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The pros and cons of muscle co-contraction in osteoarthritis of the kneeComment on the article by Lewek et al.

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1354
LETTERS
patients with early disease, and thus was not designed or
powered to be able to address that question.
Cecilia P. Chung MD, MPH
Annette Oeser, BS
Tebeb Gebretsadik, MPH
Ayumi Shintani, PhD, MPH
C. Michael Stein, MD
Vanderbilt University School of Medicine
Nashville, TN
1. Pincus T, Summey JA, Soraci SA Jr, Wallston KA, Hummon NP.
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SE. Cardiovascular death in rheumatoid arthritis: a populationbased study. Arthritis Rheum 2005;52:722–32.
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decrease over time in the incidence of vasculitis or other extraarticular manifestations in rheumatoid arthritis: results from a community-based study. Arthritis Rheum 2004;50:3729–31.
DOI 10.1002/art.21781
The pros and cons of muscle co-contraction in
osteoarthritis of the knee: comment on the article by
Lewek et al
To the Editor:
In a recent issue, Lewek et al presented a study on
co-contraction of antagonist muscles of the upper and lower
leg in patients with osteoarthritis (OA) of the knee (1). Their
main findings are that patients with OA have higher levels of
co-contraction than healthy controls, and that better knee
stability correlates positively with higher co-contraction in
patients with OA. The authors then suggest that the higher
level of co-contraction needs to be counteracted because of the
risk of increased disease progression. In our opinion, such an
approach could be detrimental to the functioning of patients
with OA.
Co-contraction of antagonist leg muscles in subjects
with unstable knees has been reported previously. Doorenbosch and Harlaar showed that there is increased cocontraction in patients with lesions of the anterior cruciate
ligament as compared with healthy control subjects (2). Likewise, differences in muscle activity patterns, including significant increases in co-contraction, have been reported during
walking in patients with OA of the knee when compared with
age- and sex-matched controls (3,4). We believe that Lewek et
al rightly conclude that antagonist muscle co-contraction is
used to stabilize the knee joint in the absence of adequate
stabilization by the passive restraint system (ligaments and
capsule) of the knee. Furthermore, we have found evidence
that, in the absence of adequate stabilization by the passive
restraint system, muscle activity becomes even more important
in maintaining walking ability in knee OA (manuscript submitted). Thus, co-contraction seems to enhance stability of the
knee joint and consequently walking ability in knee OA.
We do not agree with the suggestion by Lewek et al
that co-contraction needs to be counteracted. First, the chain
of effects starting with muscle co-contraction and resulting in
progression of OA through an increase in intraarticular compression is as yet hypothetical and needs to be confirmed
empirically. Second, there is evidence that counteracting the
process of co-contraction will decrease the stability of the knee
and thereby reduce walking ability. Based on the current
evidence, counteracting co-contraction is not a sound therapeutic option. On the contrary, there is ample evidence that
enhancing muscle function through exercise therapy is effective in reducing pain and disability in knee OA (5).
Martijn Steultjens, PhD
Joost Dekker, PhD
Jan van Breemen Institute
Vu University Medical Centre
Martin van der Esch
Jan van Breemen Institute
Amsterdam, The Netherlands
1. Lewek MD, Ramsey DK, Snyder-Mackler L, Rudolph KS. Knee
stabilization in patients with medial compartment knee osteoarthritis. Arthritis Rheum 2005;52:2845–53.
2. Doorenbosch CA, Harlaar J. A clinically applicable EMG-force
model to quantify active stabilization of the knee after a lesion of
the anterior cruciate ligament. Clinical Biomech (Bristol, Avon)
2003;18:142–9.
3. Childs JD, Sparto PJ, Fitzgerald GK, Bizzini M, Irrgang JJ.
Alterations in lower extremity movement and muscle activation
patterns in individuals with knee osteoarthritis. Clinical Biomech
(Bristol, Avon) 2004;19:44–9.
4. Hortobagyi T, Westerkamp L, Beam S, Moody J, Garry J, Holbert
D, et al. Altered hamstring-quadriceps muscle balance in patients
with knee osteoarthritis. Clinical Biomech (Bristol, Avon) 2005;20:
97–104.
5. Fransen M, McConnell S, Bell M. Therapeutic exercise for people
with osteoarthritis of the hip or knee: a systematic review. J Rheumatol 2002;29:1737–45.
DOI 10.1002/art.21775
Reply
To the Editor:
We thank Dr. Steultjens and colleagues for their
comments on our study of knee stabilization in patients with
medial compartment knee osteoarthritis (OA), and welcome
the invitation to emphasize some key points relating to our
work that may be misconstrued by readers of the article. We
agree with the assertion that muscle activity is vital to joint
stability, particularly when passive restraints are compromised,
such as in people with anterior cruciate ligament (ACL)
deficiency and knee OA. However, we do not feel that muscle
co-contraction, as we define it, is always beneficial in either
population.
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