Neuromuscular Exercise post Partial Medial

Meniscectomy: Randomized Controlled Trial

CLINICAL SCIENCES
MICHELLE HALL1, RANA S. HINMAN1, TIM V. WRIGLEY1, EWA M. ROOS2, PAUL W. HODGES3,
MARGARET P. STAPLES4, and KIM L. BENNELL1
1
Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, School of Health Sciences, University of
Melbourne, Melbourne, Victoria, AUSTRALIA; 2Research Unit for Musculoskeletal Function and Physiotherapy, Institute
of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, DENMARK; 3Department of
Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, St. Lucia, Brisbane, Queensland,
AUSTRALIA; and 4Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine,
Monash University, Cabrini Institute, Malvern, Victoria, AUSTRALIA

ABSTRACT
HALL, M., R. S. HINMAN, T. V. WRIGLEY, E. M. ROOS, P. W. HODGES, M. P. STAPLES, and K. L. BENNELL. Neuromuscular
Exercise post Partial Medial Meniscectomy: Randomized Controlled Trial. Med. Sci. Sports Exerc., Vol. 47, No. 8, pp. 15571566,
2015. Purpose: This study aimed to evaluate the effects of a 12-wk, home-based, physiotherapist-guided neuromuscular exercise
program on the knee adduction moment (an indicator of mediolateral knee load distribution) in people with a medial arthroscopic partial
meniscectomy (APM) within the past 312 months. Methods: An assessor-blinded, randomized controlled trial including people age
3050 yr with no to mild pain after medial APM was conducted. Participants were randomly allocated to either a 12-wk neuromuscular
exercise program that targeted neutral lower limb alignment or a control group with no exercise. The exercise program included eight
individual sessions with one of seven physiotherapists in private clinics, together with home exercises. Primary outcomes were the peak
external knee adduction moment during normal-paced walking and during one-leg sit-to-stand. Secondary outcomes included additional
measures of knee joint load distribution, patient-reported outcomes, maximal knee and hip muscle strength, and physical function
measures. Results: Of 62 randomized participants, 60 (97%) completed the trial. There were no significant between-group differences in the
change in peak knee adduction moment during normal-paced walking (mean difference (95% confidence interval), 0.22 (j0.11 to
0.55) NIm/body weight  height %, P =0.19) or during one-leg sit-to-stand (j0.01 (j0.33 to 0.31) NIm/body weight  height %, P = 0.95).
There were also no significant between-group differences for any of the secondary outcomes. Conclusions: In patients 312 months after a
medial APM, a neuromuscular exercise program did not alter the peak knee adduction moment, a key predictor of osteoarthritis structural
disease progression. (Australia and New Zealand Clinical Trials Registry, #ACTRN12612000542897.) Key Words: NEUROMUSCULAR
EXERCISE, KNEE ADDUCTION MOMENT, ARTHROSCOPIC PARTIAL MENISCECTOMY, OSTEOARTHRITIS

M
eniscal injury is a potent risk factor for knee os-
teoarthritis (21), and the medial meniscus is more
commonly damaged compared with the lateral
meniscus (9). Despite evidence questioning the efficacy of
surgical treatment for meniscal tears (17,20), arthroscopic
partial meniscectomy (APM) is a routine and commonly used
surgical procedure. Estimates suggest that approximately
Address for correspondence: Kim Bennell, BAppSc (Physio), Ph.D., Centre
for Health, Exercise and Sports Medicine, Department of Physiotherapy,
University of Melbourne, Parkville, Melbourne, Victoria, Australia 3010;
E-mail: k.bennell@unimelb.edu.au.
Submitted for publication August 2014.
Accepted for publication November 2014.
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML PDF versions
of this article on the journal_s Web site (www.acsm-msse.org).
0195-9131/15/4708-1557/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE
Copyright 2015 by the American College of Sports Medicine
DOI: 10.1249/MSS.0000000000000596
50% of people develop radiographic knee osteoarthritis within
1020 yr from meniscal surgery (24). Middle-age people with
degenerative meniscal tears have greater risk for development
of symptomatic and radiographic knee osteoarthritis than youn-
ger individuals with traumatic meniscal tears (10). Therefore,
middle-age APM patients are a subgroup who could benefit
more from targeted strategies to prevent or delay knee oste-
oarthritis than younger individuals with traumatic tears.
Many authors agree that mechanical factors contribute to
symptomatic and structural knee osteoarthritis (1,12,33).
Knee osteoarthritis after medial APM is thought to relate to
higher medial knee joint load. Using three-dimensional gait
analysis, mediolateral knee joint load distribution is esti-
mated using the knee external adduction moment (KAM).
Peak KAM during walking seems higher in people after
APM than that in controls (16,35) and increases over time
after surgery (16). Other data show a relationship between
higher KAM parameters and increased risk of knee pain onset
(1) and structural disease progression in people with es-
tablished knee osteoarthritis (3,25). Thus, KAM reduction
could provide a plausible mechanism to prevent or delay the
onset or progression of knee osteoarthritis after medial APM.

1557

Copyright 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 Exercise is an attractive option that targets neuromuscular fea-
tures (e.g., coordination and control of the knee and surrounding
muscles), and in particular could potentially reduce higher
CLINICAL SCIENCES
KAM during functional tasks. Neuromuscular exercises are
commonly performed in weight-bearing functional postures.
Importance is placed on features such as movement control
and quality plus alignment of the lower limb and trunk. The
focus on neutral alignment of the knee is the feature most
likely to modify KAM. Results from pilot studies support the
potential efficacy of neuromuscular exercise to reduce KAM
in people with knee osteoarthritis during gait and a one-leg sit-
to-stand rise (37,38). However, despite these pilot studies,
other randomized controlled trials have found no change in
KAM during gait after exercise programs in people with
established knee osteoarthritis (4,13). Although gait is arguably
the most clinically relevant task to reduce KAM, it is also of
interest to evaluate the effect of exercise on more challenging
tasks such as one-leg sit-to-stand or one-leg hop. Determining
the effect of neuromuscular exercise on a spectrum of tasks
with varying difficulty will provide better understanding of the
potential of exercise to alter KAM, a key predictor of structural
change, albeit during gait. Furthermore, a randomized con-
trolled trial in people after APM reported improved physical
function (11) and cartilage quality assessed using delayed
gadolinium-enhanced magnetic resonance imaging (dGEMRIC)
(29) after 4 months of neuromuscular exercise training. To
date, no study has rigorously evaluated the effects of neuro-
muscular exercise on the KAM during tasks of varying dif-
ficulty in people who are at high risk of developing or
progressing structural knee osteoarthritis.
The primary objective of this randomized controlled trial
was to evaluate the effect of a 12-wk neuromuscular exercise
program (similar to that aimed to ensure lower limb align-
ment (4) and shown to improve cartilage quality (29) and
physical function (11)) during walking and one-leg sit-to-
stand in people after a medial APM. The primary hypothesis
was that peak KAM during normal-paced walking and one-
leg sit-to-stand would reduce in a neuromuscular exercise
group when compared with that in a nonintervention control
group. This study investigated individuals with or without
early signs of knee osteoarthritis, as the purpose of this
intervention was to prevent or delay the onset or progression
of structural disease in this population. Furthermore, indi-
viduals with or without minimal pain were included to ex-
clude the potential role of pain reduction as a mediator of
change in the primary outcome.
METHODS
Participants
Sixty-two volunteers age 3050 yr with an isolated
medial APM within the past 312 months were recruited
from May 2012 to July 2013, with follow-up completed in
November 2013. All participants were identified by screening
the surgical records of eight orthopedic surgeons, except for
1558 Official Journal of the American College of Sports Medicine
Copyright 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
one participant who responded to a university advertisement.
The institutional ethics committee approved the study, and
participants provided a written informed consent. The main
exclusion criteria included the following: (i) an average overall
pain severity greater than three out of 10 in the past week on a
numeric rating scale, (ii) moderate or severe radiographic
osteoarthritis, defined as KellgrenLawrence grade 3 or 4
(22), (iii) lower limb surgery (other than one knee arthros-
copy), (iv) complete anterior or posterior cruciate ligaments
tears, (v) body mass index above 36 kgImj2 (to reduce
excessive soft tissue movement and minimize artifact in
marker data acquisition), (vi) other forms of arthritis, dia-
betes, and cardiac circulatory conditions that limit everyday
activities (32).
Procedures
This was an assessor-blinded, randomized controlled trial.
The detailed protocol for this study has been published (15)
and summarized here. Potentially eligible individuals re-
ceived an information letter from their orthopedic surgeon.
Two weeks later, these individuals underwent telephone
screening and were invited to participate. If eligible and in-
terested, posteroanterior weight-bearing knee radiographs
were obtained to confirm eligibility. Randomization was in
permuted blocks of six or eight, stratified by gender, to ei-
ther the exercise group (ALIGN program, a rehabilitation
program that aims to ensure neutral alignment of the lower
limb) or control group. An independent researcher prepared
the randomization schedule using a computer-generated
random number table. Group allocations were sealed in
opaque, consecutively numbered envelopes by the same in-
dependent researcher and stored in a central locked location.
The envelopes were opened in sequence by a different in-
dependent researcher not involved in recruitment or assess-
ment of participants who subsequently disclosed the group
allocation to the participant. Participants were not blinded to
group allocation but were unaware of the study hypothesis.
Intervention
Eligibility to deliver the intervention required that phys-
iotherapists had experience in musculoskeletal physiother-
apy and work in private practice. Seven physiotherapists
(five male and two female physiotherapists) based in seven
private practices around metropolitan Melbourne delivered
the ALIGN program. They had an average of 8 yr (SD, 4.3;
range, 320 yr) of clinical musculoskeletal experience. Three
(43%) held postgraduate masters-level qualifications. Phys-
iotherapists received a detailed treatment manual and attended
a 3-h training session before trial involvement. Physiothera-
pists received payment for delivering the intervention.
Participants visited the physiotherapist of their choice eight
times over the 12-wk period, as follows: twice in week 1, once
in week 2, and fortnightly thereafter. The first session lasted
45 min, and the remaining seven sessions lasted approximately
30 min. The focus during the first session was to introduce the
http://www.acsm-msse.org
program and thereafter to progress the program as appropriate. Oxford, United Kingdom) and three force plates (AMTI Inc.,
Participants were asked to perform home exercises on both Watertown, MA) embedded in the walkway. The peak KFM
legs at least three times per week over 12 wk (15). was assessed on the basis of in vivo evidence suggesting that

Neuromuscular exercises. The ALIGN exercise pro-
gram is described in detail elsewhere (15). Participants per-
formed six exercises with the aim of maintaining neutral
mediolateral alignment of the lower limb while engaging
the trunk muscles during functional exercises (Table 1) (see
Appendix, Supplemental Digital Content 1, Details of the
exercises used in the ALIGN neuromuscular exercise program,
http://links.lww.com/MSS/A482). Exercises were selected on
the basis of previous reports that these exercises or similar
variations had improved cartilage quality and physical func-
tion in people after APM and reduced peak KAM in people
with knee osteoarthritis (11,29,38). The participant and phys-
iotherapist guided progression of exercise. Participants were
encouraged to progress as they felt able to increase the volume
of exercises performed, e.g., aiming to begin with two sets of
12 repetitions, progressing to two sets of 15 repetitions, three
sets of 12 repetitions, and three sets of 15 repetitions. Progres-
sion of exercise by the physiotherapist aimed to increase the
exercise intensity, which was achieved by the following: hold-
ing a medicine ball while performing the exercises, increasing
the load by filling the medicine ball with water, increasing the
duration of the hold phase of the exercise, changing the di-
rection, and/or changing the supporting surface.
Outcome Measures
The same blinded assessor performed measures at base-
line (week 0) and follow-up (week 13) in the Movement
Laboratory at the Centre for Health Exercise and Sports
Medicine, University of Melbourne, Australia.
Three-dimensional movement analysis. Participants
underwent three-dimensional movement analysis during the
following three tasks: (i) walking (normal and fast pace), (ii)
one-leg sit-to-stand, and (iii) one-leg hop for maximum dis-
tance, all wearing standardized footwear (Dunlop Volley,
Pacific Brands, Australia). In each task, the external KAM
and external knee flexion moment (KFM) were measured
using a 12-camera motion analysis system (Vicon MX,
CLINICAL SCIENCES
medial tibiofemoral contact force may not reduce despite a
reduction in peak KAM if the peak KFM increases simul-
taneously (39). A seven-segment model was constructed
using Vicon Body Builder according to previously described
methods (5). After the application of 33 reflective markers,
participants completed a series of calibration trials that in-
corporated functional approaches to define hip centers and the
knee joint flexion/extension helical axes according to Besier
et al. (5). Marker trajectories and ground reaction forces
(GRF) were low-pass-filtered at 6 Hz for walking (23) and
one-leg sit-to-stand and at 12 Hz for one-leg hop using a dual-
pass Butterworth filter. Inverse dynamics programmed in the
Vicon Body Builder (5) was used to calculate net external
moments in the shank coordinate frame. Testretest reliability
(coefficient of multiple determination, r2) of knee adduction
abduction moment and knee flexionextension moment curves
has been reported to be Q0.75 (5). KAM and positive KAM
impulse (positive area under the KAMtime curve) and KFM
were normalized by dividing by body weight (N) times body
height (m) and expressed as a percentage.
Participants performed two walking conditions: a self-
selected normal-paced walk described as a pace you would
walk normally and a self-selected fast-paced walk described
as a pace you would walk when in a hurry. Two
photoelectric beams measured speed. If the self-selected
walking speed at follow-up was more than T5% of baseline
walking speed, participants were asked to adjust their walking
speed accordingly, such that six trials were captured at a speed
within T5% of baseline speed (matched walking speed to
baseline). The following three measures were obtained and
averaged over six trials: peak KAM during the first half of
stance, because it is typically the larger of two peaks (3), KAM
impulse during the stance phase of walking, given its asso-
ciation with structural disease progression (3), and peak KFM
throughout stance, considering its association with increased
medial tibiofemoral joint contact force (39).
For the one-leg sit-to-stand task, participants sat in a
standardized position at baseline and follow-up (15). Using

TABLE 1. Summary of the neuromuscular exercise program ALIGN (see Appendix, Supplemental Digital Content 1, Details of the exercises used in the ALIGN neuromuscular exercise
program, http://links.lww.com/MSS/A482).
Neuromuscular Exercise Program ALIGN
Abdominal crunches Lying supine with knees flexed on exercise ball, participants perform abdominal crunches. This was progressed by increasing the number
of repetitions performed. Beginning with two sets of 12 repetitions and progressing to two sets of 15 repetitions, three sets of 12 repetitions,
and three sets of 15 repetitions.
Bridge Lying supine with flexed knees on the exercise ball, participants elevate the pelvis and lower pelvis to the floor with a towel between their knees.
Progression included holding the evaluated position using one leg, and rolling the exercise ball toward and away from the body using both
legs/one leg.
Lunge Standing upright, participants step forward and return to starting position. Progressions included holding an exercise ball, stepping onto foam,
and a combination of these.
Incomplete circle Standing upright on one leg, participants rotate the opposite limb in a semicircular motion. Progressions include holding an exercise ball,
standing on a foam, and a combination of these.
Get tapping The participant stands upright on one leg on a stepper while the opposite limb taps the ground behind. Progressions include tapping the ground
in front of step, holding an exercise ball and standing on foam, and a combination of these.
Knee bends Standing on both legs in front of a chair with feet hip-width apart, participants bend their knee so the bottom nearly touches the chair or heels
remain in full contact with the floor. Progressions include holding an exercise ball, elastic band resisting knee abduction, standing on foam,
standing on one leg, and a combination of these.

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Copyright 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 one leg only, participants were instructed to rise up from the
chair and return to seated position. The non-weight bearing
leg was held slightly flexed in front of the body. Data
CLINICAL SCIENCES
collection for this task was defined as the period from when
the GRF reached 100 N to the point when the GRF dropped
below 100 N. The overall peak KAM, peak KFM, and KAM
impulse during the rise-and-sit-down phase of this task were
measured and averaged over three trials.
For the one-leg hop for distance task, participants were
instructed to hop forward as far as possible and land steadily
and the hop distance was measured (15). The peak KAM
and peak KFM were calculated for the longest hop.
Self-reported pain and physical function. Self-
reported pain during the past week was assessed on an 11-
point numeric rating scale with terminal anchors of no
pain (score, 0) and worst pain possible (score, 10) (2).
Pain, other symptoms, activities of daily living function,
sport and recreation, and knee-related quality of life were
also assessed using the valid and reliable Knee Injury
Osteoarthritis Outcome Score (KOOS) (30). At follow-up,
participants were asked to rate their (i) overall change, (ii)
change in pain, and (iii) change in physical function (com-
pared with those at baseline) on a seven-point ordinal scale
(1, much worse; 7, much better). Ratings were dichotomized
such that moderately better or much better were con-
sidered to be improved.
Muscle strength. Maximal isometric and isokinetic
concentric knee muscle strength were assessed using an
isokinetic dynamometer (Humac NORM; CSMi, Lawrence,
MA). For isometric quadriceps and hamstring testing, par-
ticipants were securely seated with 60- knee flexion and the
peak of three maximal contractions was recorded. Isokinetic
quadriceps and hamstring strength testing was performed at
60- Isj1, and the participant performed five maximal efforts.
The peak of five trials was recorded. Isometric hip adductor
and abductor muscle strength was assessed using a handheld
dynamometer, with the participant lying supine (Lafayette
Manual Muscle Test System 01163; Lafayette Instrument,
Lafayette, Indiana) (28). The peak force measurements
generated during two maximal efforts against the manual
resistance were averaged as the measure of hip muscle
strength (28). For all strength tests, participants received
strong standardized encouragement. Values are reported as
torque normalized to body mass (NImIkgj1).
Physical performance tasks. Tests of physical per-
formance included the following: (i) maximum number of
controlled one-leg rises in 30 s (8), (ii) maximum number of
knee bends in 30 s (8), and (iii) the one-leg hop for distance
test with the farthest distance jumped over at least three
maximal hops, with arms across the chest, recorded (15).
Other measures. The KellgrenLawrence grading sys-
tem was used to determine radiographic osteoarthritis severity
(22). Demographic information was collected at baseline.
Adverse effects and cointerventions were assessed from par-
ticipant logbooks and physiotherapist treatment notes. Ad-
herence to the neuromuscular exercise program was determined
1560 Official Journal of the American College of Sports Medicine
Copyright 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
by the number of home exercise sessions recorded as com-
pleted by participants in their logbooks. Home exercise ad-
herence was expressed as the number of completed (and
recorded) exercise sessions as a percentage of the 36 pre-
scribed sessions (3 times per week for 12 wk). After the com-
pletion of the 12-wk program, physiotherapists also recorded
their perceived impression of the participants overall adher-
ence to the ALIGN program on an 11-point scale (0, not at
all; 10, completely as instructed) (7). A global indication
of physical activity was assessed using the Lower Extremity
Activity Scale (36). A clinical measure of static frontal plane
alignment of the knee in standing was measured at baseline
using an inclinometer (18).
Sample Size
The primary end points were peak KAM during the
stance phase of normal-paced walking and a one-leg sit-to-
stand task. This study was powered to detect a between-
group difference in change in peak KAM of 10%, equating
to an approximate reduction of 0.20 NIm/(body weight
(BW)  height (HT))% for peak KAM with an anticipated
SD of the change score of 0.3 NIm/(BW  HT)% in the
ALIGN group and no change in the control group. Although
the minimal clinically important difference to be detected
for a change in KAM indices remains unknown, we spec-
ulated that a 10% reduction could plausibly be associated
with a significant reduction in risk of disease progression
(25). On this basis, a sample of 27 participants per group
was required for a two-tailed comparison of the groups
using ANCOVA, adjusting for baseline values as covari-
ates, with 80% power and an alpha level of 0.05. To allow
for 15% dropout, 31 participants were recruited per group.
Statistical Analysis
Main comparative analyses between groups were per-
formed blinded to group allocation using an intention-to-
treat approach. Two-tailed significance was set at P G 0.05.
For continuous outcome measures, differences in mean
change (follow-up minus baseline) were compared between
groups using ANCOVA, adjusting for baseline scores of the
outcome variable. For normal- and fast-paced walking, anal-
ysis was performed for walking speeds that were unmatched
and matched to baseline walking (within T5% of baseline
walking speed). Model diagnostic checks used residual plots.
Results are presented as estimated differences with 95% con-
fidence intervals (CI). The Pearson chi tests were used to
compare medication use and cointerventions between the
groups. Log binomial regression was used to compare likeli-
hood of improvements overall and in function and pain.
RESULTS
Outcome measures. Of the 415 individuals identified
as potentially eligible, 156 (38%) were ineligible, 152 (37%)
http://www.acsm-msse.org
were not interested in participating, and 34 (8%) could not TABLE 2. Demographic and clinical characteristics of the ALIGN and control groups, de-
scribed as mean (SD) or n (%) unless otherwise stated.
be contacted. Sixty-two participants (31 ALIGN and 31 con-
ALIGN Group Control Group
trol participants) were randomized, and 60 (31 (100%) ALIGN

CLINICAL SCIENCES
Characteristics n = 31 n = 31
and 29 (94%) control participants) completed the follow-up
Age (yr) 42.8 (5.4) 43.2 (5.6)
assessment (Fig. 1). Two participants in the control group Time from surgery (months) 6.4 (2.5) 6.6 (2.6)
withdrew from the study because of relocation overseas and Males 23 (74%) 22 (73%)
Height (cm) 175.8 (0.7) 174.5 (0.6)
excessive time commitments. At baseline, participant char- Body mass (kg) 81.5 (12.3) 81.1 (9.9)
acteristics were similar between groups (Table 2). The cohort Body mass index (kgImj2) 26.3 (3.1) 26.6 (2.9)
was predominantly male, had minimal radiographic osteo- Affected knee (right:left) 21:10 21:10
Dominant side affected 28 (90%) 29 (94%)
arthritis, and was slightly overweight. According to the KOOS Knee alignmenta (-) 1.1 (2.1) 0.6 (2.4)
subscales, the cohort had similar levels of function and NRS average knee pain over the past week 1.0 (0.8) 1.3 (0.9)
Symptoms onset (slow:sudden) 11:19 13:18
symptoms to those of a population-based age-matched refer- Radiographic disease severityb
ence group (27). Grade 0 12 12
Grade 1 12 12
Grade 2 7 7
Current drug usec
Analgesia (paracetamol combinations) 1 4
Nonsteroidal anti-inflammatories 3 3
Topical anti-inflammatories 0 0
Glucosamine/chondroitin products 3 7
Oral corticosteroid 0 0
Topical liniment rubs 0 0
Fish oil 1 2
a
Values greater than zero indicate varus.
b
Using the KellgrenLawrence grading system.
c
Defined as at least once per week.
NRS, numeric rating scale (scored from 0 to 10, where 10 is the maximal pain).

There were no significant differences between the ALIGN

FIGURE 1Flow diagram of study protocol.
and control groups for absolute changes in peak KAM dur-
ing normal-paced gait within T5% of baseline walking speed
(mean difference, 0.22 (95% CI, j0.11 to 0.55) NIm/(BW 
HT)%; P = 0.19) or peak KAM during one-leg sit-to-stand
(j0.01 (95% CI, j0.33 to 0.31) NIm/(BW  HT)%; P =
0.95) (Table 3). Similarly, no between-group differences
were observed for changes in peak KAM for walking speed
unmatched to baseline (see Table, Supplementary Digital Con-
tent 2, Results of gait variables using unmatched walking
speed to baseline assessment, http://links.lww.com/MSS/A483).
Neither group showed significant within-group change in
peak KAM during either normal-paced gait or one-leg sit-
to-stand (Table 3).
There were no between-group differences for changes in
any of the secondary outcomes (Table 3). In the ALIGN
group, significant improvements were observed in the num-
ber of knee bends and one-leg rises performed in 30 s, maxi-
mum one-leg hop, and knee-related quality of life (KOOS). In
addition, in the ALIGN group, walking speed increased for
normal-paced gait and peak KFM increased during a one-leg
hop for distance. In the control group, significant improve-
ments were found in the number of one-leg knee bends,
number of one-leg rises performed in 30 s, and knee-related
quality of life (KOOS) and walking speed increased for normal-
paced gait.
Because not all participants reported pain or physical
dysfunction before the trial, the seven-point scale of im-
provement in pain was only completed by 24 (77%) ALIGN
participants and 27 (87%) control participants and the scale

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 CLINICAL SCIENCES

1562
TABLE 3. Mean (SD) of groups, mean (SD) change within groups, and mean (95% CI) difference in change between groups, adjusted for baseline scores.
Groups Change within Groups Difference in Change between Groupsa
Week 0 Week 13 Week 13Week 0 Week 13Week 0
Outcome ALIGN (n = 31) Control (n = 31) ALIGN (n = 31) Control (n = 29) ALIGN (n = 31) Control (n = 29) ALIGN Minus Control P Value
Normal-paced gait
Peak KAM (NIm/(BWHT)%)b 2.61 (0.93) 2.81 (0.96) 2.50 (1.05) 2.83 (0.93) j0.12 (j0.33 to 0.09) 0.07 (j0.21 to 0.36) j0.22 (j0.55 to 0.11) 0.19
KAM impulse (NImIs/(BWHT)%) 0.85 (0.34) 0.93 (0.34) 0.80 (0.32) 0.93 (0.37) j0.05 (j0.12 to 0.02) 0.01 (j0.07 to 0.09) j0.07 (j0.18 to 0.03) 0.15
Peak KFM (NIm/(BWHT)%) 4.75 (1.88) 4.79 (1.58) 5.09 (1.47) 5.10 (1.53) 0.34 (j0.09 to 0.77) 0.38 (j0.03 to 0.79) j0.03 (j0.53 to 0.47) 0.90
Walking speed (mIsj1) 1.36 (0.16) 1.41 (0.16) 1.39 (0.17) 1.43 (0.15) 0.03 (0.00 to 0.05) 0.04 (0.00 to 0.07) j0.01 (j0.05 to 0.03) 0.55
Fast-paced gait
Peak KAM (NIm/(BW  HT)%) 3.39 (1.14) 3.72 (1.52) 3.21 (1.33) 3.76 (1.41) j0.18 (j0.48 to 0.12) 0.06 (j0.41 to 0.53) j0.32 (j0.83 to 0.18) 0.20
KAM impulse (NImIs/(BW  HT)%) 0.78 (0.29) 0.87 (0.40) 0.74 (0.29) 0.85 (0.31) j0.04 (j0.11 to 0.03) j0.01 (j0.13 to 0.12) j0.07 (j0.18 to 0.05) 0.25
Peak KFM (NIm/(BW  HT)%) 7.42 (2.36) 7.64 (1.59) 7.36 (2.03) 7.82 (1.46) j0.06 (j0.52 to 0.39) 0.12 (j0.38 to 0.63) j0.27 (j0.86 to 0.31) 0.35
Walking speed (mIsj1) 1.85 (0.22) 1.92 (0.20) 1.82 (0.25) 1.91 (0.18) j0.04 (j0.07 to j0.01) j0.01 (j0.04 to 0.03) j0.04 (j0.08 to 0.01) 0.13
One-leg sit-to-stand
Peak KAM (NIm/(BW  HT)%)b 2.80 (0.93) 2.82 (0.76) 2.74 (0.84) 2.70 (0.89) j0.08 (j0.34 to 0.19) j0.08 (j0.31 to 0.16) 0.01 (j0.31 to 0.33) 0.95
KAM impulse (NImIs/(BW  HT)%) 4.85 (2.19) 5.42 (2.84) 4.74 (2.90) 4.16 (2.82) j0.14 (j1.07 to 0.79) j1.17 (j1.96 to j0.38) 0.90 (j0.25 to 2.05) 0.12
Peak KFM (NIm/(BW  HT)%) 8.78 (1.44) 8.50 (1.40) 8.99 (1.26) 8.26 (1.27) 0.14 (j0.21 to 0.48) j0.14 (j0.55 to 0.27) 0.43 (j0.04 to 0.90) 0.07
Stance time (s) 3.36 (1.17) 3.62 (0.99) 3.18 (1.21) 2.83 (1.01) j0.17 (j0.70 to 0.35) j0.81 (j1.15 to j0.47) 0.48 (j0.06 to 1.01) 0.08
One-leg hop

Official Journal of the American College of Sports Medicine

Peak KAM (NIm/(BW  HT)%) 5.91 (2.17) 6.62 (2.85) 6.08 (2.12) 5.95 (2.68) 0.01 (j0.91 to 0.94) j0.56 (j1.66 to 0.54) 0.17 (j1.02 to 1.37) 0.77
Peak KFM (NIm/(BW  HT)%) 18.08 (4.94) 18.23 (3.70) 19.86 (4.02) 18.40 (5.09) 1.36 (0.11 to 2.61) 0.40 (j1.10 to 1.90) 1.13 (j0.49 to 2.74) 0.17
Isometric strength (NImIkgj1)
Hip abduction 1.96 (0.48) 1.95 (0.42) 1.95 (0.38) 1.91 (0.34) j0.03 (j0.14 to 0.08) j0.04 (j0.14 to 0.07) 0.02 (j0.10 to 0.15) 0.73
Hip adduction 1.61 (0.39) 1.58 (0.40) 1.60 (0.37) 1.58 (0.33) j0.02 (j0.12 to 0.09) j0.01 (j0.11 to 0.09) 0.00 (j0.12 to 0.12) 0.97
Knee extension 2.25 (0.53) 2.35 (0.48) 2.29 (0.46) 2.22 (0.47) 0.04 (j0.04 to 0.13) j0.12 (j0.28 to 0.05) 0.13 (j0.04 to 0.30) 0.12
Knee flexion 1.13 (0.31) 1.15 (0.32) 1.22 (0.31) 1.16 (0.32) 0.09 (0.00 to 0.17) 0.01 (j0.06 to 0.08) 0.07 (j0.03 to 0.18) 0.16
Isokinetic strength at 60- Isj1 (NImIkgj1)
Knee extension 1.87 (0.50) 1.86 (0.43) 1.94 (0.52) 1.74 (0.51) 0.05 (j0.04 to 0.14) j0.13 (j0.32 to 0.06) 0.18 (j0.02 to 0.38) 0.08
Knee flexion 0.95 (0.26) 1.00 (0.26) 1.01 (0.30) 0.99 (0.26) 0.06 (j0.03 to 0.15) j0.02 (j0.10 to 0.07) 0.06 (j0.06 to 0.17) 0.34
Physical function
30-s knee bends (reps)c 24.1 (9.3) 22.5 (6.7) 28.6 (9.7) 26.0 (6.7) 4.3 (2.3 to 6.2) 3.5 (1.6 to 5.4) 1.1 (j1.5 to 3.7) 0.40
Maximum one-leg hop (m) 1.07 (0.31) 1.17 (0.28) 1.20 (0.26) 1.20 (0.30) 0.11 (0.05 to 0.18) 0.03 (j0.04 to 0.11) 0.06 (j0.03 to 0.16) 0.21
30-s one-leg rises (reps)c 10.7 (4.1) 11.7 (4.1) 13.3 (4.9) 14.9 (4.0) 2.5 (1.3 to 3.7) 3.3 (2.0 to 4.6) 1.0 (j2.7 to 0.7) 0.23
Lower extremity activity scale (118) 13.7 (2.3) 13.7 (2.5) 13.5 (2.7) 13.0 (3.2) j0.2 (j0.8 to 0.5) j0.7 (j1.9 to 0.6) 0.5 (j0.8 to 1.7) 0.46
KOOS (0100)
Pain 88.9 (9.7) 87.3 (9.3) 90.5 (9.4) 90.8 (9.1) 1.6 (j1.9 to 5.1) 3.2 (0.1 to 6.3) j1.0 (j5.0 to 3.1) 0.63
Symptoms 88.6 (14.5) 85.3(10.7) 90.2 (9.9) 87.6 (11.8) 1.6 (j2.2 to 5.4) 1.7 (j2.2 to 5.7) 1.2 (j3.3 to 5.6) 0.60
Physical function 96.2 (5.7) 93.8 (7.9) 95.4 (7.7) 95.1 (6.1) j0.8 (j3.4 to 1.9) 1.6 (j0.4 to 3.7) j1.2 (j4.3 to 1.8) 0.42
Sport and recreation 85.5 (14.7) 80.3 (15.9) 87.3 (19.1) 85.9 (13.6) 1.8 (j6.1 to 9.6) 5.7 (j0.4 to 11.8) j0.3 (j8.7 to 8.1) 0.94
Knee-related quality of life 68.2 (22.6) 70.2 (17.3) 76.9 (17.1) 75.4 (15.1) 9.0 (1.9 to 16.1) 5.4 (0.6 to 10.2) 2.5 (j4.1 to 9.1) 0.45
a
Controlling for baseline value of the variable.
b
Results remained unchanged, excluding two participants who did not perform the exercises.
c
Number completed in 30 s.
Gray highlight denotes primary outcomes.

Copyright 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
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of physical improvement was only completed by 23 (74%) home-based neuromuscular exercise program on the peak
ALIGN participants and 26 (84%) control participants. Of KAM during walking and one-leg sit-to-stand in middle-
those reporting problems at baseline, improvement in pain age people with no to mild pain after medial APM. We

CLINICAL SCIENCES
at follow-up was not different between the groups and was found no evidence that the 12-wk neuromuscular exercise
reported by 7/25 (28%) of ALIGN participants and 4/25 (16%) program investigated here alters the peak KAM in this group
controls (relative risk (95% CI), 0.57 (0.091.71); P = 0.32). with no or minimal symptoms, who are at high risk of de-
Participants in the ALIGN group were more likely to per- veloping or progressing early knee osteoarthritis. Some
ceive an improvement in physical function, with improve- between-group differences were observed in improvement
ment reported by 10/23 (43%) ALIGN participants compared for self-reported pain, physical function (in those with minor
with only 3/24 (13%) control participants (relative risk pain and physical dysfunction at baseline), and overall im-
(95% CI), 0.29 (0.090.91); P = 0.04). Participants in the provement, favoring those in the ALIGN group.
ALIGN group were more likely to report overall improve- Peak KAM during normal-paced walking was selected as
ment (14/30 (47%) ALIGN participants and 5/29 (17%) a primary outcome, given its association with progression of
control participants (relative risk (95% CI), 0.38 (0.160.92); medial tibiofemoral osteoarthritis (25) and the relevance of
P = 0.03)). medial joint loading to this medial APM group. We antici-
Adherence, adverse events, medication use and pated that KAM would reduce in the ALIGN group because
cointerventions. From a maximum of eight, the number the exercises were designed to encourage neutral frontal
of physiotherapy sessions attended by the ALIGN group plane alignment of the lower limb and this could plausibly
ranged from 0 to 8 with a median (interquartile range (IQR)) be expected to reduce one of KAMs two primary de-
of 8 (1). From a maximum of 36 required home exercise terminants, the length of the kneeGRF lever arm (19).
sessions, the ALIGN group completed a median (IQR) of 29 Contrary to our hypothesis, we found no difference in change
(10) sessions with a range of 034 among the 29/31 partic- in peak KAM during walking between the groups. This was
ipants who returned the logbook. One participant attended despite excellent adherence to the ALIGN program, and
no physiotherapy sessions, as the person withdrew from re- scope to reduce peak KAM during gait (i.e., peak KAM
ceiving the intervention because of increased knee pain for was approximately 26% larger than that in healthy controls
reasons unrelated to the study. One participant scored zero (16)). Failure to reduce KAM in this study might be ex-
for adherence to home exercises because the participant did plained by poor transfer of the trained skills to gait. No
not begin the program. Physiotherapist-perceived impres- exercises in the ALIGN program resemble the heeltoe
sions of the participants overall adherence to the ALIGN action of gait, and this degree of task specificity may be
program ranged from 3 to 10, with a median (IQR) of 10 (2). required to modify gait.
There were no major adverse events. Thirty-nine minor ad- Although not statistically significant, the difference in
verse events were reported by 16/31 (52%) ALIGN partici- change in peak KAM during normal- and fast-paced walking
pants and predominately related to increased knee pain and between the groups was approximately 7% (Table 2). The
back pain. Cointerventions and medication use during the current study was powered to detect a 10% difference in
trials were similar for the ALIGN and control groups (Table 4). change in peak KAM between the two groups. Thus, a larger
sample size may have produced a statistically significant
difference in support of our hypothesis. The nonsignificant
difference might also reflect KAM measurement error (6).
DISCUSSION
Importantly, the magnitude and direction of peak KAM
The aim of this assessor-blinded randomized controlled change (i.e., approximately 5% decrease in ALIGN and 2%
trial was to evaluate the effects of a physiotherapist-guided, increase in controls) are consistent across both normal- and
fast-paced walking. It is of interest to note that we observed
TABLE 4. Medications and cointerventions reported as n. no between-group change in peak KFM during gait, to alter
Measure ALIGN Control medial tibiofemoral joint contact force (39).
Medication usea n = 31 n = 29 Peak KAM during one-leg sit-to-stand was also included
Analgesia (paracetamol combinations) 1 3
Nonsteroidal anti-inflammatories 3 1
as a primary outcome, because an uncontrolled pilot study
Topical anti-inflammatories 0 3 found a 14% reduction in peak KAM during this task after
Glucosamine/chondroitin products 3 5 an 8-wk neuromuscular exercise program in people (n = 13)
Oral corticosteroid 0 1
Topical liniment rubs 0 0 with early knee osteoarthritis (38). Despite the similarity of
Fish oil 1 1 the current sample in terms of age and radiographic disease
Cointerventionsb 2/31 6/29
Other physiotherapy 1 2
severity and using a similar neuromuscular training pro-
Exercise 0 2 gram, we did not find a reduction. There are three issues to
Osteopathy 0 1 consider in relation to this finding. First, unlike peak KAM
Acupuncture 0 1
Hydrotherapy 1 0 during walking, it is unknown whether people after APM
a
Defined as at least once per week recorded during the last month of trial.
have a higher peak KAM during one-leg sit-to-stand than
b
Recorded during the entire trial. that of controls. Thus, it is unknown whether participants

NEUROMUSCULAR EXERCISE AFTER MENISCECTOMY Medicine & Science in Sports & Exercised 1563

Copyright 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 had scope to reduce peak KAM during this task. Second,
KAM can be altered by foot progression angle (34), knee
flexion, and hip rotation (14). The reduction in peak KAM
CLINICAL SCIENCES
observed in the pilot study could be explained by these
aforementioned variations during testing, rather than the
8-wk neuromuscular exercise program. Third, the clinical
relevance of reduced peak KAM during one-leg sit-to-stand
remains unknown.
This is the first randomized controlled trial to evaluate the
effects of neuromuscular exercise on KAM in a population
with good function and minimal symptoms but were at risk
for development or progression of knee osteoarthritis. De-
spite failure to find a difference between groups, this study
makes an important contribution to knowledge. A recent
study on the effect of neuromuscular exercise on KAM
during walking in people with painful established knee
osteoarthritis speculated that KAM may not alter because of
the lack of task specificity (4) or that changes in peak KAM
might only be revealed in more demanding tasks. Our study
argues against these issues, as we found no evidence that
neuromuscular training alters peak KAM during a demand-
ing one-leg sit-to-stand task despite its inclusion in the
ALIGN program. This finding questions the efficacy of this
neuromuscular exercise program to reduce KAM during
such functional tasks. Other forms of neuromuscular train-
ing that target different aspects of function may be effective,
but this requires further study. It has also been speculated
previously that training both the affected and unaffected leg
may accentuate the effect of neuromuscular exercise on
KAM (4). Although participants in the current study per-
formed the ALIGN program on both limbs, peak KAM did
not reduce in our study. Overall, our findings concur with
and further substantiate evidence from clinical trials that
report no effect of exercise, regardless of type, on KAM in
people with knee osteoarthritis (4,13).
Although KAM measurement has excellent reliability (6),
it also has limitations as a primary outcome. Peak KAM is
widely used because it has been shown to relate to structural
cartilage change (25) but is only a surrogate measure of the
latter. Because we did not quantify structural change in this
study, we cannot conclude that neuromuscular exercise does
not delay or prevent osteoarthritic structural change in APM
patients. Indeed, a supervised 16-wk neuromuscular exer-
cise program found improved cartilage quality assessed using
dGEMRIC in people 35 yr after medial APM (29). In
that study, dGEMRIC was associated with osteoarthritic
changes in the same cohort 11 yr later (26), which sup-
ports dGEMRIC as a clinically relevant indicator of ad-
verse structural change.
The strengths of our study include rigorous study design
with methodological features to minimize bias such as the
following: concealed allocation, excellent participant reten-
tion, and good adherence to the ALIGN program. Several
limitations of this study warrant consideration. First, only
15% of those identified as potentially eligible from private
surgical records participated and this questions the potential
1564 Official Journal of the American College of Sports Medicine
Copyright 2015 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
generalizability of the results. The most frequent reason that
people declined was lack of interest to participate. Although
our participants had similar KOOS scores to that of other
APM populations 35 yr after surgery, they reported less
difficulty in performing activities associated with sport and
recreation (15,29,31,35). Such observations may suggest
better baseline neuromuscular control with less scope for
improvement. Second, the lack of participant blinding re-
quires consideration. Although a placebo intervention would
provide a more optimal comparator, design of a credible
placebo treatment for neuromuscular exercise is difficult.
Furthermore, because the placebo effect on objective out-
comes is minimal in knee osteoarthritis (40), we deemed a
placebo treatment unnecessary, given the objective nature of
our primary outcome (peak KAM). Third, we did not for-
mally assess the adherence of the physiotherapists to the
standardized ALIGN intervention protocol.
In conclusion, our results show no change in peak KAM
during walking or one-leg sit-to-stand after neuromuscular
exercise in an APM cohort, who reported good function and
few symptoms. Future studies are required to assess long-
term effects of neuromuscular exercise on structural mea-
sures of osteoarthritis onset and progression and the effect
of more task-specific protocols before the disease-
modifying effect of neuromuscular exercise can be con-
clusively determined.
The study physiotherapists providing the physiotherapy treat-
ments were Ian McFarland, Riley Bodger, Laurie McCormack, John
Pompei, Anthony Feron, Josh Heery, and Alison Harding. We thank
the following orthopedic surgeons and their staff for assisting with
participant recruitment: Mr. Tim Whitehead, Prof. Julian Feller, Mr.
Rohan Price, Mr. Cameron Norsworthy, Mr. Robert Steele, Mr. Chris
Kondogiannis, and Mr. Peter Gard. The authors thank Mr. Joel
Martin and Ms. Penny Campbell for randomizing the participants
and managing the home exercise equipment and Mr. Ben Metcalf
for providing the randomization schedule. The authors also thank
Ms. Janine Topp for her contribution to data acquisition by assisting
with data collection and processing.
This study was funded by an Australian National Health and
Medical Research Council Program grant (#631717). K. L. B. and
R. S. H. were partly funded by Australian Research Council Research
Future fellowships (#FT 0991413 and #FT 130100175), and P. H. is
supported by a National Health and Medical Research Council fel-
lowship (#APP1002190). M. H. was supported by a Ph.D. scholar-
ship from a National Health and Medical Research Council Program
grant (#631717). The study sponsor did not play any role in the study
design, collection, and analysis or interpretation of data or in the
writing of the article or decision to submit the manuscript for publi-
cation. None of the funders had any role in the study other than to
provide funding.
The authors contributions were as follows: M. H., significant
manuscript writer, concept and design, data acquisition, data anal-
ysis, and data interpretation; R. S. H., concept and design, signifi-
cant manuscript reviewer, data interpretation, and statistical
expertise; T. V. W., significant manuscript reviewer, concept and
design, and data analysis and interpretation; E. M. R., significant
manuscript reviewer, concept and design, and data interpretation;
P. W. H., obtained funding, significant manuscript reviewer, concept
and design, and data interpretation; M. P. S., significant manuscript
reviewer, statistical analysis, and data interpretation; K. L. B.,
http://www.acsm-msse.org
obtained project funding, significant manuscript reviewer, concept
and design, and data interpretation. All authors provided feedback
on the draft of this article and read and approved the final article.
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