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Home Stretching Exercise is Effective for

Improving Knee Range of Motion and Gait in
Patients with Knee Osteoarthritis

Article in Journal of Physical Therapy Science · July 2009

DOI: 10.1589/jpts.21.113

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Original Article J. Phys. Ther. Sci.
21: 113–119, 2009
Home Stretching Exercise is Effective for
Improving Knee Range of Motion and Gait in
Patients with Knee Osteoarthritis

OSAMU AOKI, PT, MS1), NOBUHIRO TSUMURA, MD2), AIKO KIMURA, PT3),
SOH OKUYAMA, PT3), SATOSHI TAKIKAWA, MD2), SOICHIRO HIRATA, MD, PHD4)
1)
Department of Rehabilitation, Rehabilitation Nishi-Harima Hospital, Hyogo Prefectural
Rehabilitation Center at Nishi-Harima:1–7–1 Koto, Shingu-cho, Tatsuno, Hyogo, Japan.
TEL: +81 791-58-1050, FAX: +81 791-58-1070, E-mail: aoki-o@umin.ac.jp
2)
Department of Orthopedics, Central Hospital, Hyogo Prefectural Rehabilitation Center
3)
Department of Rehabilitation, Central Hospital, Hyogo Prefectural Rehabilitation Center
4)
Faculty of Health Sciences, Kobe University School of Medicine

Abstract. [Purpose] The purpose of this study was to assess the effects of home-based knee stretching
exercises on knee range of motion (ROM) and gait speed in patients with knee osteoarthritis awaiting total
knee arthroplasty. [Subjects] Thirty-six patients with severe knee osteoarthritis were randomly allocated to
stretching (n=17) and control (n=19) groups. [Method] The subjects in the stretching group were instructed
to perform home-based knee stretching exercises once a day for about 80 days, whereas the subjects in the
control group were told to maintain their current level of physical activity. Outcomes assessed percentage
changes in the total range of knee ROM in the supine position (S-ROM), pain, gait speed and knee ROM
during gait (G-ROM). [Results] The stretching group showed significantly greater improvement in S-ROM,
gait speed and G-ROM than the control group (control vs stretching; S-ROM, 0.4 ± 8.6% vs 9.5 ± 16.2%;
gait speed, 1.6 ± 11.4% vs 11.6 ± 10.7%; G-ROM, 0.6 ± 15.2% vs 14.2 ± 14.6%; p<0.05 for all). Pain was
significantly decreased in the stretching group compared to the control group (median values: –15.6% and
6.5%, p<0.01).
Key words: Osteoarthritis, Stretching, Home exercise

(This article was submitted Oct. 28, 2008, and was accepted Dec. 1, 2008)

INTRODUCTION Moreover, land-based exercise was shown to reduce

Knee osteoarthritis (OA) is associated with
numerous symptoms such as deformity, pain,
muscle weakness and limited range of motion
(ROM). These symptoms cause difficulty in
performing activities of daily living (ADL),
including walking. At present, OA is not curable
and the goal of management is to maintain or
improve function and quality of life.
Exercise therapy for knee OA has small-to-
moderate beneficial effects on pain and disability1).
pain and improve physical function for knee OA2).
It is widely accepted that regular exercise, such as
muscle exercise and walking, is beneficial for the
management of pain and improvement of physical
function in patients with knee OA3,4) . Although
home-based exercises have advantages over clinic-
or hospital-based exercises because they are
inexpensive and easy to perform, there are concerns
about long-term implementation of home-exercise
regimens. In a long-term study conducted by Deyle
et al.5), the effects of a home-exercise program that
114 J. Phys. Ther. Sci. Vol. 21, No. 2, 2009
Table 1. Patient characteristics at registration (N=36)
Characteristics Mean ± SD
Male / Female (n) 0 / 36
Joints (n) bilateral OA =31, unilateral OA =5
Age (y) 73.3 ± 5.8
BMI (kg / m2) 26.2 ± 3.0
Duration from the onset of pain (y) 9.8 ± 7.4
FTA (°) 187.3 ± 5.2
Note. Values are means ± standard deviations (SD) unless
included ROM, stretching and strengthening
exercises on lower extremity function were almost
equal to those of supervised exercise even after 1
year. Other studies6–10) have consistently shown that
a home-based exercise regimen is beneficial for
strength, pain, gait speed and self-efficacy. In these
studies, however, the exercises were mainly
comprised of muscle-strengthening exercises.
Hence, the effects of stretching alone are not well
known.
Home exercises, including muscle stretching,
ROM and strength training, have been reported to
cause an improvement in stiffness and in the
Western Ontario and McMaster Universities
Osteoarthritis Index pain subscale11) . Similarly,
Rogind et al. 12) reported that a combination of
clinic-based exercises (strengthening, stretching
and balance) and 3 months of home-based exercises
(strengthening and stretching) reduced pain and
improved gait speed. These two studies indicated
that these exercises improved both impairments
(e.g. strength and ROM) and activities (e.g. gait
speed).
As a part of the traditional Japanese lifestyle,
which includes kneeling on tatami mats, bilateral
deep knee flexion is frequently required. Therefore,
it is important to maintain or improve knee ROM in
patients with knee OA. Stretching is one type of
exercise performed to maintain or improve ROM
and has been shown to improve ROM in healthy
elderly people13). However, little is known about the
effect of the stretching exercises on static and
dynamic knee ROM in knee OA patients, despite
the fact that most of these patients have limited
ROM. Restriction of activity is imposed by lack of
knee flexion angle 14), and knee flexion angle is
associated with disability (e.g. walking, sitting
down in a chair, reclining on a bed and bending over
to pick up a weight from the floor) in knee OA
patients, whereas extension angle is not15).
We hypothesised that exercise regimens that
included only knee flexion stretching would
improve ROM and gait speed. The present study
was designed to determine whether home-based
stretching exercise was effective for improving
ROM and gait. Generally, it is considered that
stretching means muscle stretching, but factors of
knee contracture are not only muscle but also
capsule, ligament and so on. In this study, we
defined the objects of stretching exercise as
muscles, myofascia, capsule, ligament and skin.
METHODS
Patients
Thirty-six patients with severe knee OA
established on radiographs were recruited from an
outpatient clinic of a large rehabilitation hospital
(Table 1). Subjects having unilateral or bilateral OA
and planning to undergo total knee arthroplasty
(TKA) were included in this study. Patients who
could not follow instructions and lie prone, and who
had self-reported severe cardio respiratory disease,
neurological disease, or lower limb disorders other
than knee OA were excluded from the study.
Participants were explained the purpose of the study
and consented to participation; they were randomly
allocated to stretching (17 women with 33 affected
joints; mean ± SD age=72.3 ± 5.2 years; BMI=26.6
± 3.5; duration from the onset of pain=10.3 ± 6.9
years; FTA =187.9 ± 4.9°) and control groups (19
women with 34 affected joints; mean ± SD
age=74.4 ± 6.4 years; BMI=25.8 ± 2.4; duration
from the onset of pain=9.3 ± 7.9 years; FTA=187.3
± 5.6°) (Table 2).
The stretching group was instructed to perform
home-based stretching exercises every day and to
record it daily on a calendar until admission for
surgery. They performed two exercises daily: 1)
knee flexion assisted by hand while sitting on the
floor and 2) knee flexion assisted by hand (or by the
opposite leg if difficult to reach with the hand)
while the subject was in a prone position (Fig. 1).
Participants had to keep the knee flexed as much as
possible for 30 seconds and complete a minimum of
10 such repetitions at least once a day. The subjects
in the control group were instructed to maintain
their current level of physical activity.
 115

Table 2. Group characteristics at the time of registration

Characteristics Control (n=19) Stretching (n=17) p-value*
Male / Female (n) 0 / 19 0 / 17 -
Joints (n) 34 (bilateral=30, unilateral=4) 33 (bilateral=32, unilateral=1) -
Age (y) 74.4 ± 6.4 72.3 ± 5.2 0.30
BMI (kg /m2) 25.8 ± 2.4 26.6 ± 3.5 0.32
Years knee OA (y) 9.3 ± 7.9 10.3 ± 6.9 0.63
FTA (°) 187.3 ± 5.6 187.9 ± 4.9 0.41
Kellgren-Lawrence grade,
median (interquartile range) IV (IV to IV) IV (III to IV) 0.22
Note. Values are means ± standard deviations (SD) unless otherwise indicated.
*Comparison between groups (Student’s t-test or Wilcoxon’s rank-sum test).

Fig. 1. Guidance for stretching.

1. Knee flexion exercise while sitting on the floor (mainly stretching for the quadriceps
femoris muscle).
2. Knee flexion exercise in a prone position (mainly stretching for the rectus femoris
muscle).
Participants had to keep the knee flexed as much as possible for 30 seconds and
complete a minimum of 10 such repetitions at least once a day.

Outcome measures G-ROM of the knee was measured three times,

We evaluated the participants at the time when
they were registered for a TKA operation and just
after admission to hospital for the operation.
Measurements included the total range of knee
ROM in the supine position (S-ROM), pain, gait
speed and knee ROM from maximum flexion to
extension during gait (G-ROM). For the
measurement of gait speed and G-ROM, the
participants were asked to walk along a 10-m line
three times. S-ROM was measured from maximum
extension to flexion with a goniometer by a
physiotherapist blinded to the participants. Pain
experienced during gait was quantitatively
evaluated using a 100-mm visual analogue scale.
Gait speed was calculated from the step duration
and length determined from force plate data; we
used the mean of three such values for analysis.
and the mean of these measurements was used in the
analysis. We used a three-dimensional optical
motion capture system with six cameras (Mac3D
system; Motion Analysis Co., CA) and two force
plates (1200 mm × 600 mm; Kistler Japan Co.,
Tokyo, Japan) with a sampling rate of 60 Hz.
Markers were placed at a point on the lower 2/3rd
part of the line drawn from the anterior superior
iliac spine to the greater trochanter and at the knee
and ankle joints.
Analysis
For baseline comparison, the mean age, BMI,
duration from the onset of pain, FTA, S-ROM, gait
speed and G-ROM at the time of registration for a
TKA were compared between the groups using
Student’s t-test after confirmation of a normal
116 J. Phys. Ther. Sci. Vol. 21, No. 2, 2009

Table 3. Evaluation values at registration, and percentage changes from registration to admission
Control Stretching
Registration* Admission Change (%)† Registration* Admission Change (%) † p-value‡
S-ROM (°) 109.9 ± 23.5 109.1 ± 20.4 0.4 ± 8.6 110.0 ± 25.6 117.6 ± 20.2§ 9.5 ± 16.2 0.007
(mean ± SD)
Pain (mm) 45.5 49.5 6.5 60.0 43.5§ –15.6 0.002
(median, (21.0 to 67.3) (39.5 to 62.8) (–20.0 to 42.0) (41.5 to 75.5) (36.0 to 64.8) (–27.8 to –4.9)
interquartile range)
Gait speed (m / min) 32.4 ± 12.9 32.1 ± 11.4 1.6 ± 11.4 33.2 ± 7.3 36.9 ± 8.2§ 11.6 ± 10.7 0.01
(mean ± SD)
G-ROM (°) 39.6 ± 13.3 39.4 ± 12.6 0.6 ± 15.2 37.4 ± 10.5 42.1 ± 11.7§ 14.2 ± 14.6 <0.001
(mean ± SD)
Note. Values are means ± standard deviations (SD) or median and interquartile range.
Abbreviations: S-ROM, knee ROM in the supine position; G-ROM, knee ROM during gait
*No significant difference between groups at registration (Student’s t-test or Wilcoxon’s rank-sum test).
†
Percentage changes from registration to admission.
‡
Comparison of percentage changes between groups (Student’s t-test or Wilcoxon’s rank-sum test).
§Significant difference between registration and admission (p<0.05 for all, paired t-test or Wilcoxon’s signed-rank test).

distribution. Kellgren-Lawrence grade and the RESULTS

severity of pain were compared between the groups
using Wilcoxon’s rank-sum test. In addition, we
compared S-ROM, pain, gait speed, G-ROM
between registration and admission by paired t-test
or Wilcoxon’s signed-rank test.
We calculated the percentage changes in S-ROM,
gait speed, pain and G-ROM from the time of
registration to admission as outcoms using the
following formula:
These changes were compared between the
groups by using Student’s t-test and Wilcoxon’s
rank-sum test.
In this study, participants had to wait about 3
months until admission because of hospital
circumstances. In addition, participants didn't need
to visit hospital until admission, so that we couldn’t
regulate the intervention term. We assessed the dose
effects of the number of days for which the
participants had performed stretching exercises and
the percentage change in S-ROM, pain, gait speed
and G-ROM using Spearman’s correlation analysis.
We used JMP IN 5.1 (SAS Institute Japan, Tokyo,
Japan) for statistical analysis, and a significance
level of p=0.05.
At baseline comparison, there were no significant
differences in any measurement between the groups
(age, p=0.30; BMI, p=0.46; duration from the onset
of pain, p=0.57; FTA, p=0.65; Kellgren-Lawrence
grade, p=0.22; S-ROM, p=0.98; pain, p=0.09; gait
speed, p=0.80; G-ROM, p=0.46).
There was no significant difference in duration
from registration to admission between the control
(82.3 ± 34.5 days; range: 25–146 days) and
stretching group (80.7 ± 32.2 days; range: 30–142
days). The percentage of days for which the
participants performed the exercises during the
study period was 93.1 ± 4.3% in the stretching
group.
In the comparison of S-ROM, pain, gait speed, G-
ROM between at the time of registration and
admission, significant differences were obtained in
the stretching group (p<0.05 for all).
Mean changes in S-ROM, gait speed and G-ROM
were significantly greater in the stretching group
than in the control group (control vs stretching; S-
ROM: 0.4 ± 8.6% vs 9.5 ± 16.2%; gait speed: 1.6 ±
11.4% vs 11.6 ± 10.7%; G-ROM: 0.6 ± 15.2% vs
14.2 ± 14.6%; p<0.05 for all). Pain was
significantly decreased in the stretching group
compared to the control group (p<0.01) [median
values (interquartile range): –15.6 (–27.8 to –4.9)
and 6.5 (–20.0 to 42.0)] (Table 3).
There were no significant relationships between

the number of days and the percentage change in S-
ROM, pain, gait speed and G-ROM (p=0.44, 0.99,
0.94, 0.83, respectively).
DISCUSSION
The effectiveness of regular exercise in the
management of pain and improvement of physical
function has been established in patients with knee
OA 3,4,16–18). In the present study, the stretching
group showed significantly greater improvement in
S-ROM than the control group and the mean
percentage change was about 9%. This could be
partly attributed to performing knee flexion
exercises once a day. Of interest was the finding by
Szabo et al.19) who reported that the flexion ROM in
Muslim patients with knee OA, whose religious
tradition involves frequent deep flexion of the knee,
similar to the Japanese tradition, was better than that
of non-Muslim patients, who did not have such
traditions. Moreover, they mentioned that the
restriction of knee movement might be prevented by
regular exercise.
Pain decreased by about 15% from the time of
registration to admission in the stretching group.
Minor et al.20) reported that the pain subscale of the
arthritis impact measurement scale was improved
by ROM exercise, isometric training and relaxation
exercises in patients with rheumatoid arthritis and
osteoarthritis. In addition, another study8) showed
that pain scores improved compared with baseline
in the stretching training group as compared with
controls. Our findings agree with those of these
otheres. Fredericson and Yoon21) reported that tight
quadriceps muscles lead to high patellofemoral
stresses. Although the mechanisms of pain
improvement are not yet known, we speculate that
improvement in soft tissue flexibility may have led
to a reduction in knee pain in the stretching group.
Our results indicate an improvement of 11.6% in
gait speed from the time of registration to
admission, whereas Minor et al. 20) reported no
change in 50-foot walking time in patients with
rheumatoid arthritis and OA who performed ROM
exercises. This discrepancy may be due to the
differences in sample populations between the two
studies; our study included patients with severe
knee OA (as indicated by a low gait speed) awaiting
surgery, whereas the patients in the study of Minor
et al.20) were recruited from the community.
Lee et al.22) reported that maximal knee flexion
117
angle during gait of normal elderly people aged 65.4
± 6.2 years was 57.1 ± 7.7° and minimal knee
flexion was 4.6 ± 4.9°. Similar to our unpublished
data, G-ROM in 11 normal old people aged 66.3 ±
4.0 years was 59.1 ± 3.2°. In this study, G-ROM
was improved about 14%, and was about 42° at the
time of admission in the stretching group. However,
we regarded this as insufficient for normal gait. We
postulate that pain improvement led to an
improvement of gait speed, and improvement of G-
ROM seemed to result from improvement of S-
ROM and pain.
Generally, a home-based exercise regimen is
prescribed to patients as a part of the rehabilitation
program to maintain their functions, and improve
their impairments and ADL23). However, whether
therapist interventions are more effective than
home-based exercise regimens in the long term is
debatable24). The advantage of home exercises is
that patients can perform them at any time and at
low cost. However, disadvantages include a
possible lack of continuity and incorrect
performance of the maneuvers because of lack of
supervision. In previous studies, researchers
regularly contacted their participants by telephone
or home visits to ensure that the prescribed
exercises were being performed9,23,25). However,
we did not contact the participants during the course
of the present study. Nevertheless, the mean
compliance rate based on the self-reported calendar
was unexpectedly high (93%). The limited period of
waiting time for surgery (i.e. about 3 months) may
have contributed to the participants' motivation to
perform the exercises. Henry et al.26) reported that a
simple, as opposed to a complex, home-based
exercise regimen was essential to ensure the
continuity of exercise and improvement in physical
function. In the present study, the participants were
prescribed a simple exercise regimen consisting of
only two exercises, and the patients were given a
self-report calendar at the time of registration,
which may also have contributed to the high
compliance rate.
Because the period of home-based stretching
exercises ranged from 30 to 140 days, we assessed
the dose effects on S-ROM, pain, gait speed and G-
ROM using correlation analysis. No significant
relationships were observed. Harvey et al. 13)
reported that a minimum of 3 weeks is required to
improve ROM by stretching. This might partly
account for our result that there was no dose effect
118 J. Phys. Ther. Sci. Vol. 21, No. 2, 2009
on S-ROM. However, we could not account for the
lack of a significant correlation between the period
of exercise and the improvement in pain, gait speed
and G-ROM.
In the present study, the home-based stretching
exercise regimen was effective even in patients with
severe knee OA awaiting TKA. Knee flexibility
after TKA is dependent on the preoperative range of
flexion27,28), and a preoperative improvement in S-
ROM may provide better results after surgery.
Moreover, simple preoperative home-based
stretching exercises are easy to perform and are
beneficial for knee OA if the compliance with the
exercise regimen is good.
ACKNOWLEDGEMENTS
We are grateful to Shinji Kimata, PT; Yaho Aoki,
PT, MS; Maiko Maeda, PT, MS; and Rintaro Oki,
PT, for assistance with data collection.
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