J. Phys. Ther. Sci.

30: 307–312, 2018

The Journal of Physical Therapy Science

Original Article

Effect of a physiotherapy rehabilitation program

on knee osteoarthritis in patients with different
pain intensities

Amr Almaz Abdel-aziem1)*, Elsadat Saad Soliman2), Dalia Mohammed Mosaad3),

Amira Hussin Draz3)
1) Department of Biomechanics, Faculty of Physical Therapy, Cairo University: 7 Ahmed Elziat Street,
Ben Elsaryat, El Dokki, Giza, Egypt
2) Department for Musculoskeletal Disorders and its Surgery, Faculty of Physical Therapy, Cairo

University, Egypt
3) Department of Basic Sciences, Faculty of Physical Therapy, Cairo University, Egypt

Abstract. [Purpose] To examine the effect of physiotherapy rehabilitation program on moderate knee osteoar-
thritis in patients with different pain intensities. [Subjects and Methods] Sixty subjects (37 men and 23 women)
with moderate knee osteoarthritis participated in the current study. Randomization software was used to select the
participating subjects’ numbers from the clinic records. They were classified into three groups according to pain
intensity: mild, moderate, and severe pain groups. All groups underwent a standard set of pulsed electromagnetic
field, ultrasound, stretching exercises, and strengthening exercises. Pain intensity, knee range of motion, knee
function, and isometric quadriceps strength were evaluated using the visual analogue scale, universal goniometer,
Western Ontario and McMaster Universities osteoarthritis index, and Jamar hydraulic dynamometer, respectively.
The evaluation was performed before and after a 4-week rehabilitation program. [Results] All groups showed sig-
nificant differences in pain intensity, knee range of motion, isometric quadriceps strength, and knee function. The
score change in moderate pain group was significantly greater than those in mild and severe pain groups. [Conclu-
sion] Pain intensity is one of the prominent factors that are responsible for the improvement of knee osteoarthritis.
Consequently, pain intensity should be considered during rehabilitation of knee osteoarthritis.
Key words: Knee osteoarthritis, Pain intensity, Quadriceps strength
(This article was submitted Oct. 2, 2017, and was accepted Nov. 28, 2017)

INTRODUCTION
Degenerative joint arthritis is the most common joint disorder that is caused by biomechanical stresses affecting both
the articular cartilage and subchondral bone. Degenerative osteoarthritis (OA) is the most common form of arthritis and is
a major cause of morbidity and functional limitation, especially in elderly patients1). The incidence of knee OA is expected
to increase over the next decades2). Knee OA is directly related to disabilities due to pain, quadriceps dysfunction, and
impaired proprioception. Moreover, knee OA is responsible for the impaired ability of the quadriceps muscle to control force
in patients with OA. Nevertheless, exercise therapy is effective in reducing the pain and improving the function of patients
with knee OA3).
Unlike many other pain conditions in which the underlying injury typically heals or resolves, OA is a disease that does
not resolve. Thus, OA is typically accompanied by chronic pain. Whether, and to what degree, this ongoing chronic pain (i)
plays an important nociceptive role, (ii) represents maladaptive pain, or (iii) reflects other aspects of the pain experience are
not clear4).

*Corresponding author. Amr Almaz Abdel-aziem (E-mail: amralmaz@yahoo.com; amralmaz74@gmail.com)

©2018 The Society of Physical Therapy Science. Published by IPEC Inc.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Deriva-
tives (by-nc-nd) License. (CC-BY-NC-ND 4.0: https://creativecommons.org/licenses/by-nc-nd/4.0/)

307
 Pain is one of the most commonly reported and prominent factors that are responsible for physical inactivity in patients
with knee OA5). This impairment in physical activity associated with knee OA has important implications for aerobic power
and cardiovascular health. Hence, patients with OA are at a particular risk of poor health outcomes6). Pain pattern and severity
of knee OA as either absent, mild, moderate, severe, or very severe could affect the range of motion (ROM) that involves
daily activities and quality of life7).
Moreover, muscle weakness in knee OA usually results in joint stiffness and decreasing ROM that involves daily activi-
ties8). Quadriceps muscle impairment in knee OA is well documented in the literature. In addition, the differences in the
magnitudes of muscle strength are caused by the differences in the subjects’ characteristics, OA severity, pain severity, and
definition of the control group9–11). Patients with knee OA experience chronic form of pain and show a declining ability to use
their joints, which consequently weakens the muscles. Hence, these destabilise the joints and reduce the physical functions
of patients; further, the motions required for the patients’ daily activities become restricted12).
Although pain is a symptom of OA that is present in almost all classification criteria for OA, there is often a discordance
between reports of pain and radiologic OA13–15). It is suggested that this discordance applies, in particular, to the less severe
grades of knee OA and that pain is more common in more severe grades of OA (1 and 2)13, 14). Moreover, Erden et al.
reported that pain intensity and degrees of inaccuracy of knee joint position sense were positively correlated at 60° and
90° knee flexions. The relationship between pain intensity and knee joint position sense is very important for patients with
OA in the improvement of rehabilitation programs16). Given these findings, only few studies have considered pain severity
during rehabilitation programs for patients with knee OA. Therefore, the aim of this study was to examine the effect of a
physiotherapy treatment program on moderate knee OA with different grades of pain intensity.

SUBJECTS AND METHODS

In this study, 78 patients with moderate bilateral knee OA were identified as potential participants based on the orthopaedic
physical therapy clinic records. Seven patients did not meet the inclusion criteria, and five subjects refused to participate in
the study. A total of 66 patients were recruited via convenience sampling. The participants were classified into three groups
according to their pain intensity17): mild pain group (23 subjects), moderate pain group (21 subjects), and severe pain group
(22 subjects). At the end of the 4-week treatment period, outcome data were available for 20/23 patients in the mild pain
group, 20/21 in the moderate pain group, and 20/22 in the severe pain group. Some participants withdrew from the study and
were lost to follow-up. Thus, 60 subjects (37 men and 23 women) participated in the current study. Their demographic data
are shown in Table 1.
The inclusion criteria were as follows: age between 45 and 62 years, ≤grade 2 radiographic severity according to the
Kellgren/Lawrence scale18), diagnosis of moderate bilateral knee OA according to the American College of Rheumatology
criteria19), knee pain for more than 3 months in most days of the week, and patients are not obese. The criteria for the stages of
knee OA are illustrated in Table 2. Conversely, the exclusion criteria were as follows: inflammatory knee disorders, metabolic
bone disease, history of knee trauma, previous knee surgery, previous intra-joint injection, and use of analgesics in the past 3
months20). Written informed consent was obtained from all subjects. The study was conducted in accordance with the 1975
Helsinki Declaration principles, as revised in 1996. The study procedures were approved by the institutional review board of
Faculty of Physical Therapy, Cairo University (Approval No. P.T.REC/012/001751).
The intensity of knee pain was evaluated using the visual analogue scale (VAS) after the patients have remained in a
weight-bearing state for 5 minutes (walking or standing)21). The pain level was rated by each patient from 0 to 10 cm, where
0 represented ‘no pain’, and 10 represented ‘unbearable pain’. The pain was also graded as follows: 0 to 4 mm, no pain; 5 to
44 mm, mild pain; 45 to 74 mm, moderate pain; and 75 to 100 mm, severe pain17). Based on these grades, the three groups
of knee OA were created.
Measurement of active knee flexion ROM: While the patients were lying supine on an examination table, active knee
flexion ROM was measured using a plastic universal goniometer with 25-cm arms, while the goniometer’s pivot tip was
placed on the femur’s lateral epicondyle. The patients maintained maximum flexion of the knee joint with hip flexion. The
angle between the maximum flexion and maximum extension was described as the excursion range. The range was measured
thrice, and the mean value was calculated21).
The patients’ disability was evaluated using the valid and reliable modified Western Ontario and McMaster Universities
osteoarthritis index (WOMAC)22). It is a questionnaire that evaluates disabilities in performing daily living activities. This
method is relevant and appreciated for its simplicity and allows assessment of the patients’ opinions of their functional
disabilities.
The isometric quadriceps strength was measured using Jamar hydraulic dynamometer (Lafayette, IN 47903, USA). Such a
device has been proven to have a good to excellent reliability in different populations23, 24). The patients were instructed to sit
on the side of the bed with their back flat, arms crossed, hip at 90° flexion, and knee at 30° flexion. After ensuring stabilisa-
tion in these steps, the therapist held the dynamometer between his hand and the patients’ limb segment. The dynamometer
was positioned two finger widths above the lateral malleolus on the anterior aspect of the tibia, and the patients were then
instructed to push the dynamometer with their maximum strength for 5 seconds. The mean value of the three repetitions with
2-minute intervals was calculated25).

J. Phys. Ther. Sci. Vol. 30, No. 2, 2018 308

 Table 1. Demographic data of participants

Mild pain group (n=20) Moderate pain group (n=20) Severe pain group (n=20) p value
Age (yrs) 55.90 ± 5.01 55.73 ± 5.80 56.10 ± 5.74 0.930
Height (cm) 170.14 ± 5.17 171.91 ± 4.34 170.34 ± 5.17 0.195
Weight(kg) 75.34 ± 5.94 76.17 ± 5.14 77.42 ± 6.53 0.274
Body mass index (kg/m 2) 26.14 ± 3.90 25.10 ± 3.72 26.00 ± 4.53 0.479
Gender (female/male) 8/12 6/14 9/11 0.610
Data are presented as mean ± standard deviation, p<0.05.

Table 2. Criteria of knee OA stages

Stage Knee pain Radiographic osteophytes Age Morning stiffness Crepitus Bony enlargement in physical examination
I √ √ <40 - - -
II √ √ >40 <30 min √ -
II √ √ >40 >30 min √ -
IV √ √ >40 >30 min √ √
- Findings absent, √ Findings present.

In this study, the treatment program was firstly initiated for treating knee OA based on the Battecha and Soliman pro-
gram26). All groups underwent a standard set of pulsed electromagnetic field (PEMF), ultrasound (US), and stretching and
strengthening exercises. A PEMF device (ASA/Easy terza series, Italy) was used to provide electromagnetic therapy. The
pulse frequencies were 50 Hz for the solenoids and up to 100 Hz for the applicators. The solenoid encircled the target limb
segment at the level of the knee. Each patient was exposed to low-intensity 15 GPMF (Gauss permagnetic field) with a
frequency of 50 Hz for 30 minutes per session. Thereafter, a US device (ITO, US/100, Japan) was used to provide deep
heating therapy. Continuous US waves with a 1-MHz frequency and 1-watt/cm2 power were applied using a 4-cm2-diameter
applicator. The US therapy lasted for 5 minutes per session27). Both PEMF therapy and US therapy were continued for three
sessions weekly for 4 weeks.
Immediately after PEMF and US application, each patient was asked to perform stretching exercises and strengthening
exercises in the following fixed sequence: hamstrings muscle stretching and calf muscle stretching. The physical therapist
repeated the passive stretching exercises thrice per session. Each stretch was sustained for 30 seconds, with 10-second
rest intervals28). After a rest period of 5 minutes, the patients were asked to perform the following: 1) isometric quadriceps
contraction (quadriceps drill) in full knee extension maintained for 5 seconds, followed by a 5-second rest; the exercise was
performed for 20 repetitions per session29); and 2) straight leg raising exercise in a crock lying position (the patients were
asked to tense the quadriceps muscle, elevate the limb to 45° and maintain it for 6 seconds, and lower the limb slowly and
then relax for 6 seconds; the exercise was performed for three sets of 10 repetitions per session)28). Both stretching and
strengthening exercises were performed for three sessions weekly for 4 weeks. The evaluation and treatment procedures
were done for the patients by the same therapist before and after the treatment period. They were instructed to maintain their
activity levels during the study period30).
Data were analysed using the Statistical Package for Social Sciences (IBM Corp.: Armonk, NY USA) version 20.0. A
one-way analysis of variance was used to compare the effect of the physical therapy treatment on the VAS score, knee ROM,
quadriceps strength, and WOMAC score among the three groups with knee OA. Score changes were also calculated. The
level of significance was set at p<0.05.

RESULTS
The descriptive statistics of the VAS score, knee ROM, quadriceps strength, and WOMAC score of the three groups are
presented in Table 3. The pre-intervention VAS score of the mild pain group was lower than those of the moderate and severe
pain groups (p=0.001), and that of the moderate pain group was lower than that of the severe pain group (p=0.001). There was
a significant reduction in pain intensity owing to the interventions in the three groups (p=0.001). The post-intervention VAS
score of the mild pain group was significantly lower than those of the moderate and severe pain groups (p=0.001); further, the
post-intervention VAS score of the moderate pain group was significantly lower than that of the severe pain group (p=0.001).
The pre-intervention ROM of the mild pain group was greater than those of the moderate and severe pain groups (p=0.001),
without a significant difference between the pre-intervention ROMs of the moderate and severe pain groups (p=0.063). There
was a significant improvement in the ROM owing to the interventions in the three groups (p=0.001). The post-intervention
ROM of the mild pain group was significantly greater than those of the moderate and severe pain groups (p=0.008 and 0.001,
respectively); moreover, the post-intervention ROM of the moderate pain group was significantly greater than that of the

309
 Table 3. The values of pain intensity, knee ROM, quadriceps strength, and WOMAC of the three groups
Variables Mild pain group (n=20) Moderate pain group (n=20) Severe pain group (n=20)
Pre Post Change Pre Post Change Pre Post Change
score score score
Pain intensity 2.59 ± 1.45 ± −1.14 ± 6.06 ± 4.04 ± −2.02 ± 7.86 ± 6.50 ± −1.36 ±
0.63 0.51 0.44 0.51 0.63 0.36 0.43 0.50 0.28
Knee ROM (°) 111.65 ± 122.50 ± 10.85 ± 101.65 ± 115.40 ± 13.75 ± 96.70 ± 107.20 ± 10.50 ±
8.34 7.96 3.20 7.78 10.30 4.23 7.05 8.28 4.51
Quadriceps 22.15 ± 26.25 ± 4.10 ± 19.23 ± 23.94 ± 4.72 ± 17.38 ± 21.03 ± 3.65 ±
strength (kg) 4.08 4.35 1.78 3.62 4.17 1.46 3.02 3.51 1.25
WOMAC 28.40 ± 21.85 ± −6.55 ± 46.85 ± 33.13 ± −7.73 ± 57.13 ± 51.28 ± −5.85 ±
5.12 4.46 1.70 5.17 5.27 1.48 5.18 4.88 1.26
Data are presented as mean ± standard deviation.

severe pain group (p=0.002).

The pre-intervention isometric quadriceps strength of the mild pain group was greater than those of the moderate and
severe pain groups (p=0.019 and 0.001, respectively), without a significant difference between the moderate and severe
pain groups (p=0.137). There was a significant improvement in the quadriceps strength of the three groups (p=0.001, 0.001,
and 0.004, respectively). There was no significant difference between the post-intervention quadriceps strength of the mild
and moderate pain groups (p=0.098). The post-intervention quadriceps strength of the mild and moderate pain groups was
significantly greater than that of the severe pain group (p=0.001 and 0.012, respectively).
The pre-intervention WOMAC score of the mild pain group was lower than those of the moderate and severe pain groups
(p=0.001), and that of the moderate pain group was lower than that of the severe pain group (p=0.001). There were signifi-
cant improvements in the WOMAC scores owing to the interventions in the three groups (p=0.001). The post-intervention
WOMAC score of the mild pain group was significantly lower than those of the moderate and severe pain groups (p=0.001),
and that of the moderate pain group was significantly lower than that of the severe pain group (p=0.010).
The VAS score, knee ROM, and WOMAC score changes in the moderate pain group were significantly greater than those
in the mild and severe pain groups (p=0.001, 0.001, 0.026, 0.013, 0.016, and 0.001, respectively). In the same context, there
was no a significant difference between the mild and severe pain groups (p=0.064, 0.784, and 0.143, respectively).
There was no significant difference in the quadriceps strength score changes among the mild, moderate, and severe pain
groups (p=0.203, 0.290 and 0.350, respectively). However, the score change in the moderate pain group was significantly
greater than that in the severe pain group (p=0.030).

DISCUSSION
To the best of our knowledge, this is the first study to classify patients with moderate knee OA according to their pain
intensity. The results of this study support the hypothesis that a physiotherapy treatment program has different effects in
patients with moderate knee OA with different grades of pain intensity, indicating that the magnitude of pain is one of the
prominent factors that are responsible for the improvement of knee OA. However, these results are not supported by the
findings of Külcü et al. who reported that there is no relationship between VAS scores and regular physical activity habit and
symptom duration in patients with knee OA31).
The patient classification completely depended on the pain intensity, since many previous studies have shown that there
is a discordance in the relationship between pain and radiologic OA. There are patients with a Kellgren/Lawrence grade of
3 or 4 for knee OA without any pain in the knee13–15). For example, 29.9% of patients with Kellgren/Lawrence grade 2 and
64.1% of those with Kellgren/Lawrence grade 3 in the knee in an open population study experienced pain at some points32).
In the pretreatment condition, it was observed that the patients with knee OA with moderate and severe pain showed
significant declines in the knee ROM, isometric quadriceps strength, and level of functional performance, which may be due
to the level of pain that resulted in the weakening of muscle strength, instability of the knee joint, and decreased physical
function33). Moreover, the impairments of muscle activation are magnified in subjects with knee OA ranging from 8 to 25% in
populations of varying disease severities34). Reduced voluntary activation of the muscles and decreased contractile rates are
meaningful as these explain the strength decline and changes in muscle size35), which were experienced by the patients with
knee OA with moderate and severe pain in the current study. However, a recent study discovered that pain did not influence
the thigh muscle electromyogram (EMG) amplitudes or proprioceptive acuity in patients with mild and moderate knee OA
during a stair climbing task36).
The rehabilitation program decreased the pain intensity and improved the knee ROM, isometric quadriceps strength, and
level of functional performance in all knee OA groups. In addition, it was clear that the rehabilitation program had more
drastic effects in the moderate pain group. Thus, the levels of improvement in the moderate pain group were superior to those

J. Phys. Ther. Sci. Vol. 30, No. 2, 2018 310

in the other groups in all measurement outcomes. The compatibility of the results of the VAS and WOMAC is consistent with
the findings of Riddle and Stratford who concluded that the WOMAC scores are most strongly associated with pain intensity
in patients with unilateral and bilateral pain37).
The significant improvement in the muscle strength of the three groups might be explained by the findings of Lewek et
al. who reported that the arthrogenic inhibition of the quadriceps muscles of patients with knee OA may be corrected using
exercise training34). Moreover, the results of the current study are in line with the findings of Knoop et al. who reported
that all grades of knee OA severity can achieve improvement in pain and functional performance after an exercise therapy
program38). However, it should be noted that this study included an exercise program only, which was applied in patients
with knee OA with different grades (mild, moderate, and advanced knee OA); conversely, the current study included patients
with moderate knee OA only, and the rehabilitation program included stretching exercises, PEMF, and US. The difference
in the intervention and patient characteristics could explain the greater improvement in the moderate pain group than in the
severe pain group.
The lesser improvement level in the severe pain group in all outcome measures may be explained by the greater inactivity
caused by the higher pre-intervention pain levels experienced by the patients in this group, which had profound adverse
effects on skeletal muscle function and metabolism in terms of weakness and atrophy39). In addition, the knee extensors have
a prominent role in resisting gravity; they undergo a greater magnitude of weakness and atrophy than other groups of muscles
during inactivity40).
Conversely, the findings of this study revealed a trend toward greater improvements in the moderate pain group, which can
be explained by the greater reduction in the score change in the pain in this group. In the same circumstances, the reduction
of pain can improve the level of function, ameliorate physical impairment41), and reduce the restriction of movements (knee
ROM) as a protective mechanism in patients with knee OA42). In addition, the chronic form and level of pain can result in
muscle weakness, and it seemed that the greater pain reduction and strengthening exercises in this group were responsible for
improving the isometric quadriceps strength33).
This study has several limitations. Firstly, it did not have a control over the daily activities of the patients. Secondly, the
long-term effects of this treatment were not identified. Thirdly, the outcome measures of the study did not involve functional
tests, such as the 6-minute walk test. Further research studies with longer durations evaluating the effects of physiotherapy
rehabilitation programs should be conducted on patients with knee OA, especially those with severe pain. Finally, further
studies are needed to examine the effects of rehabilitation programs on the hip and ankle joints of patients with OA with
different degrees of pain, since previous studies have reported that examination of the hips may be indicated in patients with
knee OA43). Moreover, knee OA leads to weakness of the ankle joints, plantar flexors, and dorsiflexors44) and deficits in ankle
proprioception45).
In this study, all patients with moderate knee OA with different grades of pain can benefit from a physiotherapy rehabilita-
tion program, which was shown to be highly effective in patients with moderate pain, although this effect might be reduced
in patients with severe pain. Hence, the effects of physiotherapy treatment programs might be optimised by identifying the
grade of pain and subgroups of patients.

Conflict of interest
No conflict of interest is declared by authors.

REFERENCES

1) Bosomworth NJ: Exercise and knee osteoarthritis: benefit or hazard? Can Fam Physician, 2009, 55: 871–878. [Medline]
2) Hootman JM, Helmick CG: Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum, 2006, 54: 226–229. [Medline]
[CrossRef]
3) Alnahdi AH, Zeni JA, Snyder-Mackler L: Muscle impairments in patients with knee osteoarthritis. Sports Health, 2012, 4: 284–292. [Medline] [CrossRef]
4) Neogi T: The epidemiology and impact of pain in osteoarthritis. Osteoarthritis Cartilage, 2013, 21: 1145–1153. [Medline] [CrossRef]
5) Veenhof C, Huisman PA, Barten JA, et al.: Factors associated with physical activity in patients with osteoarthritis of the hip or knee: a systematic review.
Osteoarthritis Cartilage, 2012, 20: 6–12. [Medline] [CrossRef]
6) Naal FD, Impellizzeri FM: How active are patients undergoing total joint arthroplasty?: A systematic review. Clin Orthop Relat Res, 2010, 468: 1891–1904.
[Medline] [CrossRef]
7) Chan KK, Chan LW: A qualitative study on patients with knee osteoarthritis to evaluate the influence of different pain patterns on patients’ quality of life and
to find out patients’ interpretation and coping strategies for the disease. Rheumatol Rep, 2011, 3: 9–15. [CrossRef]
8) Segal NA, Torner JC, Felson DT, et al.: Knee extensor strength does not protect against incident knee symptoms at 30 months in the multicenter knee osteoar-
thritis (MOST) cohort. PM R, 2009, 1: 459–465. [Medline] [CrossRef]
9) Bennell KL, Hunt MA, Wrigley TV, et al.: Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus ma-
lalignment: a randomised controlled trial. Osteoarthritis Cartilage, 2010, 18: 621–628. [Medline] [CrossRef]
10) Rice DA, McNair PJ, Lewis GN: Mechanisms of quadriceps muscle weakness in knee joint osteoarthritis: the effects of prolonged vibration on torque and
muscle activation in osteoarthritic and healthy control subjects. Arthritis Res Ther, 2011, 13: R151 [CrossRef]. [Medline]
11) Soliman ES, Abdel-Aziem AA: Effect of pain severity on quadriceps isokinetic peak torque in knee osteoarthritis. Int J Ther Rehabil Res, 2014, 3: 17–22.

311
12) Creaby MW, Wrigley TV, Lim BW, et al.: Self-reported knee joint instability is related to passive mechanical stiffness in medial knee osteoarthritis. BMC
Musculoskelet Disord, 2013, 14: 326. [Medline] [CrossRef]
13) Bedson J, Croft PR: The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Muscu-
loskelet Disord, 2008, 9: 116. [Medline] [CrossRef]
14) Duncan R, Peat G, Thomas E, et al.: Symptoms and radiographic osteoarthritis: not as discordant as they are made out to be? Ann Rheum Dis, 2007, 66: 86–91.
[Medline] [CrossRef]
15) Wluka AE: Remember the Titanic: what we know of knee osteoarthritis is but the tip of the iceberg. J Rheumatol, 2006, 33: 2110–2112. [Medline]
16) Erden Z, Otman S, Atilla B, et al.: Relationship between pain intensity and knee joint position sense in patients with severe osteoarthritis. Pain Clin, 2003, 15:
293–297. [CrossRef]
17) Jensen MP, Chen C, Brugger AM: Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J
Pain, 2003, 4: 407–414. [Medline] [CrossRef]
18) Michael JW, Schlüter-Brust KU, Eysel P: The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Dtsch Arztebl Int, 2010, 107:
152–162. [Medline]
19) Altman RD: Criteria for classification of clinical osteoarthritis. J Rheumatol Suppl, 1991, 27: 10–12. [Medline]
20) Altman R, Asch E, Bloch D, et al. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association: Development of criteria for the
classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Arthritis Rheum, 1986, 29: 1039–1049. [Medline] [CrossRef]
21) Huang MH, Lin YS, Lee CL, et al.: Use of ultrasound to increase effectiveness of isokinetic exercise for knee osteoarthritis. Arch Phys Med Rehabil, 2005, 86:
1545–1551. [Medline] [CrossRef]
22) Guermazi M, Poiraudeau S, Yahia M, et al.: Translation, adaptation and validation of the Western Ontario and McMaster Universities osteoarthritis index
(WOMAC) for an Arab population: the Sfax modified WOMAC. Osteoarthritis Cartilage, 2004, 12: 459–468. [Medline] [CrossRef]
23) Mentiplay BF, Perraton LG, Bower KJ, et al.: Assessment of lower limb muscle strength and power using hand-held and fixed dynamometry: a reliability and
validity study. PLoS One, 2015, 10: e0140822 [CrossRef]. [Medline]
24) Stark T, Walker B, Phillips JK, et al.: Hand-held dynamometry correlation with the gold standard isokinetic dynamometry: a systematic review. PM R, 2011,
3: 472–479. [Medline] [CrossRef]
25) Balki S, Göktaş HE, Öztemur Z: Kinesio taping as a treatment method in the acute phase of ACL reconstruction: a double-blind, placebo-controlled study.
Acta Orthop Traumatol Turc, 2016, 50: 628–634. [Medline] [CrossRef]
26) Battecha KH, Soliman ES: Utilization of pulsed electromagnetic field and traditional physiotherapy in knee osteoarthritis management. Int J Physiother Res,
2015, 3: 978–985. [CrossRef]
27) Kozanoglu E, Basaran S, Guzel R, et al.: Short term efficacy of ibuprofen phonophoresis versus continuous ultrasound therapy in knee osteoarthritis. Swiss
Med Wkly, 2003, 133: 333–338. [Medline]
28) Deyle GD, Henderson NE, Matekel RL, et al.: Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled
trial. Ann Intern Med, 2000, 132: 173–181. [Medline] [CrossRef]
29) O’Reilly SC, Muir KR, Doherty M: Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann
Rheum Dis, 1999, 58: 15–19. [Medline] [CrossRef]
30) Ng MM, Leung MC, Poon DM: The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic
knees: a randomized controlled trial with follow-up evaluation. J Altern Complement Med, 2003, 9: 641–649. [Medline] [CrossRef]
31) Külcü DG, Yanık B, Atalar H, et al.: Associated factors with pain and disability in patients with knee osteoarthritis. Arch Rheumatol, 2010, 25: 77–81.
32) Lethbridge-Cejku M, Scott WW Jr, Reichle R, et al.: Association of radiographic features of osteoarthritis of the knee with knee pain: data from the Baltimore
Longitudinal Study of Aging. Arthritis Care Res, 1995, 8: 182–188. [Medline] [CrossRef]
33) Kheshie AR, Alayat MS, Ali MM: High-intensity versus low-level laser therapy in the treatment of patients with knee osteoarthritis: a randomized controlled
trial. Lasers Med Sci, 2014, 29: 1371–1376. [Medline] [CrossRef]
34) Lewek MD, Rudolph KS, Snyder-Mackler L: Quadriceps femoris muscle weakness and activation failure in patients with symptomatic knee osteoarthritis. J
Orthop Res, 2004, 22: 110–115. [Medline] [CrossRef]
35) Stevens JE, Stackhouse SK, Binder-Macleod SA, et al.: Are voluntary muscle activation deficits in older adults meaningful? Muscle Nerve, 2003, 27: 99–101.
[Medline] [CrossRef]
36) de Oliveira DC, Barboza SD, da Costa FD, et al.: Can pain influence the proprioception and the motor behavior in subjects with mild and moderate knee osteo-
arthritis? BMC Musculoskelet Disord, 2014, 15: 321. [Medline] [CrossRef]
37) Riddle DL, Stratford PW: Unilateral vs bilateral symptomatic knee osteoarthritis: associations between pain intensity and function. Rheumatology (Oxford),
2013, 52: 2229–2237. [Medline] [CrossRef]
38) Knoop J, Dekker J, van der Leeden M, et al.: Is the severity of knee osteoarthritis on magnetic resonance imaging associated with outcome of exercise therapy?
Arthritis Care Res (Hoboken), 2014, 66: 63–68. [Medline] [CrossRef]
39) Narici MV, de Boer MD: Disuse of the musculo-skeletal system in space and on earth. Eur J Appl Physiol, 2011, 111: 403–420. [Medline] [CrossRef]
40) Clark BC: In vivo alterations in skeletal muscle form and function after disuse atrophy. Med Sci Sports Exerc, 2009, 41: 1869–1875. [Medline] [CrossRef]
41) Lee AS, Ellman MB, Yan D, et al.: A current review of molecular mechanisms regarding osteoarthritis and pain. Gene, 2013, 527: 440–447. [Medline] [Cross-
Ref]
42) Erhart-Hledik JC, Favre J, Andriacchi TP: New insight in the relationship between regional patterns of knee cartilage thickness, osteoarthritis disease severity,
and gait mechanics. J Biomech, 2015, 48: 3868–3875. [Medline] [CrossRef]
43) Cliborne AV, Wainner RS, Rhon DI, et al.: Clinical hip tests and a functional squat test in patients with knee osteoarthritis: reliability, prevalence of positive
test findings, and short-term response to hip mobilization. J Orthop Sports Phys Ther, 2004, 34: 676–685. [Medline] [CrossRef]
44) Draz AH, Abdel-aziem AA: Isokinetic assessment of ankle dorsiflexors and plantarflexors strength in patients with knee osteoarthritis. Int Musculoskelet
Med, 2015, 37: 164–169. [CrossRef]
45) Draz AH, Abdel-Aziem AA, Elnahas NG: The effect of knee osteoarthritis on ankle proprioception and concentric torque of dorsiflexor and plantar-flexor
muscles. Physiother Pract Res, 2015, 36: 121–126. [CrossRef]

J. Phys. Ther. Sci. Vol. 30, No. 2, 2018 312