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Efficacy of Hip Strengthening Exercises
Efficacy of Hip Strengthening Exercises
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Lun et al Clin J Sport Med Volume 25, Number 6, November 2015
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Clin J Sport Med Volume 25, Number 6, November 2015 Hip Strengthening and Knee Osteoarthritis
t-tests were used to determine whether there was a statistically groups were assessed for SMWT distance, ROM measures of
significant difference (P , 0.05) in mean change scores the knee and hip for the most affected joint, and Cybex peak
between the 2 treatment groups. torque of the leg and hip of the most affected joint.
Mean change with 95% confidence intervals (CIs) for
the Hip and Leg treatment groups and the difference
between the mean changes with 95% CIs between treat- RESULTS
ment groups were assessed for the KOOS Symptoms,
Activities of Daily Living (ADL), Sport and Recreation Subjects
Function (SRF), and QOL scores and the WOMAC The Figure shows the flow of subjects through the
Stiffness and PF scores. study. One hundred two subjects were randomized into treat-
Mean change with 95% CIs for the Hip and Leg ment groups with 51 subjects per treatment group. Four sub-
treatment groups and the difference between the mean jects who were randomized into a treatment group did not
changes with 95% CIs between the Hip and Leg treatment start the group exercise therapy. Thirteen and 14 subjects
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Lun et al Clin J Sport Med Volume 25, Number 6, November 2015
TABLE 1. Demographic Data for Study and Dropout Populations (Mean 6 SD, Unless Otherwise Indicated)
Subject Characteristics Dropout Characteristics
Hip (n = 37) Leg (n = 34) Hip (n = 14) Leg (n = 17)
Age (yr) 63.42 6 9.61 61.38 6 7.70 62.00 6 8.92 58.76 6 8.03
Gender
Male 16 16 6 6
Female 21 18 8 11
Height (m) 1.72 6 0.10 1.72 6 0.08 1.69 6 0.10 1.68 6 0.12
Weight (kg) 86.33 6 14.79 90.49 6 19.24 86.61 6 18.38 87.82 6 22.21
BMI 29.33 6 4.17 30.75 6 6.27 30.36 6 5.47 30.92 6 6.20
KL grade, median 3* 3 3† 3‡
Bilateral/unilateral, n/n 27/10 29/5 9/5 11/6
KOOS pain 51.95 6 11.53 53.27 6 8.22 50.00 6 10.56 51.53 6 12.50
*n = 34, 3 subjects without x-ray evaluation.
†n = 9, 5 subjects without x-ray evaluation.
‡n = 14, 3 subjects without x-ray evaluation.
BMI, body mass index.
from the Hip and Leg exercise groups, respectively, withdrew both treatment groups are seen in Table 4. The improvements
from the study after starting their exercise programs. The observed in these secondary subscales tended to be larger in
reasons for subject withdrawal included lack of time avail- magnitude in the Leg exercise group.
ability/lack of compliance (14 subjects), personal/health-
related reasons (5 subjects), knee surgery (2 subjects), or no
reason provided (10 subjects). Thirty-seven and 34 subjects
Secondary Outcome Measures of Function
from the Hip and Leg exercise groups, respectively, com- Six-Minute Walk Test
pleted the exercise program and 12-week testing and were The Hip exercise group improved their walking
included for analysis. distance by an average of 20.8 m (3%), whereas the Leg
A comparison of the study population and dropout exercise program improved their distance by approximately
population subject characteristics according to treatment 26.0 m (4%) (Table 5). The change in both groups was not
group is seen in Table 1. The baseline characteristics of significant.
the patients within the 2 intervention groups were generally
similar. Range of Motion
None of the hip or knee ROM measures changed
Change in Subjective Scores of Pain significantly (Table 6).
A statistically and clinically significant improvement in
the KOOS and WOMAC pain subscale scores was observed
in both Hip and Leg groups (Tables 2 and 3, respectively). Cybex Isokinetic Muscle Strength
There was no statistical or clinical difference (P = 0.19) in the There were small increases in both leg and hip strength
change in KOOS score observed between the 2 groups. There at the completion of 12 weeks of exercise in both groups
was a statistically significant (P = 0.041) but not clinically (Table 7). Based on the 95% CI, only knee flexion strength in
significant (Δ = 7.79) improvement in score between the 2 the Leg group significantly increased.
groups in the WOMAC score.
Program Progression
Secondary KOOS and WOMAC Subscales Table 8 shows a similar progression of subjects using
The change in KOOS Symptom, ADL, SRF, and QOL greater resistance Thera-Band elastic bands as they pro-
subscales and WOMAC Stiffness and PF subscales scores for gressed through the 12 weeks of the study.
TABLE 2. The Baseline and Posttreatment KOOS Pain Scores, Mean Change in KOOS Pain Scores (95% CI), Difference Between
Mean Scores (95% CI), and the Detected P Value for the 2-Sided t Test Between the Hip and Leg Exercise Groups
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D, (95% CI) (95% CI) P
Hip program 51.96 6 11.52 62.26 6 12.47 10.27 (5.79-14.75)* 24.68 (211.81 to 2.45) 0.19
Leg program 53.27 6 8.22 68.22 6 14.79 14.95 (9.34-20.56)*
*P , 0.01 for within-group 1 sample t test comparison of mean.
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Clin J Sport Med Volume 25, Number 6, November 2015 Hip Strengthening and Knee Osteoarthritis
TABLE 3. The Baseline and Posttreatment WOMAC Pain Scores, Mean Change in WOMAC Pain Scores (95% CI), Difference
Between Mean Scores (95% CI), and the Detected P Value for the 2-Sided t Test Between the Hip and Leg Exercise Groups
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D, (95% CI) (95% CI) P
Hip program 60.27 6 15.94 70.27 6 13.49 10.00 (5.40-14.60)* 27.79 (215.25 to 20.33) 0.04
Leg program 58.53 6 14.54 76.32 6 16.34 17.79 (11.84-23.75)*
*P , 0.01 for within-group 1 sample t test comparison of mean.
TABLE 4. The Baseline and Posttreatment KOOS and WOMAC Subscale Scores for the Hip and Leg Exercise Groups (Mean 6 SD),
Mean Change With 95% CI for Both Treatment Groups, and the Difference Between Mean Changes With 95% CI for the KOOS
and WOMAC Subscale Scores
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D, (95% CI) (95% CI)
Hip KOOS symptoms 53.44 6 12.26 64.48 6 14.79 11.04 (6.11-15.98) 3.04 (24.22 to 10.32)
Leg KOOS symptoms 56.18 6 13.38 64.18 6 16.60 8.00 (2.64-13.35)
Hip KOOS ADL 60.95 6 15.04 69.47 6 14.07 8.52 (3.75-13.30) 26.10 (213.90 to 1.60)
Leg KOOS ADL 61.93 6 13.62 76.55 6 16.36 14.62 (8.51-20.74)
Hip KOOS SRF 38.10 6 22.18 48.92 6 25.28 10.81 (2.52-19.10) 215.07 (229.10 to 21.08)
Leg KOOS SRF 33.68 6 20.39 59.56 6 25.95 25.88 (14.41-37.35)
Hip KOOS QOL 33.61 6 17.14 42.26 6 17.43 8.65 (3.99-13.30) 26.24 (213.75 to 1.27)
Leg KOOS QOL 33.27 6 14.33 48.16 6 15.73 14.89 (8.91-20.86)
Hip WOMAC stiffness 58.45 6 17.44 68.89 6 15.93 8.45 (3.81-13.78) 212.50 (222.00 to 22.30)
Leg WOMAC stiffness 48.69 6 21.38 69.62 6 23.52 20.94 (13.15-28.73)
Hip WOMAC PF 61.83 6 16.38 70.63 6 13.97 8.80 (3.81-13.78) 27.40 (214.86 to 0.05)
Leg WOMAC PF 60.12 6 13.66 76.32 6 17.10 16.20 (10.63-21.77)
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Lun et al Clin J Sport Med Volume 25, Number 6, November 2015
TABLE 5. The Baseline and Posttreatment SMWT Distances for the Hip and Leg Treatment Groups (Mean 6 SD), Mean Change
With 95% CI for Both Treatment Groups, and the Difference Between Mean Changes With 95% CI for the SMWT Distances
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D, (95% CI) (95% CI)
Hip SMWT (m) 618.6 6 81.3 639.3 6 81.3 20.8 (5.9-36.0) 25.2 (226.4 to 16.0)
Leg SMWT (m) 605.3 6 86.3 631.3 6 92.4 26.0 (11.0-41.0)
The exact mechanism by which improvements in a ceiling effect may be created for the test. In this study, the
symptoms occur with hip strengthening exercises is unknown. SMWT was performed on a circular 200-m track as opposed
However, it may be that improvements in hip strength help to walking back and forth on in a corridor.5,13,16,17,19,68 This
provide a more stable pelvis and improved dynamic lower difference in protocol may have resulted in greater walking
extremity alignment, including lowering the knee adduction distances because subjects did not need to pause to turn
moment.38,41,66 This may explain many of the improvements around within a corridor but would not have affected the
seen in both groups; however, because biomechanical varia- change in walking distance.
bles were not measured in this study, no conclusion can be The magnitude of SMWT change did not correspond
made as to if these changes occurred. the magnitude of change in the subjective measures of
function as measured by the KOOS ADL and the WOMAC
Secondary KOOS and WOMAC Subscales PF subscales (Table 4). Similar findings have been previously
From the secondary subscales of the KOOS and WOMAC reported,13,17,68 suggesting that the subjective interpretation of
questionnaires, both the Hip and Leg exercise programs also PF may improve more with exercise therapy than the actual
result in improved self-reported symptoms of joint function and performance of functional tasks such as walking.
QOL outcomes. This would not be unexpected because if there is
a decrease in knee pain, an increase in knee function and QOL Joint Range of Motion
should correspondingly occur. Knee and hip ROM were not significantly changed in
either treatment group. This finding is not unexpected because
Six-Minute Walk Test degenerative joint disease results in intra-articular changes
The improvement in walking distance in both treatment that will limit ROM. Previous studies have not measured knee
groups was small (,5%) and would be unlikely to be con- and hip ROM as an outcome, so the finding of this study
sidered a clinically significant finding.53,67 The improvement cannot be compared.
observed in this study is less than the 9% improvement re-
ported by Deyle et al17. One possible explanation for this Leg and Hip Muscle Strength
finding is that the baseline function of subjects within both Leg and hip muscle strength did not change signifi-
treatment groups was high, as reflected by the baseline meas- cantly in either treatment group (Table 7). This finding is
urements of 615 m for the Hip group and 605 m for the Leg somewhat unexpected given the significant improvements in
group. Jenkins67 reported that a high pretraining test distance knee pain and QOL outcome measurements. When the com-
of 600 m implies an average walking speed of 6 km an hour. pliance data for both exercise programs were examined
The high pretraining performance may have limited the abil- (Table 8), higher resistance Thera-Band was progressively
ity to improve walking distance because the determinant of used by all the subjects as the program progressed. This
performance at that speed is based on the mechanical factors would indirectly indicate that the subjects were in fact get-
of walking like stride length rather than joint function; thus, ting stronger and requiring more resistance while performing
TABLE 6. The Baseline and Posttreatment ROM Measures for the Hip and Leg Exercise Groups (Mean 6 SD), Mean Change With
95% CI for Both Treatment Groups, and the Difference Between Mean Changes With 95% CI for the ROM Measures
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D (95% CI) (95% CI)
Hip KE (degrees) 5.19 6 4.16 5.35 6 3.91 0.16 (20.73 to 1.06) 20.01 (21.12 to 1.09)
Leg KE (degrees) 6.35 6 6.08 6.53 6 5.48 0.18 (20.45 to 0.80)
Hip KF (degrees) 121.35 6 8.31 123.35 6 8.57 1.89 (0.06 to 3.73) 21.22 (23.67 to 1.21)
Leg KF (degrees) 119.91 6 10.81 123.03 6 9.81 3.12 (1.53 to 4.70)
Hip HIR (degrees) 29.73 6 9.12 30.92 6 9.28 1.19 (20.47 to 2.85) 20.75 (23.03 to 1.52)
Leg HIR (degrees) 26.76 6 10.25 28.32 6 5.35 1.94 (0.40 to 3.48)
Hip HER (degrees) 28.81 6 8.84 31.31 6 7.45 2.51 (0.66 to 4.36) 1.28 (21.27 to 3.84)
Leg HER (degrees) 28.32 6 5.35 29.56 6 6.17 1.23 (20.51 to 2.98)
Hip patrick (cm) 29.17 6 8.11 28.05 6 8.51 21.06 (22.50 to 0.39) 0.84 (20.97 to 2.65)
Leg patrick (cm) 30.34 6 6.81 28.44 6 6.72 21.90 (22.96 to 20.83)
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Clin J Sport Med Volume 25, Number 6, November 2015 Hip Strengthening and Knee Osteoarthritis
TABLE 7. The Baseline and Posttreatment Strength Measures for the Hip and Leg Exercise Programs (Mean 6 SD), Mean Change
With 95% CI for Both Treatment Groups, and the Difference Between Mean Changes With 95% CI for the Strength Measures
Difference in Mean D, Difference
Baseline, Mean 6 SD Posttreatment, Mean 6 SD Mean D, (95% CI) (95% CI)
Hip KE (Nm) 97.99 6 38.71 100.26 6 39.44 2.26 (1.67 to 6.67) 25.90 (212.73 to 0.93)
Leg KE (Nm) 93.28 6 36.99 101.45 6 38.20 8.16 (2.37 to 13.96)
Hip KF (Nm) 63.47 6 28.27 67.64 6 28.76 4.17 (1.67 to 6.67) 25.28 (210.54 to 20.02)
Leg KF (Nm) 57.20 6 21.56 66.65 6 28.42 9.45 (4.68 to 14.22)
Hip HIR (Nm) 70.90 6 29.54 74.63 6 27.59 3.73 (20.63 to 8.09) 0.10 (26.12 to 6.32)
Leg HIR (Nm) 72.64 6 26.80 76.27 6 29.54 3.62 (20.80 to 8.06)
Hip HER (Nm) 46.12 6 15.98 49.34 6 18.20 3.21 (1.38 to 5.05) 0.68 (22.29 to 3.65)
Leg HER (Nm) 46.38 6 16.06 48.91 6 14.42 2.54 (0.17 to 4.90)
the exercises. Studies examining leg strengthening in exercises used in this study were closed-kinetic chain isotonic
healthy older adults show that subjects may lose their ability exercises, whereas open-chain isokinetic strength was mea-
to generate greater torque at higher velocities with age.69 sured. It is possible that the isotonic exercises used in this
Another study suggested that when strengthening with elas- study developed strength that was functional and not detected
tic resistance, early strength gains are explained by neural by isokinetic measurement. Another possible reason for mea-
adaptations, which results in resistance progression; how- suring an increase in muscle strength is that measurement of
ever, over 10 weeks, their subjects saw increases in both muscle strength depends on voluntary effort. Knee pain dur-
muscular endurance and fat-free mass.70 ing the strength testing may have prevented subjects from
A possible reason for an apparent lack of improved providing maximum effort, and thus underestimate a subject’s
strength was the difference between strengthening and true muscle strength.72 However, subjectively, pain was
measurement techniques.71 Many of the leg strengthening reduced through the course of the study, which makes this
hypothesis less likely. The final possible reason for not seeing
an improvement in strength is that KOA may cause a form of
TABLE 8. Thera-Band Color Used to Perform Exercises Over reflexive inhibition of the leg muscles, which prevents a mea-
the 12-Week Strengthening Programs (Percent of Group surable change in leg strength.73 Other mechanisms and adap-
Population) tations such as improved joint stability and coordination and
Yellow Red Green Blue Black intramuscular biomechanical and neuromuscular adaptations
Week No. (%) (%) (%) (%) (%) may affect the knee joint in a way that knee pain and function
Hip exercise could be improved.
1 75 25 One limitation of the study was that the location of
2 20 51 26 3 KOA (ie, medial, lateral, patellofemoral, or 3-compartment
3 3 49 36 12 disease) was not controlled. Another limitation of the study
4 3 32 41 24 was that there was no combined leg and hip strengthening
5 3 32 41 24 treatment group, so it is unknown if there is an additive
6 5 14 50 31 or synergistic effect of exercise on the subject’s symptoms.
7 3 11 47 39 Another limitation of this study was that intention-to-
8 6 46 48 treat analysis was not performed. However, Table 1 shows
9 3 34 63 that there were a similar number of dropouts from both
10 38 62 treatment groups, and that the characteristics of the study
11 38 62 subjects and drop-out subjects are essentially identical.
12 38 62 Also, the reasons for subject drop-out were not directly
Leg exercise related to the effectiveness or other aspects exercise inter-
1 64 30 6 vention per se.
2 19 47 31 3 The results of this study indicate that hip strengthening
3 3 42 42 13 exercises should be strongly recommended as part of the
4 22 39 39 exercise prescription of patients with KOA. Future studies
5 17 39 44 should explore the mechanism by which hip strengthening
6 21 34 45 exercises improve knee pain and if the effects of hip and leg
7 13 41 46 strengthening exercises are additive or synergistic.
8 7 30 56 7
9 7 30 56 7
10 3 40 50 7 CONCLUSIONS
11 3 40 50 7 The results of this study found that hip and leg strength-
12 3 40 50 7 ening exercises provided an equally significant improvement
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Lun et al Clin J Sport Med Volume 25, Number 6, November 2015
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ACKNOWLEDGMENTS 24. Lim BW, Hinman RS, Wrigley TV. Does knee malalignment mediate the
The authors thank the Canadian Academy of Sport effects of quadriceps strengthening on knee adduction moment, pain, and
Medicine Research Fund for their unrestricted financial function in medial knee osteoarthritis? A randomized controlled trial.
support of this study. Arthritis Rheum. 2008;59:943–951.
25. Peloquin L, Bravo G, Gauthier P. Effects of a cross-training exercise
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