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Original Investigation
February 16, 2021

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

Author Affiliations
  • 1J.B. Snow Biomechanics Laboratory, Department of Health and Exercise Science, Wake Forest University, Winston-Salem, North Carolina
  • 2Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 3Department of Health and Exercise Science, Wake Forest University, Winston-Salem, North Carolina
  • 4Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 5Department of Kinesiology, East Carolina University, Greenville, North Carolina
  • 6Department of Radiology and Radiologic Science, Vanderbilt University, Nashville, Tennessee
  • 7Rheumatology Department, Royal North Shore Hospital and Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Sydney, Australia
  • 8Department of Radiology, VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts
  • 9Department of Physiotherapy, The University of Melbourne, Parkville, Victoria, Australia
  • 10Division of Rheumatology, Allergy and Immunology and the Thurston Arthritis Research Center, University of North Carolina School of Medicine, Chapel Hill
JAMA. 2021;325(7):646-657. doi:10.1001/jama.2021.0411
Visual Abstract. Effect of High-Intensity Strength Training on Knee Pain and Knee Joint Compressive Forces Among Adults With Knee Osteoarthritis
Effect of High-Intensity Strength Training on Knee Pain and Knee Joint Compressive Forces Among Adults With Knee Osteoarthritis
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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