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Effect of High-Intensity Strength Training on Knee Pain and Knee Joint Compressive Forces Among Adults With Knee OsteoarthritisThe START Randomized Clinical Trial

Educational Objective
To learn the effect of high-intensity strength training on knee pain and knee joint compressive forces in patients with knee osteoarthritis.
1 Credit CME
Key Points

Question  Is high-intensity strength training more effective than low-intensity strength training and attention control for the outcomes of knee pain and knee joint compressive forces in participants with knee osteoarthritis?

Findings  In this randomized clinical trial involving 377 participants with knee osteoarthritis, high-intensity strength training, compared with low-intensity strength training and an attention control, did not significantly improve knee pain or knee joint compressive forces at 18 months.

Meaning  These findings do not support the use of high-intensity strength training over low-intensity strength training or attention control in adults with knee osteoarthritis.

Abstract

Importance  Thigh muscle weakness is associated with knee discomfort and osteoarthritis disease progression. Little is known about the efficacy of high-intensity strength training in patients with knee osteoarthritis or whether it may worsen knee symptoms.

Objective  To determine whether high-intensity strength training reduces knee pain and knee joint compressive forces more than low-intensity strength training and more than attention control in patients with knee osteoarthritis.

Design, Setting, and Participants  Assessor-blinded randomized clinical trial conducted at a university research center in North Carolina that included 377 community-dwelling adults (≥50 years) with body mass index (BMI) ranging from 20 to 45 and with knee pain and radiographic knee osteoarthritis. Enrollment occurred between July 2012 and February 2016, and follow-up was completed September 2017.

Interventions  Participants were randomized to high-intensity strength training (n = 127), low-intensity strength training (n = 126), or attention control (n = 124).

Main Outcomes and Measures  Primary outcomes at the 18-month follow-up were Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) knee pain (0 best-20 worst; minimally clinically important difference [MCID, 2]) and knee joint compressive force, defined as the maximal tibiofemoral contact force exerted along the long axis of the tibia during walking (MCID, unknown).

Results  Among 377 randomized participants (mean age, 65 years; 151 women [40%]), 320 (85%) completed the trial. Mean adjusted (sex, baseline BMI, baseline outcome values) WOMAC pain scores at the 18-month follow-up were not statistically significantly different between the high-intensity group and the control group (5.1 vs 4.9; adjusted difference, 0.2; 95% CI, −0.6 to 1.1; P = .61) or between the high-intensity and low-intensity groups (5.1 vs 4.4; adjusted difference, 0.7; 95% CI, −0.1 to 1.6; P = .08). Mean knee joint compressive forces were not statistically significantly different between the high-intensity group and the control group (2453 N vs 2512 N; adjusted difference, −58; 95% CI, −282 to 165 N; P = .61), or between the high-intensity and low-intensity groups (2453 N vs 2475 N; adjusted difference, −21; 95% CI, −235 to 193 N; P = .85). There were 87 nonserious adverse events (high-intensity, 53; low-intensity, 30; control, 4) and 13 serious adverse events unrelated to the study (high-intensity, 5; low-intensity, 3; control, 5).

Conclusions and Relevance  Among patients with knee osteoarthritis, high-intensity strength training compared with low-intensity strength training or an attention control did not significantly reduce knee pain or knee joint compressive forces at 18 months. The findings do not support the use of high-intensity strength training over low-intensity strength training or an attention control in adults with knee osteoarthritis.

Trial Registration  ClinicalTrials.gov Identifier: NCT01489462

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Article Information

Corresponding Author: Stephen P. Messier, PhD, J.B. Snow Biomechanics Laboratory, Department of Health & Exercise Science, Worrell Professional Center, Wake Forest University, 1834 Wake Forest Rd, Winston-Salem, NC 27109 (messier@wfu.edu).

Accepted for Publication: January 13, 2021.

Author Contributions: Drs Messier and Beavers had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Messier, Mihalko, Beavers, Nicklas, DeVita, Hunter, Bennell, Loeser.

Acquisition, analysis, or interpretation of data: Messier, Mihalko, Beavers, Carr, Hunter, Lyles, Guermazi, Bennell, Loeser.

Drafting of the manuscript: Messier, Mihalko, Beavers, Nicklas, DeVita, Bennell.

Critical revision of the manuscript for important intellectual content: Messier, Mihalko, Nicklas, Carr, Hunter, Lyles, Guermazi, Bennell, Loeser.

Statistical analysis: Beavers.

Obtained funding: Messier, Mihalko.

Administrative, technical, or material support: Messier, Beavers, Nicklas, DeVita, Carr, Hunter, Lyles, Guermazi, Loeser.

Supervision: Messier, Nicklas, Carr, Lyles.

Conflict of Interest Disclosures: Dr Messier reported receiving grants from the National Institute of Arthritis Musculoskeletal and Skin Diseases. Dr Mihalko reported receiving grants from the National Institutes on Health (NIH). Dr Beavers reported receiving grants from the NIH. Dr Nicklas reported grants from Wake Forest School of Medicine. Dr Hunter reported receiving personal fees from Pfizer, Lilly, Merck Serono, and TLCBio. Dr Guermazi reported receiving personal fees from MerckSerono, Pfizer, TissueGene, Galapagos, Roche, AstraZeneca, Boston Imaging Core Lab (BICL) LLC and is the president and founder of BICL. Dr Bennell reported receiving grants from the NIH, the National Health and Medical Research Council, and Medibank Private and personal fees from UpToDate. Dr Loeser reported receiving grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and Bioventus and personal fees from Unity Biotechnology. No other disclosures were reported.

Funding/Support: This study was supported by grants 1R01AR059105-01 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and P30 AG21332 from the National Institute on Aging.

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We thank the START research staff and the START participants for their important contributions. The participants did not receive compensation for their contributions, and the staff were not compensated besides their salaries.

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