Original ArticleThe reliability of isometric strength and fatigue measures in patients with knee osteoarthritis
Introduction
Lower limb muscle strength has been shown to be an important correlate of locomotor function in patients with osteoarthritis of the knee (Hurley, 1999; McCarthy and Oldham, 2004). Patients with osteoarthritis of the knee may suffer from arthrogenous inhibition of their quadriceps muscles due to joint effusion (Young, 1993); thus, muscle function may be more significantly affected in these patients than in other knee pain syndromes. Isometric muscle strength has been used as a reliable and valid method of assessing exercise treatment in these patients (Fisher et al., 1991, Fisher et al., 1993; Marks, 1993, Marks, 1994; Fisher and Pendergast, 1994). However, isolated knee, open kinetic chain testing may be undesirable or even contraindicated in pathological conditions of the knee joint (Palmitier et al., 1991). For example, greater muscle isolation of the quadriceps during open kinetic chain testing has been shown to produce extremely high and potentially damaging tibiofemoral joint shearing forces (Bynum et al., 1995; Wilk et al., 1996). Furthermore, Nisell and Ericson, 1999, demonstrated that patellar compression forces were almost 12 times higher than walking and six times higher than running during open kinetic chain knee extension testing. They advised that patients with patellofemoral pain undergoing open kinetic tests should only perform submaximal efforts, a principle at odds with the rationale of strength testing procedures where a maximum voluntary contraction is required.
However, the tibiofemoral and patellofemoral stresses generated during OKC testing can be reduced by using a closed kinetic chain “leg press” test (Steinkamp et al., 1993). The reliability of closed kinetic chain isometric peak torque testing has been shown to be excellent with healthy young subjects and subjects with patellofemoral pain (Callaghan et al., 2000) (intra-class correlation coefficients, ICCs of 0.82 and 0.92, respectively) but never established in subjects with knee osteoarthritis.
Patients with knee osteoarthritis complain of muscle fatigue and a number of methods of quantifying this effect have been proposed. One method of measuring endurance involves the monitoring of change in the electromyographical (EMG) signal from muscle during a sustained contraction. As a muscle maintains a contraction, a reduction in action potential velocity leads to a reduction in the median frequency of the EMG signal power spectrum (Bigland-Ritchie et al., 1981; Elfving et al., 2000). The rate of median frequency decline has been used as an index of muscle fatigue by a number of authors (Bigland-Ritchie et al., 1983; Dolan et al., 1995). The reliability of EMG spectral shift has been evaluated, using the closed kinetic chain isometric procedure, in the quadricep muscles of 20 young, healthy subjects (Callaghan et al., 2001). Callaghan et al. found inter-visit reliability to be acceptable in vastus medialis oblique (VMO ICC 0.72), vastus lateralis (VL ICC 0.74) but poor in rectus femoris (RF ICC 0.33). Thus, with a distinct lack of evidence, in relation to patients with knee osteoarthritis, this study aimed to evaluate the reliability of closed kinetic chain isometric testing and the rate of decline in EMG median frequency in subjects with knee osteoarthritis.
Section snippets
Design
The study was a intra-rater reliability study. Subjects were asked to perform a replicate assessment of lower limb “leg press” isometric extension strength and sustained sub-maximal isometric contraction on two occasions. The duration between tests was 1 week. The same rater rated all assessments.
Subjects
Ethical permission for the trial was obtained from the Central Manchester Healthcare Trust Local Research Ethics Committee (LREC). Written consent was obtained from subjects according to the
Results
The subjects were of the similar age and had levels of pain consistent with previous studies (Hurley and Scott, 1998), (see Table 1).
The reliability of the maximum voluntary isometric extension peak torque test was excellent, with an excellent ICC statistic, narrow 95% CIs and low SEM and SDD values (See Table 2). The initial median frequency indices also demonstrated excellent ICC and SDD statistics for all three heads of the quadriceps; however, the fatigue slopes for all three muscles were
Discussion
The reliability of measures of lower limb muscular strength and quadriceps muscle fatigue had not been established in patients with knee osteoarthritis, prior to this work. Due to the provocative nature of open kinetic chain in patients with knee pain (Bynum et al., 1995; Wilk et al., 1996) testing the reliability of these measures was undertaken using a less provocative, closed kinetic chain procedure. The inter-visit reliability of the strength and EMG measures was established and a number of
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