Journal of Bodywork & Movement Therapies 23 (2019) 881e887

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Journal of Bodywork & Movement Therapies

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PREVENTION & REHABILITATION: Original Research

Efficacy of core exercises in patients with osteoarthritis of the knee:

A randomized controlled clinical trial
Daniel Hernandez a, *, Mariana Dimaro a, Emliano Navarro a, Javier Dorado a,
Matías Accoce b, Sandra Salzberg a, Pablo Oscar Policastro a
a
Physical Therapy Service of Hospital Durand, Buenos Aires, Argentina
b
Physical Therapist of Sanatorio Anchorena San Martín, Argentina

a r t i c l e i n f o a b s t r a c t

Article history: Trial design: Randomized, evaluator blinded, controlled, parallel group.
Received 29 May 2019 Methods: This trial was conducted between July 2011 and January 2015 at a public hospital in Argentina.
Accepted 2 June 2019 Patients older than 40 years with a medical diagnosis of osteoarthritis (OA) were randomly assigned to
the experimental group (EG) or control group (CG). Both groups performed conventional exercises 3
Keywords: times a week for 12 weeks and core exercises were added to the EG intervention.
Knee osteoarthritis
The objective was to compare the efficacy of conventional treatment combined with core muscle
Pain
strengthening exercises, with conventional treatment alone in terms of short- and medium-term pain
Exercise therapy
Rehabilitation
reduction and physical function in patients with knee OA.
The primary outcome was knee pain assessed using a visual analog scale and the secondary outcome was
physical function assessed at baseline, week 8 and 12, and 2 follow-up visits held 1 month and 3 months
after the end of treatment.
Results: 113 patients were randomized to a CG (n ¼ 60) or EG (n ¼ 53). 66 patients were eliminated and
25 patients in the EG and 22 in the CG were analyzed.
Both pain reduction and improved physical function were observed throughout the intervention in both
groups. At the end of the treatment, a statistically and clinically significant pain reduction was observed
in the EG. No adverse effects were reported.
Conclusion: The combination of core muscle activation exercises and conventional treatment was more
effective in short-term pain reduction in patients with knee OA.
© 2019 Elsevier Ltd. All rights reserved.

1. Introduction to be effective at improving physical function and decreasing pain.

Osteoarthritis (OA) causes pain and disability, reduces quality of
life and increases morbidity and mortality risk. It has a multifac-
torial etiology and commonly involves the knee. It becomes more
prevalent with age, affecting >70% in patients over 65. Women are
more likely to suffer from it than men. Age and obesity are major
risk factors (Escalante et al., 2010; Guilak, 2011). Treatments include
nonpharmacological (first-line therapy), and pharmacological
therapy and surgery (Jamtvedt et al., 2008; Escalante et al., 2010).
Different exercise programs for periarticular muscles have proved
* Corresponding author. Hospital General de Agudos Carlos G. Durand, Av. Díaz

lez 5044, 1405, Buenos Aires, Argentina.
Ve
E-mail addresses: danifhernandez@hotmail.com, danifhernandez@gmail.com
(D. Hernandez).
However, there is no consensus on the superiority of one protocol
over others (Deyle et al 2000, 2005; Jamtvedt et al., 2008; Lange
et al., 2008; Lin et al., 2009; Carvalho et al., 2010; Henriksen
et al., 2014; Wellsandt and Golightly, 2017).
Biomechanical stress plays a fundamental role in chondrocyte
activity and cartilage health. Abnormal loads can lead to metabolic
alterations and affect the mechanical properties of articular carti-
lage and other joint tissues (Guilak, 2011). During activities of daily
living, especially those involving single-leg stance, such as single-
limb support during gait-trunk movements compensate for hip
muscle weakness and/or lack of pelvic control altering the mo-
ments of force acting on the knee. For instance, pelvic drop on the
side opposite to the stance leg due to hip abductor and external
rotator deficit moves the center of gravity to the opposite leg,
leading to knee varus stress and, consequently, increasing

https://doi.org/10.1016/j.jbmt.2019.06.002
1360-8592/© 2019 Elsevier Ltd. All rights reserved.
882 D. Hernandez et al. / Journal of Bodywork & Movement Therapies 23 (2019) 881e887
compressive loads on the medial femorotibial compartment of the
knee (Powers, 2010).
The ability to produce a greater hip abduction moment during
gait protects the ipsilateral knee against OA progression in the
medial femorotibial compartment, which is the area most
commonly affected by OA (Chang et al., 2005). Other authors have
also stressed the importance of improving proximal dynamic sta-
bility to prevent and treat lower limb pathologies (Leetun et al.,
2004; Zazulak et al., 2007; Oliver et al., 2010; Sled et al., 2010).
The lumbopelvic-hip complex or “core” can be described as a
muscular box consisting of the abdominals, the paraspinals and
glutes, the diaphragm, the pelvic floor and the hip girdle muscu-
lature. The core controls trunk position and pelvis related move-
ment, optimizing the production, transfer, and control of force and
motion to the distal segments of the kinetic chain (Akuthota et al.,
2008; Oliver et al., 2010).
Biomechanical factors seem to play a critical role in the pro-
gression of OA (Guilak, 2011), since it reduces the strength of the
muscles that stabilize the knees (Escalante et al., 2010). Available
evidence on the use of core exercises to treat knee OA is insufficient
(Henriksen et al., 2014; Bartholdy et al., 2016) and we have not
found previous studies comparing the efficacy of exercises aimed at
stimulating core muscles in patients with knee OA. Therefore, the
purpose of this study was to evaluate the efficacy of a core muscle
exercise program combined with conventional treatment versus
conventional treatment alone in short- and medium-term pain
reduction and physical function in patients with knee OA.
Our study was based on the hypothesis that, for patients with
knee OA, a combined treatment regime including core musculature
plus conventional exercises reduces pain scores by 2 or more points
on the visual analog scale (VAS) and improves physical function in
the short- and medium-term with statistically significant differ-
ences as compared with conventional treatment.
2. Materials and methods
This randomized, evaluator blinded, controlled, parallel group
trial was carried out between July 2011 and January 2015. The
study population consisted of consecutive patients with medical
diagnosis of knee OA referred by the Orthopedics Department to
the Physical Therapy Department of Hospital Durand (Buenos
Aires City). Patients were over 40 years of age and had consulted
for knee pain and/or difficulty in activities of daily living dsuch as
climbing or descending stairs, walking, getting up from a chair or
kneelingd over the previous month. OA diagnosis was confirmed
by an orthopedist based on radiographic and clinical findings. The
medical diagnosis was made by an orthopedist specialized in
knee conditions based on the patient's medical history (knee pain
plus crepitus with active motion, morning stiffness or bony
enlargement, age and physical examination to rule out other
causes of knee pain) and image studies (radiographic signs to
confirm knee OA).
The exclusion criteria involved patients with a history of intra-
articular knee fracture, hip OA, lower limb joint replacement, in-
flammatory arthritis, spine surgery, lower limb surgery within the
prior 6 months, corticoid injection within the prior 3 months,
physical limitations to exercise, and illiterate patients and/or pa-
tients with apparent communication difficulties. We did not
include patients with a diagnosis other than knee OA (such as knee
sprain or Baker's cyst), even when their radiographs showed
degenerative symptoms, or those with a diagnosis of knee OA
whose clinical evaluation by the physical therapist at baseline was
not consistent with knee OA based on age, history and physical
examination.
Researchers eliminated the data from patients who 1) missed
more than 20% of treatment sessions and/or 3 assessment visits, 2)
started other non-pharmacological or surgical knee treatment
during the study, or 3) decided to abandon the study.
The trial was approved by the hospital's Ethics Committee and
all patients signed an informed consent form.
The primary outcome in the study was knee pain experienced in
the prior 24 h. Pain was measured using a 100-mm VAS. The sec-
ondary outcome was physical function. Physical function was
assessed with the Timed Up and Go Test (TUG), Step Test (ST), 6-
Minute Walk Test (6MWT) and the short-form of the Western
Ontario and McMaster Universities Arthritis Index (WOMAC)
function subscale.
TUG measures the time it takes for an individual to stand up
from an armchair, walk 3 m, turn 180 , walk back to the chair, and
sit down (Steffen et al., 2002).
ST records the number of times an individual can place his/her
foot onto a 15-cm-high step and return it to the floor as fast as
possible in 15 s using his/her non-affected (or less symptomatic) leg
while keeping the other leg on the floor (Hinman et al., 2002).
6MWT is a submaximal test of functional capacity. Individuals
are asked to walk as far as possible along a 30-m hallway within a
6-min period (ATS Committee on Proficiency Standards for Clinical
Pulmonary Function Laboratories, 2002).
The short-form WOMAC function subscale consists of 8 ques-
tions about the degree of difficulty encountered in doing an activity,
ranging from 0 (none) to 4 (extreme difficulty) (Garone et al., 2008).
Study patients were assessed by a physical therapist at baseline
(T0), week 8 (T1), week 12 i.e end of treatment (T2), and 1 month
(T3) and 3 months (T4) after the end of treatment (follow-up visits).
The initial evaluation consisted of anamnesis, physical examination
(inspection, palpation, active range of motion, routine orthopedic
tests of the knee), X-rays (if available), knee pain, TUG, ST, 6MWT
and the short-form of the WOMAC function subscale.
Evaluators were blinded to group assignment. Patients were
randomized either to a control group (CG) or to the experimental
group (EG) by an external physical therapist with allocation
concealment by opaque sequentially numbered sealed envelopes.
CG patients were subjected to “conventional exercises”. Such ex-
ercises, based on a program described by Deyle et al. include warm-
up and mobility as well as strengthening and stretching exercises
(Deyle et al 2000, 2005). On the other hand, EG patients performed
conventional exercises plus exercises aimed at the activation of the
muscles considered important for core stability according to elec-
tromyography tests (Ekstrom et al., 2007; Akuthota et al., 2008;
Bjerkefors et al., 2010; Imai et al., 2010). (See Appendix).
Treatment consisted of triweekly sessions for three months.
During the first 4 weeks, all sessions were supervised by a physical
therapist who controlled, dosed and increased the duration or
difficulty of exercises according to patients’ evolution. Exercises
were not supposed to cause or increase pain. From weeks 5e8,
patients attended 2 supervised interventions and completed the
third one at home. From weeks 9e12, patients attended 1 super-
vised intervention and completed 2 exercise sessions at home.
Patients received an exercise sheet with instructions and a form to
record treatment adherence and nonsteroidal anti-inflammatory
drug (NSAID) use at home.
For the purposes of statistical analysis, numerical variables with
a symmetrical distribution were expressed as mean ± standard
deviation (SD), and those with an asymmetrical distribution as
median and range. Confidence intervals were calculated at 95%.
Student's or Mann-Whitney's test were used as appropriate.
Nominal variables between groups were compared using Pearson's
Chi-Squared Test or Fisher's exact test as appropriate. Hypotheses
related to the main outcomes were tested using repeated measures
analysis of variance (repeated measures ANOVA) in terms of
 D. Hernandez et al. / Journal of Bodywork & Movement Therapies 23 (2019) 881e887 883

Fig. 1. Flow diagram describing patient progress.

measurement times (5 levels), groups, and time* group interaction. 3. Results

The corresponding assumptions were evaluated for intra- and
inter-group factors. Researchers also analyzed intra-subject and
inter-subject effect tests. In the case of time*group interaction, re-
sults were analyzed according to simple effects. The sample size
required to obtain 80% power was 28 subjects per group, assuming
a 2-point clinically significant difference for pain (Tubach et al.,
2005). A value of p  0.05 was considered significant. SPSS
version 20 was used for analysis.
Initially, this study enrolled 113 subjects. 53 patients were ran-
domized to the EG and 60 to the CG. After randomization, the pa-
tients initiated the treatment within less than a week. 28 EG
patients (52%) and 38 CG patients (63%) did not complete treatment
and were removed from the study. Therefore, the EG and CG con-
sisted of 25 and 22 patients respectively (see Fig. 1). Table 1 de-
scribes the demographic characteristics of the sample analyzed (see
Table 1).

Table 1
Baseline demographic characteristics of study population.

Characteristics Experimental Group (n ¼ 25) Control Group (n ¼ 22) P

Women 68% 72.7% 0.72

Men 32% 27.3%
Age, years (mean ± SD) 64.16 ± 10.96 60.14 ± 9.78 0.19
BMI (mean ± SD) 28.62 ± 6 27.62 ± 6.14 0.58
Time of evolution of symptoms, months (median, range) 11.5 (1e120) 8.5 (1e72) 0.63
Knee affected (right) 60% 63.6% 0.72
NSAID use 56% 40.9% 0.3
Walking aids 4% 13.6% 0.32

SD: standard deviation; BMI: body mass index; NSAID: nonsteroidal anti-inflammatory drug.
884 D. Hernandez et al. / Journal of Bodywork & Movement Therapies 23 (2019) 881e887

Table 2 Table 2 describes pain. The intra-subject contrast test showed a

Pain visual analog scale. significant time association for both groups (F ¼ 28.90; p < 0.01)
Times Group Mean (SD) Median (range) n p and an interaction between treatment and time (F ¼ 6.09; p ¼ 0.01)
T0 Experimental 6.92 (±2.6) 7.4 (1.2e10) 25 0.25
(see Table 2).
Control 6.11 (±2.11) 6.25 (1.6e9.9) 22 With regard to physical function over time, TUG, ST, and short-
T1 Experimental 3.17 (±2.88) 2.5 (0e9.8) 25 0.26 form WOMAC function subscale showed a significant association
Control 4.07 (±2.42) 4 (0.3e9.5) 22 with time in both groups (F ¼ 65.02; p < 0.001; F ¼ 28.87; p < 0.001
T2 Experimental 2.42 (±2.35) 1.3 (0e7) 25 0.01a
and F ¼ 47.46; p < 0.001, respectively) (see Fig. 2). However, the
Control 4 (±2.83) 3.8 (0.5e9.7) 22
T3 Experimental 3 (±2.89) 1.65 (0e8.7) 24 0.21 interaction between treatment and time was not significant, which
Control 3.61 (±2.9) 3.7 (0e9.5) 21 enabled intra-group comparisons between measurement times
T4 Experimental 3.8 (±2.97) 4.3 (0e9.8) 23 0.46 (see Table 3). No statistically significant differences were found in
Control 3.63 (±2.8) 2.8 (0e8.4) 20
the inter-group comparison for TUG (p ¼ 0.24), ST (p ¼ 0.32), and
Timea Group p ¼ 0.01
short-form WOMAC function subscale (p ¼ 0.14).
SD: standard deviation. The 6MWT could not be analyzed because it did not meet any
a
Significant difference.

Fig. 2. Behavior of physical function over time A) Timed Up and Go Test; B) Short-form WOMAC function subscale; C) Step Test. Data are expressed as mean for A, B and C; *p ¼ 0.01.
 D. Hernandez et al. / Journal of Bodywork & Movement Therapies 23 (2019) 881e887 885

Table 3
Intra-group comparison for Timed Up and Go Test, Step Test and the short-form WOMAC function subscale at times of measurement.

Variable Times T1 T2 T3 T4

Timed Up and Go test T0 2.28 (p < 0.01)a 3.78 (p < 0.01)a 3.63 (p < 0.01)a 3.35 (p < 0.01)a
T1 1.55 (p ¼ 0.01)a 1.41 (p < 0.01)a 1.12 (p < 0.01)a
T2 0.14 (p ¼ 0.7) 0.43 (p ¼ 0.21)
T3 0.28 (p ¼ 0.25)

Step test T0 0.76 (p ¼ 0.18) 1.58 (p ¼ 0.06) 2.45 (p < 0.01)a 2.48 (p < 0.01)a
T1 0.82 (p ¼ 0.02)a 1.69 (p < 0.01)a 1.72 (p < 0.01)a
T2 0.87(p ¼ 0.08) 0.9 (p ¼ 0.01)a
T3 0.24 (p ¼ 0.93)

Short-form WOMAC function subescale T0 8.19 (p < 0.01)a 9.08 (p < 0.01)a 9.21 (p < 0.01)a 8.73 (p < 0.01)a
T1 0.89 (p ¼ 0.22) 1.01 (p ¼ 0.2) 0.53 (p ¼ 0.6)
T2 0.12 (p ¼ 0.81) 0.35 (p ¼ 0.68)
T3 0.35 (p ¼ 0.68)

Data are expressed as mean difference.

a
Significant difference.

assumptions, except for the normality one. Time comparisons be-
tween groups showed no significant differences (T0 p ¼ 0.94; T1
p ¼ 0.12; T2 p ¼ 0.43; T3 p ¼ 0.37; T4 p ¼ 0.43).
Given our small sample, we were not able to conduct any
inferential analysis on the use of NSAIDs. Results are shown
descriptively (see Fig. 3).
No adverse effects were reported during this trial.
4. Discussion
Exercise is a safe, nonpharmacological intervention recom-
mended as first-line treatment for knee OA. Exercise improves
patients’ symptoms, mobility, quality of life, and psychological
health (Bartholdy et al., 2016; Wellsandt and Golightly, 2017). The
results of this study suggest that an exercise program aimed at
augmenting core muscle activation may be beneficial in reducing
pain and improving physical function in patients with knee OA.
Our sample analyzed consisted of 47 patients, mostly women
Fig. 3. Description of NSAID use over time Data are expressed as percentage. NSAID:
nonsteroidal anti-inflammatory drug.
(70.2%), mean age (62.3 ± 10.5 SD), body mass index (28 ± 6 SD),
similar values were found in prior studies. There was a clinically
significant reduction in pain behavior in all subjects over the
intervention period, as previously reported (Deyle et al., 2005; Lin
et al., 2009; Escalante et al., 2010; Sled et al., 2010; Henriksen
et al., 2014; Bartholdy et al., 2016). When a marked reduction in
the use of NSAIDs was observed, group comparisons showed sta-
tistically and clinically significant differences in favor of the EG at
the end of treatment and over a month's follow-up. Even though
exercise-related reduction of pain and improvement of physical
function have been described as short-lasting, this therapy might
delay or reduce the need for arthroplasty (Deyle et al 2000, 2005;
Escalante et al., 2010).
There is a large evolution time range of symptoms in each group
due to different reasons: 1) each group had a younger patient
whose knee OA symptoms began one month before the study; 2)
three elderly patients had been diagnosed long before the study; 3)
two EG patients reported symptoms had begun 120 months prior to
the study; and finally, 4) one CG patient referred symptoms had
appeared 72 months before. There is no error or experimental bias
at this point, and the norm applies to this population. An interac-
tion between treatment and time was detected, which implies that
the changes observed cannot be strictly attributed to the efficacy of
the intervention. Nevertheless, since knee OA is a chronic pathol-
ogy and the median time of symptom evolution prior to enrollment
was 11.5 months and 8.5 months for EG and CG respectively, we
consider that the influence of time on trial results might be
irrelevant.
The analgesic effect of exercise on individuals with OA may also
be attributed to a variety of factors, such as endogenous opioid
release, a decrease in depression (reducing perceived disability),
weight loss, and modification of knee biomechanics. Unfortunately,
all these factors were not assessed. As for knee biomechanics, there
is conflicting evidence as to the influence of exercise programs.
Previous studies on knee biomechanics are not comparable to our
intervention (Sled et al., 2010; McQuade and de Oliveira, 2011;
Henriksen et al., 2014).
The reason for the noted improvement might be explained by
the inactivity of subjects who are reluctant to move due to their
knee pain. This study did not assess physical activity level. How-
ever, all patients were able to either perform the exercises without
pain or exercises were not found to increase their pain. None of our
patients was reluctant to move his/her knee and no adverse effects
were reported. Only one patient was not satisfied with the treat-
ment and abandoned the program.
TUG, ST, 6MWT and short-form WOMAC function subscale
886 D. Hernandez et al. / Journal of Bodywork & Movement Therapies 23 (2019) 881e887
presented a similar behavior pattern, showing a visible improve-
ment over the treatment period. Such pattern continued during
follow-up with no statistically significant differences between
groups. Consistent with previous reports, TUG scores improved in
all subjects when the treatment included physical exercise
(Mizusaki et al., 2013), and statistically significant differences were
observed only when subjects were compared with an education
group (Oliveira et al., 2012).
The WOMAC questionnaire is available in numerous versions
(Lin et al., 2009). We used the short-form function subscale, vali-
dated for the Argentine population (Garone et al., 2008). No pre-
viously published studies have used this version, precluding
comparison of results.
Previous studies have compared conventional non-
pharmacological interventions to no treatment or placebo in knee
OA patients. Some of them have reported statistically significant
benefits in physical function and pain, as opposed to the develop-
ment of OA without treatment (Deyle et al., 2000; Jamtvedt et al.,
2008; Lange et al., 2008; Lin et al., 2009). We consider that the
improvement noted in our study is not due to the natural evolution
of OA. It is also worth mentioning that we did not include a patient
group without treatment as it is unethical to do so when an
effective intervention is available.
Hip and knee OA is known to reduce muscular strength and
atrophy the muscles that stabilize these joints (Escalante et al.,
2010). Core exercises, like the ones performed by EG, could
improve the coordination and stability of the trunk, pelvis, hips and
knees by stimulating important muscles of the lumbopelvic-hip
complex as well as periarticular muscles of the knee. Appropriate
training programs aimed at gaining strength have proved to help
prevent loss of muscle strength and could potentially protect joints
against pathologic stress. Although there is evidence that exercising
other muscles (away from the knee) is helpful in reducing OA knee
pain (Carvalho et al., 2010; McQuade and de Oliveira, 2011;
Henriksen et al., 2014), we have not found previous studies
comparing the efficacy of exercises aimed at stimulating core
muscles combined with a conventional exercise program.
4.1. Limitations
Some of the limitations of our study were attrition, small sample
size analyzed, lack of a second control group of individuals without
any specific core exercises, the inclusion of patients with different
degrees of knee OA, lack of discrimination of the affected com-
partments and the fact that patients' physical activity level was not
assessed. One of the main limitations was the high dropout rate
(58%), higher than previously reported ones: 9.8e52% (Deyle et al.,
2000). Thus, we were not able to conduct intention-to-treat anal-
ysis. The most common reasons for dropout were transportation,
work and family-related problems, as reported in previous studies
(Deyle et al., 2000; Sled et al., 2010). Our hospital is a public health
center that provides care to patients residing in remote areas. Cost
and time of transportation, the need to return to work as soon as
possible and the duration of the treatment may, at least partially,
have accounted for our high dropout rate. Previous studies have also
identified low adherence to exercise therapy programs among pa-
tients with knee OA (Bartholdy et al., 2016). The sample size
calculated to assume a 20% b error was not achieved, so results
cannot be extrapolated to the entire knee OA population. Sometimes
patients live far away or move to the city to undergo rehabilitation.
Access to radiographs when they started rehabilitation at the
Physical Therapy Department was not always possible since some of
them report having lost them or leaving them behind. As a conse-
quence, we could not report the affected compartments or degree of
OA as these data were not always included in the medical order.
5. Conclusion
In our experience, incorporating exercises that stimulate core
muscle activation into conventional treatment was more effective
at reducing short-term pain in patients with knee OA than con-
ventional exercises alone. TUG, ST, 6MWT, and short-form WOMAC
function subscale scores showed no statistically significant differ-
ences between groups.
There is little evidence about the use of core exercises in the
treatment of knee OA. Incorporating core exercises may be clini-
cally beneficial and could potentially reduce progression of knee
OA. Further research is needed to confirm our findings and include
core exercises in future management protocols of knee OA and
possibly other forms of lower kinetic chain OA such as hip OA.
5.1. Clinical relevance
 Incorporating core exercises may improve pain and potentially
reduce further progression of knee OA.
 In this trial, conventional treatment plus exercises that stimu-
late core muscle activation was more effective at reducing short-
term pain in patients with knee OA than conventional exercises
alone.
 Core exercises may be clinically beneficial and could be included
in management protocols of knee OA and potentially other
forms of lower kinetic chain OA, but further research is needed.
Conflicts of interest
None to declare.
Declarations of interest
None.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Acknowledgments
We are grateful to Silvina Dell’Era and Hospital Durand’s Phys-
ical Therapy Residency Program (2008-2015) for their invaluable
assistance and contribution to this trial. We would also like to thank
Hospital Durand’s Physical Therapy and Orthopedics Departments
for providing their support.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jbmt.2019.06.002.
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