Original research| Volume 97, ISSUE 6, P857-865, June 2016

Effects of Leg-Press Training With Moderate Vibration on Muscle Strength, Pain, and Function After Total Knee Arthroplasty: A Randomized Controlled Trial

Published:January 04, 2016DOI:


      • Muscle weakness and functional impairments often persist for years after total knee arthroplasty.
      • Untrained women, older people with knee osteoarthritis, and patients after total knee arthroplasty achieve improvements of knee muscle strength through whole-body vibration training and progressive resistance training.
      • Both functional physiotherapy and leg-press training with moderate vibrations are effective in improving strength and function in patients after total knee arthroplasty.
      • Leg-press training involving moderate vibration is a safe, effective, and time-saving procedure in restoring muscle strength and functional capacity shortly after total knee arthroplasty.



      To examine the effects of a time-saving leg-press training program with moderate vibration on strength parameters, pain, and functional outcomes of patients after total knee arthroplasty (TKA) in comparison with functional physiotherapy.


      Randomized controlled trial.


      Outpatient rehabilitation department at a university teaching hospital.


      Patients (N=55) with TKA were randomly allocated into 2 rehabilitation groups.


      Six weeks after TKA, participants either underwent isokinetic leg-press training combined with moderate vibration (n=26) of 15 minutes per session or functional physiotherapy (n=29) of 30 minutes per session. Both groups received therapy twice a week for a period of 6 weeks. Participants were evaluated at baseline (6wk after TKA) and after the 6-week rehabilitation program.

      Main Outcome Measures

      The main outcome measure was maximal voluntary contraction (MVC) of the involved leg. Secondary outcome measures were pain assessed with a visual analog scale (VAS), range of motion, stair test, timed Up and Go test, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).


      Both groups showed statistically significant improvements in MVC of knee extensors measured on the knee dynamometer (leg-press group: from 0.8±.06 to 1±.09Nm/kg body weight [BW], physiotherapy group: from 0.7±.06 to 0.9±.06Nm/kg BW; P<.05) and in closed kinetic chain on the leg press (leg-press group: from 8.9±.77 to 10.3±1.06N/kg BW, physiotherapy group: from 6.7±.54 to 9.1±.70N/kg BW; P<.05) and in pain at rest (leg-press group: from 2±.36 to 1.3±.36 on the VAS, physiotherapy group: from 1.2±.28 to 1.1±.31; P<.05), WOMAC scores, and functional measurements after 6 weeks of training. There was no significant difference between the 2 groups concerning strength, pain, and functional outcomes after training (P>.05).


      Isokinetic leg-press training with moderate vibration and functional physiotherapy are both effective in regaining muscle strength and function after TKA; however, isokinetic leg-press training is considerably less time consuming.


      List of abbreviations:

      BW (body weight), MVC (maximal voluntary contraction), ROM (range of motion), TKA (total knee arthroplasty), TUG (timed Up and Go), VAS (visual analog scale), WBV (whole-body vibration), WOMAC (Western Ontario and McMasters University Osteoarthritis Index)
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      1. Eurostat Statistics Database. 2015. Accessed January 26, 2016.

        • Walsh M.
        • Woodhouse L.J.
        • Thomas S.G.
        • Finch E.
        Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects.
        Phys Ther. 1998; 78: 248-258
        • Ritter M.A.
        • Berend M.E.
        • Harty L.D.
        • Davis K.E.
        • Meding J.B.
        • Keating E.M.
        Predicting range of motion after revision total knee arthroplasty: clustering and log-linear regression analyses.
        J Arthroplasty. 2004; 19: 338-343
        • LaStayo P.C.
        • Meier W.
        • Marcus R.L.
        • Mizner R.
        • Dibble L.
        • Peters C.
        Reversing muscle and mobility deficits 1 to 4 years after TKA: a pilot study.
        Clin Orthop Relat Res. 2009; 467: 1493-1500
        • Moffet H.
        • Collet J.P.
        • Shapiro S.H.
        • Paradis G.
        • Marquis F.
        • Roy L.
        Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: a single-blind randomized controlled trial.
        Arch Phys Med Rehabil. 2004; 85: 546-556
        • Bade M.J.
        • Kohrt W.M.
        • Stevens-Lapsley J.E.
        Outcomes before and after total knee arthroplasty compared to healthy adults.
        J Orthop Sports Phys Ther. 2010; 40: 559-567
        • Pozzi F.
        • Snyder-Mackler L.
        • Zeni J.
        Physical exercise after knee arthroplasty: a systematic review of controlled trials.
        Eur J Phys Rehabil Med. 2013; 49: 877-892
        • Schache M.B.
        • McClelland J.A.
        • Webster K.E.
        Lower limb strength following total knee arthroplasty: a systematic review.
        Knee. 2014; 21: 12-20
        • Minns Lowe C.J.
        • Barker K.L.
        • Dewey M.
        • Sackley C.M.
        Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials.
        BMJ. 2007; 335: 812
        • Stevens-Lapsley J.E.
        • Balter J.E.
        • Kohrt W.M.
        • Eckhoff D.G.
        Quadriceps and hamstrings muscle dysfunction after total knee arthroplasty.
        Clin Orthop Relat Res. 2010; 468: 2460-2468
        • Vahtrik D.
        • Gapeyeva H.
        • Aibast H.
        • et al.
        Quadriceps femoris muscle function prior and after total knee arthroplasty in women with knee osteoarthritis.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 2017-2025
        • Huang C.H.
        • Cheng C.K.
        • Lee Y.T.
        • Lee K.S.
        Muscle strength after successful total knee replacement: a 6- to 13-year followup.
        Clin Orthop Relat Res. 1996; : 147-154
        • Berth A.
        • Urbach D.
        • Awiszus F.
        Improvement of voluntary quadriceps muscle activation after total knee arthroplasty.
        Arch Phys Med Rehabil. 2002; 83: 1432-1436
        • Meier W.
        • Mizner R.L.
        • Marcus R.L.
        • Dibble L.E.
        • Peters C.
        • Lastayo P.C.
        Total knee arthroplasty: muscle impairments, functional limitations, and recommended rehabilitation approaches.
        J Orthop Sports Phys Ther. 2008; 38: 246-256
        • Boonstra M.C.
        • De Waal Malefijt M.C.
        • Verdonschot N.
        How to quantify knee function after total knee arthroplasty?.
        Knee. 2008; 15: 390-395
        • Valtonen A.
        • Poyhonen T.
        • Heinonen A.
        • Sipila S.
        Muscle deficits persist after unilateral knee replacement and have implications for rehabilitation.
        Phys Ther. 2009; 89: 1072-1079
        • Farquhar S.
        • Snyder-Mackler L.
        The Chitranjan Ranawat Award: the nonoperated knee predicts function 3 years after unilateral total knee arthroplasty.
        Clin Orthop Relat Res. 2010; 468: 37-44
        • Mizner R.L.
        • Petterson S.C.
        • Clements K.E.
        • Zeni Jr., J.A.
        • Irrgang J.J.
        • Snyder-Mackler L.
        Measuring functional improvement after total knee arthroplasty requires both performance-based and patient-report assessments: a longitudinal analysis of outcomes.
        J Arthroplasty. 2011; 26: 728-737
        • Silva M.
        • Shepherd E.F.
        • Jackson W.O.
        • Pratt J.A.
        • McClung C.D.
        • Schmalzried T.P.
        Knee strength after total knee arthroplasty.
        J Arthroplasty. 2003; 18: 605-611
        • Mizner R.L.
        • Petterson S.C.
        • Stevens J.E.
        • Axe M.J.
        • Snyder-Mackler L.
        Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty.
        J Rheumatol. 2005; 32: 1533-1539
        • Yoshida Y.
        • Mizner R.L.
        • Ramsey D.K.
        • Snyder-Mackler L.
        Examining outcomes from total knee arthroplasty and the relationship between quadriceps strength and knee function over time.
        Clin Biomech (Bristol, Avon). 2008; 23: 320-328
        • Petterson S.C.
        • Mizner R.L.
        • Stevens J.E.
        • et al.
        Improved function from progressive strengthening interventions after total knee arthroplasty: a randomized clinical trial with an imbedded prospective cohort.
        Arthritis Rheum. 2009; 61: 174-183
        • Ciolac E.G.
        • Greve J.M.
        Muscle strength and exercise intensity adaptation to resistance training in older women with knee osteoarthritis and total knee arthroplasty.
        Clinics (Sao Paulo). 2011; 66: 2079-2084
        • Jakobsen T.L.
        • Kehlet H.
        • Husted H.
        • Petersen J.
        • Bandholm T.
        Early progressive strength training to enhance recovery after fast-track total knee arthroplasty. A randomized controlled trial.
        Arthritis Care Res (Hoboken). 2014; 66: 1856-1866
        • Trans T.
        • Aaboe J.
        • Henriksen M.
        • Christensen R.
        • Bliddal H.
        • Lund H.
        Effect of whole body vibration exercise on muscle strength and proprioception in females with knee osteoarthritis.
        Knee. 2009; 16: 256-261
        • Sitja-Rabert M.
        • Rigau D.
        • Fort Vanmeerghaeghe A.
        • Romero-Rodriguez D.
        • Bonastre Subirana M.
        • Bonfill X.
        Efficacy of whole body vibration exercise in older people: a systematic review.
        Disabil Rehabil. 2012; 34: 883-893
        • Delecluse C.
        • Roelants M.
        • Verschueren S.
        Strength increase after whole-body vibration compared with resistance training.
        Med Sci Sports Exerc. 2003; 35: 1033-1041
        • Roelants M.
        • Delecluse C.
        • Verschueren S.M.
        Whole-body-vibration training increases knee-extension strength and speed of movement in older women.
        J Am Geriatr Soc. 2004; 52: 901-908
        • Johnson A.W.
        • Myrer J.W.
        • Hunter I.
        • et al.
        Whole-body vibration strengthening compared to traditional strengthening during physical therapy in individuals with total knee arthroplasty.
        Physiother Theory Pract. 2010; 26: 215-225
        • Wang P.
        • Yang L.
        • Liu C.
        • et al.
        Effects of whole body vibration exercise associated with quadriceps resistance exercise on functioning and quality of life in patients with knee osteoarthritis: a randomized controlled trial.
        Clin Rehabil. 2015 Oct 1; ([Epub ahead of print])
        • Kern H.
        • Kovarik J.
        • Franz C.
        • et al.
        Effects of 8 weeks of vibration training at different frequencies (1 or 15 Hz) in senior sportsmen on torque and force development and of 1 year of training on muscle fibers.
        Neurol Res. 2010; 32: 26-31
        • Hamstra-Wright K.L.
        • Huxel Bliven K.
        Effective exercises for targeting the gluteus medius.
        J Sport Rehabil. 2012; 21: 296-300
        • Da Silva E.M.
        • Brentano M.A.
        • Cadore E.L.
        • De Almeida A.P.
        • Kruel L.F.
        Analysis of muscle activation during different leg press exercises at submaximum effort levels.
        J Strength Cond Res. 2008; 22: 1059-1065
        • Simao A.P.
        • Avelar N.C.
        • Tossige-Gomes R.
        • et al.
        Functional performance and inflammatory cytokines after squat exercises and whole-body vibration in elderly individuals with knee osteoarthritis.
        Arch Phys Med Rehabil. 2012; 93: 1692-1700
        • Brokelman R.B.
        • van Loon C.J.
        • Boog G.J.
        Surgeon satisfaction agreement after total knee arthroplasty using a visual analogue scale: a single surgeon series.
        Arch Orthop Trauma Surg. 2008; 128: 255-259
        • Stucki G.
        • Meier D.
        • Stucki S.
        • et al.
        [Evaluation of a German version of WOMAC (Western Ontario and McMaster Universities) Arthrosis Index].
        Z Rheumatol. 1996; 55 ([German]): 40-49
        • Jakobsen T.L.
        • Christensen M.
        • Christensen S.S.
        • Olsen M.
        • Bandholm T.
        Reliability of knee joint range of motion and circumference measurements after total knee arthroplasty: does tester experience matter?.
        Physiother Res Int. 2010; 15: 126-134
        • Podsiadlo D.
        • Richardson S.
        The timed “Up & Go”: a test of basic functional mobility for frail elderly persons.
        J Am Geriatr Soc. 1991; 39: 142-148
        • Almeida G.J.
        • Schroeder C.A.
        • Gil A.B.
        • Fitzgerald G.K.
        • Piva S.R.
        Interrater reliability and validity of the stair ascend/descend test in subjects with total knee arthroplasty.
        Arch Phys Med Rehabil. 2010; 91: 932-938
        • Aalund P.K.
        • Larsen K.
        • Hansen T.B.
        • Bandholm T.
        Normalized knee-extension strength or leg-press power after fast-track total knee arthroplasty: which measure is most closely associated with performance-based and self-reported function?.
        Arch Phys Med Rehabil. 2013; 94: 384-390
        • Marcus R.L.
        • Yoshida Y.
        • Meier W.
        • Peters C.
        • Lastayo P.C.
        An eccentrically biased rehabilitation program early after TKA surgery.
        Arthritis. 2011; 2011: 353149
        • Kern H.
        • Pelosi L.
        • Coletto L.
        • et al.
        Atrophy/hypertrophy cell signaling in muscles of young athletes trained with vibrational-proprioceptive stimulation.
        Neurol Res. 2011; 33: 998-1009
        • Escobar A.
        • Riddle D.L.
        Concordance between important change and acceptable symptom state following knee arthroplasty: the role of baseline scores.
        Osteoarthritis Cartilage. 2014; 22: 1107-1110
        • Ruhdorfer A.
        • Wirth W.
        • Eckstein F.
        Relationship between isometric thigh muscle strength and minimum clinically important differences in knee function in osteoarthritis: data from the osteoarthritis initiative.
        Arthritis Care Res (Hoboken). 2015; 67: 509-518
        • Escobar A.
        • Quintana J.M.
        • Bilbao A.
        • Arostegui I.
        • Lafuente I.
        • Vidaurreta I.
        Responsiveness and clinically important differences for the WOMAC and SF-36 after total knee replacement.
        Osteoarthritis Cartilage. 2007; 15: 273-280
        • Vuorenmaa M.
        • Ylinen J.
        • Kiviranta I.
        • et al.
        Changes in pain and physical function during waiting time and 3 months after knee joint arthroplasty.
        J Rehabil Med. 2008; 40: 570-575
        • Lorentzen J.S.
        • Petersen M.M.
        • Brot C.
        • Madsen O.R.
        Early changes in muscle strength after total knee arthroplasty. A 6-month follow-up of 30 knees.
        Acta Orthop Scand. 1999; 70: 176-179
        • Mizner R.L.
        • Petterson S.C.
        • Snyder-Mackler L.
        Quadriceps strength and the time course of functional recovery after total knee arthroplasty.
        J Orthop Sports Phys Ther. 2005; 35: 424-436
        • Kramer J.F.
        • Speechley M.
        • Bourne R.
        • Rorabeck C.
        • Vaz M.
        Comparison of clinic- and home-based rehabilitation programs after total knee arthroplasty.
        Clin Orthop Relat Res. 2003; : 225-234
        • Steffen T.M.
        • Hacker T.A.
        • Mollinger L.
        Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds.
        Phys Ther. 2002; 82: 128-137
        • Stevens-Lapsley J.E.
        • Bade M.J.
        • Shulman B.C.
        • Kohrt W.M.
        • Dayton M.R.
        Minimally invasive total knee arthroplasty improves early knee strength but not functional performance: a randomized controlled trial.
        J Arthroplasty. 2012; 27: 1812-1819.e2
        • Kumar P.J.
        • McPherson E.J.
        • Dorr L.D.
        • Wan Z.
        • Baldwin K.
        Rehabilitation after total knee arthroplasty: a comparison of 2 rehabilitation techniques.
        Clin Orthop Relat Res. 1996; : 93-101

      Linked Article

      • Efficacy and Safety of Leg-Press Training With Moderate Vibration After Total Knee Arthroplasty Remains Unclear
        Archives of Physical Medicine and RehabilitationVol. 97Issue 11
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          With great interest we read the article by Bily et al.1 We appreciate the effort of the study group to evaluate an innovatory method of rehabilitation after a total knee arthroplasty (TKA). This type of research is needed because of the lack of evidence-based rehabilitation programs after TKA. The topic of the study is also relevant with regard to the increasing rate of TKAs and the related growing financial burden to the health care system. However, we have some concerns about the study.
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