Impact of Isokinetic training on pain in patients’ with Knee osteoarthritis-A Meta-analysis

 

Naresh Bhaskar Raj^1*, Soumendra Saha², Amran Ahmed Shokri³, Srilekha Saha²,Hazliza Razali⁴, Nur Yanti Haryana Othman⁴, Mahadeva Rao US⁵

¹Senior Lecturer, Faculty of Health Sciences, Universiti Sultan Zainal Abidin (UniSZA), 21300, Terengganu Darul Iman, Malaysia.

²School of Health Sciences,Universiti Sains Malaysia, 16150, Kelantan DarulNaim, Malaysia.

³Professor, School of Medical Sciences, Universiti Sains Malaysia, 16150, Kelantan Darul Naim, Malaysia.

⁴Post Graduate Student, Faculty of Health Sciences, UniSZA, 21300 Kuala

Nerus, Terengganu Darul Iman, Malaysia.

⁵Professor, School of Basic Medical Sciences, UniSZA, 20400, Kuala Terengganu, Malaysia.

 

ABSTRACT:

The incidence of osteoarthritis has been alarming over the years due to increase in the proportion of the aged people. Osteoarthritis has been commonly found to affect the knee joint, the most important joint in the context of weight bearing function of the lower limb. Cartilage destruction and subchondral bone erosion along with other entities affecting the entire structure of the knee are associated with osteoarthritis. Isokinetic training has been used to train athletes and to measure the function of the muscles for almost 5 decades .It has found its application in assessment and training of patients with various disorders. Osteoarthritis of knee is one such disorder where the application of the isokinetic training has been increasing over the years. There have been controversies over the effect of isokinetic training in patients with osteoarthritis of knee. Hence the magnitude of the effect of isokinetic training on functional parameters in patients with osteoarthritis of knee needs to be evaluated. A thorough online literature search was done on Web of Science, ProQuest, PubMed, Ebscohost, CINAHL between 1990 and 2014. Ten articles measuring the effect of isokinetic training on osteoarthritis of knee were included and methodologically assessed. Data from the trials were extracted based on the demographic characteristics, outcomes measured, isokinetic training protocol and the other interventions used. Standardized effect sizes with 95%confidence interval (CIs) were calculated from the preintervention and post intervention means of the isokinetic training group and other intervention group. About 10 studies were included in the review and 9 articles were analysed for reduction in pain.Isokinetic training was not so beneficial in reducing the pain associated with osteoarthritis. Since there was so much of heterogeneity among the studies the result of the analysis should be inferred with caution. Yet there is no definitive evidence to confirm the effects of isokinetic training on osteoarthritis of knee.

 

 

 

 

 

 

 

INTRODUCTION:

The most common form of arthritis affecting the human is osteoarthritis.^[1,2] Osteoarthritis is a disease that is painful and causes disability thereby reducing the quality of life. Osteoarthritis mainly affects the synovial joints. Researchers have been trying hard to find out the exact cause of osteoarthritis but still the exact etiological factor of osteoarthritis is unknown. In their attempt to find out the cause of osteoarthritis,researchers have been successful in revealing the risk factors that are considered to be important in the development of osteoarthritis. Of those risk factors hormonal decrement during menopause^[2], joint trauma^[3], genetic susceptibility^[4], obesity and metabolic disorders.^[5-8] Osteoarthritis has been diagnosed as a disease affecting the entire structure of the joint. Previously osteoarthritis was considered to be a non-inflammatory joint disease but recently there is evidence of inflammation to be associated with osteoarthritis.^{[9, 10]} At present there is no curative treatment for osteoarthritis and all the treatment methods are palliative. Appropriate treatment techniques and an holistic approach is essential in the process of rehabilitation of Osteoarthritis patient.^[11] There has been increase in the elderly population around the globe thereby increasing the incidence of osteoarthritis.^[12] Performance of the muscle has been evaluated by isokinetic dynamometers since its inception in the year 1967. Isokinetic dynamometers have produced high reliable parameters such as torque, work and power.^[13] Nowadays isokinetic devices are used in for wide range of populations such as elderly, adults, athletes and patients with various disorders.^[14,15] Isokinetic training has been used in osteoarthritis of knee to improve the strength of the knee muscle and also to improve the functional outcomes of patients with knee osteoarthritis.^[16] Some researchers have found isokinetic training to be effective for patients with osteoarthritis whereas few researchers have found negative results with isokinetic training in osteoarthritis. To date there is no concrete evidence to say that isokinetic is effective or ineffective in osteoarthritis of knee. A systematic review has revealed that isokinetic training was effective in improving the strength of the quadriceps femoris muscle ut has not revealed anything on the improvement in pain.^[17] With such a background we intended to perform a meta-analytic review regarding the impact of isokinetic training on patients with osteoarthritis of knee.The objective of this review is to examine the effectiveness of isokinetic training in patients with osteoarthritis of knee by systematically analysing the outcomes of the previous studies performed.

 

SOURCES:

A total of 928 articles specific to the search terms were found of which 128 were duplicates. A hand search did not yield any articles. Based on the title and abstract 800 articles were searched. This lead to elimination of 787 articles. The remaining 13 articles were assessed based on the inclusion criteria. Three articles were excluded due to the fact that one study did not provide the data^[16]; one study was performed on patellofemoral pain syndrome^[18] and other on anterior cruciate ligament reconstruction.^[19]10 articles met the criteria for inclusion and were taken up for analysis.9 articles were analysed for reduction of pain.

 

The following databases were searched using the terms isokinetic training OR isokinetic exercise OR isokinetic strength training and osteoarthritis of knee OR osteoarthrosis of knee OR knee osteoarthritis OR knee osteoarthrosis: Physiotherapy evidence Database (PEDro), Cumulative Index of Nursing and allied Health literature (CINAHL), Sport DISCUS, PubMed, Proquest. Evidence relating to isokinetic training and osteoarthritis of knee between the years 1990-2014 were extracted and analysed.

 

Table 1.PEDro scores of the RCT

Study	Criteria for inclusion?	Allocated randomly?	Allocation concealed?	Groups similar at baseline?	Participants blinded?	Therapist blinded?
Maurer et al., 1999[21]	Yes	Yes	No	Yes	No	No
Gur et al., 2002[22]	Yes	Yes	No	Yes	No	No
Huang et al., 2003[23]	Yes	Yes	Yes	Yes	No	No
Eyigor 2004[24]	Yes	Yes	No	Yes	No	No
Huang et al.,2005[25]	Yes	Yes	Yes	Yes	No	No
Cetin et al., 2008[26]	Yes	Yes	No	Yes	No	No
Weng et al .,2009[27]	Yes	Yes	Yes	Yes	No	No
Akyol et al., 2010[28]	Yes	Yes	Yes	Yes	No	No
Rosa et al., 2012[29]	Yes	No	No	Yes	No	No
Malas et al .,2013[30]	Yes	Yes	No	Yes	No	No
Score	10/10	9/10	4/10	10/10	0/10	0/10

Continue table 1.

Study	Assessors blinded?	Follow up of subjects?	Treated intentionally?	Comparison of groups ?	Point and variability Measures?	Score
Maurer et al., 1999[21]	No	Yes	Yes	Yes	No	6/11
Gur et al., 2002[22]	No	Yes	Yes	Yes	Yes	7/11
Huang et al., 2003[23]	Yes	Yes	Yes	Yes	Yes	9/11
Eyigor 2004[24]	No	Yes	Yes	Yes	Yes	7/11
Huang et al.,2005[25]	Yes	Yes	Yes	Yes	Yes	9/11
Cetin et al., 2008[26]	Yes	Yes	Yes	Yes	Yes	8/11
Weng et al .,2009[27]	Yes	Yes	Yes	Yes	Yes	9/11
Akyol et al., 2010[28]	No	Yes	Yes	Yes	Yes	8/11
Rosa et al., 2012[29]	No	Yes	Yes	Yes	Yes	6/11
Malas et al .,2013[30]	No	Yes	Yes	Yes	Yes	7/11
Score	4/10	10/10	10/10	10/10	9/10	6.9

 

Figure 1.MOOSE flow diagram showing the selection of trials

 

STUDY SELECTION:

(i)     CRITERIA FOR INCLUSION:

Trials in which isokinetic training was used for reduction of pain in osteoarthritis of knee were included in this review.

 

(ii)   EXCLUSION CRITERIA:

Articles published in languages other than English

Research designs other than RCT

Researches using healthy participants

Outcome measures other than pain

Researches in which the mean values of pain were not given.

 

(iii)  METHODOLOGICAL ASSESSMENT:

The quality of the included trials was graded using PEDro scale.^[29]In PEDro scale the trials are rigorously analysed and classified based on 11 criteria .These are eligibility criteria, random allocation, concealed allocation, baseline similarity, blinding of subjects, assessor and therapist, follow up, intention to treat analysis, statistical comparison and point estimate. The reliability of PEDro scale is a high.^[31] The score of the included trials in this review averaged about 7 which reveals that the methodological quality of the studies were good.

 

(iv)  DATA EXTRACTION:

The included trials were analysed and the data pertaining to the following were extracted and tabulated.

1    Number of patients

2    Age

3    Gender

4    Outcomes measured

5    Characteristics of isokinetic training

6    Characteristics of other interventions

7    Mean differences in pain

 

Table 2.Demographic characteristics of the included trial

Researcher	Diagnosis	Age	Population	Male/female	Outcomes
Maurer et al., 1999[21]	Osteoarthritis	66.4±8.8	113	66/47	VAS Strength Arthritis impact scale WOMAC Short form 36
Gur et al., 2002[22]	Osteoarthritis	55±12	23	NA	Functional capacity Knee pain Muscle strength –Peak torque
Huang et al., 2003[23]	Knee osteoarthritis	62 ± 4.5	132	39/93	Visual analog scale-Pain 50 m walking test Lequesne index Isokinetic Peak torque
Eyigor 2004[24]	Knee osteoarthritis	53.14±6.73	39	6/33	Disease severity Pain 15 m walking WOMAC Lequesne index Arthritis impact measurement scale Short form 36 Muscle strength
Huang et al.,2005[25]	Osteoarthritis	62.0±8.4	120	25/95	Ambulation speed Lequesne index ROM VAS Peak Torque
Cetin et al., 2008[26]	Knee osteoarthritis	59.82 ± 9.05 yrs	100	0/100	50 m walking test Pain Peak torque Index for severity of knee osteoarthritis(Lequesne)
Weng et al .,2009[27]	Osteoarthritis	64±7.5	132	26/106	Range of motion Strength Pain Lequesne index
Akyol et al., 2010[28]	Osteoarthritis	56.60±8.13	40	0/20	VAS WOMAC 6 min walk dist. Muscle strength Quality of life Depression
Rosa et al., 2012[29]	Osteoarthritis	59	66	6/60	Pain Strength Range of motion
Malas et al .,2013[30]	Knee osteoarthritis	58.8 ± 7.2	61	NA	50 foot walk test Peak torque Ultrasound evaluation WOMAC

*NA-Not available

*VAS-Visual analog scale

*WOMAC-Western Ontario McMaster Universities Osteoarthritis Index

*ROM-Range of motion

 

 

ANALYSIS OF SUBJECTS:

A total of 826 subjects were used in the trials mentioned. The age of the subjects ranged from as low as 40 till 70 years. The total number of male subjects was 168. The female subjects amounted to about 658. There was no information on the male and female participants in two of the trials.

Isokinetic device:

Four of the included trials used cybex isokinetic device^{[22,24,25,28]}, three of the trials made use of Kin-com equipment^[23,25,27]in one trial Biodex device were used^[30], one trial used a stationary cycle^[29] and in one trial there was no data on the equipment used.^[21]

 

 

 

Table 3.Characteristics of isokinetic training in the included trial

Researcher	Device	Mode of Contraction	Velocity	Repetitions
Maurer et al., 1999[21]	NA	Concentric for knee extensors	90,120,150 deg/sec	3sets of 3 extensions at 3 velocity 3 times a week for 8 weeks. 1 minute rest after each set
Gur et al., 2002[22]	Cybex 6000	Concentric –eccentric for knee flexors and extensors Concentric for knee flexors and extensors	30,60,90,120,150,180	12 reps 2 min rest between knee flexors and extensors and 5 minutes between legs
Huang et al., 2003[23]	Kin-com	5 reps of concentric and eccentric for knee extensors 5 reps of eccentric and concentric for knee flexors at 60% peak torque	30 and 120 deg /sec	1-5 sets for first 5 session 6 sets from 6th to 24th session 3 times a week for 8 weeks 5 sec rest-sets 10 sec rest-different modes 10 min-between legs
Eyigor 2004[24]	Cybex	Concentric contraction 3 sets of 6 repetitions at 60,90,120 and 180 degree/sec	60,90,120,180	20 sec between sets 3 days a week for 6 weeks
Huang et al.,2005[25]	Kin-com 505	5 reps of Concentric-eccentric for knee extensors 5 reps Eccentric -concentric for knee flexors at 60% peak torque	30 and 120 at 60%peak torque	1-5 sets till 5th session 6 sets from 6th -24th session 3 times a week for 8 weeks. 5 sec rest-sets 10 sec rest-different modes 10 min-between legs
Cetin et al., 2008[26]	Cybex	5 repetitions of concentric contraction for knee extensors and knee flexors	60,120,180	20 secs between sets and 60 secs between legs 3 times a week for 8 weeks 1-5 sets for first 5 session 5 sets from 6th to 24th session
Weng et al .,2009[27]	Kin-com	5 reps of concentric and eccentric for knee extensors 5 reps of eccentric and concentric for knee flexors at 60% peak torque	30 and 120 deg /sec	1-5 sets for first 5 session 6 sets from 6th to 24th session 3 times a week for 8 weeks 5 sec rest-sets 10 sec rest-different modes 10 min-between legs
Akyol et al., 2010[28]	Cybex	Concentric and concentric- flexors and extensors	60,90,120,150,180	10 repetitions 10 sec rest between different modes and 10 min rest between right and left leg
Rosa et al., 2012[29]	Stationary cycle	NA	-	40 min of cycling with 5 min rest after 10 min of cycling Resistance increased from 1kg to 3 kg 4 days per week for 8 weeks
Malas et al .,2013[30]	Biodex 3	Concentric –concentric 5 reps at 60 deg/sec 10 reps at 120 deg/sec 15 reps at 240 deg/sec	60,120,240	3 sets at each velocity 10 sec rest between different velocity and 30 seconds rest between different cycle,5 days /week for 3 weeks

 

 

 

TYPE OF ISOKINETIC TRAINING

Different modes of isokinetic training have been used in the included trials. Few trials used only concentric contraction^[21,24,30], few used concentric eccentric, three studies used the same kind of training^[23,25,27] concentric eccentricfor knee extensors^{[22,23,25,27]} and eccentric concentric for knee flexors^[23,25,27] while in one study^[29] there was no mode of contraction since the researcher used stationary bicycle to impart isokinetic exercise.

 

 

 

TREATMENT FOR CONTROL GROUP:

A wide range of differences were noted in the other intervention group. The other intervention group consisted of just educational intervention^[21], no treatment^[22], isometric/isotonic strengthening^[23], progressive resisted exercise ^[24]and provision of electrotherapy modalities like short wave diathermy ^[26,28]and ultrasound.^[25] The types of intervention used and the description about those are tabulated in Table 4.

 

 

 

 

 

Table 4.Characteristics of other intervention in the included trial

Researcher	Other interventions	Exercise description	Repetitions
Maurer et al., 1999[21]	Educational intervention	Lecture Video Nutritional guidelines Discussion	4 sessions
Gur et al., 2002[22]	No treatment	-	-
Huang et al., 2003[23]	Isotonic strengthening Isometric strengthening	5 reps of concentric-eccentric at maximum velocity Isometric hold at various angle using Kin-com	3 times a week for 8 weeks
Eyigor 2004[24]	Progressive resisted exercise	3 sets of 10 repetitions 1st set 10 reps at 50%10 RM 2nd set at 75% 10RM 3rd set at 10RM	5 days a week for 6 weeks
Huang et al.,2005[25]	Continuous ultrasound Pulsed ultrasound No treatment	100%duty cycle 1MHz 1.5W/cm2 5 min 25% duty cycle 1MHz 2.5W/cm2	3 times a week for 8 weeks
Cetin et al., 2008[26]	SWD+hotpacks+isokinetic exercise TENS+ hotpacks+isokinetic exercise Ultrasound+ hotpacks+isokinetic exercise Hotpacks+isokinetic	SWD -15 mins TENS-60-100Hz,60 m secs pulse duration for 20 mins Ultrasound -1MHz,1.5W/cm2 for 10 mins Hot packs-	3 times a week for 8 weeks
Weng et al .,2009[27]	Warm up cycling No treatment	-	-
Akyol et al., 2010[28]	SWD +Isokinetic	Short wave diathermy for 20 mins+isokinetic exercises	10 repetitions 10 sec rest between different modes and 10 min rest between right and left leg
Rosa et al., 2012[29]	Isometric exercise	6 exercises	4 days/week for 8 weeks
Malas et al .,2013[30]	Isotonic strengthening Exercises	Lifting 1.5 kg weight at 90 repetitions/day	5 days /week for 3 weeks

 

 

MEASUREMENT OF OUTCOMES:

The main outcome measure considered for analysis in the review was pain. Pain was measured separately by Visual analog scale or as a subset of WOMAC (Western Ontario McMasters Universities osteoarthritis index). Pain in most of the trials was measured before intervention and after intervention; in few trials follow up measurement of pain was also undertaken.

 

RESULTS:

Table 5.Mean differences in measurement of pain

Researcher	Isokinetic	Other interventions	Standard mean difference
			IV	95%CI
				Lower	Upper
Maurer et al., 1999[21]	143.79(49)	167.11(49)	-	-	-
Gur et al., 2002[22]	16.6 ± 7.3(8)	10.3±4.5(9)	1.0549	0.0386	2.0711
Huang et al., 2003[23]	2.5±1.8(56)	3.2±1.6(60)	-0.4119	-0.7799	-0.0439
Eyigor 2004[24]	0.57±1.34(21)	0.94±1.66(18)	-0.2474	-0.8793	0.3845
Huang et al.,2005[25]	3.7±0.7(50)	3.3±0.8(54)	0.5308	0.1394	0.9221
Cetin et al., 2008[26]	4.10± 1.32(20)	3.36±1.33(20)	0.5585	-0.0733	1.1902
Weng et al .,2009[27]	3.6±0.7(62)	3.1 ± 0.8(58)	0.6667	0.2989	1.0345
Akyol et al., 2010[28]	6.35±2.62(20)	5.95±4.13(20)	0.1157	-0.5047	0.736
Rosa et al., 2012[29]	5.50±2.17(33)	7.48±3.77(33)	-0.6437	-1.1386	-0.1489
Malas et al .,2013[30]	8.2±4.5(20)	5.4±2.9(19)	0.7356	0.0868	1.3843

 

*IV-Inverse Variance *CI-Confidence Interval

Fig 2. Forest plot showing trials on reduction in pain

 

DISCUSSION:

This review was done on 10 trials that used isokinetic training for osteoarthritis of knee. A sum of about 826 participants with osteoarthritis of knee was used in the trials. There was a wide range of variations in the trials regarding the mode of isokinetic training used; the number of repetitions performed, the duration of the training session, the modalities used along with isokinetic training and the equipment used to impart isokinetic training. With regard to isokinetic training, there was lot of discrepancies in the mode of contraction, the muscle trained, the velocities used to train, the repetitions and the duration of the training session. A similar isokinetic training protocol was evident in three trials.^[23,25,27] The common duration of training in most of the trials was 3 times a week for 8 weeks amounting to 24 sessions.^{[21,24,26,23,25,27]} An exception to the regular isokinetic training was noticed in one of the trial. A stationary bicycle was used to train the patients with knee osteoarthritis in one trail thereby the details of velocity, mode of contraction were not included in the review.^[29] Out of 10 studies included in the review 9 studies were taken up for pooled analysis.The effect size and 95%confidence interval of all the included trials was calculatedfor reduction of pain. One trial was not included in the pooled analysis due to the unavailability of standard deviation values. ^[21]The means and standard deviations of the post intervention were collected for both the isokinetic groups and the other intervention groups. Standardised effect sizes and 95% confidence intervals were calculated. Few studies were not presented with the standard deviations thereby were not included for effect size calculation. Few studies presented the mean in the form of percentage or proportion thereby calculation of effect size was not possible for those studies. The standardised effect sizes allowed us to compare the results among different studies. The data were separated based on the outcomes of reduction in pain. Effect sizes were classified as weak (d≤0.2), small (d=0.2-0.5) moderate (d=0.5-0.8) and strong (d≥0.8).^[33]The effects wereweak for the reduction in pain. We calculated the effect size using the mean and standard deviation obtained from the post intervention data from the isokinetic training group and other intervention groups. The findings of the effect size clarified that two of the included articles had a weak effect size with 95%CI crossing zero^[24,28]. A moderate effect size was found in five studies with none of the 95%CI crossing zero^{[25, 26, 27, 29, 30]}. One study had a large effect size and a 95%CI that does not cross zero.^[22] The details of the effect size and 95%CI are shown in Table 5. Pooled analysis of the mean differences showed that the overall effect size for reduction in pain was about 0.22 with a 95%confidence interval (CI) of -0.16-0.60.The Chi² value of about 38.05 with df of 8. The I² value of 79% suggest substantial heterogeneity of the studies. Out of 9 studies analyzed three studies favored isokinetic training for reduction of pain and six studies favored other interventions. The I² value is an indicator of the heterogeneity of the studies. A value of 0% indicates no heterogeneity, 25% low, 50% moderate and 75% high heterogeneity.Higgins et al., 2003 suggested that an I2 value of 0% reveals no heterogeneity, 25% low, 50% moderate and 75% high heterogeneity.^[34] The variation in the study outcomes may be due to patient related, intervention related, co-intervention related and outcome related causes.^[35] However definitive evidence that isokinetic training is beneficial inreducing pain associated with osteoarthritis cannot be concluded based on wide 95 %CI and the wide range of effect sizes. Effect sizes and 95%CI of all the interventions overlap revealing that definitive effects of reduction in pain between isokinetic training and other interventions may not exist. When considering the reduction of pain there was a homogeneous collection of weak to moderate effect size with two 95%CI crossing zero for isokinetic training. The same trend was observed in the other interventions group with a homogeneous collection of weak to strong effect size with two 95%CI crossing zero. Gur et al., 2002^[22] reported a large effect size of 1.00 with a large 95%confidence interval of 0.03-2.03.This could be due to the fact that the researcher compared two forms of isokinetic training on patients with osteoarthrosis of knee rather than comparing it with other forms of intervention. Hence the result should be considered as favoring isokinetic training in the reduction of pain. A low level of patient compliance was noticed for isokinetic training due to pain induced by exercise but this has not hindered the reduction of disability in osteoarthritis.^[23] Of the 6 studies favouring other interventions, 5 studies have intervened the patients with electrotherapy modalities intended for pain relief and this could well be the reason for better pain relief in the other intervention group compared to that of isokinetic training. Our review has identified the trend in isokinetic training regarding reduction in pain. It is evident that pain associated with osteoarthritis neither reduced nor worsened following isokinetic training. It is also clear that other interventions involving pain relief modalities were effective in reducing pain. The result of the review should be inferred with caution as there were discrepancies in the studies included. The findings of our review can change with inclusion of more related literature.

 

LIMITATIONS:

Only few studies were included in this review. There were dissimilarities in the studies included in the review. Lack of blinding of subjects, assessors and therapists were evident in the literatures included. This can lead to methodological bias. These biases can be avoided if the researchers follow more appropriate method of reporting trials.

 

SUGGESTIONS FOR FUTURE TRIALS:

Future review should be conducted with more studies included in the review. More trials investigating the effect of isokinetic training on osteoarthritis should be conducted. The methodological bias should be minimised by the researchers. Isokinetic training should be compared with other form of exercise training to validate the exact effect of the isokinetic training.

 

CONCLUSION:

With the help of this review it can be concluded that isokinetic training is not effective in reducing pain associated with osteoarthritis of knee as compared with that of various other interventions. The result of this review should be examined with caution due to the limited number of studies included in the review.

 

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Accepted on 08.06.2018                     © RJPT All right reserved

Research J. Pharm. and Tech 2018; 11(8): 3402-3410.