF |
Segal et al. (2009) [106] | Americans with knee OA or at risk for knee OA ( | Cybex 350 dynamometer measured concentric knee flexor & extensor strength (PT) @ 60 | Reliability: knee strength test-retest (ICC |
Segal et al. (2010) [107] | Americans with knee OA or risk factors for knee OA ( | Cybex 350 dynamometer measured knee flexor & extensor strength (PT) @ 60 | Validity: male knee flexor & extensor strength SGNF |
Segal et al. (2011) [108] | Americans who were non-obese ( | Biodex System 3 dynamometer measured knee extensor strength (PT) @ 60 | Validity: No difference in strength by BMI or presence of knee OA. |
Serrão et al. (2012) [109] | Brazilians with knee OA ( | Biodex System 3 dynamometer measured concentric & eccentric knee extensor strength (body weight adjusted PT) @ 90 | Validity: SGNF inverse correlation of concentric & eccentric extensor strength with WOMAC pain ( |
Serrão et al. (2015) [110] | Brazilian males with knee OA ( | Biodex System 3 dynamometer measured concentric & eccentric knee flexor & extensor strength (bodyweight adjusted PT) @ 90 & 180 | Validity: eccentric knee extensor strength in group without knee OA SGNF |
Table 1, continued | |||
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Authorship (year) | Participants | Isokinetic procedures | Findings |
Shakoor et al. (2017) [111] | Americans with knee OA or at high risk for knee OA ( | Cybex 350 dynamometer measured isokinetic extensor strength (bodyweight adjusted PT) @ 60 | Responsiveness: |
Silva et al. (2018) [112] | Brazilians with knee OA & sleep apnea ( | Biodex System 3 measured isometric knee extensor strength (bodyweight adjusted PT) @ 60 | Validity: concentric knee extensor strength @ 90 & 180 |
Skou et al. (2016) [113] | Americans with knee OA ( | Cybex 350 dynamometer measured knee extensor strength (PT) @ 60 | Validity: no difference in risk for TKA by knee extensor strength when adjusted for radiographic severity. |
Slemenda et al. (1997) [114] | Americans with knee OA ( | Kin-Com 500H dynamometer measured concentric & eccentric knee flexor & extensor strength (PT) @ 60 & 120 | Validity: knee extensor strength in knee OA group SGNF |
Slemenda et al. (1998) [115] | Elderly Americans (mean age | Kin-Com 500H dynamometer measured concentric knee flexor & extensor strength (PT, body weight adjusted PT, & lower extremity muscle mass adjusted PT) @ 60 | Validity: knee strength (body weight adjusted) in females with knee OA SGNF |
Stefanik et al. (2011) [116] | Americans with knee OA or at risk for knee OA ( | Cybex 350 dynamometer measured concentric knee extensor strength (bodyweight adjusted PT & BMI adjusted PT) @ 60 | Validity: individuals in the lowest tertile of knee extensor strength had SGNF |
Tan et al. (1995) [117] | Turkish females with radiographic knee OA & knee pain ( | Cybex-350 dynamometer measured knee flexor & extensor strength (PT, & agonist/antagonist ratio) @ 60 & 180 | Validity: knee flexor & extensor isometric & isokinetic strength in both OA groups SGNF |
Tang et al. (2005) [118] | Taiwanese with bilateral knee OA ( | Kin-Com dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT) @ 80 & 240 | Responsiveness: SGNF |
Table 1, continued | |||
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Authorship (year) | Participants | Isokinetic procedures | Findings |
Tok et al. (2011) [119] | Turks with knee OA assigned to receive conventional physical therapy with combined continuous passive motion & electrical stimulation ( | Cybex 6000 dynamometer measured concentric & eccentric flexor & extensor strength (PT & work) @ 60 | Responsiveness: SGNF improvement in right flexor strength but not left or knee extension strength for group receiving continuous passive motion & electrical stimulation. |
Tuna and Balcı (2014) [120] | Turkish females with knee OA ( | Cybex NORM 6000 measured knee flexor & extensor strength (PT, work) @ 90 & 180 | Validity: no difference in extensor strength @ 90 |
Tuna et al. (2016) [121] | Turks with knee OA ( | Cybex NORM 6000 measured knee flexor & extensor strength (PT & work) @ 60 & 180 | Validity: SGNF correlation between cartilage thickness & isometric knee flexor ( |
Valtonen et al. (2015) [122] | Finns with late stage knee OA ( | Humac NORM dynamometer measured knee flexor & extensor strength (PT & power) @ 60 & 180 | Validity: knee strength on affected knee SGNF |
van der Esch et al. (2006) [123] | Dutch with knee OA ( | EnKnee dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT) @ 60 | Validity: SGNF correlation between knees for extensor strength ( |
van der Esch et al. (2007) [124] | Dutch with symptomatic knee OA ( | EnKnee dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT) @ 60 | Validity: SGNF correlation between limbs for knee extensor ( |
van der Esch et al. (2008) [125] | Dutch with knee OA ( | EnKnee dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT) @ 60 | Validity: No correlation of varus-valgus range of motion or mid-stance position with muscle strength. |
Table 1, continued | |||
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Authorship (year) | Participants | Isokinetic procedures | Findings |
van der Esch et al. (2008) [126] | Dutch with knee OA ( | EnKnee dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT) @ 60 | Validity: Variation in walking time, Get Up and Go Test, & WOMAC physical function scores were partially explained ( |
van der Esch et al. (2012) [127] | Dutch with knee OA ( | EnKnee dynamometer measured knee flexor & extensor muscle strength (body weight adjusted PT) @ 60 | Validity: knee strength & pain do not moderate the association of self-reported knee instability with activity limitations. |
Wageck et al. (2016) [128] | Brazilians with knee OA assigned to kinesiotape ( | Biodex System 4 dynamometer measured knee flexor & extensor strength (bodyweight adjusted PT) @ 60 | Responsiveness: no difference in knee flexor & extensor strength between groups. |
Weng et al. (2009) [129] | Taiwanese with bilateral knee OA (mean age | Kin-Com 505 dynamometer measured concentric & eccentric knee flexor & extensor strength (PT) @ 60 & 180 | Responsiveness: SGNF |
Wessel et al. (1996) [130] | Canadian females with knee OA ( | Kin-Com dynamometer measured isokinetic knee extensor strength (PT) @ 30, 60, & 90 | Validity: knee extensor strength in worse knee SGNF |
White et al. (2010) [131] | Americans with knee OA or at risk for knee OA ( | Cybex 350 dynamometer measured knee extensor strength (PT) @ 60 | Responsiveness: reaching MCID in WOMAC physical function @ follow-up was associated with |
Wu et al. (2008) [132] | Taiwanese with knee OA & normal ( | Cybex Norm dynamometer measured knee extensor strength (body weight adjusted PT) @ 80, 120, & 240 | Validity: knee extensor strength in groups with knee OA SGNF |
Wu et al. (2018) [133] | Taiwanese with bilateral knee OA (mean age | Biodex System 3 measured concentric isokinetic strength (PT) of knee flexors & extensors @ 60 & 180 | Responsiveness: SGNF |
Yázigi (2018) [134] | Portuguese with obesity & knee OA ( | Biodex System 3 measured bilateral isokinetic & isometric knee flexor & extensor strength (bodyweight adjusted PT). | Validity: SGNF correlation between all strength measures & 6 minute Walk Test ( |
Yilmaz et al. (2010) [135] | Turks with knee OA assigned strength training with EMG-biofeedback ( | Cybex dynamometer measured knee flexor & extensor strength (PT) @ 60 & 180 | Responsiveness: SGNF |
Table 1, continued | |||
Authorship (year) | Participants | Isokinetic procedures | Findings |
Yoon et al. (2018) [136] | Japanese females with knee OA assigned whole body vibration therapy & maslinic acid supplementation ( | Biodex System 4 measured maximal isometric knee extensor strength (bodyweight adjusted PT) @ 60 | Responsiveness: knee with Kellgren-Lawrence grade |
2.Methods
PubMed was searched for articles potentially related to isokinetic testing and knee arthritis on July 7, 2019. The search string included “isokinet
3.Results and discussion
The PubMed search identified 312 potentially relevant articles. After review, 183 articles were excluded leaving 129 articles for inclusion in this report. Relevant information from these articles are summarized in Table 1 [8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136].
The summarized information demonstrates that isokinetic dynamometry is frequently utilized to measure strength of the knee flexor and extensor muscles in the presence of OA. Testing has been reported throughout the world with Asia, Europe, North America, and South America producing the bulk of published work. Various dynamometers have been used although Biodex, Cybex, En-Knee, and Kin-Com are most frequently reported. Most protocols have measured concentric contractions, with a primary outcome of peak torque (PT) or PT adjusted for body weight while fewer studies have reported work, power, fatigue, and agonist/antagonist ratio. Isokinetic test velocities range from 30 to 240
Isokinetic knee strength measurements have demonstrated convergent validity with several related factors. Knee flexor and extensor strength have been shown to be strongly correlated (
The clinimetric properties of isokinetic knee strength measurement have been supported via known groups or conditions validity in various ways. Dominant limb strength is larger than non-dominant limb strength [79] and strength measurements in the lower extremity affected with knee OA tend to be lower than in the unaffected limb [64, 67, 122, 130] but no difference has also been reported [87]. Knee extensor strength tends to be greater in individuals without knee OA than with knee OA [8], younger adults have greater strength than older adults [8, 66, 88], and middle-aged adults with knee OA have similar strength to older adults without knee OA [8]. Knee flexor and extensor strength also tends to be greater in males than females [18, 50, 51, 61, 105, 107]. Body weight is inversely correlated with knee extensor strength more frequently in females than males [29, 115], and those who develop incident knee OA [115].
Healthy adults tend to have stronger knee flexors [23, 30, 33, 45, 48, 79, 115, 117] and extensors [19, 21, 23, 30, 33, 38, 45, 48, 66, 79, 82, 91, 110, 114, 115, 117, 132] than individuals with knee OA, however some studies have reported no difference in the flexors [30, 66] and extensors [38, 120] based upon presence or absence of knee OA. Knee flexor [19, 33, 45] and extensor [20, 33, 45] strength tends to be larger in the early stages of OA than later in the natural course, although some studies have reported no strength differences based upon disease severity [29, 51]. Isometric knee strength is reportedly lower in the presence of knee OA [21, 25, 60, 117] and worsens with disease severity [66] with few exceptions [20, 91]. A correlation appears to exist between knee cartilage integrity and isometric knee flexor and extensor strength [66, 121], but not isokinetic strength [121]. The variability in knee extensor isokinetic and isometric strength may be partially explained by patellofemoral cartilage integrity, extent of cartilage lesions, loose bodies, synovitis or effusion, and pain [20]. Significantly higher medial and lateral patellofemoral joint cartilage damage and lateral patellofemoral bone marrow lesions have been found in those in the lowest tertile of knee extensor strength [116].
Pain appears to be negatively correlated with knee strength (
Functional measurements have been associated with knee strength measurement utilizing isokinetic dynamometers. Knee strength has been identified as inversely associated with functional ambulation measures including the Get Up and Go Test [13, 46, 102, 124, 126], Timed Up and Go Test [26, 49], 6 minute Walk Test [49, 134], 100-meter walk test [123, 124], 20-meter walk test [18], gait speed [92, 93, 122], and walking time [67]. Difficulty rising from a chair has been associated with lower knee extensor strength in females [18]. Functional performance on the 30-second Chair Stand Test has been correlated with knee flexor and extensor strength (
Other contributing factors association with knee strength have been reported in patients with knee OA. An inverse correlation may be present between markers of systemic inflammation [40, 103] or vitamin D levels [65] and knee strength in participants with knee OA [40, 103]. Knee strength appears to be negatively influenced by comorbidity [51] and sleep apnea [112]. A history of falling may [41] or may not [10] be associated with lower knee strength values. Levinger et al. [69] have reported fewer steps after an induced forward fall in individuals with higher knee extensor strength performance.
The relative reliability of isokinetic dynamometry in measuring knee strength in the presence of knee OA has been characterized using intraclass correlation coefficients (ICCs). Test-retest reliability for knee isokinetic strength measurement has been noted as strong with ICCs
Numerous studies have documented significant increases in knee strength after exercise interven- tions [11, 15, 16, 27, 42, 43, 47, 52, 54, 55, 56, 57, 58, 59, 60, 64, 73, 78, 80, 82, 85, 87, 89, 90, 96, 97, 98, 121, 129, 135] including strength/power training [27, 47, 55, 56, 80, 82, 85, 89, 90, 121, 135], isokinetic exercise [47, 52, 57, 58, 59, 64, 73, 78, 98, 129], aerobic exercise [11, 80, 87, 90], stretching [85, 90], kinesthesia and balance exercises [43], physical therapy/ physiotherapy [24, 60, 97], hydro/aquatic therapy [42, 54], Baduanjin [15, 16], and exercise education [96]. Two studies reported no difference in knee strength subsequent to physiotherapy [28] or aquatic or land-based exercise [70] both however conflicting with the positive effects of exercise reported in the majority of studies.
Thermal modalities including short wave dia- thermy [9, 34], hot packs [34], laser [31], and ultrasound [34, 58, 59] have reportedly been associated with additional improvements in knee strength over exercise interventions alone. Electric modalities including transcutaneous electric stimulation [37], neuromuscular electric stimulation [77, 119], and biofeedback [135] have also been reported to produce improvements in knee strength when combined with exercise interventions. Whole body vibration training in combination with exercise may [27] or may not [85] produce larger increases in knee strength than exercise training alone, or maslinic acid supplementation [136]. Kinesiotape tends to produce no difference in knee strength compared with sham taping [84, 128]; conflicting results have been reported relative to control applications [17]. Although sparsely reported, knee extensor strength may improve with application of a magnetic knee wrap [35] or knee brace [76]. Intraarticular hyaluronic acid injections tend to increase knee strength measures [44, 58, 83, 118] with one study reporting no difference [24]. Wu et al. [133] reported increased knee strength after platelet rich plasma injections although no difference was identified compared to placebo injection.
The available evidence of isokinetic measurement of knee strength the presence of knee OA is extensive, dating to at least the work of Lankhorst et al. [67] in 1985. Numerous studies have evaluated the association of knee strength and the presence and severity of knee OA, age, gender, and body type. Isokinetic dynamometry has been shown to be a valid and reliable measure of knee flexor and extensor muscle strength. In the presence of knee OA, change in knee strength over time and with various interventions have been reported.
This review utilized only one database (PubMed) which may have limited the pool of available articles meeting the search and inclusion criteria. It is unlikely, however, that the inclusion of additional databases would substantially alter the summary provided in this review.
4.Conclusion
Isokinetic measurement of knee strength is well-supported for individuals with knee OA. The evidence supports utilization of isokinetic measurement for the identification of strength impairments and subsequent responsiveness to therapeutic interventions.
Conflict of interest
The author declares no conflict of interest.
References
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