Does a weight-training exercise programme given to patients four or more years after total knee arthroplasty improve mobility: A randomized controlled trial

Does a weight-training exercise programme given to patients four or more years after total knee arthroplasty improve mobility: A randomized controlled trial

Archives of Gerontology and Geriatrics 64 (2016) 45–50 Contents lists available at ScienceDirect Archives of Gerontology and Geriatrics journal home...

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Archives of Gerontology and Geriatrics 64 (2016) 45–50

Contents lists available at ScienceDirect

Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger

Does a weight-training exercise programme given to patients four or more years after total knee arthroplasty improve mobility: A randomized controlled trial Bayram Unvera,* , Serkan Bakirhanb , Vasfi Karatosunc a b c

School of Physiotherapy and Rehabilitation, Dokuz Eylül University, Izmir 35340, Turkey School of Health, Department of Physiotherapy and Rehabilitation, Izmir University, Izmir 35350, Turkey Department of Orthopaedics, School of Medicine, Dokuz Eylül University, Izmir 35340, Turkey

A R T I C L E I N F O

A B S T R A C T

Article history: Received 9 December 2014 Received in revised form 24 December 2015 Accepted 5 January 2016 Available online 6 January 2016

Aim: To investigate the effects of the home exercise therapy performed after at least four years postoperatively on skeletal muscle strength and functionality in patients with total knee arthroplasty (TKA). Methods: Sixty patients (age; 69.66  7.53, weight; 81.56  14.43 kg, 10 male, 50 female) followed up four or more years were randomly divided into two groups. An 8-week exercise program was designed for bilateral TKA patients. While the patients in one group were assigned to weighted exercise group, the patients in the other group were assigned to non-weighted exercise group. The primary outcome was the isometric muscle strength of quadriceps femoris (QF) and hamstring muscles assessed by Hand-Held Dynamometer. The secondary outcomes were the pain level, 30 s sit-to-stand test, 10 m walk test, range of motion, and the knee function score of the Hospital for Special Surgery. The assessments were performed before and after the treatment. Results: After treatment, significant differences were found in all evaluation parameters (except rest pain and range of motion) in favour of the weighted group. QF muscle strength changes (kg); weighted group: 1.99  1.70, non-weighted group: 0.51 1.14 (p = 0.000), 30 s sit-to-stand test changes (repetitions); weighted group: 3.66  2.23, non-weighted group: 1.70  1.95 (p = 0.000), 10 m walk test changes (seconds); weighted group: 2.60  1.30, non-weighted group: 0.83  3.51 (p = 0.000). Conclusion: Home exercise programs applied to TKA patients after at least four years postoperatively was effective in increasing muscle strength, decreasing severity of pain, and improving functional activities. The improvements were significantly greater in weighted compared with the non-weighted exercise group. ã 2016 Elsevier Ireland Ltd. All rights reserved.

Keywords: Arthroplasty Knee Exercises Late phase Physical therapy Rehabilitation Mobility Function

1. Introduction Muscle weakness is of particular concern after total knee arthroplasty (TKA) and, as such, interventions to improve skeletal muscle strength in patients with TKA are highly recommended. (Ciolac & Greve, 2011; LaStayo et al., 2009; Liao, Liou, Huang, & Huang, 2013; Maffiuletti, Bizzini, Widler, & Munzinger, 2010; Meier et al., 2008; Minns Lowe, Barker, Holder, & Sackley, 2012;

* Correspondence author at: Dokuz Eylul University, School of Physical Therapy and Rehabilitation, Department of Orthopedic Physiotherapy, TR-35340 Balçova, Izmir, Turkey. Fax: +90 2324124946. E-mail addresses: [email protected], [email protected] (B. Unver), [email protected] (S. Bakirhan), vasfi[email protected] (V. Karatosun). http://dx.doi.org/10.1016/j.archger.2016.01.003 0167-4943/ ã 2016 Elsevier Ireland Ltd. All rights reserved.

Petterson et al., 2009). In accordance, a great number of studies have investigated the efficacy of strength training in this population. (Ciolac & Greve, 2011; Frost, Lamb, & Robertson, 2002; Kramer, Speechley, Bourne, Rorabeck, & Vaz, 2003; LaStayo et al., 2009; Levine, McElroy, Stakich, & Cicco, 2013; Maffiuletti et al., 2010; Minns Lowe et al., 2012; Moffet et al., 2004; Petterson et al., 2009; Unver, Karatosun, & Bakirhan, 2005). Since the decrease in the quadriceps femoris (QF) muscle strength and limitations in functional activities are greater during the early postoperative period, thus far studies have mostly focus on this period (Frost et al., 2002; Huang, Chen, & Chou, 2012; Kramer et al., 2003; Levine et al., 2013; Liao et al., 2013; Maffiuletti et al., 2010; Minns Lowe et al., 2012; Moffet et al., 2004; Petterson et al., 2009; Unver et al., 2005). Few studies have investigated the effectiveness of rehabilitation programs after the first postoperative year in TKA

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patients (Ciolac & Greve, 2011; LaStayo et al., 2009). Considering the small sample size, variability in the amount of time since TKA surgery, minimal invasive surgical technique used, and the inclusion of both unilateral and bilateral TKA’s, these studies were underpowered and their patients formed a heterogeneous cohort (Ciolac & Greve, 2011; LaStayo et al., 2009). The existing studies do not guide us on how to improve mobility in such situation. Strengthening exercises are the most effective intervention for improving muscle strength and functionality and have been recommended in the guidelines for knee osteoarthritis management and in clinical reviews for TKA rehabilitation (Ciolac & Greve, 2011; Frost et al., 2002; Iwamoto, Sato, Takeda, & Matsumoto, 2011; Meier et al., 2008; Minns Lowe, Barker, Dewey, & Sackley, 2007). Although there is still no evidence that the type of strengthening exercises (isometric, isotonic, isokinetic, concentric, concentriceccentric, and dynamic modalities) have an important impact on the program outcome (Carvalho, Bittar, Pinto, Ferreira, & Sitta, 2010; Ciolac & Greve, 2011; Frost et al., 2002; Iwamoto et al., 2011; Meier et al., 2008; Minns Lowe et al., 2007, 2012; Yilmaz, Polat, Karaca, Kucuksen, & Akkurt, 2013), progressive isometric and isotonic strengthening exercises with/without weights may be practical and they could be continued by older patients without difficulty at home (Carvalho et al., 2010; Frost et al., 2002; Huang et al., 2012; Iwamoto et al., 2011; Sashika, Matsuba, & Watanabe, 1996; Trudelle-Jackson & Smith, 2004; Yilmaz et al., 2013). According to literature, exercise programs including simple isometric and isotonic exercises without weights and range of motion exercises were also effective for increasing the skeletal muscle strength and functionality (Carvalho et al., 2010; Frost et al., 2002; Huang et al., 2012; Iwamoto et al., 2011; Petterson et al., 2009; Sashika et al., 1996; Trudelle-Jackson & Smith, 2004; Yilmaz et al., 2013). However, randomized controlled trials are warranted to investigate the effectiveness of strengthening exercises in individuals after a TKA. Therefore, we performed a single-blind randomized controlled trial to assess the efficacy of two different rehabilitation programs (weighted vs. non-weighted exercises), on skeletal muscle strength and functional capacity in patients with primary bilateral TKA with a standard paramedian incision at least 4 years ago. We hypothesized that (I) both of the exercise groups would significantly improve on all outcome measures after 8-week exercise program, and (II) the weighted exercise group would have significantly more improvements on all outcome measures compared with the non-weighted exercise group. 2. Participants and methods Sixty patients (mean age; 69.66  7.53 years, 10 male, 50 female, mean height; 159.93  7.22 cm, mean weight; 81.56  14.43 kg, BMI; 32.00  6.11 kg/cm2) followed up four or more years after bilateral TKA were included the study. The patients registered on the orthopedic physiotherapy department patient list, who had undergone bilateral TKA at least 4 years ago in Dokuz Eylul University Hospital, were recruited though the telephone calls. All participants provided written informed consent prior to participation. The preoperative diagnosis was knee osteoarthritis for all the patients. All operations were performed by the same surgeon (VK) using the paramedian approach. All knees were implanted with cemented and cruciate retaining TKA (Nexgen1, Zimmer, Warsaw, IN, USA). The inclusion criteria: The patients who (a) had had TKA at least 4 years ago, (b) had not developed operation-related complications (revision/infection), (c) had a Hospital for Special Surgery (HSS)

knee score below 85 and (d) underwent standard paramedian approach were included in the study. The exclusion criteria: Patients who (a) had heart, liver, renal, gastrointestinal or endocrinological diseases, malignancy, rheumatoid arthritis, gout, or a previous fracture of the lower limbs, (b) were not able to perform exercises or tests due to medical or musculoskeletal problems, (c) had neurological or medical conditions causing locomotor disability were excluded from the study. An experimental design with two groups was used. The study was designed as a single-blind randomized controlled trial. The patients were allocated into one of two groups using a Table of random numbers from a computer program and patients with numbers 1–30 were allocated to weighted exercise group (N = 30), and numbers 31–60 to non-weighted exercise group (N = 30). The patients were blind as to their intervention allocation. This study was approved by the Ethics Committee of Dokuz Eylul University Hospital (protocol number: 239/2009) and was in accordance with the Declaration of Helsinki. This study was conducted at the Dokuz Eylul University, School of Physical Therapy and Rehabilitation, a public, not-for-profit institution. 2.1. Intervention Subjects were allocated in a different set of exercises depending of group assignment. Subjects in the weighted exercise group performed 12 basic isometric, active resisted range of motion, various resisted straight leg raising exercises, and static stretching exercises for the lower limbs (Carvalho et al., 2010; Frost et al., 2002; Huang et al., 2012; Iwamoto et al., 2011; Petterson et al., 2009; Sashika et al., 1996; Trudelle-Jackson & Smith, 2004; Yilmaz et al., 2013). These exercises consisted of QF sets, hamstring sets, ankle pumps, terminal knee extension with weight, straight leg raising with weight in supine, side-lying, and prone, hip and knee flexionextension with weight in supine, knee flexion-extension with weight in prone, and in sitting, static stretching exercises for hamstrings and gastrosoleous muscles. For weighted exercises, De Lateur’s technique, a method with stable low weight, was used (Yilmaz et al., 2013). They started with the lowest weight (1 kg) and progressed up to a maximum of 2 kg. We choose De Lateur’s technique, because it has been generally suggested that resistance exercise intensity should have a slower and decreased rate of progression in older adults than in younger adults, mainly in older adults with physical limitations (Ciolac & Greve, 2011; Yilmaz et al., 2013). The exercise protocol for the non-weighted exercise group was similar to weighted exercise group. But all exercises were performed without weight. Subjects in both groups were instructed to perform 10 repetitions of each exercise at home one time a day for 8 weeks. The first follow-up visit was scheduled within the first 2 weeks to ensure that subjects were performing the exercises correctly and to progress the exercises as needed. If patients were experiencing increased pain, the intensity of the exercise program was not changed. Otherwise, all exercises were progressed to 15 repetitions. A second follow-up visit was scheduled within the next 2 weeks after the first visit. During the second follow-up visit, exercises were again checked for proper form and progressed to 20 repetitions. After the second follow-up visit, subjects continued to exercise on their own at home for the remainder of the 8-week period. The patients took no pain medication during the intervention. All these interventions were supervised by the same physiotherapist (SB).

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2.2. Assessment procedure and outcome measurement The primary outcome was the isometric muscle strength of QF and hamstring muscles. The secondary outcomes were the pain intensity level, 30 s sit-to-stand test, 10 m walk test, active range of motion, and the knee score of the HSS. The patients were evaluated before treatment and re-evaluated after the 8 weeks by the same physiotherapist (SB). The maximum isometric muscle strength of QF and hamstring muscles of all the patients was measured using Hand-Held Dynamometer (HHD) (model 01 163, Lafayette Instrument Company, Lafayette, Ind., USA). Before the measurement, the subjects were seated with the hips on the edge of the bed, knees at 90 of flexion, feet free and arms crossed on the chest, without a support. Before the test was started, the subjects were orally informed about the application technique of the test. They were also asked to perform sub-maximal contraction against the evaluator’s hands in order to ensure the correct movement. Afterward the subjects completed maximum knee extension during the test, the physiotherapist performing the measurement stabilized the femur with one hand and placed the dynamometer perpendicularly over the leg 1–2 cm above the level of the malleoli with the other hand. During the test, while the physiotherapist stabilized the dynamometer, the person undergoing the test was asked to exert maximum force against the device. During the test, the “make test” technique which requires isometric contraction was used. (The “make test” is the exertion of maximum force by the person who was surveyed while the dynamometer is held stable by the investigator). When the knee extension was achieved, the participant was asked to continue maximum isometric contraction for 5 s. Then the mean value of three consecutive maximum contraction measurements taken at intervals of 60 s was obtained. For the maximum isometric muscle strength of hamstring muscles of all the patients was measured using HHD. Before the measurement, subjects lay prone on the bed, knees at 90 of flexion. Same measurement techniques were used. The use of HHD provides a quick, simple, valid, reliable and sensitive outcome measurement of the human muscle strength and a high level of agreement [intra-class correlation coefficient (ICC) = 0.91] can be obtained with this type of quantified muscle testing (Roy & Doherty, 2004). Pain intensity of the knees was measured by a numerical rating scale. Subjects were asked to verbally rate the pain in and around the knee during activity and rest on the numeric rating scale from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable (Notarnicola et al., 2011). The timed sit-to-stand test: This is an objective functional measure of strength correlating with ambulatory independence (Minns Lowe et al., 2012). The number of completed sit-to-stands (arms folded) in 30 s was recorded. The reliability, content and concurrent validity, and responsiveness for this test have been reported previously (ICC = 0.92) (Unver, Kalkan, Yuksel, Kahraman, & Karatosun, 2015). The 10 m timed walk test (in seconds): This measures functional physical activity in the elderly (Minns Lowe et al., 2012). The

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patients were asked to complete the 10 m distance between the two points at a normal walking speed. This measure is reliable and valid (ICC = 0.95–0.99) (Scivoletto et al., 2011). The HSS knee rating scale is a disease-specific test used to evaluate knee disabilities and methods of treatment, especially TKA. The knee physical function of all patients was evaluated using the HSS knee score criteria based on a total of 100 points. HSS knee scores can be used to evaluate a patient before knee surgery and to monitor his/her function after the surgery. HSS scoring system has been shown to be a reliable, valid, responsive and acceptable outcome measure (ICC = 0.98–0.99) (Narin, Unver, Bakirhan, Bozan, & Karatosun, 2014). The active knee range of motion was measured using a fullcircle manual goniometer made of flexible clear plastic with arms 30 cm in length. The patient positioned in the prone position. The ICC for knee flexion in the prone position with knee replacement was 0.97 (Unver, Karatosun, & Bakirhan, 2009a). 2.3. Statistical analysis All statistical analyses were performed with SPSS for Windows (version 15.0, SPSS Inc., 233 South Wacker Drive, 11th Floor, Chicago, IL, 60606-6307). The data were expressed as mean  standard deviation. The Kolmogorov–Simirnov test was used for the determination of the normal distribution. Independent-sample ttests were used to compare the data for two randomized groups at baseline. The paired t-test was used to assess the difference between the various pre-test and post-test values. Differences in the posttest scores between the groups at the end of the 8-week intervention were assessed by analysis of covariance, using the pre-test results for both groups as the covariate. The level of statistical significance for all tests for differences was set at p < 0.05. 3. Results Between January 2012 and May 2012, a total of 60 patients with bilateral TKA were included in the study. All patients completed the study. The two groups were similar in terms of their demographic characteristics (Table 1). A significant improvement was observed in all the post-treatment evaluation parameters of the weighted and non-weighted groups compared to those of the pre-treatment parameters (Table 2). Before the treatment, the HSS knee score was the only one significant difference between the weighted and non-weighted exercise groups in (Table 2). The post-test adjusted means for variables in both the weighted and non-weighted exercise groups, using the pre-test results for both groups as the covariate, are listed in Table 3. 3.1. Pain intensity After treatment, resting pain levels assessed by the numeric rating scale were not significantly different in the groups (p > 0.05). Activity pain level was significantly reduced in the weighted exercise group compared with the non-weighted exercise group (p = 0.000).

Table 1 Demographic characteristics of the patients.

Age, year Height, cm Weight, kg Body mass index, kg/cm2 Gender, male/female

Weighted treatment group (n = 30)

Non-weighted treatment group (n = 30)

p value

69.53  160.96  82.16  31.82  6M/24F

69.80  158.90  80.92  32.17  4M/26F

0.892 0.271 0.750 0.832 0.497

9.2 7.8 14.7 6.05

5.3 6.4 14.3 6.2

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Table 2 Changes in outcome for weighted treatment group and non-weighted treatment group. Items

Pretest

Posttest

Changes

95%CI

p

Mean (SD)

Mean (SD)

Mean

(SD)

(Low)

(High)

Pain at rest (numerical rating scale) Weighted treatment group Non-weighted treatment group

1.66 (1.12) 1.80 (1.62)

0.73 (0.98) 0.90 (1.37)

0.93 0.90

(0.86) (1.02)

0.609 0.515

1.257 1.284

0.000y 0.000y

Activity pain (numerical rating scale) Weighted treatment group Non-weighted treatment group

2.73 (1.59) 3.16 (2.00)

1.36 (1.09) 2.56 (1.56) **

1.36 0.60

(1.27) (1.19)

0.891 0.154

1.841 1.045

0.013y 0.000y

Quadriceps muscle strength (kg) Weighted treatment group Non-weighted treatment group

10.58 (1.90) 9.76 (1.88)

12.57 (1.53) 10.28 (1.84) **

1.99 0.51

(1.70) (1.14)

2.624 0.946

1,355 0.905

0.000y 0.000y

Hamstring muscle strength (kg) Weighted treatment group Non-weighted treatment group

7.11 (1.43) 6.95 (1.78)

8.37 (0.98) 7.35 (1.20) **

1.25 0.40

(1.04) (1.51)

1.647 0.965

0.865 0.165

0.000y 0.000y

Knee flexion range of motion ( ) Weighted treatment group Non-weighted treatment group

91.81 (11.41) 93.06 (10.96)

96.16 (10.66) 97.30 (7.52)

4.35 4.23

(4.71) (6.70)

6.109 6.738

2.590 1.728

0.000y 0.000y

30 s Sit-to-stand test (repetitions) Weighted treatment group Non-weighted treatment group

13.16 (2.18) 11.96 (2.53)

16.83 (2.15) 13.66 (2.57) **

3.66 1.70

(2.23) (1.95)

4.500 2.428

2.832 0.971

0.000y 0.000y

10 m walk test (s) Weighted treatment group Non-weighted treatment group

9.26 (1.98) 9.83 (2.49)

6.66 (1.56) 9.00 (2.84) **

2.60 0.83

(1.30) (3.51)

2.113 0.478

3.086 2.145

0.008y 0.004y

79.65 (5.02) 74.26 (6.05) *

84.11 (4.84) 78.38 (4.94)

4.46 4.11

(5.54) (4.71)

6.535 5.907

2.397 2.326

0.000y 0.000y

HSS knee scores Weighted treatment group Non-weighted treatment group

**

*p < 0.05, **p < 0.05 (Differences between the weighted and non-weighted treatment groups were examined Independent t test). y p < 0.05 (Differences between pretest and posttest values of groups), HSS: Hospital for Special Surgery.

3.2. Muscle strength

4. Discussion

After treatment, the weighted exercise group had significantly more strength gain in QF and hamstring muscles compared with the non-weighted exercise group (p = 0.000).

In the present study, we investigated the effects of home exercise programs (weighted and non-weighted exercises), applied during the late-phase, on muscle strength and functional activities in patients with bilateral TKA. The results have showed that the weighted exercise group had a significant greater improvement in muscle strength and functional activities than those of non-weighted exercise group. It was found that weighted exercise programs especially focusing on the knee musculature had positive effects on the muscle strength, gait speed, and functional activities. There were two studies investigating the changes in the muscle strength and functional activities after the strengthening exercises in subjects at least one year after TKA. LaStayo et al. who investigated the effects of a 12-week resistance exercise on the muscle strength in patients having undergone TKA through Minimal Invasive Surgery reported that strengthening exercises increased the QF muscle strength significantly at the end of the first postoperative year (LaStayo et al., 2009). Ciolac and Greve (2011) reported that resistance exercises applied twice a week for 13 weeks are effective in increasing muscle strength on older female patients (n = 7) who got unilateral TKA (Ciolac & Greve, 2011). In our study, different from these studies, the patients (n = 60) having undergone bilateral TKA with the standard incision and followed 4 or more years were investigated.

3.3. Timed sit-to-stand test After treatment, the weighted exercise group had significantly more performance on the timed sit-to-stand test compared with the non-weighted exercise group (p = 0.000). 3.4. Timed 10 m walk test After treatment, the weighted exercise group had significantly more walking speed assessed by the timed 10 m walk test compared with the non-weighted exercise group (p = 0.000). 3.5. The HSS knee score After treatment, the weighted exercise group had significantly more functional gain in knee assessed by the HSS compared with the non-weighted exercise group (p = 0.009). There were no incidents of harm and adverse events related to the exercise intervention.

B. Unver et al. / Archives of Gerontology and Geriatrics 64 (2016) 45–50 Table 3 The posttest adjusted means of variables in weighted treatment group and nonweighted treatment group, using pretest as covariate. Items

Mean

(SD)

95%CI

p

(Low)

(High)

Pain at rest (VAS) Weighted treatment group Non-weighted treatment group

0.73 0.90

(0.98) (1.37)

0.480 0.562

1.071 1.153

0.819

Activity Pain (VAS) Weighted treatment group Non-weighted treatment group

1.36 2.56

(1.09) (1.56)

1.14 2.10

1.82 2.78

0.000

Quadriceps muscle strength Weighted treatment group Non-weighted treatment group

12.57 10.28

(1.53) (1.84)

11.85 10.06

12.78 10.99

0.000

Hamstring muscle strength Weighted treatment group Non-weighted treatment group

8.33 7.37

(0.98) (1.20)

8.01 7.06

8.66 7.71

0.001

Knee flexion range of motion ( ) Weighted treatment group Non-weighted treatment group

96.16 97.30

(10.66) (7.52)

94.84 95.09

98.37 98.62

0.041

Sit-to-stand repetitions (30 s) Weighted treatment group Non-weighted treatment group

16.83 13.66

(2.15) (2.57)

15.86 13.02

17.75 13.94

0.000

10 m walk test (s) Weighted treatment group Non-weighted treatment group

6.66 9.00

(1.56) (2.84)

5.95 8.10

7.56 9.71

0.000

HSS knee scores Weighted treatment group Non-weighted treatment group

84.11 78.38

(4.84) (4.94)

81.25 77.96

84.53 81.24

0.009

HSS: Hospital for Special Surgery.

In our study, it was found that non-weighted and weighted exercises, although performed in the 4th year or more, helped to increase the muscle strength and functional activities. Our results support the findings of previous studies (Ciolac & Greve, 2011; LaStayo et al., 2009; Sashika et al., 1996; Trudelle-Jackson & Smith, 2004). However, in the current study both of the exercise programs were applied by the same physiotherapist. Therefore, either the experience or skills among physiotherapists was excluded. This seems as one of the strong points of our study. An imbalance between the QF and hamstring muscles changes the way the forces go through the joint due to abnormal cocontraction, leads to joint instability and abnormal movement patterns and thus early loosening of the prosthetic joint, which necessitates the revision of the prosthesis (Meier et al., 2008; Stevens-Lapsley, Balter, Kohrt, & Eckhoff, 2010). Knee osteoarthritis affects the hamstring muscle more than the QF muscle (Hafez et al., 2013). Therefore, changes in the hamstring muscle strength should be carefully analyzed. LaStayo et al. (2009) did not investigate the changes in the hamstring muscle strength. Ciolac and Greve (2011) investigated the changes in the QF and the hamstring muscle strength. In our study, different from the LaStoya et al.’s study (LaStayo et al., 2009), similar to Ciolac and Greve’s study (Ciolac & Greve, 2011), both of the QF and the hamstring muscle strength were investigated. Hamstring muscle strength was significantly increased more in the weighted exercise group than the nonweighted exercise group (Table 3). Our results were similar to the results of Ciolac and Greve (2011). Therefore, we consider that latephase strengthening exercises play an important role in the improvement of the hamstring muscle strength. Increases in both QF and hamstring muscle strength have been shown to increase general knee stability (Hafez et al., 2013). Enhanced knee stability results in reducing the loads on the prosthesis in the long term

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after TKA and in better functional performance of the lower extremity. In several studies, it has been determined that pain persists in 20–44% of the patients in the postoperative 3 and 4 years after TKA (Puolakka et al., 2010; Wylde, Hewlett, Learmonth, & Dieppe, 2011). There is no study investigating the effectiveness of exercise programs on the association between pain and knee muscle strength in the long term after TKA. In the present study, a significant reduction was observed in pain in both groups. However, it was determined that the weighted exercise program was more effective treatment method in the reduction of activityrelated pain than the non-weighted exercise program. We consider that this reduction in pain is probably due to the increase in the QF and hamstring muscles strength and the decrease in the forces acting on the prosthesis. These results were similar to the previous studies (Carvalho et al., 2010; Doi et al., 2008; Iwamoto et al., 2011; Yilmaz et al., 2013) Patients generally require at least 105 degrees of active knee flexion for basic daily activities (Unver, Karatosun, & Bakirhan, 2009a,2009b). In our study, the range of motion of the knee of the patients with TKA in both groups was determined to be lower than the patients reported in the literature. Therefore, we consider that it would be useful for the patients to continue performing range of motion exercises in the late-phase after TKA in order to better maintaining their functional activities. In several studies, a significant correlation has been reported between the QF muscle strength and the ability for the repetitions of the sit-to-stand test (Boonstra, Schwering, De Waal Malefijt, & Verdonschot, 2010; Minns Lowe et al., 2012; Unver et al., 2005). In our study, it was determined that the patients in the weighted exercise group were able to perform more repetitions in 30 s sit-tostand test compared with the patients in the non-weighted exercise group. This result obtained in this study is important because it indicates that the greater QF muscle strength in the weighted exercise group contributed to the increase the performance on the sit-to-stand test. After the TKA, the step length is shortened, double support time becomes longer, and a decrease occurs in walking speed and walking scores (Liao et al., 2013; Meier et al., 2008). The number of studies investigating the late-phase effects of different treatment methods on walking parameters after TKA is limited (Ciolac & Greve, 2011; LaStayo et al., 2009). Different from these studies, in our study, the effects of exercise programs on the walking speed were inspected and it was determined that the walking speed in the late-phase after the surgery was higher in the patients in the weighted exercise program than the patients in the non-weighted exercise program. This outcome is important because it shows that the weighted strength training program used in the present study may be effective in improving the walking speed of patients with TKA. In previous studies, home exercise programs (progressive isometric and isotonic strengthening exercises with/without weights), when performed regularly, were reported to have positive effects on muscle strength and functional capacity in arthroplasty and osteoarthritis patients (Carvalho et al., 2010; Doi et al., 2008; Huang et al., 2012; Iwamoto et al., 2011; Kramer et al., 2003; Sashika et al., 1996; Trudelle-Jackson & Smith, 2004; Yilmaz et al., 2013). Our results support the findings of previous studies. There are some certain limitations of our study. First, assessor physiotherapist was not blind. Second, the exercise program was applied as a home-based program; however an exercise diary was not kept to determine the compliance of patients to exercise and if they did the exercises or not. Third, our study sample included a large proportion of female patients, and only patients with bilateral TKA, and patients took no pain medication during the intervention. Thus, the generalization of the findings of our study to other populations should be made with caution. Finally,

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