THEKNE-01881; No of Pages 7

The Knee xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

The Knee

Efficacy of passive extension mobilization in addition to exercise in the

osteoarthritic knee: An observational parallel-group study☆,☆☆
Olaf Kappetijn a,⁎, Emiel van Trijffel b,c, Cees Lucas b
a
SPOMED, Capelle aan den IJssel, The Netherlands
b
Department of Clinical Epidemiology, Biostatistics & Bioinformatics, Academic Medical Center, University of Amsterdam, The Netherlands
c
Educational Center for Musculoskeletal Therapies, Amersfoort, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Study design: Pretest post-test observational parallel-group design.

Received 3 January 2013 Objectives: To evaluate the efficacy of passive knee extension mobilization in addition to exercise therapy on
Received in revised form 26 February 2014 extension range of motion (ROM) in patients with osteoarthritis (OA) of the knee. Secondary objectives were
Accepted 9 March 2014 to determine changes in pain and functional abilities.
Available online xxxx
Background: Patients with knee OA complain of pain, limited range of motion, and impaired activities. Efficacy of
mobilization as a treatment option next to exercises has not been studied rigorously.
Keywords:
Knee osteoarthritis
Methods and measures: Thirty-four participants with persistent knee pain, a positive radiography for knee OA, and
Passive movement a passive extension deficit were included. Seventeen participants (mean age ± SD, 59.8 ± 6.1 years) were treat-
Physical therapy ed with an exercise protocol and were additionally given manual mobilizations to improve passive extension
Training ROM. The other group (mean age ± SD, 61.5 ± 7.3 years) with equal characteristics was treated with an identical
exercise therapy protocol only. Prior to participation, detailed ROM measurements were recorded next to muscle
function tests, pain (VAS), six-minute walking tests (6MWTs), a condition-specific questionnaire, and the
patient-specific function scale (PSFS). Participants in both groups completed 16 treatment sessions each.
Results: Passive mobilization significantly improved extension ROM in the intervention group (5.2 versus
8.6°, p = .017). The manually mobilized group also had better physical capacities as assessed by 6MWT,
less pain, and a lower PSFS score.
Conclusion: A combined protocol including exercise therapy and passive mobilization was beneficial for
patients with OA of the knee complaining of pain, decreased extension ROM and decreased limited abilities.
Level of evidence: Therapy, 2b.
© 2014 Elsevier B.V. All rights reserved.

1. Introduction general health problem with a high prevalence in adults of

Osteoarthritic disease is defined as a slowly progressive joint
disorder characterized by increasing joint pain, stiffness and limitations
in range of motion (ROM). Osteoarthritis (OA) of the knee is also
associated with pain or discomfort and limited functional abilities [1,2].
Eventually, progressive pain and further limited activities may necessi-
tate surgical treatment. Osteoarthritis of the knee results in disabling
symptoms in an estimated 10% of people aged 55 and older. A quarter
of these people are severely disabled [3,4]. A cross-sectional health
examination survey in the US also showed that OA is considered a
☆ No author or related institution has received any financial benefit from research in
this study.
☆☆ This trial, including consent procedure, was approved and registered by the Medical
Ethics Committee of the Academic Medical Center, University of Amsterdam, The
Netherlands (reg.nr. NL 27414.018.09).
⁎ Corresponding author at: Dalkuidbaan 21, 2908 KC Capelle aan den IJssel, The
Netherlands.
E-mail address: olafkappetijn@yahoo.com (O. Kappetijn).
60 years and older [5]. The point prevalence in the Netherlands for
knee OA is 38.1 in every 1000 inhabitants as indicated by recent
national data [6].
When the knee is affected by arthritis, the consequent patholog-
ical changes may prevent full extension. This is usually referred to
as a flexion contracture or fixed flexion deformity [7]. Fixed flexion de-
formity is a common problem in osteoarthritic knees. A study by
Ritter et al. found that 35% of a total of 5622 knees had a flexion de-
formity before total knee replacement [8]. In a review of 697 primary
and revision knee replacements, such a deformity was present in 61%
of knees before surgery [7]. Full extension may be inhibited initially
by pain or effusion. After that, contracture and adhesions may devel-
op in the posterior capsule, the hamstring muscles, and possibly the
cruciate ligaments. Flexion contracture has an adverse effect on
function of the knee. In comparison to loss of extension seen after in-
jury or surgery of the knee joint, an extension loss produces more
subjective complaints and alteration in normal gait patterns than a
loss of flexion [9].

http://dx.doi.org/10.1016/j.knee.2014.03.003
0968-0160/© 2014 Elsevier B.V. All rights reserved.

Please cite this article as: Kappetijn O, et al, Efficacy of passive extension mobilization in addition to exercise in the osteoarthritic knee: An obser-
vational parallel-group stu..., Knee (2014), http://dx.doi.org/10.1016/j.knee.2014.03.003
2 O. Kappetijn et al. / The Knee xxx (2014) xxx–xxx

Passive manual joint mobilization as a treatment option for optimiz-
ing ROM and pain relief in the osteoarthritic knee combined with exer-
cise therapy has not been studied rigorously. There is evidence that
exercise and self-management are beneficial in knee OA patients [1,
10,11]. In addition, Deyle et al. [12,13], Moss et al. [14] and Pollard
et al. [15] have shown positive effects of manual therapy and exercise
over placebo treatment. In a systematic review, French et al. found
evidence that manual therapy has a beneficial effect compared with
exercise therapy in patients with hip OA [16]. Jansen et al. suggested
that physical therapists and manual therapists could consider adding
manual mobilization to optimize supervised active exercise programs
[17]. However, only general mobilization techniques for achieving full
ROM are mentioned in these studies. The practice guideline of the
Royal Dutch Society for Physical Therapy for management of patients
with OA of the hip and knee recommends passive joint mobilization in
addition to exercise therapy. Driven by expert opinion, passive manual
joint mobilization should only be considered as a preliminary measure
before exercise therapy in case of severe pain or functional impairment
[11]. Explicit mobilization techniques for improving range of motion
deficits are not described. According to the UK guidelines for the man-
agement of OA, manipulation and stretching should be considered as
an adjunct to local muscle strengthening and general aerobic fitness
particularly in OA of the hip [18].
The aim of this study was to evaluate the added value of passive joint
mobilization on extension ROM in patients with a fixed flexion
deformity as a result of knee OA as compared to exercise therapy
alone. Our secondary objective was to determine whether an increase
in passive extension mobility was associated with improved physical
function and decreased pain.
2. Methods
2.1. Participants
Patients between 45 and 75 years of age and suffering from knee
pain for more than three months and existing OA as confirmed by radio-
graphic imaging were included. These patients had to have a decreased
passive extension of at least 5° and also had to have a minimum of 90
degrees of flexion mobility. Patients unable to speak and write Dutch
were excluded. Patients suffering from degenerative diseases of other
lower extremity joints and patients incapable of walking 500 m without
aid were excluded. Patients who received knee surgery in the last three
months preceding the study or received an intra-articular injection in
the last six weeks prior to the study were excluded. Recruitment of par-
ticipants took place from June 2009 until February 2012.
The trial, including consent procedure, was approved and registered
by the Medical Ethics Committee of the Academic Medical Center,
University of Amsterdam, The Netherlands (reg.nr. NL 27414.018.09).
Patients were given an information letter regarding the content and
purpose of the study. All patients provided written informed consent
after reading the information letter.
2.3. Intervention
Treatment was provided in two different out-patient orthopedic
physical therapy centers, SPOMED, Capelle aan den IJssel and OREC in
Hilversum, The Netherlands. Patients in both groups were treated in
accordance with the Dutch practice guideline for the management of
patients with OA of the hip and knee [11]. Information and advice
were given to both groups of patients. These consisted of basic rules
on how to prevent further exacerbation of the symptomatic knee and
to promote adequate coping strategies. All verbal information was
strictly standardized using a script. Therapists at both centers involved
in treating patients were trained prior to the study to ensure exact
equal treatment and intervention in both cohorts.
Patients in the intervention group and the control group performed
a closely supervised standardized knee exercise program for a period of
eight consecutive weeks (see Appendix 1.). Both groups started at base-
line training twice a week according to an exercise protocol. This exer-
cise protocol is considered standard care in the Netherlands. The
standardized protocol consisted of cardiovascular exercises on a station-
ary bike and treadmill, and general closed chain exercises for improving
lower extremity and quadriceps strength and improving full range of
motion. A home-exercise program was provided including muscle set-
ting exercises and active and passive ROM exercises. Intensity and num-
ber of repetitions of strengthening exercises were increased on the basis
of patient tolerance. Before each session each patient was asked to rate
the post-training pain intensity using a numeric pain rating scale
(NPRS). Also patients were examined for adverse signs and symptoms
such as pain, effusion and increased skin temperature. Signs and symp-
toms had to be consistent or decreasing before exercise intensity or du-
ration was increased. Patients had to exercise pain free or with the least
possible pain.
Due to observed variability in treatment regarding the center-based
choice to treat patients with or without manual mobilization we chose
the cohort in Hilversum as our intervention group whereas the cohort
in the city of Rotterdam was our control group. Between the interven-
tion group and the control group the latter would be given the standard
treatment consisting of advice and exercise therapy without manual
mobilization. Only the cohort in the region of Hilversum was additional-
ly given the manual mobilization technique.
Mobilization of the knee joint was conducted with the subject seated
on a wooden bench as used in school physical education (Fig. 1).
The treatment consisted of a technique in which first the proximal
joint member was stabilized with the help of a traction girdle. Next, a

2.2. Study design

In an observational parallel-group design two cohorts were formed.

One cohort contained patients who had been referred after consulting
orthopedic surgeons in the Erasmus Medical Center university hospital
and the IJsselland Hospital, both in the city of Rotterdam, The
Netherlands. Another cohort was formed with patients who had been
referred after consulting orthopedic surgeons at Tergooiziekenhuizen,
Hilversum and Blaricum, The Netherlands. In both locations, a hospital
radiologist diagnosed present knee osteoarthritis according to the
Kellgren–Lawrence-score [19–21]. If patients in any of these hospitals Fig. 1. Mobilization technique. Restriction of movement of proximal joint member and for-
met our inclusion criteria, they were invited to participate. Patients ward motion of distal joint member in the sagittal plane improving forward translation
were subsequently referred for physical therapy. mimicking normal arthrokinematic motion.

Please cite this article as: Kappetijn O, et al, Efficacy of passive extension mobilization in addition to exercise in the osteoarthritic knee: An obser-
vational parallel-group stu..., Knee (2014), http://dx.doi.org/10.1016/j.knee.2014.03.003
 O. Kappetijn et al. / The Knee xxx (2014) xxx–xxx
forward movement of the tibia in the sagittal plane was applied improv-
ing forward translation [22]. Sustained anterior translation of the prox-
imal tibia grade III according to Maitland [22] was applied. A slight tilt
was added with the assistance of another girdle on the distal tibia.
When using this technique, additional translation assists angular exten-
sion of the knee joint mimicking normal physiological movement [23].
The mobilization was sustained for 20 s and repeated 15 times in each
session. The mobilization was performed as long as there was a limita-
tion in passive ROM. Improvement in passive ROM was assessed by
using a long-armed extendable goniometer [24]. The intervention
group was manually treated for improving knee extension for the first
12 sessions in which the other cohort (control group) only followed ex-
ercise therapy. Subjects in both groups completed exactly 16 treatment
sessions.
2.4. Measurement procedures
All data were gathered prospectively. Participants underwent a stan-
dardized interview and physical examination at the beginning of the
treatment protocol. Baseline data were collected for each patient includ-
ing age, sex, height, weight, Kellgren and Lawrence score, duration of
pain, presence of pain in one or both knees, presence of generalized
OA, previous knee surgery, current pain medication, and present activi-
ty level using a Tegner activity rating scale. Subsequently body mass
index (BMI) for each patient was calculated and registered. The primary
outcome was passive knee joint extension ROM. At baseline, this vari-
able was assessed by a physical therapist unaware of the treatment
any patient would receive. The procedure for measurement of passive
range of motion was standardized for reasons of increased reliability
[24]. One observer performed baseline and outcome measurement as
intratester reliability was found to be higher than intertester reliability
[25,26]. Inter-rater reliability of measurement of passive movements
of lower extremity joints is generally low [27]. An extendable long-
armed goniometer (model 01135 Lafayette Instrument Co., Inc., USA)
was used. Training of the assessor took place prior to the study. The as-
sessor was issued a manual for measuring passive range of motion of the
knee joint. During the first visit the participants completed two ques-
tionnaires. The knee injury and osteoarthritis outcome score (KOOS)
for assessment of symptoms and function [28] and the patient-specific
functional scale (PSFS) [29] were admitted and recorded. Quadriceps
muscle peak torque was assessed using an isokinetic dynamometric
device (Biodex Medical Systems, Inc., USA). The last test participants
underwent as part of baseline testing, was a six-minute walk test for
assessment of functional exercise capacity (6MWT) followed by assess-
ment of weight-bearing pain by means of a visual analog score (VAS)
5 min after completion of the 6MWT [30].
The total training period was two months. A post-treatment as-
sessment of primary and secondary outcomes took place during a
separate meeting within one week after the sixteenth treatment ses-
sion. Subjects of both cohorts were assessed again for passive ROM,
symptoms and functional abilities (KOOS, PSFS), 6MWT, and quadri-
ceps muscle peak force. As the primary outcome was passive joint
extension ROM, this was assessed by a trained physical therapist
unaware of the purpose of the study.
2.5. Data analysis
Means, standard deviations, medians, and range were calculated
to describe characteristics of both separate groups at baseline. Propor-
tions were calculated for dichotomous variables. As this was a non-
randomized cohort study, the principal investigator had no control
over treatment assignment. Differences between treatment groups
with respect to certain prognostic important characteristics were likely
to occur. Therefore, direct comparison of treatment effects could be
confounded by baseline characteristics. In order to check prognostic
equality between cohorts at baseline, statistical tests were performed.
Please cite this article as: Kappetijn O, et al, Efficacy of passive extension mobilization in addition to exercise in the osteoarthritic knee: An obser-
vational parallel-group stu..., Knee (2014), http://dx.doi.org/10.1016/j.knee.2014.03.003
3
Continuous data (age, BMI, quadriceps strength, extension ROM deficits,
total ROM, the condition-specific KOOS, PSFS, six-minute walking
distance, and VAS pain) were analyzed for group differences with
independent-sample T-tests. For ordinal and not-normally distributed
variables, Mann–Whitney U tests were performed. For comparison of
proportions, Chi-square tests were used. Prognostic factors influencing
disease outcome are age, sex, BMI, duration of pain in the previous
twelve months, generalized OA, and present activity level [31–35]. We
performed regression analysis for adjustment of covariates to achieve
unbiased estimates and confidence intervals for the magnitude of
treatment difference in outcome. The main outcome variable was
passive extension ROM. Treatment effect was corrected for at least base-
line extension ROM and other variables were added when significantly
different between groups at baseline or in case differences were consid-
ered large. In both cases, the association of such a variable with the pri-
mary outcome was analyzed using univariate regression. Variables
(covariates) significantly associated with the primary outcome were
then used for further correction of the treatment effect. Data were ana-
lyzed using SPSS for Macintosh (SPSS Statistics version 20.0, SPSS Inc.
IBM, Chicago, Illinois, USA). p-Values smaller than 0.05 were considered
statistically significant.
Sample size calculation showed that if a total of 34 participants
(17 per group) would be included, we could detect a mean improve-
ment of 5° of passive extension of the knee joint of the intervention
group with a two-sided alpha of .05 and a power of 80%. This indicat-
ed that we would be able to show an improvement of approximately
30%. We regarded the amount of such a treatment effect as a clinical-
ly significant effect based on earlier outcomes of a small pilot study
we performed. Both measurement error and standard deviation
were set at 5°.
3. Results
3.1. Participant characteristics
Thirty-four patients were included, of which 17 participated in the intervention
(exercise plus mobilization) group and 17 were included in the control (exercise only)
group. In the control group, 16 patients completed the study because one subject
had to withdraw after receiving knee surgery during the study due to an increase in
symptoms.
Baseline characteristics of the study participants are shown in Table 1. The inter-
vention group had a mean extension deficit at baseline of 10.2 (SD 3.2) degrees versus
9.8 (SD 2.7) degrees in the control group (p = 0.65). Total range of motion, 6MWT
scores, values of symptoms item in KOOS, and quadriceps peak force appeared to be
different but were not significantly different between groups. The Index of severity
of radiographic OA (Kellgren and Lawrence score) showed a median of II in both
the intervention and control groups. The control group had one patient with grade
I, 12 patients with grade II and four patients with grade III. The intervention group
had two patients with grade I, 10 patients with grade II and five patients with grade
III. No patient had grade IV.
3.2. Primary outcome
After three months there was a significant change in passive extension deficit in favor
of the intervention group (t (31) = 2.51, p = 0.017). The intervention group had a mean
of 5.2 (SD 4.6) degrees versus 8.6 (SD 2.9) degrees in the control group. Between-group
difference in passive extension ROM was 3.4° (Table 2). The within-group change for
the intervention group was 5.1° (p b 0.001) whereas the control group had a within
group change of 1.3°. The within-group change for the control group was not significant
(p = 0.06).
Univariate regression analysis revealed that total ROM strongly predicted the primary
study outcome variable (adjusted R2 = 0.395 (1,32), p b 0.001). Other variables did not
predict the primary outcome. Treatment effect was corrected for total ROM at baseline
and extension deficit at baseline using multiple regression analysis.
Estimates of adjusted means were 5.6 (95% Confidence interval 4.04, 7.17) degrees for
the intervention group and 8.1 (95% Confidence interval 6.49, 9.73) degrees for the control
group. Between-group difference was 2.5°.
3.3. Secondary outcomes
Total range of motion in the control group was 121.8 (SD 8.8) degrees whereas the
intervention group had 126.5 (SD 16.9) degrees (Table 3.). Difference in means between
4 O. Kappetijn et al. / The Knee xxx (2014) xxx–xxx

Table 1
Baseline characteristics of study population.

Mobilization and exercise group (n = 17)a Exercise only group (n = 17) p-Valueb

Sex, n (percentage) Female 6 (46) 7 (54) 0.72c

Male 11 (52) 10 (48)
Age, years 59.8 (6.1) 61.6 (7.3) 0.45
Body mass index, kg/m2 28.3 (4.4) 26.8 (2.6) 0.22
Duration of pain in previous year, months 10.6 (2.1) 9.3 (2.9) 0.13
Generalized osteoarthritis, n (percentage) None 10 (48) 11 (52) 0.63c
Present 7 (54) 6 (46)
Tegner activity rating scale, mediand 3 (1–6) 2 (1–4) 0.11e
Kellgren and Lawrence scored 2 (1–3) 2 (1–3) 1.00e
Extension deficit, degrees 10.2 (3.2) 9.8 (2.7) 0.65
Total range of motion, degrees 122.2 (14.8) 114.1 (12.0) 0.09
6-minute walking test, meters 499.1 (71.6) 444.8 (103.1) 0.08
Weight-bearing VAS Pain 5 min after 6MWT, mm 24.9 (21.3) 29.0 (23.8) 0.60
KOOSf Symptoms 41.2 (16.7) 53.7 (20.0) 0.06
Pain 46.6 (20.8) 52.9 (24.6) 0.41
Activity 58.4 (19.1) 55.8 (24.0) 0.73
Sport/Rec 24.4 (18.6) 27.9 (21.9) 0.62
Quality of life 49.9 (74.1) 29.7 (17.3) 0.28
Total 45.8 (14.6) 47.8 (20.7) 0.74
PSFSg, mm 1 46.4 (20.2) 58.6 (20.8) 0.09
2 56.2 (25.3) 53.5 (28.2) 0.78
3 69.3 (26.0) 66.1 (21.1) 0.71
Mean PSFS 56.6 (17.4) 61.6 (17.5) 0.40
Quadriceps peak torque (QPT) 60°/s, nm 107.3 (41.7) 87.1 (40.0) 0.17
90°/s, nm 96.1 (33.3) 74.0 (33.1) 0.06
300°/s, nm 60.9 (21.1) 47.4 (19.2) 0.06
Mean QPT, degrees/s, nm 101.7 (37.4) 80.6 (34.7) 0.10
a
Values are means with standard deviation (in brackets) unless indicated otherwise.
b
Independent-samples T-test unless indicated otherwise. If significant, rejects null hypothesis; sample means are different.
c
Pearson Chi-square test. If significant, proportion of individuals with characteristic not equal between groups.
d
Range for ordinal variables in parenthesis.
e
Group differences were tested with Mann Whitney U test. If significant, rejects null hypothesis; groups are different.
f
Knee injury and osteoarthritis outcome score. Higher values indicate fewer problems.
g
Patient-specific function scale. Lower values indicate fewer problems.

groups was 4.7° after three months. There was no significant increase in total ROM in
either group.
Group means for KOOS, PSFS, six-minute walk distance, weight-bearing pain VAS five
minutes after 6MWT, and quadriceps muscle peak torque after three months are present-
ed in Table 3. Significant differences in group means in favor of the intervention group
were observed for six-minute walking distance, visual analog scores (VAS) for weight-
bearing pain after six-minute walking test, and individual PSFS scores. Mean quadriceps
muscle peak score and KOOS scores were not significantly different between groups. Nei-
ther group had a significant change in the use of analgesics and nonsteroidal anti-
inflammatory drug (NSAID).
4. Discussion
We evaluated the additional value of manual joint mobilizations on
passive extension ROM in patients with a fixed flexion deformity as a
result of knee OA as compared to standard guideline treatment alone.
Our findings indicate that passive knee extension deficit improves
after a combined protocol. We were also able to show an increase in
six-minute walk distance, a decrease of mean VAS for weight-bearing
pain after six-minute walking test and, lower individual PSFS scores in
the mobilization group.
As our primary outcome we chose a surrogate outcome allowing for
a much smaller sample size. This gave us the opportunity to do a
smaller, less time consuming trial to reveal an effect on a physiological
level produced by this intervention. In a new, preferably randomized
trial the efficacy of this treatment on impairments on activity and
improvements of activities of daily living should be determined. The
results of this study showed a clear trend of improvements in functional
capacity and a decrease in impairments in activities of daily living how-
ever the power of this study was insufficient to make this a statistically
significant difference. The non-significant changes in muscle function in
our study may give rise to the fact that our exercise protocol was not
sufficient despite referring to expert protocols for exercise for patients
with symptomatic knee OA [36,1,11].
Several studies already showed patient relevant improvements
after more general manipulation techniques in addition to an
exercise protocol [12–15]. Our study was more specific because of

Table 2
Results within and between groups after three months for extension range of motion.

Mobilization and exercise group (n = 17) Exercise only group (n = 17) Between group differencea
b
At baseline 10.24 (8.58, 11.89) 9.77 (8.39, 11.14) −0.47 (−2.54, 1.60) p = 0.65
After three months 5.18 (2.82, 7.52) 8.56 (7.01, 10.12) 3.39 (0.64, 6.14) p = 0.02
Within group difference after 3 monthsc 5.06 (2.97, 7.15) p b 0.001 1.31 (−0.06, 2.68) p = .06 …
Covariate adjusted estimates after 3 monthsd 5.60 (4.04, 7.17) 8.11 (6.49, 9.73) −2.51 (0.18, 4.84) p = 0.04
a
Between group change scores were calculated with independent samples T-test.
b
Group means and estimated means of passive extension deficit in degrees (95% Confidence interval).
c
Within group change scores were calculated with paired samples t-test. Note. For this test statistic the exercise only group had n = 16 due to withdrawal of one subject.
d
Adjusted estimates after multiple linear regression. Covariates: total ROM at baseline and passive extension deficit at baseline.

Please cite this article as: Kappetijn O, et al, Efficacy of passive extension mobilization in addition to exercise in the osteoarthritic knee: An obser-
vational parallel-group stu..., Knee (2014), http://dx.doi.org/10.1016/j.knee.2014.03.003
 O. Kappetijn et al. / The Knee xxx (2014) xxx–xxx 5

Table 3
Results between groups after three months for secondary outcomes.

Mobilization and exercise groupa Exercise only group p-Valueb

Total range of motion, degrees 126.5 (16.9) 121.8 (8.8) 0.32

Six-minute walking distance, meters 554.9 (94.1) 449.6 (86.0) 0.01
VAS pain post-6MWT, mm 11.0 (16.2) 27.3 (23.3) 0.03
KOOSc Symptoms 51.0 (22.9) 52.3 (22.6) 0.88
Pain 58.8 (22.0) 47.0 (25.3) 0.17
ADL 63.1 (19.7) 58.0 (25.4) 0.53
Sport/Rec 31.7 (22.1) 26.4 (21.3) 0.50
Quality of Life 44.2 (18.7) 32.7 (25.3) 0.16
Total 55.1 (17.5) 47.3 (27.7) 0.28
PSFSd, mm 1 32.6 (24.9) 55.2 (26.1) 0.02
2 41.2 (25.5) 53.4 (28.1) 0.21
3 50.0 (30.0) 61.1 (23.3) 0.28
Mean PSFS 41.0 (23.4) 56.6 (20.7) 0.05
e
QPT 60 deg/s, Nm 106.7 (36.3) 82.6 (32.3) 0.06
90 deg/s, Nm 95.7 (29.7) 79.1 (33.1) 0.15
300 deg/s, Nm 61.6 (16.0) 47.5 (20.4) 0.04
Mean QPT, Nm 101.2 (32.8) 80.8 (32.2) 0.09
a
Group means (standard deviations in brackets).
b
Independent samples T-test, if significant group means are not equal; p b .05.
c
Knee injury and osteoarthritis outcome score; higher values indicate fewer problems.
d
Patient-specific function scale; lower values indicate fewer problems.
e
Quadriceps peak torque.

presumed relationships with treatment of the extension deficient
knee joint and pain, discomfort, and decreased activity level. A
study by Hoeksma et al. [37] showed that after a manual therapy
program focusing on manipulations and mobilization of the osteoar-
thritic hip joint the general perceived improvement was better than
in patients in the exercise only group. Also secondary outcomes
including pain, hip function and range of motion improved. Their
findings concur with our data. Treating range of motion deficits in
osteoarthritic conditions seems to result in an improvement in
range of motion, decrease in pain, and an improvement in activity
level. It is, however, unclear if this is the result of influencing soft tis-
sue mechanics. Once affected by OA, the joint changes structurally. A
non-inflammatory deterioration of articular cartilage is seen with re-
active new bone formation at the joint's surface and margins and the
development of bony cysts. Interestingly, the presence of radiologic
findings of OA changes is not directly related to symptoms for in-
stance pain [38]. Therefore, not only osseous or chondral structures
might be responsible for pain and discomfort. Possibly, periarticular
soft tissue may be affected as well because soft tissue contraction is
part of the OA disease [39]. More research is needed to provide
deeper insight in mechanisms explaining treatment effects of pas-
sive mobilizations in osteoarthritic joints.
Current research has begun to focus on improvement of neuromus-
cular function in conjunction with traditional exercise. Future research
should be aimed toward a possible influence of quadriceps muscle
excitability and an improved extension range of motion. Any improve-
ment in extension range of motion would likely benefit from an im-
provement in quadriceps excitability. This study was conducted to
assess direct changes in pain and functional capacity as a result of
changes in ROM.
A limitation was the relatively small improvement in ROM we
assessed. We regarded 5° as a clinically important change. However out-
comes of 6MWT, mean VAS for weight-bearing pain after six-minute
walking test, and PSFS scores suggest meaningful changes for patients.
Another potential limitation of our study is that participants were not
randomly assigned to treatment groups thereby risking unequal distri-
bution of potentially important prognostic factors. However, we pur-
posely decided for a nonrandomized design for practical reasons.
Mobilizing an osteoarthritic knee with a passive extension deficit is
not common practice in the Netherlands. By including two cohorts in
different locations we avoided contamination between groups. In a
randomized trial, modification of behavior caused by the intervention
may have affected the management of patients in the control group.
Both groups were comparable in terms of important prognostic var-
iables. In addition, by correcting treatment effects for known prognostic
variables we believe to have compensated for the lack of randomization
in our study.
5. Conclusion
We were able to demonstrate that standardized manual mobiliza-
tions and exercise therapy are more effective for improving range of
motion in extension deficient osteoarthritic knees than a standard
exercise protocol. Adding passive extension mobilizations to existing
protocols could be beneficial for patients with a fixed flexion contracture
due to mild to moderate knee osteoarthritis. We also showed a relation-
ship between improvement of extension range of motion in the osteoar-
thritic knee and decrease of pain, and improvement in functions of daily
living, and functional capacity. New research should focus further on the
effectiveness of passive mobilizations on patient-oriented outcomes.
Conflict of interest
We wish to confirm that there are no known conflicts of interest
associated with this publication and there has been no significant
financial support for this work that could have influenced its outcome.
Acknowledgments
I wish to thank various people for their contributions to this study;
the staff of SPOMED and OREC out-clinic physical therapy centers for of-
fering me the resources to execute this study and Dr. R. Verhagen and
Dr. D. Meuffels for their support in contacting eligible patients and
their useful critiques of this research work.
Especially I would like to express my gratitude to W. van Tongeren
for his useful and constructive recommendations. Advice given by H.J.
Buijtendijk and B. Legemaat has been of great help in designing the
exercise protocol. I would also like to extend my thanks to L. de Vries,
K. Luiting Maten, I. Gorter, W. Heijboer, E. van Erven, and I. Tak for
their help in gathering the data. At last I would like to thank N. Soons
for her editing skills.

Please cite this article as: Kappetijn O, et al, Efficacy of passive extension mobilization in addition to exercise in the osteoarthritic knee: An obser-
vational parallel-group stu..., Knee (2014), http://dx.doi.org/10.1016/j.knee.2014.03.003
6 O. Kappetijn et al. / The Knee xxx (2014) xxx–xxx

Appendix 1. Exercise protocol

Before each session in the physical therapy center, patients are examined for adverse signs and symptoms. Signs and symptoms have to be con-
sistent or decreasing before exercise intensity or duration is increased.

Exercises in Exercises performed under supervision of a physical therapist at an orthopedic physical therapy center. Training should be performed twice a week.⁎
orthopedic physical
therapy clinic

Treadmill walking forward Upright posture maintained throughout. Starting 4 min with a 4%
Therapist instructs correct gait quality. incline
Treadmill walking Therapist instructs correct gait quality. Starting 2 min with a 2%
backwards incline
Machine squat Prone lying Patient should extend legs completely 3 series of 10 repetitions
promoting full ROM. starting with a
maximum of 25%
bodyweight
Step ups This exercise is performed Patient should step up a stair or step block 2 series of 5 repetitions
in a standing position with one foot. Extending the knee
completely.
Partial squats Standing position. Patient should perform minisquats 2 series of 10 repetitions
Place feet shoulder standing behind a chair, bending the knees
width apart. 45° keeping the back straight.
Standing terminal Standing TKE Exercise To complete a standing TKE exercise, the Repeat 3 series of 10
knee extension patient should stand facing a pulley repetitions.
machine with a padded cord placed just
above the joint line behind the affected
knee. He or she should flex the knee
against the band at around a 30-degree
angle. Then return to starting position
emphasizing terminal knee extension.
Stationary bike Set seat height on an upright, Starting 5 min at a
cycling stationary bike to a level in normal pace.
which patient's feet can just
barely reach the pedal.

Home exercises Non-supervised exercises to be performed at home twice a day during 10 weeks.
Heel slides This exercise is performed Place the foot of the affected knee on a One bout of 30
while patient is sitting slippery surface. Patient is encouraged to repetitions
on a chair. move foot as far as possible forward and
backward to promote maximum ROM.
Extension stretch This stretch is performed in Ankle is supported with a small cushion or 5–10 min
reclining position on a bed rolled-up towel. The leg should be
or on the floor. extended in front of body with the knee
slightly above the surface.
Isometric quadriceps Reclining position on a bed Patient is instructed to tense the One bout of 20
contractions or the floor quadriceps muscles and attempt to touch repetitions. Hold the
the back of the knee to the bed or the floor. position for 5 s.
⁎Patients are instructed to perform all exercises gently and slowly. Patients have to exercise pain-free or with the least possible pain. Intensity and number of repetitions of strengthening
exercises are increased on the basis of patient tolerance.

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