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ORIGINAL ARTICLE

Effects of Kinesthesia and Balance Exercisesin Knee Osteoarthritis

Demirhan Dıracoglu, MD, Resa Aydin, MD, Akin Baskent, PT, and Ajda Celik, PT

Background: In patients with knee osteoarthritis (OA), there is aprominent loss in proprioception and kinesthesia sensation com-pared with control subjects of the same age and gender.Objectives: The aim of this study is the investigation of short-termclinical effects of kinesthesia and balance exercises in patients withknee OA.Methods: This 8-week study was conducted on 66 female patientswith knee OA who were randomized into 2 groups. The first groupreceived kinesthesia and balance exercises (such as retrowalking,walking on their toes, leaning to the sides, balance board exercises,minitrampoline exercises, plyometric exercises, and so on) in addi-tion to strengthening exercises. The second group received onlystrengthening exercises.Results: Statistically significant improvements were observed pos-texercise for both groups with respect to baseline for WOMAC,SF-36 Form, times for performing activities of daily living, isoki-netic quadriceps muscle strength, and proprioceptive sensation lev-els. In the first group with kinesthesia training, compared with thesecond group, significantly greater improvements were obtained inall the subparameters that measure functional status (WOMAC–physical function value, SF-36 Form �physical function, role limi-tations–physical and vitality–energy or fatigue variables�, 10 stairsclimbing, and 10-m walking times) and in isokinetic muscle strengthat high angular velocities (P � 0.05). The absolute angular errorpercentage (to assess proprioceptive accuracy) was significantlyimproved postexercise in both groups. There were no differencesbetween the groups.Conclusions: Additive positive effects of kinesthesia and balanceexercises in knee OA have been demonstrated. Used in clinicalapplications, they should be able to increase the functional capacitiesof patients. Long-term studies about efficacy and cost-effectivity ofthese exercises are needed.

Key Words: osteoarthritis, knee, kinesthesis, proprioception,exercise

(J Clin Rheumatol 2005;11: 303–310)

The great increase in the elderly population worldwide isthe most important change in the field of public health in

the 21st century. It is being estimated that the number ofpeople over the age of 65 will be doubled in the next 20years.1 Consequently, osteoarthritis (OA) and similar dis-eases that are more frequently encountered in advanced yearswill become much more important from both medical andeconomic aspects.2 OA is the most commonly encountereddisease of the musculoskeletal system. It is regarded as animportant socioeconomic problem because it is one of theforemost disabling conditions and its treatment entails greatexpenditures.

Factors such as age, family history, obesity, and hyper-mobility increase susceptibility to OA. In addition to these,local biomechanical factors like congenital anomalies, trauma,and occupational injuries affect the occurrence and localiza-tion of OA.3 Symptomatically, the most commonly affectedjoint in OA is the knee joint.

The physical disability arising from knee OA preventsthe performance of daily life activities and negatively affectslife quality. Several factors play roles in the occurrence ofphysical disability. These include pain, joint movement re-striction, muscle weakness, and coordination impairment.4

The coexistence of knee OA and weakness of thequadriceps group muscles are well known.5 Muscle strengthmeasurements are important in the follow-up of the diseaseand the life quality of patients.6 The isokinetic musclestrength measurement method has various advantages: itallows the examination of a muscle or muscle groups inisolation, kinematic analysis of a movement can be made, andthe numeric values obtained can be readily reproduced andcompared.7 Moreover, using this method with measurementsat high angular velocities, it is possible to evaluate high-speedand functional contractions dependent on repetitions that arefrequently used in daily life.8,9

The sensation of proprioception can be defined as theconscious or unconscious perception of the position of extrem-ities in space and being aware of the movement and position ofthe joints.10 In patients with knee OA, there is a prominent lossin proprioception compared with control subjects of the sameage and gender.11 It has been demonstrated that impaired pro-prioception adds to functional insufficiency by generating im-pairment in walking rhythm, shortening step distance, and adecrease in walking speed and total walking time.12

In the studies conducted, many different methods andmechanisms were used for the measurement of the sensation

From Istanbul University, Istanbul Medical Faculty, Department of PhysicalMedicine and Rehabilitation, Istanbul, Turkey.

Reprints: Demirhan Dıracoglu, MD, Istanbul Universitesi, Istanbul TipFakultesi, Fizikse1 Tip ve Rehabilitasyon Anabilim Dali, 34093 Capa/Istanbul, Turkey. E-mail: [email protected].

Copyright © 2005 by Lippincott Williams & WilkinsISSN: 1076-1608/05/1106-0303DOI: 10.1097/01.rhu.0000191213.37853.3d

JCR: Journal of Clinical Rheumatology • Volume 11, Number 6, December 2005 303

of proprioception. These methods can be grouped into 3distinct types:

1. Tests evaluating joint position sense: a) reproductiontests—evaluate the subject’s performance to reproducethe active and passive knee angles that were determinedbefore.10 b) Visual analog model method—evaluates thesubject’s performance to detect knee flexion range in a 2-or 3-dimetional knee model.13

2. Tests measuring the sensation of kinesthesia: threshold tests:detect threshold of joint displacement after slow (0.3–0.5°/seconds), passive, and automated knee motion.14

3. Measurement of hamstring reflex contraction latency;changes in the knee position result with a reflex con-traction of the hamstring muscle group that could bemeasured.15

Kinesthesia is described as the ability to sense themotion and its direction. The aim of this study is the inves-tigation of short-term clinical effects of kinesthesia and bal-ance exercises that would be added to routine isometric andisotonic strengthening exercises on the functional status, pain,isokinetic muscle strength, and proprioceptive sensation inpatients with OA.

PATIENTS AND METHODSSixty-six female patients between the ages of 35 and 65

who were diagnosed as having “primary osteoarthritis” ac-cording to the criteria of American College of Rheumatology(ACR),16 who had scores equal to or greater than “7” accord-ing to Lequesne Index,17 and who had radiologically stage Iand II bilateral knee OA according to the Kellgren andLawrence Scale18 were included in the study. The index ofLequesne is a questionnaire used in the evaluation of pain andfunctional status in knee OA.

Patients diagnosed as having secondary OA, patientswith active synovitis, and patients who had serious kneetrauma, surgical intervention, or intraarticular knee injectionin the last 6 months were not included in the study.

Patients who were included in the study and met inclu-sion criteria were randomized into 2 groups using the one-to-one randomization method by allocating one patient to thestudy group and the other patient to the control group one byone according to their order of application to the outpatientclinic. The Western Ontario and McMaster Universities Os-teoarthritis Index (WOMAC)19 and the Medical OutcomesStudy Short Form Health Survey (SF-36)20 were used in theassessment of the patients before and after the 8-week exer-cise program. Isokinetic muscle strength of the quadricepsand hamstring muscles, 10-m walking time, 10 stairs climb-ing time, and the sensation of proprioception in the knee weremeasured in each patient. The exercises were applied by thesame physiotherapist. For the purpose of blinding, the assess-ments were made by a physician who did not know to whichgroup the patients belonged.

Paracetamol was given as an escape medicine for paincontrol. It was asked to note the dose of paracetamol taken.

All the patients participating in the study were informedabout the study and informed written consent was obtained

from each patient. Approval of the local ethical committeewas also obtained.

Data AnalysisThe 11.0 version of the Statistical Package for Social

Science (SPSS) for Windows computer program was used forstatistical analysis. The Student t-test was used to evaluatedependent and independent parametric variables, whereas theMann-Whitney U test was used for nonparametric variables;the level of significance was accepted as P � 0.05.

Measurement of ProprioceptionIn this study, the passive–active joint position repro-

duction method in the sitting position was used. The validityand repeatability of this method in the assessment of propri-oception has been demonstrated by Beynnon et al.21 With thisaim, the Biodex System 3 Pro Multijoint System isokineticdynamometer (Biodex Medical Inc., Shirley, NY) was used.The patients were asked to actively repeat the passivelypositioned knee flexion angles of 20°, 45°, 10°, 60°, 25°, 50°,5°, 55°, 15°, and 40°. This procedure was repeated 3 times at1-day intervals and the averages for every angle were ob-tained. Care was taken to carry out the testing in a quietenvironment at constant temperature and the eyes of thesubjects were kept closed.

An “absolute angular error” value was obtained foreach angle. After this, first the averages (average absoluteangular error) and then the average error percentages (aver-age absolute angular error percentage) of the “absolute an-gular error” values obtained for each of the 10 separate angleswere calculated.

Isokinetic MeasurementUsing the Biodex System 3 Pro Multijoint System in

both extremities, the maximal torque (peak torque) values ofquadriceps and hamstring muscle groups were measured atangular velocities of 60°/s, 180°/s, and 240°/s. Peak torquemeasurement is the most valid method in the evaluation ofmuscle strength capacity.22 Peak torque/body weight (N-m/kg) ratio was used in the evaluations. During isokineticmuscle strength test, no medication was taken.

Exercise ProgramThe first group (kinesthesia group) received kinesthe-

sia, balance, and strengthening exercises and the secondgroup (strengthening group) received only strengthening ex-ercises. Patients in both groups were informed about knee OAand protective recommendations for the knee were made.

The exercises were done 3 days a week in groups of 5people in a clinical setting under the supervision of a phys-iotherapist. The total duration of the exercises was deter-mined as 8 weeks.

The kinesthesia and balance exercises regimens aregiven in Table 1 and Figures 1 through 5. Isometric andisotonic strengthening exercises applied to quadriceps andhamstring muscles are shown in Table 2. Isometric exerciseswere applied with 6-second contractions with 8 repetitionsand a rest period of 2 seconds. Isotonic exercises were startedfrom the third week and the maximum weight that can belifted 10 times (10-repetition maximum � 10 RM) was

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determined. The exercises were applied as 10 repetitions withhalf of this weight, 10 repetitions with three fourths of thisweight, and 10 repetitions with the whole 10 RM. 10 RM wasdetermined again every week.

RESULTSOf the 66 patients included in the study, 6 patients

could not complete the examination because it was difficultfor them to come to the clinic for exercises. Among thesepatients; 3 were from the first group, 3 were from the secondgroup, and all of the patients dropped out from the study in

the first 3 weeks. There were no adverse effects in patientsparticipating in the study. The statistical assessments weremade on the 60 patients who completed the exercise program.Patient compliance to the clinical exercise program was good.

TABLE 1. Lower Extremity Kinesthesia and BalanceExercises Used in the Study

1. Week 1. Modified Romberg exercise(standing in balance with eyes closed)

a) On hard ground

b) On soft ground (on a mat)

2. Retrowalking (25 m)

3. Walking on heels (25 m)

4. Walking on toes (25 m)

5. Walking with eyes closed (25 m)

6. Standing on one extremity for 30 seconds(repeated in both extremities)

Leaning forward, backward, and to the sides on

one extremity (eyes open)

Leaning forward, backward, and to the sides on

one extremity (eyes closed)

Sitting down and standing up from a high chair

slowly

2. Week (in addition) 1. Exercise with “rocker-bottom” balanceboard

2. Sitting down and standing up from a lowchair slowly

3. Plyometric exercise (crossing a height of 15cm by jumping)

4. 8 exercise

a) Walking slowly, wide circle

b) Walking quickly, wide circle

c) Walking slowly, narrow circle

d) Walking quickly, narrow circle

3. Week (in addition) 1. Exercise with “BAPS board” balance board

a) Balance with 2 legs, eyes open,multidirectional

b) Balance with 2 legs, eyes closed,multidimensional

c) Balance with one leg, eyes open,unidimensional

d) Balance with one leg, eyes closed,unidimensional

e) Balance with one leg, eyes open,multidimensional

f) Balance with one leg, eyes closed,multidimensional

2. Minitrampoline exercise (jumping andjogging)

3. Plyometric exercise (crossing a height of 15cm by jumping)

4. Carioca crossover maneuver

FIGURE 1. (A) Balance exercise toward the sides on a singlefoot while the eyes are closed. (B) Balance exercise towardthe back on a single foot while the eyes are closed. (C) Bal-ance exercise toward the front on a single foot while theeyes are closed.

FIGURE 2. Exercise with a rocker-bottom balance board.

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Mean missed visits during 8 weeks and 24 visits were 4 and6 in the first and second weeks, respectively.

There were no significant differences among the groupswith respect to age, body weight, body mass index (BMI), oreducation level (P � 0.05). Of the patients participating in thestudy, 59% were primary and secondary school graduates,18% were high school graduates, and 18% were universitygraduates; 70% were housewives and 30% were workingwomen. There were no significant differences between theeducational levels of the patients in the 2 groups (P � 0.05).Furthermore, no correlation has been found between theeducational level and the evaluated research parameters.Before exercises, there were no significant differences amongthe groups with respect to WOMAC, SF-36 Forms, andwalking times (P � 0.05) (Table 3).

In both exercise groups, statistically significant im-provements were obtained in WOMAC, SF-36 Forms, 10-meter walking time, 10 stairs climbing time, in isokineticmuscle strength measurements of the quadriceps muscle, andin proprioceptive sense measurement (ie, in all the parametersused in the investigation) at postexercise compared withpreexercise (P � 0.05).

On comparison of the groups with each other, allWOMAC scores were found to be lower in the kinesthesiagroup compared with the strengthening group at postexercise.

Yet, this difference was statistically significant only for theWOMAC–physical function value (P � 0.05) (Table 4).

On comparison of the results of the SF-36 Form atpostexercise between the kinesthesia and strengtheninggroups, the physical function, role limitations (physical) andvitality (energy or fatigue) variables were observed to besignificantly higher in the kinesthesia group (P � 0.05)(Table 4).

When 10 stairs climbing time and 10-m walking timewere assessed, the kinesthesia group had statistically signif-icantly lower values in both of these 2 parameters comparedwith the strengthening group at postexercise (P � 0.05)(Table 4).

In the assessment of isokinetic muscle strength in thekinesthesia group, no significant improvement was obtainedat an angular velocity of 60°/s in the left extremity, butsignificant increases were obtained at angular velocities of180°/s and 240°/s in both extremities. In contrast with this, inthe strengthening group, no muscle strength difference wasobtained at an angular velocity of 240°/s in both extremities,but statistically significant increases were obtained at angularvelocities of 60°/s and 180°/s (Table 5).

The “average absolute angular error percentage” valuewas used to investigate the distribution of the sensation of

FIGURE 3. Carioca crossover exercise.

FIGURE 4. Jumping with a minitrampoline exercise.



proprioception according to groups. This value decreasedstatistically significantly in both extremities in both kinesthe-sia and strengthening groups at postexercise compared withpreexercise. There was no statistically significant differencebetween the 2 groups (Fig. 6).

During the study, 5 patients used paracetamol, not morethan 500 mg daily. The 2 groups were not significantly differentfrom each other regarding paracetamol use (P � 0.05).

DISCUSSIONIn this study, we have investigated the effects of bal-

ance and kinesthesia exercises on knee OA. This is a specialexercise program aimed at restoring motor control in thelower extremities to improve static positioning, voluntarymovement execution, and responsiveness to stress.14 For this

FIGURE 5. Retrowalking exercise while the eyes are closed.

TABLE 2. Lower Extremity Isometric and IsotonicStrengthening Program Used in the Study

1. Week 1. 5-min fixed bike exercise without resistance

2. Range-of-motion and active stretchingexercises applied to hamstring and quadricepsmuscles

3. Quadriceps isometric strengthening exercise

4. Hamstring muscles isometric exercise

2. Week (in addition) 1. Short-arc terminal extension exercise for theknee joint

2. Isometric exercise for the abductor andadductor muscles of the hip joint

3. Week (in addition) 1. Short-arc terminal extension exercise withresistance for the knee joint

2. Isometric strenghtening exercise withresistance for the hamstring muscles

TABLE 3. Comparison of the Kinesthesia andStrengthening Groups Before Exercise in Regard to theResearch Parameters

Research ParametersKinesthesia

GroupStrengthening

Group P

WOMAC–physical function 4.30 � 1.6 4.34 � 1.1 0.90

SF-36–physical function 48.22 � 15.2 49.1 � 13.0 0.82

SF-36–role limitations(physical)

43.54 � 14.2 37.1 � 12.4 0.11

SF-36–vitality, energy orfatigue

45.0 � 16.5 42.14 � 17.6 0.52

10-m walking period(second)

6.87 � 1.6 6.96 � 1.7 0.84

TABLE 4. Comparison of the Kinesthesia andStrengthening Groups After Exercise in Regard to theResearch Parameters

Research ParametersKinesthesia

GroupStrengthening

Group P

WOMAC–physical function 2.00 � 1.6 2.7 � 1.4 *0.042

SF-36–physical function 69.33 � 17.8 56.25 � 16.7 *0.006

SF-36–role limitations(physical)

77.5 � 34.9 57.14 � 45.0 *0.048

SF-36–vitality, energy orfatigue

54 � 19.5 43.5 � 18.3 *0.046

10-m walking period(second)

5.21 � 1.1 5.89 � 1.3 *0.039

* P � 0.05.

TABLE 5. Isokinetic Muscle Strength Values of theQuadriceps Muscle at Variable Angular Speeds Before andAfter the Exercise

Isokinetic MuscleStrength

AngularSpeed(°/s)

BeforeExercisePT/BW

(N-m/kg)

AfterExercisePT/BW

(N-m/kg) P

Kinesthesia group 60 1.34 � 0.32 1.36 � 0.32 0.424

180 0.93 � 0.19 0.99 � 0.21 *0.001

240 0.88 � 0.15 0.91 � 0.15 *0.002

Strengthening group 60 1.32 � 0.34 1.37 � 0.35 *0.04

180 0.93 � 0.20 0.96 � 0.21 *0.03

240 0.90 � 0.16 0.89 � 0.16 0.422

PT/BW � peak torque/body weight, N-m/kg � Newton � m/kg.* P � 0.05.



purpose, we have measured the changes in functional status,isokinetic muscle strength, and proprioceptive sense accu-racy. Statistically significant positive changes were detectedin the kinesthesia group compared with the strengtheninggroup in parameters like WOMAC–physical function, SF-36–physical function, SF-36–role limitations (physical), SF-36–vitality energy or fatigue, time to climb 10 stairs, andtime to walk 10 meters. Among all the parameters investi-gated, these parameters were the most suitable ones for theassessment of the patients’ functional status. The reason forthis could be that the exercises applied to those in thekinesthesia group increased the coordination between musclegroups and the response to sensorial information. However,the number of patients and follow-up period were limited andthe change of these findings over a long period is not known.

In the kinesthesia group, parameters of functional statusand motor control improved better; this might be the result ofthe improvement of dynamic stabilization by the synergisticand synchronous working of the muscle groups. Similarly,repetitive movements that are used in the daily life exercisesmight have contributed to this improvement. Significant peaktorque increases were obtained at postexercise for isokineticmuscle strength values in the kinesthesia group at highangular velocities (240°/s), whereas no difference was de-tected in the strengthening group at these high angular ve-locities. Submaximal contractions are detected in many ac-tivities in routine daily life as repetitive (walking, running,and so on) or nonrepetitive (standing, sitting, and so on)activities. Repetitive activities contain faster contractions; forexample, angular velocity in the knee joint during walking is233°/s according to isokinetic principles; gains obtained athigh angular velocities will be closely associated with thefunctional status of the patient.8,9 Dynamic muscular stabili-zation is increased by balance and kinesthesia exercises.

Exercise regimens containing repetitive movements in-crease the ability of the person’s control over joint move-ments in all positions. Dynamic stability may help to control

abnormal joint translation that occurs during daily move-ments and may provide increased motor control through areflex route.

No difference was found between the groups withrespect to proprioceptive sense accuracy. However, 75%increase in proprioceptive sense accuracy was detected inboth exercise groups at postexercise compared with preexer-cise. These results showed that proprioception increased inconjunction with the increase in muscle power.

Theoretically, it could be predicted that balance andkinesthesia exercises affect proprioception more than stan-dard strengthening exercises. There may be 2 reasons forthe absence of any difference between the 2 groups. First, theexercise program applied might not have stimulated theproprioceptors and hence could not activate the propriocep-tive system sufficiently. To compensate for this deficiency,combining new components into the exercise program maybe suggested. A second reason may be that the proprioceptionmeasurement method was not sensitive enough. It has beendemonstrated that reproduction tests done by passive–active andactive–active methods in standing and sitting positions are validand repeatable tests in the measurement of proprioception.21

However, current studies show that different proprioceptionmeasurement tests do not confirm each other.23 Larger studiesare needed to measure loss of proprioceptive sense that isfrequently associated with OA. Furthermore, the effects ofproprioceptive sensory system on daily life activities in pa-tients with OA are not known completely. Although theyshowed that impaired proprioceptive sense had effects onfunctional parameters such as impairment in walking rhythm,shortened distance of step, and decrease in gait speed, andtotal duration of walking,24–26 in their study, Skinner et alhave not detected a one-to-one correlation between proprio-ception tests and Larson knee point that is a measure of pain,function, movement lines, and structural abnormalities.27

As a joint-bearing body weight, the knee joint is vul-nerable for traumas during daily life activities. To protect thejoint from these effects, maintenance of perfect joint stabilityis certainly required. Proprioceptive information is an impor-tant mediator of timely and appropriate voluntary and invol-untary movements.12 The association between OA and loss ofproprioceptive sense has been demonstrated.11,12,28 Althoughthe source of the proprioceptive deficit is not well known yet,it is known that it is not a local result of the disease.11 Lundet al showed that in patients with unilateral knee OA, propri-oceptive sense of both knees were impaired equally and thatthis defect was present also in elbow joints. These resultssupported that “impaired proprioception is general problemand not a local phenomenon in knee OA patients.”29 As aconsequence of the insufficient working of the proprioceptivesystem, neuromuscular control cannot be maintained, protec-tive muscle activities cannot be performed, and joint stabili-zation cannot be provided.14 In this condition, the joint isvulnerable to external traumatic stimulations.

The trauma the joint structures are exposed to willcause structural impairment of the mechanoreceptors that arethe source of proprioception and thus proprioception will bemore impaired.10 O’Connor et al have conducted several

FIGURE 6. “Average angular error percent” value that is in-versely proportional to proprioceptive sensation level in theright and the left extremities before and after exercise. Sta-tistically significant decreases have been observed in bothgroups at postexercise compared with preexercise (P �0.05). However, no significant difference has been detectedbetween the groups.



studies on a dog model, and these have provided valuableinformation on the physiological significance of sensory in-nervation that is the source of proprioceptive sensation in thepathogenesis of OA.30

There are not many studies that have investigated theeffects of similar functional exercises on life quality andproprioception in people with OA. Hurley and Scott haverecorded significant advances in Lequesne Index and inquadriceps muscle strength with an exercise protocol thatcombines progressive, resistant static bicycle exercises withisometric and isotonic strengthening components, and somefunctional exercises (like sitting–standing, standing on onefoot, and walking); however, they have not been able todetect a statistically significant increase in proprioceptivesensation accuracy.31 Irrgang et al have reported that openand closed chain exercises could be used to increase propri-oceptive sensation.32 Messier et al have conducted a FASTstudy and have demonstrated that postural balance is signif-icantly increased in patients with knee OA by long-termexercises with aerobic and weight components.33 Topp et alhave shown that dynamic exercises done in functional jointangles in patients with knee OA have increased functionalcapability and decreased knee pain.34

At present, exercises used in OA rehabilitation gen-erally focus on muscle strength, endurance, and jointflexibility. However, it is thought that this type of classicexercise program cannot yield optimal functional capacitylevels. Exercises should also meet the needs of daily livingactivities (for example, getting in a car, sitting and stand-ing from the toilet, wearing pants, and so on) and shouldincrease neuromuscular control.

This study has demonstrated that addition of kinesthe-sia and balance exercises that help neuromuscular restorationto standard strengthening exercises provides dynamic musclestrength increase with significant recoveries in the functionalstatus of the patients. Nevertheless, more studies with long-term follow-up and using different methods of proprioceptiveaccuracy are needed. Cost-effectiveness of adding kinesthesiaand balance exercises to routine exercise regimes for patientswith knee OA should be investigated. Ultimately, it mightbe feasible to include these exercises to the managementprotocols.

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31. Hurley MV, Scott DL. Improvements in quadriceps sensorimotor functionand disability of patients with knee osteoarthritis following a clinicallypracticable exercise regime. Br J Rheumatol. 1998;37:1181–1187.

32. Irrgang JJ, Neri R. The Rationale for open and closed kinetic chainactivities for restoration of proprioception and neuromuscular controlfollowing injury, In: Lephard SM, Fu FH, eds. Proprioception andNeuromuscular Control in Joint Stability. Human Kinetics. 2000:363–372.

33. Messier SP, Royer TD, Craven TE, et al. Long-term exercise and itseffect on balance in older, osteoarthritic adults: results from the Fitness,Arthritis, and Seniors Trial (FAST). J Am Geriatr Soc. 2000;48:131–138.

34. Topp R, Woolley S, Hornyak J 3rd, et al. The effect of dynamic versusisometric resistance training on pain and functioning among adultswith osteoarthritis of the knee. Arch Phys Med Rehabil. 2002;83:1187–1195.

Ekeko’s Smile

Ekeko is the god of fortune in Bolivian mythology. These figures are made of clay, are wearingtraditional Bolivian clothes and are carrying bags of grain, food and money. The ample smile

is complete with aperture at the mouth to put a cigarette.

Angel Checa, MD.Service of Rheumatology

Policlinica 26 de JulioPlaya, Ciudad de La Habana, Cuba



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