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Effects of elastic-band exercise on lower-extremity function among female

patients with osteoarthritis of the knee

Article  in  Disability and Rehabilitation · March 2012

DOI: 10.3109/09638288.2012.660598 · Source: PubMed

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 Disability & Rehabilitation, 2012; 34(20): 1727–1735
© 2012 Informa UK, Ltd.
ISSN 0963-8288 print/ISSN 1464-5165 online
DOI: 10.3109/09638288.2012.660598

Research paper

Effects of elastic-band exercise on lower-extremity function among

female patients with osteoarthritis of the knee

Ting-Fang Chang1, Tsan-Hon Liou2,3, Chi-Hsien Chen1, Yi-Ching Huang4 & Kwang-Hwa Chang1
1
Department of Physical Medicine and Rehabilitation, Taipei Medical University-Wang-Fang Hospital, Taipei, Taiwan,
2
Department of Physical Medicine and Rehabilitation, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan,
Disabil Rehabil Downloaded from informahealthcare.com by Taipei Medical University on 02/13/13

3
Graduate Institute of Injury Prevention, Taipei Medical University, Taipei, Taiwan, and 4Department of Exercise and Health
Science, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan

Objective: To investigate a new style of resistance exercise Implications for Rehabilitation

using elastic bands and explore its therapeutic effect
on the lower-extremity function of female patients with
osteoarthritis (OA) of the knee. Design: A randomized,
controlled clinical trial. Setting: University-affiliated medical
For personal use only.
• Resistance exercise is an effective means of improv-
ing the lower extremity function for people with knee
osteoarthritis (OA).
• A new model for using elastic bands combinations

center. Participants: Forty-one women with mild-to-moderate

knee OA were randomly assigned to one of two groups, an
exercise group (n = 24; age: 65.0 ± 8.4 years), and a control
group (n = 17; age: 70.8 ± 8.4 years). Interventions: The
exercise group performed supervised exercise with elastic
bands in addition to conventional modality treatments
two to three times a week for 8 weeks. The control group
received only the conventional modality treatments over
the same period. Main outcome measures: The distance of
the functional forward-reach, 30 s chair stand repetitions,
walking function (time of a 10 m walk, timed up-and-go,
and going up-and-down 13-stair tests), and Western Ontario
and McMaster Universities Osteoarthritis (WOMAC) index
scores. Results: Statistically significant improvements in
all measures were observed in the exercise group after 8
weeks (p < 0.001). Except for the outcomes on the functional
forward-reach (p = 0.108) and going up-and-down 13-stair test
(p = 0.278), there were significant differences in the extent of
improvement between the two groups. Positive changes in
the 30 s chair stand test, 10 m walk test, and timed up-and-
go test were 2.5 ± 1.4 repetitions, 1.4 ± 1.2 s, and 1.6 ± 1.1 s in
the exercise group, which were significant better than those
in the control group (0.6 ± 0.9 repetitions, 0.5 ± 1.1 s, and
0.3 ± 1.1 s, respectively) (p ≤ 0.001). The lower scores of all
three subscales of the WOMAC index were significant after 8
weeks (p ≤ 0.05), especially for pain (−2.3 ± 1.3) and physical
function (−10.7 ± 5.9) (both p ≤ 0.01), and the improvements
based on leg-press exercise and the principles of pro-
gressive resistance training leads to improved lower
extremity function in female patients with knee OA
after an 8-week period.
were all significant better than those of the control group
(p ≤ 0.05). Conclusions: A new style of resistance exercise
using elastic bands with four color combinations (yellow-red,
red-red, red-green, and green-green) over a period of 8 weeks
can significantly improve lower-extremity function among
females with mild-to-moderate knee OA.
Keywords:  Elastic band exercise, Knee osteoarthritis, Lower-
extremity function
Introduction
The beneficial effects of exercises for knee osteoarthritis (OA)
were proven by many studies [1–4]; some were reported to be
effective in reducing pain and improving the physical func-
tion of patients with mild–to-moderate OA of the knee, such
as aerobic walking [3].
In recent years, elastic-band resistance training has been
applied to athletic training [5–7], sports injury rehabilitation
[8,9], functional training of the disabled elderly [10–12], knee
OA [13,14], chronic heart failure patients [15], and even

Correspondence: Yi-Ching Huang, Department of Exercise and Health Science, National Taipei University of Nursing and Health Sciences, Taipei,
Taiwan. Tel: +886 2 28227101 ext. 3700. Fax: +886 2 28212124. E-mail: yiching@ntunhs.edu.tw
(Accepted January 2012)

1727
 1728  T.-F Chang et al.
patients with central nervous system injuries [16–19].
According to the results of those studies, physical perfor-
mances of subjects showed significant improvements. For
elastic-band resistance training, the resistance range is based
on variations in the stretching tension; therefore, there is no
need to consider the impact of gravity on the weight-bearing
load. Moreover, the exercise varies in form, that is, it depends
on the user’s stretching range and speed [20]. Topp et al. [14],
who used elastic bands as training tools, carried out a 12-week
study on patients with knee OA, and there was significant
progress in patients’ lower-extremity function, pain levels,
and scores on the daily activity inventory for both isomet-
ric and isotonic training. However, although these effects in
knee OA patients were similar to other exercise interventions
[4,10,21–23], elastic bands are more flexible, safe, portable,
and easy-to-use.
Disabil Rehabil Downloaded from informahealthcare.com by Taipei Medical University on 02/13/13
obtaining informed consent, they were randomly assigned to
two groups: one group received conventional modality treat-
ments and elastic-band exercise (exercise group), while the
other group only received conventional modality treatments
(control group). The conventional modality treatments con-
sist only of modality prescription and no exercise prescription
for all subjects, except three in the control group had habitual
exercises (included yoga, hiking and Qigong) according to our
initial screening, and the durations of these habitual exercises
were at least 3 months before the study started. It was consid-
ered that these exercises were general and not as specific as
our elastic bands exercise, and the influences of these exer-
cises were insufficient. Therefore, we permitted these habitual
exercises to be continued.
All subjects in both groups were blinded to their group-
ing, and the lower-extremity function (pre-test) was assessed

Leg-press exercises are a type of closed kinetic-chain
movement pattern which can stimulate more propriocep-
tion and kinesthetic biofeedback of the joint for improved
dynamic stability [24–28]. This style of exercise is utilized to
train patients with knee OA and showed excellent improve-
ments in muscle strength of the knee, balance ability, and
walking function [13,29,30]. The incidence of knee OA dif-
fers by gender. A population-based study in China found that
symptomatic knee OA occurs in 15% of females and 6% of
males aged ≥ 60 years [31].
Thus, the benefits of applying elastic bands and leg-press
For personal use only.
before the interventions at the rehabilitation department by
the same tester. However, five subjects did not attend the
exercise group, and ten were in the control group before the
intervention actually began (five in exercise group did not
attend because their symptoms had improved after using
oral medicine; five in the control group were absent due to
the same reason as those in the exercise group, and the other
five changed to other rehabilitation clinics on account of the
high cost charged by the medical center). Excluding the total
number of 15 drop outs, there were 25 subjects in the exer-
cise group and 20 subjects in the control group; in total, 45

exercises were combined to train female patients with knee subjects received the intervention (Figure 1). However, four
OA. The aim of this study was to investigate the effects of this subjects were excluded from the sample populations (one
new model using elastic bands, based on a lower-extremity from the exercise group who rejected participation because
leg-press exercise and the principles of progressive resistance
training, to provide female patients suffering from knee OA
with exercise recommendations and explore the therapeutic
effects. It was hypothesized that the exercise using elastic
bands combined with leg-press movements used in the pres-
ent study can effectively improve the lower-extremity func-
tion of female patients with knee OA.

Methods
Subjects, who were diagnosed with knee OA, were recruited
from the Department of Physical Medicine and Rehabilitation,
Taipei Medical University-Wang-Fang Hospital in Taiwan,
from December 2008 to August 2009. For the study group,
we recruited patients who were female, ≥45 years of age, able
to do a 90° knee flex, able to walk without assisting devices,
diagnosed with unilateral or bilateral knee OA based on the
Altman diagnosis standard [32], ≤3 on the Kellgren–Lawrence
Grading Scale [33], and showing clinical manifestations.
Those who had undergone knee or hip joint surgery, and who
had chronic diseases (such as severe cardiovascular disease
or rheumatoid arthritis), a lower-extremity fracture, lower-
extremity weakness caused by nervous system disease, or ste-
roids or hyaluronic acid injected into the knee joints within
the past 2 months were excluded from the study. In total, five
subjects were excluded after our initial screening because they
had had an injection. Sixty subjects attended the informa-
tion session and agreed to participate in the study, and after Figure 1.  Flow diagram of study subjects.

Disability & Rehabilitation


of the lack of immediate effects, and three from the control
group because of personal reasons). Ultimately, 41 subjects
completed the post-test assessments, including 24 from the
exercise group and 17 from the control group (Figure 1). The
compliance rate of the subjects who participated in the inter-
ventions was 96% in the exercise group compared to 85% in
the control group.
The institutional review board of Taipei Medical University-
Wang-Fang Hospital approved the study.
Intervention
Exercise group
In the subsequent 8-week intervention, the exercise group
received conventional modality treatments and elastic-band
exercises. The former consisted of general modality treat-
Disabil Rehabil Downloaded from informahealthcare.com by Taipei Medical University on 02/13/13
ments of physiotherapy to reduce pain and increase the
circulation of OA knees [34–36], such as shortwave dia-
thermy (SWD), hot packs, transcutaneous electrical nerve
stimulation (TENS), interferential current (IFC), and so on.
Each subject received modality treatments and elastic-band
exercise two to three times a week under supervision of the
same physical therapist. Subjects in the exercise group had
to complete 16 sessions of muscle strength training with
elastic bands over 8 weeks. After that, there was a post-test
which consisted of the same items as the pre-test; there were
measured by Chang.
For personal use only.
Elastic-bands leg-press exercise
The elastic bands that were used as training tools were pro-
duced by THERA-BAND® (Hygenic Corp., Akron, OH,
USA), and three kinds of bands labeled yellow, red, and green
based on different intensity levels were chosen, with a 20%
increase in intensity among the color-labeled bands [37,38].
Four color combinations were employed to increase the resis-
tive strength. These were yellow-red, red-red, red-green, and
green-green. Before the study, the elastic bands were tested
for elastic fatigue. The 60 cm bands in yellow-red, red-red,
red-green, and green-green combinations were examined by
subjecting them to 100% strain 270 times. The margin of error
tested beforehand was 4.73%–8.30%, which was within the
acceptable range (5%–12%) [38]. Based on training estimates,
an elastic band would be stretched 248 times, fewer than the
270 times on the pre-tests. Therefore, there was no need to test
the elastic-band fatigue again. Furthermore, it was stipulated
that an elastic band should be changed after 2 weeks of use. If
Figure 2.  Leg-press movement with elastic bands.
© 2012 Informa UK, Ltd.
Elastic-band exercise for OA of the knee  1729
obvious distortion or improper stretching occurred before
2 weeks had passed, a new band was immediately substituted
for the old one.
Before the start of the study, 10 healthy female subjects
participated in a reliability test to establish the test-retest
reliability for personal 10 repetition maxima (RM). The test
processes were as follows:
1. Standard positions: long-sitting, lying horizontally on the
bed, with the back against the wall, and positioned 90°
against the bed (see Figure 2).
2. Fastening the waist belt in the standard position. The
waist belt is a nonelastic canvas rectangle (65 × 15 cm)
with two buckles on either side, designed by the author,
to affix the bands. A subject’s feet were encircled by the
yellow-red bands, and then the ends of the bands were
inserted into the fixed buckles and stretched out a bit to
allow the subject to flex the knee as far as possible. After
that, the intensity of the bands was adjusted with the heel
gliding along the bed until the knee joint was extended
nearly completely straight. Ten maximum leg-press rep-
etitions were carried out on the condition that subjects
must feel that they were somewhat difficult, meaning
a 13-grade rating on the perceived exertion scale (RPE
scale [39], a good method for describing how the subjec-
tive intensity varies with physical intensity, and the RPE
of 13 represents a moderate intensity exercise according
to the American College of Sports Medicine (ACSM)
[40], while under no circumstances inducing knee joint
pain. Personal training elasticity means the length of the
yellow-red elastic band combination such that the subject
could extend her OA knee as straight as possible, while
feeling it was somewhat difficult (RPE = 13) for 10 RM.
This length was established as the basis for the elastic
band training for this subject. The results showed that the
intra-class correlation coefficient (ICC) of the test-retest
reliability for the same subject was 0.97 (95% confidence
interval [CI] = 0.89–0.99).
Training protocol
Two color bands were first used to increase the resistance
intensity with the intent to moderate the resistance, alleviate
any fears about the fragility of one color band, and avoid band
cracking.
1. Increasing the personal training intensity (length of
band) in four stages: The initial training intensity was estab-
lished by the results of 10 RM yellow-red elastic-band tests.
 1730  T.-F Chang et al.
Every 2 weeks, a more-intense band (indicated by color)
was substituted for a less-intense one. The intervention
period was 8 weeks, and every 2 weeks was one stage. In
each stage, different color combinations were applied, each
for the same duration as the initial training intensity, in the
following order: yellow-red, red-red, green-red, and green-
green.
2. Standards for advancement: The last session of each stage
was evaluated. When a subject was able to complete two sets
of 12 repetitions of elastic-band leg-press exercises in the last
session with RPE of 13, they were deemed capable of mov-
ing on to the next stage [15,41]. Those who failed to meet the
standard continued to perform the same exercise until they
met the criteria to move on to the next level.
3. Total training amount: There were 10 repetitions/set × 3
sets/session (day) × 2 sessions (days)/week × 8 weeks for a total
Disabil Rehabil Downloaded from informahealthcare.com by Taipei Medical University on 02/13/13
of 60 repetitions/week or 480 total repetitions.
4. Exercise procedure: (i) A subject was first asked to walk
for 5–10 min to warm up. (ii) Preparing the position: A sub-
ject was asked to assume the same posture as in the 10-RM
elastic-band leg-press exercise test and to wear elastic bands
in the assigned way. (iii) Exercise procedures: A subject was
asked to relax her body with her arms crossed and to sit with
a long-sitting posture on a bed in the rehabilitation depart-
ment and not on a floor mat to avoid stressing the lower
back and knee joint when getting up and down. Subjects
were asked to flex their knees as much as possible and then
For personal use only.
to do stepping movements (leg-presses) by fully extending
the leg to the beat of a metronome. A complete leg-press
movement included flexion to extension, extension hold-
ing, and extension to flexion (Figure 2). The complete 6 s
exercise involved 2 s of flexing (concentric contraction),
2 s of extension (isometric contraction), and 2 s of flexing
again (eccentric contraction). (iv) A subject did the leg-
press movement continually for 10 repetitions per set and
had to complete three sets. A subject could take a 1–2 min
break between training sets. Both legs were trained, begin-
ning with the affected or more severely affected leg. The
entire procedure took about 20 min. (v) After the resistance
training, there was a 5–10-min cooling down period with
gentle stretching of the quadriceps; if necessary, a subject
was treated with an ice pack for 10 min over the affected
knee to prevent swelling. (vi) During or after the training
session, if the subject felt uncomfortable, such as experi-
encing knee pain, the training intensity (length) could be
adjusted within a 5 cm range.
Control group
The control group received conventional modality treatments
as did the exercise group. Each subject received these treat-
ments two to three times a week and also took a post-test after
8 weeks of the intervention.
All subjects in the study were prohibited from concur-
rently using any Chinese medicine or alternative therapies,
to avoid any possible influence on the effects of this study.
Non-habitual exercise was also prohibited during the 8-week
intervention.
Disability & Rehabilitation
Measurements
Each test item for assessing lower-extremity function of subjects
was performed twice (pre- and post-test), and two trials were
performed for each test except the activities of dialing living
(ADL) questionnaire; the mean and standard deviation (SD)
served as outcome observations. At the same time, a visual ana-
log scale (VAS; 0–100 mm) was used to record subjects’ reaction
to pain during these functional tests and also to protect them
from any harm. On the VAS, 0 mm represented no pain at all
and 100 mm represented “the worst pain I can imagine.”
The 30 s chair stand test [42] was used to examine the
strength of the lower extremities. Subjects sat on a standard
chair without holding the arms of the chair (arms crossed
over the chest) and completed as many full stands as possible
within a 30 s time limit. The score was the total number of
stands executed correctly within 30 s. The balancing abil-
ity was examined by the functional forward-reach test [43].
Subjects were asked to lean laterally against a wall, while their
feet remained fixed on a standard line. Then, the subject was
asked to bend forward with her upper extremities parallel to
the ground in a reaching movement as far as was possible.
The distance reached was recorded with a straight edge on the
wall, in centimeters (cm).
Walking function was examined by three tests, includ-
ing the 10 m walk test, timed up-and-go test, and going
up-and-down 13-stair test. These three tests were chosen in
consideration of the generality of ADLs and environmental
convenience. The 10 m walk test was used to assess the gait
speed of subjects. A pilot test before data collection demon-
strated excellent test-retest measurement reliability for 10
young subjects who were healthy, and the mean of two trials
was recorded (r = 0.91). Subjects stood in a 10 m hallway and
were asked to walk as fast as possible from the start line, stop-
ping at the end of the line, and the walk time was recorded
in seconds. The timed up-and-go [44] is a test to assess func-
tional mobility. Subjects were asked to rise from a chair (with
or without using her arms), walk 8 feet (2.5 m), turn around,
walk back, and sit down again. The walk time was recorded in
seconds. The going up-and-down 13-stair test [30] assessed
stair-climbing ability. The test involved ascending and
descending 13 stairs located near the Department of Physical
Medicine and Rehabilitation at Taipei Medical University-
Wang-Fang Hospital; each stair was 26 cm long, 20 cm wide,
and 16.5 cm high. Each subject was asked to climb to the top
of the stairs, turn around and walk back down as fast as pos-
sible (without resting). The time spent going up and down the
stairs was recorded in seconds. All test times were measured
with a hand-held stopwatch.
The performance of ADLs was examined by the Western
Ontario and McMaster Universities Osteoarthritis (WOMAC)
index. The WOMAC index was invented by Bellamy et  al.
[45], and focuses on arthritic patients using three subscales:
pain (five questions); stiffness (two questions), and physical
function (17 questions). Five-point Likert scales (0–4) were
used for each question in the study to assess severity; a higher
score indicates greater disability, and the highest possible
score was 96.

Statistical analysis
Data of demographic variables at the baseline included height,
weight, body mass index (BMI, kg/m2), duration of the illness,
discrete variables (severity of knee OA), medications (yes/no),
habitual exercise (yes/no), and side(s) affected by OA. These
baseline data for both groups were tested for homogeneity
using the Shapiro–Wilk test, Fisher’s exact test, and Pearson
χ2 test, and differences in the continuous demographic vari-
ables and pre-test results for the two groups were evaluated
by the Mann–Whitney U test. Moreover, changes between
results of the pre- and post-test for lower-extremity function
within groups were analyzed by the Wilcoxon signed-rank
test, and differences between groups were analyzed by the
Mann–Whitney U test. Statistical significance was accepted
at p ≤ 0.05.
Disabil Rehabil Downloaded from informahealthcare.com by Taipei Medical University on 02/13/13
Elastic-band exercise for OA of the knee  1731
were recorded to establish a training standard. The average
length of the 10 RM elastic bands used in the leg-press exer-
cise tests was 80.25 ± 10.38 cm.
Results of the functional forward-reach tests showed
a significant increment (p  < 
0.05) between the pre-test
and post-test in each group, but no significant difference
(p > 0.05) was found between the two groups (Table II).
Results of the 30 s chair stand test showed a significant
increment over the 8-week period in each group (p < 0.05),
and the change in the exercise group was highly significant
(p < 0.001) (Table II). As for the results of walking function,
there were significant improvements in all three walking
tests in the exercise group (p < 0.001); subjects in the control
group also significantly improved (p < 0.01) on the going
up-and-down 13-stair test, but not on the 10 m walk or the
timed up-and-go tests. Comparing the decremental changes

in time between the two groups, the results of the 10 m walk

Results
According to the results of the Shapiro–Wilk test, most data
of the dependent variables were not normally distributed.
The results of a nonparametric analysis showed no sig-
nificant difference in demographic data or pre-test data of
lower-extremity function between the two groups (Table I).
There were 24 data of personal training elasticity from 24
subjects in the exercise group. If subjects had arthritis in both
knees, only the more severe one was tested and the results
For personal use only.
and timed up-and-go tests significantly differed (p < 0.01),
while the going up-and-down 13-stair test did not (p > 0.05)
(Table II).
All post-test results of the WOMAC subscale scores in
the exercise group showed significant decrements (p < 0.05)
after the 8-week intervention. In the control group, except
for the stiffness subscale, there were significantly decreased
scores (p < 0.05) in the other two subscales. Comparing the
decremental changes in scores between the two groups on the

Table I.  Demographic characteristics and pre-test outcomes of lower-extremity function of all subjects.
Exercise group (n = 24) Control group (n = 17)
Characteristic Mean ± SD Median Mean ± SD Median p value
Age (year) 65.0 ± 8.4 65.0 70.8 ± 8.4 69.0 0.07
Height (m) 1.5 ± 0.1 1.5 1.5 ± 0.1 1.5 0.17
Weight (kg) 59.0 ± 8.0 58.5 59.9 ± 8.0 59.0 0.69
BMI (kg/m2) 24.9 ± 3.3 25.1 25.7 ± 3.6 25.3 0.59
Knee OA diagnosis
  Duration (month) 6.8 ± 5.0 6.0 12.2 ± 9.4 6.0 0.14
  Affected side No. (%) No. (%) 0.85
  Left 4 (16.7%) 3 (17.7%)
  Right 6 (25.0%) 3 (17.7%)
  Bilateral 14 (58.3%) 11 (64.7%)
Kellgren/Lawrence level 0.30
  2nd 9 (37.5%) 3 (17.7%)
  3rd 15 (62.5%) 14 (82.4%)
Exercise habit 1.0
  Yes 5 (20.8%) 3 (17.7%)
Taking drugs for pain 0.35
  Yes 10 (41.7%) 10 (58.8%)
FFRT (cm) 82.5 ± 6.0 82.0 78.2 ± 6.5 79.5 0.13
CS-30 (reps) 11.8 ± 3.0 12.0 10.4 ± 2.8 11.0 0.23
10MWT (s) 9.3 ± 1.8 9.0 10.9 ± 3.8 9.8 0.12
TUGT (s) 9.4 ± 1.9 9.0 10.7 ± 3.0 9.8 0.22
GUD-13 (s) 21.2 ± 6.3 20.0 27.1 ± 10.6 24.5 0.09
WOMAC (score)
 Pain 4.3 ± 1.7 4.0 4.5 ± 1.7 4.0 0.57
 Stiffness 1.9 ± 1.7 2.0 1.4 ± 1.8 1.0 0.30
  Physical function 20.0 ± 8.9 17.0 22.0 ± 8.6 21.0 0.35
FFRT, functional forward-reach test; CS-30, 30-s chair stand test; 10MWT, 10-m walk test; TUGT, timed up-and-go test; GUD-13, going up-and-down 13-stair test;
* p < 0.05; ** p < 0.01; *** p < 0.001; Mann–Whitney U test, Fisher’s exact test, Pearson χ2; test.

© 2012 Informa UK, Ltd.

 1732  T.-F Chang et al.

Table II.  Changes in outcomes after the 8-week intervention between groups.
Pre-test Post-test Change 95% ICC
Item Group (n) Mean ± SD Mean ± SD Mean ± SD upper lower p
FFRT (cm) exercise (24) 82.5 ± 6.0 86.3 ± 5.1 3.8 ± 3.8††† −3.7 0.8 0.108
control (17) 78.3 ± 6.5 80.6 ± 5.6 2.4 ± 3.4††
CS-30 (reps) exercise (24) 11.7 ± 2.9 14.2 ± 3.3 2.5 ± 1.4††† −2.7 −1.1 0.000
control (17) 10.4 ± 2.8 10.9 ± 2.5 0.6 ± 0.9† ***
10MWT (s) exercise (24) 9.3 ± 1.8 7.9 ± 1.2 −1.4 ± 1.2††† −1.6 −0.1 0.001
control (17) 10.9 ± 3.8 10.4 ± 3.0 −0.5 ± 1.1 **
TUGT (s) exercise (24) 9.4 ± 1.9 7.8 ± 1.2 −1.6 ± 1.1††† −1.9 −0.5 0.001
control (17) 10.7 ± 3.0 10.3 ± 2.9 −0.3 ± 1.1 **
GUD-13 (s) exercise (24) 21.2 ± 6.3 17.5 ± 5.3 −3.8 ± 2.9††† −2.9 2.0 0.278
control (17) 27.1 ± 10.6 23.8 ± 9.2 −3.3 ± 4.8††
WOMAC
 Pain exercise (24) 4.2 ± 1.7 2.0 ± 0.9 −2.3 ± 1.3††† −2.3 −0.5 0.002**
control (17) 4.5 ± 1.7 3.7 ± 1.5 −0.9 ± 1.5†
Disabil Rehabil Downloaded from informahealthcare.com by Taipei Medical University on 02/13/13

 Stiffness exercise (24) 1.9 ± 1.7 0.8 ± 0.9 −1.1 ± 1.1†† −1.6 −0.3 0.014*

control (17) 1.4 ± 1.8 1.2 ± 1.6 −0.2 ± 1.0
  Physical function exercise (24) 20.0 ± 8.9 9.3 ± 4.8 −10.7 ± 5.9††† −9.6 −2.8 0.001**
control (17) 22.0 ± 8.6 17.5 ± 8.3 −4.5 ± 4.4††
FFRT, functional forward-reach test; CS-30, 30-s chair stand test; 10MWT, 10-m walk test; TUGT, timed up-and-go test; GUD-13, going up-and-down 13-stair test;
* p < 0.05; ** p < 0.01; *** p < 0.001; Mann–Whitney U test; †p < 0.05; †† p < 0.01; ††† p < 0.001; Wilcoxon signed ranks test.

WOMAC index, all results of the three subscales significantly the advantages of using elastic bands will improve lower-
differed (p < 0.05) (Table II). extremity function of arthritis patients.
In only a few studies of exercises for knee OA did compli-
cations result. When they did, they consisted of pain within
Discussion
For personal use only.

the range of 0%–11.8% [21]. In this study, pain symptoms

Research indicated that lower-extremity function of knee
OA patients can be improved by leg-press machine train-
ing [24,25], and the elastic-band leg-press exercise that
were utilized to train knee OA patients showed excellent
improvement as it did in previous research. However, leg-
press machines cannot easily be transported or widely used,
and they cannot flexibly adjust the intensity compared to
the elastic bands. In addition, for those who suffer from OA
pain, the elastic bands are safer for adjusting the intensity
by RPE. For these reasons, resistance exercise using elastic
bands with a leg-press movement was adopted for those
with lower-extremity joint disease. The most common way
of using elastic bands for leg-press involves subjects sitting
or standing, holding the ends of the bands with their hands
to do the training [46]. If a subject is standing in the process
of performing the activity, it takes extra upper-extremity
muscle strength and trunk balance to maintain stability.
Because elders mostly have insufficient upper-extremity
strength and balance for this kind of exercise, a system that
fixes the bands at the waist was invented instead of requir-
ing patients to hold the bands in the hands to ease the
burden on the upper extremities and also to avoid changes
in intensity due to inappropriate form. In some research,
outcomes showed that the elastic bands had high test-retest
reliability (ICC, 0.65–0.91) and so are a valid and reliable
tool for assessing and training muscle strength with stable
intensity [47,48]. Nowadays, multiple RMs are used with
elastic-band strength training, based on the RPE [15,41].
In this study, the same method was applied to set the per-
sonal training intensity (10 RM + 13 RPE). It is hoped that
(rated about 10–20 mm on the VAS) were induced during
training in three subjects, but the pain was alleviated after
placing an ice pack on the knee and resting. There was an
overall improvement in the final results, and the response of
subjects who took part in the training was highly satisfac-
tory. Therefore, the elastic-band leg-press exercise training
for knee OA patients is effective and worth promoting in
the field of OA.
Knee OA patients have impaired proprioception, and
static and dynamic balance that may result in falls [49].
Stensdotter et al. [26] and Jan et al. [30] assessed the pro-
prioception of knee OA patients who received 6–8 weeks
of leg-press machine training, and results showed that it
could decrease errors on knee joint active–active reposition
sense tests and improve the proprioception of the knee. In
this study, results of the functional forward-reach in both
groups significantly improved (p < 0.05), while there was
no significant difference between the groups after 8 weeks.
These results indicated that possible factors influencing the
balance of knee OA patients were circulatory effects pro-
duced by conventional modality treatments [35]. However,
the functional forward-reach test is a method to assess the
static balance of subjects [43], and it is not possible to exam
proprioception and dynamic balance. By the way, the test of
8 feet up-and-go is also a way to analyze dynamic balance
[44]. According to the results of this test in this study, there
was significant improvement in the exercise group. The
intervention apparently seemed to be useful for improving
the dynamic balance, but proprioception still requires fur-
ther assessment.

Disability & Rehabilitation


Lower-extremity muscle strength can be improved by elas-
tic band resistance training and leg-press resistance training
[10,13,17,30,41]. Takekawa et al. [13] applied the thera-band
to female knee OA patients twice a day for 3 months of train-
ing for knee extensors and flexors, and the strength of those
muscles significantly improved after training for 8 weeks.
Jan et  al. [30] used lower-extremity leg-press machines to
provide two different intensities of resistance (60%–80% and
10%–30% 1 RM) for training the lower-extremity strength
of 102 subjects with knee OA over 8 weeks, and there were
significant increases in the strengths of knee extensors and
flexors (p < 0.05) in both high- and low-intensity groups. In
this study where elastic bands were applied as a training tool
to perform a similar movement style as a leg-press machine,
there was a significant improvement in the 30 s chair stand
tests after 8 weeks (p < 0.001). Although this test focused on
Disabil Rehabil Downloaded from informahealthcare.com by Taipei Medical University on 02/13/13
bilateral extensor muscle strength of the lower extremities, it
did not respond to single extensor strength of the knee as in
the above studies [13,30].
Walking function in this study showed significant improve-
ment after the elastic-bands leg-press exercise training.
Walking speed and agility improved according to the outcomes
of the 10 m walk and timed up-and-go tests. These results
were similar to other studies on knee OA patients [14,23,38].
However, there was no significant difference in improvement
between the two groups on the going up-and-down 13-stair
test. This may have been due to the pain induced by greater
For personal use only.
loading on the knees with stair climbing [50]. This condition
may have occurred in this study subjects, and the pain might
have lessened their performance.
According to a study by Jan et al. [30], there was a signifi-
cant decrease in WOMAC scores (p < 0.05) of both the high-
and low-intensity groups with 8 weeks of resistance training
using leg-press machines. In this study, there were signifi-
cant decreases in pain and physical function scores on the
WOMAC index in the exercise group. Similar results were also
obtained in other muscle-training studies of knee OA [2,14].
Although the conventional modality treatments [35,36] can
increase the blood circulation around the knee, only stiff-
ness scores in the exercise group significantly decreased. This
indicates that the intervention can certainly alleviate stiffness
of knee joints. It is proposed that the elastic-bands leg-press
exercise is an active movement, and the rebound force from
the elastic bands may also promote passive movement of the
knee; thus, the stiffness of the knee can be alleviated due to
the incremental increase in joint movement. This requires
further assessment of the range of motion for proof.
Differences in the results were statistically significant.
According to these outcomes, over half of the subjects in the
exercise group had >10%–20% progressions in all measure-
ments of lower-extremity function after the 8-week interven-
tion, and this might have been clinically relevant.
In other research on exercise interventions for knee OA
patients, the training period was 6 weeks to 24 months [18,25],
with 8–16 weeks being most common [17,20,30,51,52]. In this
study, the training period was only 8 weeks and lacked long-
term follow-up. In future studies, we will try to extend the
training period and perform long-term follow up.
© 2012 Informa UK, Ltd.
Elastic-band exercise for OA of the knee  1733
Prior studies evaluated the effects of exercise training,
modality treatment, and medication [17,23]. The results
showed that additional modality treatments and medication
positively influenced exercise effects on lower-extremity func-
tion. In this study, although both groups received conventional
modality treatments, there was no strict control on the items
of the modalities, which may have created a bias. On the other
hand, medications have proven to alleviate symptoms of knee
OA, especially steroids or hyaluronic acid injections which
have at least a 1–2-week effect and even showed a sustained
effect to 12 months compared to control pain of knee OA in
some studies [53,54]. In this study, only those subjects who
had received those injections in the 2 months before recruit-
ment were excluded. In addition, there was not control for oral
medication, although there were no changes in the dose or
content of medicine in either group according to the records,
and this was also a limitation of the study. Moreover, although
subjects were grouped randomly, they still had some non-
homogeneity at the baseline, such as comorbidities because of
the small sample size, and this is a limitation which needs to
be overcome in future studies.
Conclusions
After 8 weeks of leg-press exercise training using elastic bands,
lower-extremity function of female knee OA patients had
significantly improved. Thus, the effects of this study can be
provided for medical staff, patients’ families, and patients who
would like to employ exercise to treat knee OA. Extending
the exercise-intervention time and designing different com-
binations of color bands to suit various training models are
strongly recommended for further research.
Acknowledgment
We thank all the staff in the Physical Therapy Section,
Rehabilitation Department of Wan-Fang Hospital for their
assistance and the cooperation of all participating researchers.
Declaration of Interest: There was no funding had been
received in this study.
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