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Effect of exercise and gait retraining on knee adduction moment in people with knee osteoarthritis
Nafiseh Khalaj, Noor A Abu Osman, Abdul H Mokhtar, Mahboobeh Mehdikhani and Wan AB Wan Abas
Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine 2014 228: 190
originally published online 23 January 2014
DOI: 10.1177/0954411914521155

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Review Article

Proc IMechE Part H:

J Engineering in Medicine
2014, Vol. 228(2) 190–199
Effect of exercise and gait retraining on Ó IMechE 2014
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DOI: 10.1177/0954411914521155

knee osteoarthritis pih.sagepub.com

Nafiseh Khalaj1, Noor A Abu Osman1, Abdul H Mokhtar2, Mahboobeh

Mehdikhani1 and Wan AB Wan Abas1

Abstract
The knee adduction moment represents the medial knee joint load, and greater value is associated with higher load. In
people with knee osteoarthritis, it is important to apply proper treatment with the least side effects to reduce knee
adduction moment and, consequently, reduce medial knee joint load. This reduction may slow the progression of knee
osteoarthritis. The research team performed a literature search of electronic databases. The search keywords were as
follows: knee osteoarthritis, knee adduction moment, exercise program, exercise therapy, gait retraining, gait modifica-
tion and knee joint loading. In total, 12 studies were selected, according to the selection criteria. Findings from previous
studies illustrated that exercise and gait retraining programs could alter knee adduction moment in people with knee
osteoarthritis. These treatments are noninvasive and nonpharmacological which so far have no or few side effects, as
well as being low cost. The results of this review revealed that gait retraining programs were helpful in reducing the knee
adduction moment. In contrast, not all the exercise programs were beneficial in reducing knee adduction moment.
Future studies are needed to indicate best clinical exercise and gait retraining programs, which are most effective in
reducing knee adduction moment in people with knee osteoarthritis.

Keywords
Knee joint load, gait modification, knee osteoarthritis, exercise, gait retraining

Date received: 16 March 2013; accepted: 2 January 2014

Introduction Measurement of the knee joint moment provides a

Osteoarthritis (OA) of the knee is one of the most com-
mon types of joint disease.1–3 It is associated with clini-
cal symptoms such as pain and stiffness in the knees,
decreased range of motion and muscle weakness,4–7
which are responsible for limitations in an individual’s
ability to perform physical activities and can lead to an
impaired quality of life.8–10 Some biomechanical factors
are related to knee OA, and the knee adduction
moment (KAM) is one of them.
The KAM is a reliable external measure of medial
compartment load of the knee during walking.11–13 It
results from the combination of the ground force acting
at the knee joint during normal walking (stance phase)
and the perpendicular distance that this force acts from
the center of the knee joint12,14–16 (Figure 1). KAM
shows two peaks during gait cycle: the first one is
through the early stance and the second peak is during
the late stance. The KAM during gait tends to thrust
the knee into varus, increasing the load across the med-
ial tibiofemoral articular cartilage16,17 (Figure 2).
direct indication of the knee joint load. Larger KAMs
correlate to increased joint loads, which are implicated
in the knee OA progression,11,13,18–20 as well as being
higher in people with knee OA.21–25 This higher KAM
was reported to be related to OA severity grade,18,22,26
varus alignments19,22,27 and the presence of pain in
patients with symptomatic knee OA.28
Importantly, KAM is one of only a few known
modifiable risk factors for knee OA progression.19
Thus, preventive strategies targeting this mechanical
risk factor are essential to reduce KAM during gait
1
Department of Biomedical Engineering, Faculty of Engineering,
University of Malaya, Kuala Lumpur, Malaysia
2
Department of Sports Medicine, Faculty of Medicine, University of
Malaya, Kuala Lumpur, Malaysia
Corresponding author:
Nafiseh Khalaj, Department of Biomedical Engineering, Faculty of
Engineering, University of Malaya, Kuala Lumpur 50603, Malaysia.
Email: nafisehkhalaj@siswa.um.edu.my; nafisehkhalaj@hotmail.com

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Khalaj et al.
Figure 1. Knee adduction moment.
Figure 2. Knee adduction moment graph during stance phase
of the gait cycle.
and, consequently, reduce medial joint loading.
Exercise programs and gait retraining are two nonsur-
gical intervention protocols that are used to reduce the
KAM in people with knee OA. These interventions aim
to slow the progression of knee OA and minimize the
functional limitations. Gait retraining is a noninvasive
and nonpharmacological treatment that modifies gait
pattern by using different strategies. Several sources
have proposed gait modifications as a means of
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191
influencing KAM. Their recommendations include
barefoot gait,29 gait with the toes pointed outward,30
toe-in gait, shorter stride, medial thrust gait31 and
increased medio-lateral trunk sway32 (Figure 3). These
strategies helped to reduce the KAM during gait in
people with knee OA. In addition, exercise programs
are also intervention protocols used to diminish KAM.
Muscle weakness may be one of the earliest features of
OA,33 so training the appropriate muscle by using dif-
ferent types of exercise will influence disease
progression.34
The peak KAM has become a quantitative goal for
clinical treatment of knee OA,35 and interventions that
have the potential to both improve the symptoms and
decrease the KAM are precious. However, according to
the economic burden of surgical treatments, applying
alternative treatments that are noninvasive and low cost
with minimal side effects becomes essential. Given the
essential role that KAM has on knee OA, this review
aimed to examine the effect of exercise and gait retrain-
ing interventions on KAM in people with knee OA.
Method
The literature searches were performed in four elec-
tronic databases: ScienceDirect, Wiley, Springer and
PubMed (1995–2012). The search terms included the
following: knee OA, KAM, exercise, exercise therapy,
gait retraining, gait modification and knee joint load-
ing. Combination of these terms was used for searching
(as appropriate); for instance, ‘‘gait modification and
KAM.’’ The original electronic search produced 85 ini-
tial papers of which the team excluded 73 based on
information contained in the title or abstract. All these
studies were in English, and the search excluded review
articles and studies that retrained the gait using gait
aids. In addition, only studies that used gait modifica-
tion strategies for the purpose of gait retraining were
included. Finally, the team identified a total of 12 stud-
ies as relevant to this review. The study design, study
size, anthropometric data, measurement protocols and
results of all the articles were reviewed.
Results
KAM is a surrogate measure of medial knee joint load
during gait that is often used in knee OA patients. Gait
retraining and exercise programs are noninvasive simple
treatments used to alter KAM in knee OA patients.
Gait retraining was proposed as a method for lowering
KAM by modifying gait pattern. Clinical guidelines
reinforce the importance of conservative and nonphar-
macological treatment for knee OA patients36,37 such as
exercise.38,39 Exercise is one of the best treatments with
little or no side effects.40,41 In total, 12 articles were
selected for this review; 8 of these selected articles stud-
ied people with knee OA, and the rest studied healthy
people with no knee OA and extended their results to
192 Proc IMechE Part H: J Engineering in Medicine 228(2)

Figure 3. Gait modification protocols.

Table 1. Characteristics of the participants.

Author, year Sample Sample size Gender Age, mean (SD) BMI, mean (SD)
Male Female

Thorstensson et al., 200742 Knee OA patients 11 6 5 54.6 (5.43) 25.5 (2.56)

Fregly et al., 200731 Knee OA patients 1 1 n/a 37 23.88
King et al., 200843 Knee OA patients 14 12 2 48.35 (6.51) 29.3 (3.3)
Sled et al., 201044 Knee OA patients 40 17 23 62.98 (9.73) 27.38 (5.47)
Control group 40 17 23 64.13 (9.04) 24.04 (3.24)
Thorp et al., 201033 Knee OA patients 6 1 5 59.7 (17.2) 30 (4.1)
Bennell et al., 201045 Knee OA patients 39 20 19 64.78 23.08
Control group 37 21 16 64.96 28.06
Foroughi et al., 201146 Knee OA patients 26 n/a 26 66 (8) 31.4 (5.4)
Control group 28 n/a 28 65 (7) 32.7 (8.4)
Simic et al., 201247 Knee OA patients 22 n/a n/a 68.4 (10.2) 27.9 (4.8)
Barrios et al., 201048 Healthy subjects 8 7 1 21.4 (1.6) 23.41
Hunt et al., 201114 Healthy subjects 9 3 6 18.6 (0.7) 22.29
Shull et al., 201149 Healthy subjects 9 6 3 26.6 (4.1) 21.89
Wheeler et al., 201115 Healthy subjects 16 11 5 29 n/a

OA: osteoarthritis; SD: standard deviation; BMI: body mass index; n/a: not available.

knee OA patients. The summary and results of the
reviewed articles can be found in Tables 1–3. In addi-
tion, Figure 4 provides information about participants
(healthy and knee OA) and the interventions.
Table 1 presents characteristic data of the 12 studies
and included sample (healthy or knee OA subjects),
sample size, gender, age and body mass index (BMI).
Weight means were calculated for some of the studies,
as needed. The reviewed articles provided data on 201
participants allocated to intervention programs and 105
participants allocated to control group. The number of
subjects ranged from 1 to 76. The age (mean) varied
from 26 to 68 years. Three of these studies had control
group, in which one of them was healthy44 and two
were knee OA.45,46 Sled et al.44 and Bennell et al.45 did
not use any intervention; however, Foroughi et al.46
used sham exercise for control group.
Table 2 provides brief information about the content
of the studies, which assessed the effect of exercise on
KAM. This table provides information on the OA
severity grade, OA measurement protocols, type of
intervention, motion measurement tool, duration of
treatment and results. Exercise programs aimed to
improve the strength of the lower extremity muscles,
and their intensity ranged from moderate to high.
However, the mode of exercise programs was different,
and three of six studies applied home exercise pro-
grams. The treatment duration ranged from 4 to 12
weeks.
The measurement protocols for diagnosis of knee
OA and indicating the severity were the Kellgren–
Lawrence (K/L) scale and MRI. The K/L scale is used
to diagnose the severity grade (four grades) of knee OA
through the use of radiography (X-ray). According to
K/L scale, grade 1 is doubtful knee OA, in which nar-
rowing of the joint space and possible osteophytes can
be seen. Grade 2 is mild knee OA, with small osteo-
phytes and possible narrowing of the joint. Grade 3 is

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 Table 2. Exercise intervention data in knee OA patients.

Author, year Knee OA OA measurement Type of intervention Measurement tool Treatment duration Results
Khalaj et al.

grade protocol

Thorstensson 1, 2, 3 K/L scale, KOOS Supervised moderate Vicon (six cameras); 8 weeks (twice per Reduction in peak knee adduction moment
et al., 200742 exercise program AMTI force plate week) during one leg rise
(strength and motor
control)
No significant changes in knee adduction
moment during gait in the index and the
opposite knee (comfortable fast walking)
King et al., 200843 1, 2, 3, 4 K/L scale, KOOS, Isokinetic resistance Motion capture system 12 weeks (three No significant change in mean peak knee
ASES training (high intensity) (eight cameras); force times per week) adduction moment during gait (self-selected
platform normal walking)
No change in the mean pain values and levels of
function
Sled et al., 201044 2a K/L scale Home strengthening Optotrak 3020 8 weeks (three to No reduction in knee adduction moment (self-
exercise program optoelectronic (two four times per selected normal walking speed)b
cameras); two AMTI week)
force plates
Functional improvement (sit to stand) and knee
pain reduction
Thorp et al., 2, 3 K/L scale, Home exercise; Optoelectronic (four 4 weeks (eight Reduction in knee adduction moment following
201033 WOMAC strengthening exercise cameras); force plate training sessions) exercise intervention (self-selected normal, fast
and slow walking)
Knee pain reduction
Bennell et al., 2, 3, 4 K/L scale, Home exercise designed Vicon (eight cameras); 12 weeks (five This exercise program had no significant effect
201045 WOMAC, PASE to strengthen the muscles two force plates times per week) on knee adduction moment; however, improved
symptoms and function (self-selected normal
walking speed)

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Improved symptoms (pain) and physical function
Foroughi et al., 1, 2, 3, 4 WOMAC, MRI High-intensity resistance Motion Analysis 6 months (three No change in the first peak of knee adduction
201146 training Corporation (10 times per week) moment (self-selected and maximum walking
cameras); two force speeds)
plates
Improved pain

OA: osteoarthritis; K/L: Kellgren–Lawrence; KOOS: Knee Injury and Osteoarthritis Outcome Score; ASES: Arthritis Self-Efficacy Scale; WOMAC: Western Ontario and McMaster Universities Arthritis Index; MRI:
magnetic resonance imaging.
Treatment duration: period of treatment (the number of sessions per week).
a
The median Kellgren–Lawrence grade for knee OA group was 2 and mean (SD) was 2.5 (0.91).
b
Control group had lower peak KAM than knee OA group.
193
 Table 3. Gait retraining data in knee OA patients and healthy subjects.
194

Author, year Subjects Type of intervention Utilities used for Measurement tool Results
intervention

Fregly et al., 200731
Simic et al., 201247
Barrios et al., 201048
Hunt et al., 201114
Shull et al., 201149
Wheeler et al., 201115
Knee OA Gait training by using gait
modification (medial
thrust gait pattern)
Knee OA Gait modification by using
increasing trunk lean
motion (6°, 9°, 12°)
Healthy Systematic gait retraining
program
Healthy Gait retraining by lateral
trunk lean (4°, 8°, 12°)
during gait
Healthy Gait retraininga
Healthy Gait retraining (self-
selected gait modification)
9 months self-training Motion analysis (six Reduction in knee adduction torque by 39%–
cameras); force plate 50% in the first peak and 37%–55% in the second
peak
After 1.5 years of using this gait pattern, knee
pain reduced without any problem in other
joints (self-selected walking speed)
Trained by Vicon (eight MX KAM was reduced following increased trunk lean
physiotherapist using cameras); three AMTI during gait (gait speed similar to the natural
visual real-time force plates walking trials)
biofeedback
Real-time visual and Vicon (eight cameras); 20% average reduction in peak KAM (walking
verbal feedback force plate velocity maintained at 1.46 m/s 6 2.5%)
Real-time visual Vicon (eight MX Lateral trunk lean reduced the peak KAM,
biofeedback cameras); two force particularly in medium and large trunk lean
plates condition (self-selected walking speed)
Haptic device (wearable) Vicon (eight cameras); KAM reduced by 29%–48% (self-selected walking
real-time feedback force plate speed)
Vibration and visual Vicon (eight cameras); Reduced KAM in altered gaits compared with
feedback split-belt force plate baselineb
treadmill

OA: osteoarthritis; KAM: knee adduction moment.

a
Gait retraining consisted of increased toe-in, increased toe-out, increased trunk sway and increased tibia angle.
b
Walking speed is not available.

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Proc IMechE Part H: J Engineering in Medicine 228(2)
Khalaj et al.
Knee Osteoarthritis
(n=224)
Intervention
(n=159)
No intervention and
Gait retraining Exercise program
sham exercise
Figure 4. Information about participants.
moderate knee OA, which is characterized by multiple,
moderately sized osteophytes; definite joint space nar-
rowing and possible deformation of bone ends. Finally,
grade 4 which is considered as severe knee OA and is
presented by multiple large osteophytes, severe joint
space narrowing, marked sclerosis and definite bony
end deformity. In addition, various questionnaires were
used to assess pain and physical abilities in individuals
with knee OA, including the Western Ontario and
McMaster Universities Arthritis Index (WOMAC), the
Knee Injury and Osteoarthritis Outcome Score
(KOOS) and the Arthritis Self-Efficacy Scale (ASES).
WOMAC is a set of standardized questionnaires used
to assess pain, stiffness and physical function in
patients who suffer from OA of the knee and hip.
KOOS is an instrument used to assess the patient’s
opinion about his or her knee and any associated prob-
lems. In addition, ASES is a self-administered, disease-
specific questionnaire that consists of 20 questions
about physical function, pain and other symptoms.
Table 3 presents the information of the studies that
involved gait retraining in both healthy subjects and
people with knee OA. This table contains information
on the type of intervention, the utilities used for inter-
vention, the applied measurement tools and the final
results. Six articles applied gait retraining in their stud-
ies: two of them provided data about knee OA patients
and four about the healthy subjects. The gait modifica-
tion was done by using biofeedback, which is a promis-
ing approach for gait modification training. A
biofeedback gait training system can deal with mea-
surement, analysis, training and evaluation of gait and
provides precise ‘‘feedback’’ information to the user. In
other words, it provides additional highly detailed sen-
sory information (feedback) through sensory modal-
ities,50 including visual, auditory and tactile
biofeedback in response to physical action. It provides
information on body sway51 and is used to attain the
precise amount of lean required.52 The knee loading
modification was feasible by using visual, audio, verbal
and tactile feedback.48,53,54 Furthermore, one study
used a haptic device for gait retraining.49 Haptic device
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195
Participants
(n=306)
Healthy
(n=82)
Control Intervention Control
(n=65) (n=42) (n=40)
Gait retraining No intervention
is a sensible technology that provides both tactile and
force feedback.
Discussion
The KAM is an important biomechanical risk marker
(of knee load) that can be used as a surrogate measure
for knee joint load during gait.11,12,35,55 Increased
KAM is indicative of the increased load on knee joints,
particularly medial compartment.12,56 The knee OA is
associated with higher KAM, and the findings of
Miyazaki et al.19 revealed that a one-unit increase in
KAM is associated with up to a 6.5 times increase in
the risk of knee OA progression.19 People with knee
OA walked with higher KAM compared to healthy
people, which demonstrates the increased knee joint
load in a medial compartment of the knee.21 Moreover,
the KAM is one of the known modifiable biomechani-
cal risk factor for knee OA progression.19 Therefore,
there is great interest in reducing the KAM by noninva-
sive treatment interventions in order to delay the pro-
gression of the disease. Some of the recent treatments
used to reduce KAM in knee OA are gait retraining
and exercise programs.
Gait retraining (gait pattern modifications) is a non-
invasive early treatment for people with knee OA, and
it can be effective in reducing KAM. The gait modifica-
tions that were used for gait retraining were toeing-out,
toeing-in, walking with decreased stride length, walking
with medial–lateral trunk lean and medial thrust
gait.14,15,31,47–49 A few studies used trunk lean motion,
and all the studies reported similar findings, which was
increased in trunk lean and is associated with decreased
KAM.14,47 Hunt et al.14 modified the gait pattern by
increasing the lateral trunk lean motion to the domi-
nant side (not bilaterally) by 4°, 8° and 12° soon after
the initial foot contact. Their findings revealed that
greater amount of trunk lean would result in larger
decrease in KAM. Moreover, it is interesting to note
that the combination of trunk lean (increased the trunk
sway by 7°–17°) and toe-in in healthy subjects decreases
the first peak of KAM, as confirmed by the findings of
196
Shull et al.49 They used different gait modification
methods including increased toe-in, increased toe-out,
increased trunk sway and increased tibia angle. In
order to do the modification, haptic feedback was used,
including tactor vibration motors (foot progression
angle) and rotational skin stretch devices (trunk sway
changes). Nonetheless, it is unclear whether multi-para-
meter, real-time feedback will be equally effective for
older subjects because of a potential deficiency in their
haptic sensation, proprioception, stability and endur-
ance or learning abilities. Among all the studies that
used lateral lean trunk motion for gait retraining, Simic
et al.47 modified the gait pattern in knee OA patients.
Likewise, they reported that trunk lean is a feasible gait
modification, and increased lateral trunk lean toward
the symptomatic limb significantly reduces knee load
throughout stance phase. In addition, larger angles lead
to greater reductions; knee OA patients attained early
stance peak KAM reduction of 9.3% with a peak of
6.1° lean, 11.5% reduction with 8.7° lean and 14.9%
reduction with 11.1° lean.47
The foot progression which is toe-out and toe-in is
one of the strategies used in gait retraining; it involves
walking with an increased external and internal foot
progression angle. Shull et al.49 and Wheeler et al.15
used foot progression to modify the gait pattern. Shull
et al.49 increased toe-in and toe-out angle by 13°– 25°
and reported that toeing-in caused reductions in the
first peak of the KAM. Wheeler et al.15 suggested dif-
ferent gait modifications, and one of them was walking
with foot progression. They reported that the toe-in is
the most common reported modification, as well as toe-
out gait reduced the second peak of KAM but not the
first. In addition to reducing the KAM, greater toe-out
angle is associated with a reduction in the possibility of
knee OA progression.20 Decreasing the lever arm of the
ground reaction force (GRF) vector about the center of
knee joint might explain this reduction in KAM.57
There were a few other studies that also used other
gait retraining programs and reported the same results,
which was reduction in KAM after intervention. Fregly
et al.31 used an inverse dynamic-optimizing approach
for an individual with bilateral knee OA; it was
designed to produce ‘‘normal looking’’ gait motions
that were capable of reducing both adduction torque
peaks simultaneously. According to their procedure,
normal looking means a gait motion whose trunk
orientation, arm motion, foot path and pelvis transla-
tions are similar to the patient’s normal gait. The
patient underwent 9-month self-training; although the
patient experienced reduced knee pain without any
problems at other joints, he was incapable to revert
back to his pre-training gait.31 In addition, gait modifi-
cation (hip internal rotation and adduction) in varus
aligned healthy subjects also was associated with
reduced KAM.48 Barrios et al.48 applied eight gait
training sessions by using treadmill and visual feed-
back. They instructed the subjects to walk while bring-
ing their thighs inward. However, in contrast to Fregly
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Proc IMechE Part H: J Engineering in Medicine 228(2)
et al.31 study, the training protocol did not alter the
natural gait of participants.48 One significant limitation
of gait retraining studies with healthy subjects was that
the subjects were healthy and young who did not suffer
from knee OA, and it is unclear that the methods
would similarly reduce KAM in people with knee OA.
Weakness of muscles surrounding the knee may
diminish the ability to protect the knee, disposing it to
greater physical stress, structural damage and joint
degeneration.58 Mikesky et al.59 reported that patients
with higher quadriceps and hamstring strength walk
with a lower knee joint loading. Therefore, prescribing
exercise for people with knee OA is essential in order to
reduce joint pain and load and increase the physical
function. These exercise programs might be different in
type (strengthening, aerobic and range of motion), dura-
tion, intensity and frequency. Although people with knee
OA widely use strengthening exercise programs, the tar-
geted muscles are different. Thorp et al.33 prescribed tra-
ditional exercise for strengthening the quadriceps and
hamstrings, as well as hip muscle training (gluteus med-
ius and tensor fascia latae) for a duration of 4 weeks
(eight training sessions with physiotherapist). In addition
to training sessions, they performed home exercise for
15 min on days when they did not have session with
physiotherapist. KAM was reduced following their exer-
cise intervention.33 In contrast to Thorp et al.33 findings,
King et al.43 exercise program did not have any signifi-
cant effect on KAM. They used isokinetic resistance
training, three times a week for a duration of 12 weeks
with a minimum of 1 day rest between sessions; each ses-
sion lasted for 45 min. Their exercise training program
consisted of 5 min warm up (stationary cycling), knee
extensor and flexor stretches, and reciprocal concentric
isokinetic knee extension and flexion exercises.43
Additionally, it was reported that the moderate strength-
ening exercise program only reduced KAM during one
leg rise and had no significant effect on KAM during
gait.42 Thorstensson et al.42 had 16 supervised exercise
sessions during 8 weeks, aiming to improve strength and
neuromuscular control of lower limbs. Although Thorp
et al.33 exercise intervention was 4 weeks—shortest
period among other reviewed exercise programs—it was
effective in reducing KAM. Similarly, Thorstensson
et al.42 exercise program was effective in KAM reduc-
tion, but only during one leg rise and not during gait.
Both of these studies used supervised exercise program
and asked their subjects to perform exercise at home as
well as in sessions.
A few recent studies focused on strengthening the
hip abductor and adductor muscles.44–46 Although the
researchers used different exercise regimens for
strengthening of these muscles, the findings were simi-
lar. Home strengthening exercises for hip abductor
muscles, which were performed for both legs, did not
reduce the KAM in people with knee OA.44 Sled et
al.44 provided an exercise instruction booklet and
graded resistance elastic band for all the participants
and asked them to perform the exercise three to four
Khalaj et al.
times a week for a duration of 8 weeks and complete
each set of exercise when they feel fatigue. Similar to
this, a 12-week home exercise program (five times per
week) designed to strengthen the hip abductor and
adductor muscles had no significant effect on KAM
but led to significant reduction in pain and improve-
ment in physical function.45 Moreover, performing
high-intensity resistance training three times per week
for 6 months, which aimed to strengthen major lower
limb muscles, including hip abductor and adductor, did
not change the first peak of KAM compared to a con-
trol group who underwent the sham exercise.46
Reviewed studies used different exercise programs, and
only two were effective in reducing KAM. This is due
to different factors that affect the efficiency of exercise
programs, for instance, the adherence of the patients to
exercise and the mode of exercise.
Conclusion
The findings of the reviewed studies support the benefi-
cial effect of gait retraining in knee OA, and from the
few reviewed articles, it was found that gait retraining
may have positive effect in reducing KAM. The
reviewed studies have a number of limitations which
are the number of subjects, using healthy participants
and expanding the results to individuals with knee OA,
not considering the effect of their intervention on the
other joints and lack of follow-up which means it is
unclear whether they have long-term side effects. Also,
it is unclear whether these interventions, particularly
using a biofeedback method, which was applied on
healthy subjects, will be equally effective for older indi-
viduals with knee OA. However, more longitudinal
studies are needed to investigate different gait modifica-
tion protocols in knee OA patients considering the age,
gender and knee OA severity and indicate which gait
retraining program is more beneficial with fewer side
effects. On the other hand, not all the exercise pro-
grams were beneficial for KAM reduction. The benefi-
cial effect of exercise on reducing KAM depends on the
types of exercise chosen by the therapist or researcher.
Future studies need to investigate the effect of different
types of exercise programs with different intensity and
frequency on KAM, to indicate the best clinical exer-
cise framework for individuals with knee OA.
Declaration of conflicting interests
None.
Funding
This study was supported by UM/MOHE/HIR Project
No. D000010-16001.
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