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Sedentary Behavior, Cadence, and Physical

Activity Outcomes after Knee Arthroplasty
SANDRA C. WEBBER1, SHAELYN M. STRACHAN2, and NAVJOT S. PACHU3
1
Department of Physical Therapy, College of Rehabilitation Sciences, Rady Faculty of Health Sciences, University of
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Manitoba, Winnipeg, Manitoba, CANADA; 2Faculty of Kinesiology and Recreation Management, University of
Manitoba, Winnipeg, Manitoba, CANADA; and 3Applied Health Sciences Program, University of Manitoba,
Winnipeg, Manitoba, CANADA

ABSTRACT
WEBBER, S. C., S. M. STRACHAN, and N. S. PACHU. Sedentary Behavior, Cadence, and Physical Activity Outcomes after Knee
Arthroplasty. Med. Sci. Sports Exerc., Vol. 49, No. 6, pp. 1057–1065, 2017. Purpose: This study comprehensively examined sedentary
behavior and physical activity patterns in people with severe knee osteoarthritis awaiting total knee arthroplasty (TKA) and in individuals
after TKA. Methods: Preoperative (n = 32, mean T SD = 69.9 T 5.3 yr) and 1-yr postoperative participants with TKA (n = 38, 67.9 T 7.3 yr)
wore ActiGraph GT3X+ activity monitors for 6.8 T 0.6 d. Total sedentary time, time in long sedentary bouts (Q30 min), and physical activity
outcomes (steps, time in moderate-to-vigorous physical activity [MVPA], cadence) were examined. Results: There were no differences
between pre- and postoperative groups for total sedentary time (9.3 T 1.4 vs 9.2 T 1.4 hIdj1, P = 0.62) and number of long sedentary bouts
per day (median [interquartile range] = 3.4 [1.9] vs 3.1 [2.0], P = 0.37). Daily steps, peak 30-min cadence, and peak 1-min cadence values
were greater in people after TKA compared with those awaiting surgery (5935 [3316] vs 3724 [2338], 55.6 [31.0] vs 35.9 [19.3], and 91.5 T
20.6 vs 70.0 T 23.7, respectively, all P G 0.01). There were no differences in lifestyle MVPA between groups. The number of bouts of
Freedson MVPA was greater in postoperative participants, but the differences were not substantial (one bout per week). Conclusion: Patients
report less knee pain and improved function after TKA; however, sedentary behavior does not differ and physical activity is only marginally
increased compared with those awaiting surgery. After TKA, daily walking at slow, moderate, and brisk paces and engagement in MVPA do
not match levels seen in healthy older adults, which, when combined with high levels of sedentary behavior, leaves patients at increased risk
for physical disability and cardiovascular disease. Key Words: ACCELEROMETER, KNEE REPLACEMENT, OSTEOARTHRITIS,
PEDOMETER, WALKING

C
urrently, 4.4 million Canadians live with osteoarthri-
tis, and this number is projected to double to 9 million
(one in four Canadians) by 2031 (4). Joint pain, stiff-
ness, and swelling associated with osteoarthritis are a leading
cause of disability in older adults. The knee is the most
common joint requiring arthroplasty surgery (8), the definitive
treatment for end-stage knee osteoarthritis, and the procedure
typically results in substantial reductions in pain and im-
provements in physical function. Despite these changes that
Address for correspondence: Sandra Webber Ph.D., M.Sc., B.M.R.(PT), De-
partment of Physical Therapy College of Rehabilitation Sciences, Rady Faculty
of Health Sciences, University of Manitoba, R106-771 McDermot Avenue,
Winnipeg, MB, Canada, R3E 0T6; E-mail: sandra.webber@umanitoba.ca.
Submitted for publication November 2016.
Accepted for publication January 2017.
0195-9131/17/4906-1057/0
MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ
Copyright Ó 2017 by the American College of Sports Medicine
DOI: 10.1249/MSS.0000000000001207
would seem to facilitate increased physical activity, research
has demonstrated that activity levels usually do not change
substantially after total knee arthroplasty (TKA) (3,23,31). A
recent systematic review found no changes in objectively
measured physical activity 6 months after TKA, with more
consistent small positive changes apparent 1-yr postsurgery
(3). However, even at the 1-yr mark, people with TKA were
less physically active compared with healthy controls (3) with
only 5% meeting national physical activity guidelines (23).
This is concerning because the majority of individuals who
require TKA are obese (7), which puts them at increased risk
for cardiovascular disease (13) and cancer (33). Controlling
for body mass index, individuals with osteoarthritis are still at
increased risk of cardiovascular disease and overall death
compared with the general population (30). Engaging in
physical activity has been shown to reduce risks related to
cancer (50) and cardiovascular disease (2) in the general
population and is similarly recommended for those with os-
teoarthritis and/or TKA.
Although physical activity is important, it is also relevant
to consider sedentary behavior levels after TKA surgery.

1057

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 Sedentary behavior includes all waking behaviors performed
in a seated or reclining posture that require low energy
expenditure; this is distinct from being physically inactive
CLINICAL SCIENCES
(not meeting physical activity guidelines) (34). High levels of
sedentary behavior are associated with health risks (e.g.,
metabolic syndrome, type 2 diabetes, and cardiovascular
disease) (6,19) and, in people with osteoarthritis, have been
shown to be linked to reduced physical function (35), increased
blood pressure (37), and weight gain (32). Whether sedentary
behavior levels change in people with osteoarthritis after TKA
has not yet been explored.
Physical activity and sedentary behavior can be measured
using self-report instruments and objective activity monitoring
(with accelerometers or pedometers). Self-report instruments
can place significant burden on participants and have been
shown to overestimate physical activity compared with ob-
jective measures in people with osteoarthritis (25) and after
TKA (31). Although no comparison of sedentary behavior
instruments has been conducted in individuals with osteoar-
thritis, studies in healthy older adults suggest that people may
either under- or overestimate sedentary time using self-report,
depending on the tool that is used (1,22). The most frequent
objective outcomes used to characterize physical activity in
people with osteoarthritis and/or after TKA include: time
spent in light and moderate-to-vigorous physical activity
(MVPA Q1952 (12) or Q2020 (38) activity counts per minute)
(23,25,29), steps per day (46), daily activity time, and total
activity counts (3). Sedentary behavior has been reported in
people with osteoarthritis using total daily sedentary time (G100
activity counts per minute) in absolute terms or as a percentage
of monitor wear time (32,35,37).
Although outcomes used to describe physical activity and
sedentary behavior in this patient population have been rele-
vant, further analyses of activity monitor data may be neces-
sary to reveal subtle changes in behavior after TKA. For
example, given that the majority of Canadians who undergo
TKA surgery are older adults (mean 67 yr of age) (8), it may
be appropriate to consider using activity monitor cut points
designed to categorize activity intensities specific to older
adults (17). Because walking is a common physical activity
undertaken by older adults, cadence (steps per minute) may
be another relevant outcome to detect differences in walking
patterns in pre- and postoperative patients. Daily time spent in
different cadence bands (e.g., 60–79 steps per minute, 80–99
steps per minute) (42) as well as peak 30-min cadence (average
steps per minute recorded for the 30 highest, but not neces-
sarily consecutive minutes in a day) and peak 1-min stepping
cadence (steps per minute recorded for the highest single
minute in a day) represent variables previously studied in
adults and older adults (40–42) that have not been examined in
the TKA population. In terms of sedentary behavior, analyses
of sedentary bouts have been recommended to allow for
characterization of patterns of accumulation of sedentary time
(10,36). The primary objective of this study was to compre-
hensively compare sedentary behavior and physical activity
patterns in people with severe knee osteoarthritis awaiting
1058 Official Journal of the American College of Sports Medicine
Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
TKA and in individuals 1-yr post-TKA. Sedentary behavior
has not previously been examined in these patient groups, and
only small differences in physical activity have been detected
(3). Comprehensive analyses may identify areas for targeted
rehabilitation interventions to improve health in relation to
these lifestyle factors. Second, we were interested in comparing
the agreement between self-reported and objective measures of
sedentary behavior in this patient population to guide the se-
lection of outcome measures in future studies.
METHODS
Participants. A sample of participants was recruited
through telephone calls to patients on the waiting lists and
on the 1-yr follow-up lists of four orthopedic surgeons. A
target of 40 preoperative and 40 postoperative participants was
set to provide 80% power (two-tailed t-test, P G 0.05) to detect
a 6% (SD = 9%) (14) change in sedentary time postsurgery,
allowing for 8% attrition. Criteria for entry into the study
included patients waiting for (preoperative) or 1-yr completed
(postoperative) single primary TKA and the ability to walk
for at least 3 min. Individuals were excluded if they had one
or more previous hip or knee joint arthroplasty surgeries and/
or other conditions that limited mobility (e.g., recent acute
cardiovascular event and Parkinson"s disease). One hundred
and fifteen preoperative and 89 postoperative patients were
initially contacted by telephone. Of these, 40 preoperative and
40 postoperative participants were entered into the study. Rea-
sons for potential participants not being entered into the study are
detailed in Figure 1. All participants provided written informed
consent. Ethical approval for this study was granted from the
University of Manitoba Health Research Ethics Board.
Questionnaires. During the study visit, participants com-
pleted a basic demographic questionnaire and the Longitudinal
Aging Study Amsterdam (LASA) Sedentary Behavior Ques-
tionnaire (48). Self-reported sedentary time on the LASA
has been shown to be moderately associated with sedentary
time measured by accelerometry in older adults (48). LASA
sedentary time was averaged across weighted weekday and
weekend days.
Physical measures. Height and weight were measured
using a standard stadiometer/scale. A tape measure was used
to measure waist circumference horizontally around the trunk
directly above the iliac crests. Active range of motion of the
operative knee was measured using a goniometer with the pa-
tient lying supine. For the Timed Up and Go (TUG) test, par-
ticipants stood from a chair (47 cm seat height) with or without
using the armrests, walked forward 3 m at a comfortable pace,
and then turned around and returned to the chair. Each partici-
pant performed two trials with the second being used for anal-
ysis. The TUG test has been shown to be a reliable and valid test
of functional mobility in older adults after TKA (24).
Activity monitoring. At the study visit, participants were
given an ActiGraph GT3X+ activity monitor (ActiGraph,
Pensacola, FL) to wear on an elastic waist strap at the level of
the right iliac crest (anterior axillary line) during all waking
http://www.acsm-msse.org

FIGURE 1—Flow chart detailing recruitment to study sample.
hours for seven consecutive days along with a sheet to note
when the monitor was worn each day. Participants were also
asked to complete the 7-d Sedentary and Light Intensity
Physical Activity Log (SLIPA) at the end of each day when
they wore the monitor (5). The SLIPA has been shown to
have concurrent validity with accelerometry for measuring
sedentary and light physical activity time in adults (5). Time
recorded in all SLIPA activities conducted in a seated or
lying position was summed to represent sedentary behavior
(SLIPA-SB). After 7 d, the monitors were mailed back
along with the log sheets. ActiLife6 software (ActiGraph)
was used to initialize (100 Hz) and download the GT3X+
devices (default filter, 1-min epochs). All participants in the
present analysis recorded a minimum wear time of 10 hIdj1
for 5–7 d (6.8 T 0.6 d) (38). Nonwear periods were defined
as intervals of at least 90 consecutive minutes with zero
activity counts (allowing for up to two consecutive minutes
of counts between 0 and 100) (35).
To analyze physical activity, steps per day and time spent in
different physical activity intensities were calculated using
ActiLife6 software (ActiGraph). Freedson cut points were
used to define sedentary (0–99 counts per minute), light (100–
1951 counts per minute), and MVPA (Q1952 counts per minute)
(12). MVPA was also measured using a lifestyle cut point (Q760
counts per minute), which captures activities Q3.6 METs (28)
and has been suggested to better reflect older adults" free-living
SEDENTARY BEHAVIOR AND PHYSICAL ACTIVITY
Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
CLINICAL SCIENCES
moderate-intensity activity (17). Total daily minutes spent in
different physical activity intensities were calculated along with
time spent in MVPA bouts (Q10 consecutive min at the
minimum MVPA threshold, allowing for interruptions of 1 or
2 min below threshold) (17). A custom R program (https://
www.r-project.org/) was used to detect all sedentary time
during valid wear time (G100 activity counts per minute). In
addition, long sedentary bouts (Q30 consecutive minutes with
G100 activity counts per minute for each minute) were also
identified.
Peak 30-min stepping cadence (average cadence for the
highest 30 nonconsecutive minutes per day) and peak 1-min
stepping cadence (highest cadence for 1 min during the day)
were identified for each day and averaged across valid days
(44). Daily step data were also grouped into cadence bands
as per previous literature (number of minutes per day with
cadences in the following ranges): 1–19 steps per minute
(incidental movement), 20–39 (sporadic movement), 40–59
(purposeful steps), 60–79 (slow walking), 80–99 (medium
walking), and Q100 (brisk walking). Although studies in
healthy individuals have traditionally presented an additional
cadence band (Q120 steps per minute) (44), only 15% of our
sample registered any minutes at Q120 steps per minute during
7 d of monitoring. Therefore, for the purposes of this study,
the bands 100–119 steps per minute and Q120 steps per minute
have been collapsed and represented as Q100 steps per minute.
Medicine & Science in Sports & Exercised 1059
 TABLE 1. Characteristics of participants.
six cadence bands (0.05/6 = P G 0.006), but P G 0.05 was
Preoperative Postoperative
Characteristic (n = 32) (n = 38) P
used for statistical significance in all other analyses.
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Age (yr) 69.9 T 5.3 67.9 T 7.3 0.19

Sex (male/female) 11/21 16/22 0.52
BMI (kgImj2) 32.7 (6.7) 30.5 (6.1) 0.29
Waist Circumference (cm) 107.8 T 14.3 105.2 T 14.1 0.45 RESULTS
Timed Up and Go (s) 9.5 (3.2) 7.4 (1.8) G0.001
Active knee flexion (-) 120 (19.8) 120 (15.0) 0.99 Characteristics of participants are presented in Table 1.
Active knee extension (-)* j10 (8.5) j8.5 (5.0) 0.03 GT3X+ data from eight preoperative and two postoperative
Walking limited by knee pain 28 6 G0.001
participants were excluded from analyses because they did not
Data are presented as mean T SD or median (IQR). meet wear time requirements. Among the postoperative partici-
IQR, interquartile range; BMI, body mass index. Independent-samples t-tests were used
for normally distributed data, and Mann–Whitney rank sum tests for nonnormally distributed pants, walking was less frequently limited by pain (P G 0.001),
data. TUG times were faster (P G 0.001), and knee extension was
*Negative values for knee extension reflect a lack of extension (flexion contracture).
greater (P = 0.03) compared with preoperative individuals.
Sedentary behavior measures are reported in Table 2.
Current physical activity guidelines recommend that older
GT3X+ wear time did not differ between the groups, and
adults participate in at least 150 min of moderate-to-vigorous
there were no differences in GT3X+-measured total sedentary
physical activity (in bouts of 10 min or more) each week (9). time or in the number or duration of long sedentary bouts per
Because researchers have suggested that cadences Q100 steps day. SLIPA-SB and LASA values also did not differ between
per minute represent moderate-intensity physical activity in pre- and postoperative participants.
adults (44), the number of minutes per week when cadences Postoperative participants demonstrated greater physical
exceeded 100 steps per minute was also identified. activity as measured by step counts (P G 0.01) and Freedson
Statistical analysis. All analyses were conducted using MVPA (sporadic minutes as well as activity accumulated in
SPSS version 24 (IBM Corp., Armonk, NY), Excel 2016 bouts, both P = 0.02, Table 3). Analyses by cadence (Table 3)
(Microsoft Office Professional Plus 2016, Redmond, WA), also revealed greater daily peak 1- and 30-min cadence as
and SigmaPlot version 11.0 (Systat Software Inc., San Jose, well as weekly minutes spent walking Q100 steps per minute
CA). All data were checked for normality. Normal data are in the postoperative compared with preoperative participants
presented as mean T SD, and nonnormal data are presented as (all P G 0.01). Steps per day acquired in different cadence
median (interquartile range). Independent-samples t-tests and bands are shown in Figure 2. Preoperative participants accu-
Mann–Whitney rank sum tests were used to detect differences mulated significantly fewer steps in the 40–59, 60–79, and
in demographic, sedentary behavior, and physical activity 80–99 steps per day bands compared with postoperative in-
data between preoperative and postoperative groups. A one- dividuals (all P G 0.001).
way repeated-measures ANOVA was used to detect differ- To address our secondary objective, self-reported and ob-
ences among mean values of sedentary time measured with jective measures of sedentary behavior were compared with
the GT3X+, SLIPA-SB, and LASA. Bland–Altman plots the participant groups combined. All measures of daily sed-
were also generated to assess for differences between the entary time were statistically different from one another:
measurements within individuals. To allow for comparison GT3X + = 9.2 T 1.4 hIdj1, SLIPA-SB = 6.7 T 2.5 hIdj1, and
with previous research, Pearson correlations were also cal- LASA = 10.3 T 3.7 hIdj1 (all comparisons P G 0.05). Cor-
culated to determine the association between self-reported relations between sedentary time measured by GT3X+ and
(SLIPA-SB and LASA) and GT3X+ sedentary time. A LASA and between GT3X+ and SLIPA-SB were not signif-
Bonferroni correction was applied to the P value for detecting icant (P = 0.21 and P = 0.07, respectively), whereas LASA
group differences in the number of daily steps in each of the
TABLE 3. GT3X+ physical activity measures.
Preoperative Postoperative
TABLE 2. Sedentary behavior measures.
GT3X+ Activity Measure (n = 32) (n = 38) P
Preoperative Postoperative Steps per day 3724 (2338) 5935 (3316) G0.01
Sedentary Behavior Measure (n = 32) (n = 38) P Min of light PA per day (Freedson) 264.0 T 73.3 291.7 T 91.0 0.17
GT3X+ sedentary time (hIdj1) 9.3 T 1.4 9.2 T 1.4 0.62 Min of MVPA per day (Freedson) 6.5 (11.8) 13.9 (18.3) 0.02
GT3X+ sedentary time (percentage 66.9 T 9.0 63.8 T 10.0 0.18 No. MVPA bouts per day (Freedson) 0 (0.14) 0.14 (0.71) 0.02
of wear time) Min in MVPA bouts per day (Freedson) 0 (1.8) 2.1 (10.4) 0.02
GT3X+ daily number of sedentary 3.4 (1.9) 3.1 (2.0) 0.37 Min of MVPA per day (lifestyle) 67.0 (77.9) 100.0 (82.0) 0.09
bouts Q30 min No. MVPA bouts per day (lifestyle) 1.3 (2.8) 1.9 (1.8) 0.15
GT3X+ daily min in sedentary 178.8 (116.2) 151.1 (109.3) 0.39 Min in MVPA bouts per day (lifestyle) 17.0 (43.5) 29.9 (39.2) 0.05
bouts Q30 min Daily peak 30-min stepping cadence 35.9 (19.3) 55.6 (31.0) G0.01
SLIPA-SB sedentary time (hIdj1) 7.2 T 2.7 (n = 28) 6.3 T 2.4 (n = 34) 0.17 (steps per minute)
LASA sedentary time (hIdj1) 11.2 T 4.1 (n = 23) 9.7 T 3.3 (n = 32) 0.14 Daily peak 1-min stepping cadence 70.0 T 23.7 91.5 T 20.6 G0.01
GT3X+ wear time (hIdj1) 13.9 T 1.1 14.4 T 1.1 0.09 (steps per minute)
Per week minute cadence Q100 0 (7) 11 (48) G0.01
Data are presented as mean T SD or median (IQR).
IQR, interquartile range; SLIPA-SB, 7-d Sedentary and Light Intensity Physical Activity Data are presented as mean T SD or median (IQR).
Log—Sedentary Behavior; LASA, Longitudinal Aging Study Amsterdam Sedentary Behavior IQR, interquartile range; MVPA, moderate-to-vigorous physical activity; PA, physical
Questionnaire. Independent-samples t-tests were used for normally distributed data, and activity. Independent-samples t-tests were used for normally distributed data, and
Mann–Whitney rank sum tests for nonnormally distributed data. Mann–Whitney rank sum tests for nonnormally distributed data.

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 CLINICAL SCIENCES
FIGURE 2—Daily minutes in cadence bands for participants with os-
teoarthritis and TKA. *Significant difference (Mann–Whitney rank
sum tests, all P G 0.001).

and SLIPA-SB were significantly correlated (r = 0.48, P G

0.001). Bland–Altman plots depicting the degree of agreement
between the different measures of sedentary time (Fig. 3)
demonstrated a large degree of variability between all mea-
sures. This appeared to be systematically distributed such that
the SLIPA-SB and LASA both tended to underestimate lesser
amounts of sedentary time and overestimate higher levels of
sedentary time compared with the GT3X+ (Fig. 3, plots A
and B). Limits of agreement were slightly wider for the
LASA than the SLIPA-SB when both were compared with
GT3X+ sedentary time. In comparing the two self-reported
measures of sedentary behavior (Fig. 3, plot C), the SLIPA-
SB tended to overestimate lesser amounts of sedentary time
and underestimate higher levels of sedentary time compared
with the LASA.

DISCUSSION
Results of our study, which included a comprehensive anal-
ysis of both sedentary behavior and physical activity patterns,
demonstrated that total daily sedentary time and time spent in
long sedentary bouts did not differ between people waiting for
TKA and 1-yr post-TKA. This is concerning because previous
research has established that high levels of sedentary behavior
put people with osteoarthritis at elevated risk for reduced
physical function, increased physical frailty, and increased
blood pressure, independent of time spent in moderate physical
activity (35,37). Some physical activity outcomes revealed that
postoperative participants were slightly more active than preop-
erative people (e.g., steps per day, cadence variables, and
Freedson MVPA); however, other outcomes showed no differ-
ences between the groups (e.g., Freedson light physical activity
and lifestyle MVPA). Importantly, for most of the physical ac-
tivity outcomes assessed in this study, participants in both groups
did not meet levels seen in the general population (39,41,42). FIGURE 3—Bland–Altman plots of differences between sedentary
time per day: (A) SLIPA-SB vs GT3X+, (B) LASA vs GT3X+, (C)
Although physical activity has been studied extensively in SLIPA-SB vs LASA. Solid line, mean difference; dashed lines, 95%
people with arthritis and in those after TKA, comparisons of limits of agreement.

SEDENTARY BEHAVIOR AND PHYSICAL ACTIVITY Medicine & Science in Sports & Exercised 1061

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 sedentary behavior have not been previously conducted. We
found no differences between study groups in both self-
reported (SLIPA-SB and LASA) and objectively measured
CLINICAL SCIENCES
sedentary time. Daily sedentary time measured by GT3X+
in our study (9.3 and 9.2 h, respectively, for pre- and post-
operative participants) was similar to that reported in Os-
teoarthritis Initiative studies (9.8–9.9 hIdj1 in people with
or at high risk for osteoarthritis) (35,37). Comparable re-
sults were demonstrated in a large systematic review that
included more than 20,000 older adults (mean age = 72 yr,
sedentary time = 9.4 hIdj1) (21) and in the Women"s
Health Study (mean age = 71 yr, sedentary time = 9.7 hIdj1)
(36). The U.S. National Health and Nutrition Examination
Survey (NHANES) reported daily sedentary times equal to
9.9 and 9.2 hIdj1 in older adults with and without mobility
disabilities, respectively (26).
Because monitor wear time can substantially alter seden-
tary time recorded over the course of a day, we also calcu-
lated sedentary time as a percentage of wear time. The value
obtained in our study (65% T 10% of wear time) was very
similar to results published from the large data sets included
in the Osteoarthritis Initiative, NHANES, and Women"s Health
studies (63%–69%) (26,35–37). Although it is concerning that
sedentary behavior levels do not differ in people post-TKA
compared with those awaiting surgery, sedentary time for both
groups falls within the range observed in older adults in the
general population and those with osteoarthritis or other forms
of mobility disability. Although this suggests that people with
osteoarthritis/TKA may be at similar risk as the average pop-
ulation for developing metabolic disease related to sedentary
behavior, studies have shown that high levels of sedentary time
are also associated with accelerated physical decline in people
with osteoarthritis (35).
Pre- and postoperative participants in our study engaged in
3.4 and 3.1 (P = 0.37) continuous bouts of sedentary behavior
lasting 30 min or more per day, respectively, representing
32% and 27% of the groups" daily sedentary time. These
findings are similar to those reported in the Women"s Health
Study (31.5% of total sedentary time was accumulated in
bouts Q30 min in duration) (36), which reinforces that total time
spent in sedentary behaviors as well as the pattern of accu-
mulation of sedentary time does not differ substantially from
the general population in patients with osteoarthritis/TKA.
Participants 1-yr post-TKA accumulated a greater number
of steps per day compared with individuals on the waiting
list in our study (5935 vs 3724 steps per day). These daily
step counts are similar to levels reported in previous
pedometer/accelerometer studies of people with osteoarthritis
and/or TKA (46,47) and appear to fall within the average
range of steps per day reported for 65–69 yr olds in the
general population (3302–5269 steps per day, NHANES
study of older adults) (45). However, it is important to note
that our data were not adjusted to remove steps recorded at
slow walking speeds as was done with the NHANES data
(to make accelerometer-derived data more consistent with
what would be recorded by a commercial pedometer) (45).
1062 Official Journal of the American College of Sports Medicine
Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Although daily walking in the individuals post-TKA was
similar to that of age-matched peers, individuals on the
waiting list took substantially fewer steps per day and
participants in both groups did not meet the 7000–10,000
steps per day recommended for older adults (43).
Although statistical differences were shown between the
groups, both pre- and postoperative participants in our study
accumulated very few minutes of sporadic MVPA per day
(7 and 14 minIdj1, respectively) and very few MVPA bouts
(0 and 1 bout per week, respectively) when Freedson cut
points (Q1952 counts per minute) were applied (Table 3).
Similar to our findings, other analyses that used Troiano
cut points (Q2020 counts per minute) demonstrated that
individuals with knee osteoarthritis or TKA accumulated
11–24 sporadic minutes of MVPA per day (11,23,35) and
less than one MVPA bout per day (23). Compared with
NHANES data, it appears that people with osteoarthritis/
TKA engage in substantially less MVPA than age-matched
Americans who registered 34 minIdj1 (39).
We also analyzed our data using a lifestyle cut point to
define MVPA (Q760 counts per minute) (28) because par-
ticipants rarely engaged in MVPA that met the Freedson
criteria, and the lifestyle cut point has been suggested to
better reflect older adults" free-living moderate-intensity ac-
tivity (17). Although there were no differences between
groups in the lifestyle analysis, participants in both groups
accumulated 7–10 times more minutes of sporadic lifestyle
MVPA compared with Freedson MVPA and engaged in one
to two lifestyle MVPA bouts per day (Table 3). Previous
analyses in older adults reported that 35%–39% of individuals
engaged in Q150 min of MVPA per week (in bouts of 10 min
or more) when lifestyle criteria were applied (17,18). In our
study, 49% of individuals (13 pre- and 21 postoperative
participants) reached this threshold, which suggests that
people with osteoarthritis and/or TKA are similarly active at
this ‘‘lifestyle’’ moderate-intensity compared with the general
population of older adults.
In addition to analyzing activity data with different cut
points, we also compared the groups on several cadence
outcomes. Peak 30-min and 1-min stepping cadence values
were significantly lower in the preoperative group compared
with postoperative individuals (36 vs 56 steps per minute
and 70 vs 92 steps per minute, respectively, both P G 0.01).
Peak 30-min cadence has been shown to vary between 62
and 78 steps per minute (15,40), and peak 1-min cadence has
been measured at approximately 100 steps per minute (15,40)
in studies that included adults 50–90 yr of age. According to
NHANES data, adults who participate in limited daily activ-
ity (2500–4999 steps per day) typically demonstrate a peak
30-min cadence equal to 61 steps per minute (categorized as
slow walking) (42) and a peak 1-min cadence of 95 steps per
minute (41). The peak cadence levels in our study were lower
than normative values reported in NHANES for similarly
age participants (41); however, the post-TKA participants"
outcomes approached those recorded in similarly inactive
individuals.
http://www.acsm-msse.org
 The cadence threshold of 100 steps per minute is thought
to represent brisk walking and is sometimes used to prescribe
moderate-intensity activity in adults (27,44). However, it
should be noted that this threshold (and other cadence cate-
gories, e.g., denoted as ‘‘slow walking’’ or ‘‘medium walk-
ing’’) may not be valid in older adults who are deconditioned
and/or have chronic disease. Although high-functioning,
community-dwelling older adults are capable of walking at
cadences Q100 steps per minute in laboratory settings, one
small study demonstrated that people 61–81 yr of age aver-
aged only 8 minIdj1 above this threshold during daily life
(40). Analysis of NHANES data also determined that people
spent approximately 7 minIdj1 walking at cadences that
exceeded 100 steps per minute (42). In our study, the median
number of minutes per week spent walking Q100 steps per
minute was 0 for the preoperative group and 11 (G2 minIdj1)
for the postoperative group, suggesting that even after TKA,
individuals engage in very little brisk walking compared with
the general population.
We also separated step data into cadence bands to make
comparisons between pre- and postoperative groups (Fig. 2).
Preoperative participants spent significantly fewer minutes
per day walking in cadence ranges representative of purpose-
ful stepping (40–59 steps per minute), slow walking (60–79
steps per minute), and medium walking (80–99 steps per
minute) compared with individuals 1-yr post-TKA. Partici-
pants in both groups spent approximately 337 minIdj1 in the
lowest cadence band (1–19 steps per minute), which was very
similar to NHANES data (,350 min) for individuals Q60 yr of
age (42). However, compared with this NHANES sample of
older adults, our participants spent substantially fewer minutes
per day walking in all cadence bands beyond 1–19 steps per
minute (42). In fact, our post-TKA participants spent only
about half as many minutes per day in the bands spanning
20–100+ steps per minute and the differences were even
greater for the preoperative participants (44).
A secondary objective of our study involved comparing
self-reported and objective measures of sedentary behavior in
people with osteoarthritis and TKA. Unlike previous work
conducted in healthy older adults that found no differences
and moderate correlations between daily sedentary time
measured with the LASA questionnaire and a GT3X activity
monitor (48), GT3X+ results in our study were significantly
different from, and not correlated with, LASA sedentary time.
The LASA tended to underestimate lesser amounts of sed-
entary time and overestimate higher levels of sedentary time
compared with the GT3X. This questionnaire asks partici-
pants to state how much time they spend ‘‘on average’’ in
different sedentary behaviors (48). Participants in our study
completed the LASA during the study visit, the day before
they began wearing the activity monitor. In the original study,
participants completed the questionnaire after they had worn
activity monitors for 8 d. Wearing an activity monitor can
heighten awareness of time spent in sedentary behavior and
physical activity, and this may have resulted in greater
agreement between the two measures in the original study.
SEDENTARY BEHAVIOR AND PHYSICAL ACTIVITY
Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Because the SLIPA-SB asks about the amount of time spent in
specific sedentary behaviors during the previous day, we had
participants complete this log at the end of each day during the
CLINICAL SCIENCES
7-d monitoring period. However, SLIPA-SB and GT3X+
sedentary time were also significantly different (6.7 vs 9.2 h,
P G 0.001) and not correlated with each other in our study.
Similar to the LASA, the SLIPA-SB underreported lower
levels of sedentary time and overestimated higher levels of
sedentary time. A previous study in 22 young adults found a
strong positive correlation (r = 0.86) between SLIPA-SB and
GT3X sedentary time (5). Our results suggest that the SLIPA
may not be valid for use in people with osteoarthritis and/or
TKA. Older adults may have difficulty accurately estimating
how much time they spend engaged in the 23 sedentary and
light physical activities listed on the SLIPA and/or the exam-
ple activities may not fully encompass relevant options for
older adults. In addition, our participants estimated time spent
in sedentary behavior only during their waking hours when
they wore the activity monitors rather than an entire 24-h period.
This may have also influenced their accuracy in estimating
the amount of time spent in different activities. Further
study is warranted before using either the LASA or the
SLIPA to measure sedentary behavior in older adults with
mobility limitations.
Overall, people 1-yr post-TKA spent similar amounts of
time in sedentary behavior compared with individuals on the
waiting list; however, they demonstrated small positive dif-
ferences in terms of the total number of steps walked per day
(and those walked at 40–89 steps per minute), the number of
minutes of Freedson MVPA per day, and the values recorded
for peak 30-min and 1-min cadences. People with osteo-
arthritis and those post-TKA spent similar amounts of time
being sedentary compared with the average population
(21,26,36). In terms of some physical activity outcomes,
the postoperative group also performed comparably with
other older adults (steps per day [45] and lifestyle MVPA per
day [17]) and relatively inactive adults (peak cadences) (41)
monitored in population studies. In the post-TKA group,
minutes of Freedson MVPA per day did not meet levels
recorded using more conservative Troiano cut points in age-
matched older adults (39). Peak cadences and those recorded
in bands across 20–100+ steps per minute were also below
age-matched levels in the post-TKA group (41,42).
The results of this study point to the need for further in-
vestigation of strategies to reduce sedentary behavior and
increase physical activity after TKA. Because high levels of
sedentary time are associated with physical decline and addi-
tional health risks in people with osteoarthritis, and sedentary
levels do not change after TKA, it is important to identify new
approaches to reduce sedentary time in these patients, perhaps
in postoperative rehabilitation and/or community programs. A
recent review determined that education, persuasion, and modify-
ing the social and physical environment are important components
of interventions successful in reducing sedentary behavior (16).
Behavior change techniques related to self-monitoring and
problem-solving were also important components of successful
Medicine & Science in Sports & Exercised 1063
 programs (16). Our findings suggest that after TKA, people
do not walk as much or as quickly as age-matched individuals.
Patients may benefit from having further assessment after the
CLINICAL SCIENCES
acute phase of rehabilitation is complete to determine any
factors that limit their ability to walk faster and further.
Gaining a better understanding of factors that influence en-
gagement in physical activity after TKA (e.g., previous ac-
tivity habits, comorbidities, continuing symptoms about the
knee, and sociocultural factors) may allow for more effective
and individually-targeted interventions (20,49).
This study had several limitations as well as strengths.
Although the postoperative participants were highly con-
sistent in terms of time since surgery (median = 52 wk,
interquartile range = 4), the preoperative participants were
on a waiting list and we do not know when they received
surgery, which means they may have been a more hetero-
geneous group. Our sample size was relatively small, and
because eight preoperative participants did not meet wear
time criteria for inclusion in the study (perhaps because very
long sedentary bouts were incorrectly classified as nonwear
time), our results may underestimate sedentary time and/or
overestimate activity time in the preoperative group. How-
ever, we are confident that this did not substantially affect
our findings because they are consistent with previous litera-
ture reporting sedentary behavior (35) and physical activity
(46,47) in people with osteoarthritis. We sampled pre- and
postoperative people at the same point in time and were un-
able to measure changes in individual participants before and
after surgery. Nevertheless, our sample was representative of
patients who have osteoarthritis requiring TKA in Canada in
terms of age (8) and body mass index (7).
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In summary, although less individuals report knee pain
and most report improved function after TKA, levels of sed-
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