Journal Pre-proofs

Hip Abductor Muscle Weakness and Slowed Turning Motion in People with
Knee Osteoarthritis

Hirotaka Iijima, Ayanori Yorozu, Yusuke Suzuki, Ryo Eguchi, Tomoki

Aoyama, Masaki Takahashi

PII: S0021-9290(20)30059-2
DOI: https://doi.org/10.1016/j.jbiomech.2020.109652
Reference: BM 109652

To appear in: Journal of Biomechanics

Received Date: 27 July 2019

Revised Date: 21 December 2019
Accepted Date: 22 January 2020

Please cite this article as: H. Iijima, A. Yorozu, Y. Suzuki, R. Eguchi, T. Aoyama, M. Takahashi, Hip Abductor
Muscle Weakness and Slowed Turning Motion in People with Knee Osteoarthritis, Journal of Biomechanics
(2020), doi: https://doi.org/10.1016/j.jbiomech.2020.109652

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Hip Abductor Muscle Weakness and Slowed Turning Motion in People with Knee

Osteoarthritis

Hirotaka Iijima, PT, PhD1,2,3; Ayanori Yorozu, PhD4; Yusuke Suzuki, PT, PhD2; Ryo Eguchi,

MSc5; Tomoki Aoyama, MD, PhD2; Masaki Takahashi, PhD1

1Department of System Design Engineering, Faculty of Science and Technology, Keio

University, Yokohama, Japan

2Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto

University, Kyoto, Japan

3Japan Society for the Promotion of Science, Tokyo, Japan
4Graduate School of Science and Technology, Keio University, Yokohama, Japan
5School of Science for Open and Environmental Systems, Graduate School of Science and

Technology, Keio University, Yokohama, Japan

Authors’ e-mail addresses:

iijima.hirotaka.4m@yt.sd.keio.ac.jp (Hirotaka Iijima [HI])

ayanoriyorozulab@gmail.com (Ayanori Yorozu [AY])

yusuke-suzuki@nuhw.ac.jp (Yusuke Suzuki [YS])

eguchi.ryo@keio.jp (Ryo Eguchi [RE])

aoyama.tomoki.4e@kyoto-u.ac.jp (Tomoki Aoyama [TA])

takahashi@sd.keio.ac.jp (Masaki Takahashi [MT])

1
Corresponding author:

Hirotaka Iijima, PT, PhD

3-14-1 Hiyoshi, Kohoku-ku, Yokohama 223-8522, Japan

Tel.: +81-45-563-1141; Fax: +81-45-566-1660

E-mail: iijima.hirotaka.4m@yt.sd.keio.ac.jp

Keywords: Laser-TUG; Turning; Quadriceps muscle; Hip abductor muscle; Knee osteoarthritis

Word count: 3220 words

Abstract

Laser range sensor-based timed up and go (laser-TUG) test can evaluate performance in TUG

subtasks (sit-to-walk [STW], walking a short distance, and turning). This study aimed to test the

hypothesis that weaker hip abductor muscle strength is more significantly associated with slowed

turning speed than with the other TUG subtasks (STW and straight walking) after controlling for

quadriceps muscle strength in patients with knee osteoarthritis (OA). Community-dwelling

participants with knee OA (Kellgren and Lawrence [K&L] grade ≥ 1; mean age, 68.6 years;

70.3% women) underwent laser-TUG. Spatiotemporal gait parameters in TUG and the TUG

subtasks were evaluated as outcome measures. The isometric muscle strength of the hip abductor

and quadriceps was measured using a hand-held dynamometer. Multiple linear regression

analysis was performed to examine the relationship between muscle strength as an independent

variable and spatiotemporal parameters as dependent variables. The relative importance of hip

abductor muscle strength was determined using the percentages of unique variance. Participants

with weaker hip abductor muscle strength demonstrated 0.094 m/s slower turning speed after

adjustment for covariates including quadriceps muscle strength. The unique variance explained

2
by hip abductor muscle strength in turning speed was 2.1%. However, no significant

relationships were confirmed between weak hip abductor muscle strength and the time to

perform TUG and the straight walking (forward and return) phase. These findings indicate that

turning motion may be more sensitive to aggravated hip abductor muscle weakness and may

show better response to hip muscle strengthening exercises. Longitudinal studies are warranted

to elucidate this issue.

1. Introduction

1.1 Importance of Mobility Assessment in Knee Osteoarthritis

Physical function, defined as the ability to perform daily activities(Terwee et al., 2006), is

typically considered one of the most important outcome measures in patients with knee

osteoarthritis (OA). Approximately 20% of patients with knee OA show functional decline

within 30 months of follow-up despite a reduction in knee pain(White et al., 2011), indicating

that an objective functional assessment is needed to obtain a complete picture of knee OA.

Among several functional measures used in clinical practice, the timed up-and-go (TUG) test is a

well-validated functional measure of ambulatory transition in people with knee OA and is

recommended by the Osteoarthritis Research Society International(Dobson et al., 2012). Patients

with knee OA show poorer TUG performance than healthy adults(Khalaj et al., 2014), which

indicates the importance of functional assessment in knee OA.

1.2 Novel Mobility Assessment System: Laser-TUG

TUG incorporates different subtasks that represent distinct functional constructs (sit-to-walk

3
[STW], walking a short distance, and turning), and the total timed score limits the interpretation

of the proportional contribution of these subtasks. A laser range sensor-based leg tracking system

can capture the trajectories of both legs by scanning a single laser beam in a horizontal plane and

thereby calculates the spatiotemporal gait parameters of TUG subtasks(Yorozu et al., 2015). This

new technology-based TUG (laser-TUG) has been applied in characterizing ambulation in

healthy older adults(Adachi et al., 2017) and in people with mild cognitive

impairment(Nishiguchi et al., 2017). Given that the proportional contribution of TUG subtasks

could differ among patients with knee OA even if they show the same total TUG time, applying

this new technology to individuals with knee OA could provide a deeper understanding of OA-

related mobility limitation.

1.3 Hip Abductor Muscle Weakness in Knee OA and Its Potential Relationship to Poor Turning

Motion

Weak hip abductor muscles, not only weak quadriceps muscles(Omori et al., 2013), are a feature

of individuals with knee OA(Deasy et al., 2016). Patients with knee OA have 8–24% and 14–32%

weaker isometric and isokinetic hip abductor muscles than do healthy adults, respectively(Deasy

et al., 2016). Previous studies demonstrated that reduced hip abductor muscle strength contributes

to poor TUG performance in individuals who had undergone total knee arthroplasty(Alnahdi et al.,

2014) and in those with severe knee OA who is scheduled for total knee arthroplasty(Loyd et al.,

2017) even after controlling for quadriceps muscle strength. Hip abductors three-dimensionally

regulate the center of mass (COM) during turning and are distinct from the muscles used during

level walking(Pandy et al., 2010; Patla et al., 1999). Turning requires acceleration of the COM

toward the center of curvature and rotation of the pelvis in a new direction through hip abductor

4
muscle-regulated coordination of the inner and outer lower-limbs(Patla et al., 1999; Ventura et al.,

2015). Thus, it is plausible that weak hip abductor muscle contributes to poor TUG particularly

through poor turning phase performance even after controlling for quadriceps muscle strength.

However, no study examined the specific contribution of hip abductor muscle to poor turning

motion, which represents a crucial knowledge gap.

1.4 Study Hypothesis and Practical Relevance

The current study aimed to test the hypothesis that relatively weaker hip abductor muscle

strength is more significantly associated with slowed turning speed than with the other subtasks

(STW and straight walking) in the TUG even after controlling for quadriceps muscle strength.

This knowledge could contribute to clarifying mobility limitation related to hip abductor muscle

weakness(Alnahdi et al., 2014; Piva et al., 2011). It could also seve as a first step in justifying the

need for an interventional study with hip abductor muscle strengthening exercise for improving

turning-related mobility limitation, which has not been adequately addressed in previous

randomized controlled trials(Bennell et al., 2010; Sled et al., 2010).

2. Methods

2.1 Participants

Elderly participants with knee pain were identified through a mailed survey and were invited to

attend a research meeting at our university in September 2017 for an original cohort study of knee

OA(Iijima et al., 2018). The number of participants was set to recruit the minimum sample size

5
ensuring adequate statistical power; however, no restrictions were imposed on the upper limit of

participants recruitment owing to the observational nature of the study. The ethical committee of

the university approved the study (approval no. C1297), and written informed consent was

obtained from all participants before enrollment. All recruited participants had a history of pain in

one or both knees. The eligibility criteria included (1) age ≥ 45 years; (2) Kellgren and Lawrence

(K&L) grade ≥ 1, using the original scale(Kellgren and Lawrence, 1957); and (3) ability to walk

independently on a flat surface without any ambulatory-assistive device. Further information was

provided in previous study(Iijima et al., 2018).

2.2 Measurements

In all participants, the following were evaluated as outcome measurements: (1) laser-TUG-based

spatiotemporal parameters and (2) lower-limb muscle strength.

2.2.1 Laser-TUG-based Spatiotemporal Parameters

The spatiotemporal gait parameters of each limb measured during the TUG test were also evaluated

using laser-TUG(Yorozu et al., 2015). Supplemental Appendix S1, Fig. 1 shows an overview of

the laser-TUG system. This system can capture the trajectories of both legs (approximately 0.27

m height from ground level) by scanning a single laser beam in a horizontal plane at a frequency

of 40 Hz. The system measures the position and velocity of both legs in the TUG field coordinate

system based on the characteristic leg patterns determined by the laser range sensor scanned data.

Supplemental Appendix S1, Fig. 2 shows an overview of the leg-tracking algorithm of laser-TUG.

Details about the measurement apparatus and leg tracking algorithm were provided in the previous

study(Yorozu et al., 2015). The root-mean-squared error of the x and y coordinates of the leg

6
trajectories were 0.047 and 0.028 m, respectively, when compared with those from a three-

dimensional motion capture system used in healthy participants(Yorozu et al., 2015). Participants

were instructed to perform the TUG test(Podsiadlo and Richardson, 1991) as fast as possible. The

intra-rater reliability of TUG was excellent (intra-class correlation [ICC1,1]: 0.970; 95% confidence

interval [CI]: 0.950, 0.980) and the minimum detectable change (MDC95) was 1.100 s in

individuals with a K&L grade between 1 and 3(Alghadir et al., 2015). The TUG task was

automatically divided into the following three phases: (1) forward phase, (2) turning phase, and

(3) return phase. The time taken to perform the complete TUG test, gait speed in TUG, STW time,

and gait speed in each phase (forward, turning, and return) were evaluated as outcome measures

of TUG. Fig. 1 provides a summary of the primary outcome measures.

2.2.2 Muscle Strength

The maximum isometric quadriceps and hip abductor strengths values (Nm/kg) in both legs were

measured using a hand-held dynamometer (μTas F-1; Anima Corp., Tokyo, Japan) in accordance

with a method previously validated for use in community-dwelling elderly fallers(Wang et al.,

2002). Details of the measurement procedure for each muscle are provided in Supplemental

Appendix S1, Method 1. MDC95 was calculated using 100 randomly selected participants (i.e., 200

knees) to determine the smallest degree of change that is outside the error of the muscle strength

testing. The MDC95 value was 0.227 and 0.132 Nm/kg for the quadriceps strength and hip abductor

strength, respectively. The intra-rater reliability was excellent for quadriceps strength (ICC1,1:

0.939; 95% CI: 0.921, 0.954) and hip abduction strength (ICC1,1: 0.936; 95% CI: 0.916, 0.951).

2.2.3 Participants’ Characteristics and Covariates

7
Data on age, sex, and height were self-reported by the participants. Body mass was measured on a

weighing scale, with the participants clothed without shoes. Body mass index (BMI) was

calculated by dividing the body mass by the square of height. Knee pain severity was evaluated

using the Japanese Knee Osteoarthritis Measure (JKOM)(Akai et al., 2005) subcategory “pain and

stiffness.” The radiographic OA severity in both knees was assessed in the anteroposterior short

view in the weight-bearing position using the original version of the K&L grading system(Kellgren

and Lawrence, 1957), as described in previous study(Iijima et al., 2017). Patients were asked: “In

which knee do you have pain: right, left, or both?” Patients who answered “both” to this question

were identified as having bilateral knee pain. Depressive symptoms were evaluated using the 15-

item version of the Geriatric Depression Scale (GDS; range 0–15 points)(Yesavage and Sheikh,

1986). Pain catastrophizing was assessed using the Pain Catastrophizing Scale (PCS; range 0–52

points)(Sullivan et al., 1995). Further information is provided in Supplemental Appendix S1,

Method 2.

2.3 Statistical Analyses

All data analyses were performed using JMP Pro 13.0 (SAS Institute, Cary, NC, USA.) or SPSS

Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY, USA). A p-value of < 0.05 was

considered statistically significant. The index knee was defined as the more painful knee in either

the past or present. If the patients felt that both knees were equally painful, the index knee was

randomly selected using a computer-generated permuted block randomization scheme(Vickers,

2006). At least 128 participants were needed for the present study, accounting for a potential 10%

dropout rate due to the exclusion criteria and missing data (see Supplemental Appendix S1,

Method 3).

8
2.3.1 Multiple Linear Regression Analyses

Separate multiple linear regression analyses were performed to examine the association between

muscle strength in the index limb and TUG performance. In these analyses, TUG outcome

measures provided in Fig. 1 were included as dependent variables and the other variables were

included as independent variables. Each model has three steps. Step 1 included the following

covariates: age, female sex, index knee K&L grade, JKOM pain score, GDS, and PCS. In step 2,

quadriceps muscle strength was further included. In step 3, hip abductor muscle strength was

further included. These covariates were selected a priori based on clinical judgment. Presence of

bilateral knee pain and K&L grade of the non-index knee were not considered covariates because

these parameters highly correlated with K&L grade of the index-knee. We checked the features of

the regression model by comparing the residuals vs. fitted values (i.e., the residuals had to be

normally distributed around zero), and independence between observations.

2.3.2 Commonality Analyses

The relative importance of lower muscle strength (quadriceps and hip abductor) was determined

using the percentages of unique variance explained by this variable. Commonality analysis

quantifies the percentage of variance that is unique to each muscle strength (i.e., not shared with

the other included factors)(Rowell, 1991). The unique contribution of each independent variable

in a model is defined as the partition of variance attributed to it when entered last in a regression

analysis.

2.3.3 Moderation Analyses

9
Moderation analysis was performed to determine whether the relationship between hip abductor

muscle strength and gait speed was moderated by TUG subtasks (1: forward; 2: turning; 3: return).

We included the interaction terms of TUG subtasks × hip abductor muscle strength as independent

variables in multiple linear regression analysis, with adjustments for the covariates mentioned

above.

2.3.4 Sensitivity Analyses

Sensitivity analysis was performed to assess whether the relationship between hip abductor muscle

strength and gait speed was influenced by the inclusion of non-index limb muscle strength in

multiple linear regression analyses instead of index limb muscle strength.

3. Results

Of the 296 participants initially recruited for the original OA cohort study, 173 (58.4%) randomly

selected participants underwent laser-TUG (Fig. 2A). No patient’ demographic characteristics and

pain profile markedly differed between selected and non-selected participants (data not shown).

Among the selected 173 participants, 6 (3.4%) and 2 (1.1%) were excluded because of having a

K&L grade of 0 and missing radiographic data, respectively. Thus, 165 participants were included

in the final analysis (mean age, 68.6 [50–85] years; mean BMI: 22.8 kg/m2; 70.3% women). Table

1 shows the participants’ characteristics.

Of 165 TUG data, 91 (55.2%) and 74 (44.8%) data from right turns and left turns in the TUG tests,

10
respectively, were used for analyses. The time required to perform TUG did not differ between

right and left turns or between turns to the index and non-index knee sides (data not shown). Fig.

2B shows representative images of laser-TUG, illustrating that the gait speed and trajectory differ

in each phase even if the TUG time was similar. Fig. 2C shows the means and 95% CI of each

measure.

3.1 Association between Lower-limb Muscle Strength and TUG Performance

Table 2 shows the results of a multiple linear regression analysis of the relationship between lower-

limb muscle strength in the index knee limb and TUG performance. In all of the models, the

combination of age, sex, index knee K&L grade, knee pain intensity, GDS, and PCS explained

4.2–16.6% of the variance in TUG performance. Moderation analysis detected no significant

interactions in TUG subtasks × hip abductor muscle strength (p = 0.998).

When the dependent variables were the gait speed in the turning phase, the additive effects of

quadriceps muscle strength significantly explained an additional 2.6% of variance, and hip

abductor muscle strength significantly explained an additional 2.1% of variance above that of

quadriceps strength. The unique variance explained by quadriceps and hip abductor muscle

strength on gait speed in the turning phase was 1.3% and 2.1%, respectively. Weaker hip abductor

muscle strength (per -1 Nm/kg) was significantly associated with a 0.095 (95% CI: 0.001, 0.188)

m/s decrease in gait speed in the turning phase.

When the dependent variables were TUG subtasks other than turning, although the additive effects

of quadriceps muscle strength significantly explained an additional 2.7–4.1% of variance, the

11
results indicated no significant additional effect of hip abductor muscle strength that explained

0.3–1.8% of variance. The unique variance explained by quadriceps and hip abductor muscle

strength in these variables was 2.2–3.0%, and 0.3–1.8%, respectively.

Sensitivity analysis including non-index limb muscle strength revealed similar results: weaker hip

abductor muscle strength (per -1 Nm/kg) was significantly associated with a 0.089 (95% CI: 0.001,

0.178) m/s decrease in gait speed in the turning phase with a unique variance of 2.0%.

4. Discussion

This study revealed that hip abductor muscle strength weakness was significantly associated with

slowed turning speed in people with knee OA even after controlling for quadriceps muscle strength,

which support hypothesis. Figure 3 provides a graphic abstract. Although a task specific

contribution of hip abductor strength was not clearly indicated by moderation analysis and the

unique variance of hip abductor muscle strength was low, this finding may indicate impaired

turning motion in patients with weak hip abductor muscle strength, which could not be adequately

captured by a stopwatch-based traditional TUG test. Turning motion in patients with knee OA has

been paid less attention. Therefore, these findings may provide new mechanistic insights into

mobility limitation in patients with knee OA.

4.1 Additive Effect of Hip Abductor Muscle Strength on Explaining Mobility Limitation in TUG

The observed relationship between weak hip abductor strength and slowed turning speed has not

12
been previously reported and may be responsible for the wide variability in TUG performance in

patients with knee OA. The results of communality analysis demonstrated that the unique variance

in turning speed explained by hip abductor muscle strength was higher than the unique variance

explained by quadriceps muscle strength. This indicates that the explanatory power of hip abductor

strength with respect to turning speed was higher than that of quadriceps muscle strength. Our

findings reinforce the findings of a previous study showing that reduced hip abductor muscle

strength contributes to a poor TUG time after controlling for quadriceps muscle strength in people

who underwent total knee arthroplasty(Alnahdi et al., 2014) and in those with severe knee OA who

were scheduled for total knee arthroplasty(Loyd et al., 2017). However, turning motion has not

been examined in these studies. Since turning, not only straight walking, is a major component of

daily activities(Glaister et al., 2007), and the hip abductor muscle regulates the COM in the frontal

plane during turning(Patla et al., 1999; Ventura et al., 2015), further studies on the role of hip

muscle strength in turning motion in people with knee OA are of interest.

It should be acknowledged that overall unique variance of hip abductor muscle strength on TUG

was 0.3-2.1% that is relatively lower than previous studies in people who were scheduled (15.0%)

or underwent total knee arthroplasty (2.1%) (Alnahdi et al., 2014; Loyd et al., 2017). Mild disease

profile of recruited participants in this study may contribute to the between-trial difference. The

low unique variance implies that hip abductor muscle strength may not be a strong predictor for

TUG. Nevertheless, even with a low unique variance, statistically significant p-value indicates an

existence of a significant relationship between weaker hip abductor muscle and slower turning

speed.

13
4.2 Practical Relevance of Observed Relationship between Weak Hip Abductor Strength and

TUG

The decreased turning speed in individuals with weaker hip muscle strength independent from

quadriceps muscle strength has practical relevance. It is also noteworthy that we detect no

significant relationships between weak hip abductor muscle strength and the time to perform TUG,

which might imply that poor turning motion related to hip abductor weakness could not be

adequately captured by a stopwatch-based traditional TUG test. Although the moderation analysis

did not clearly indicate a task-dependent role of hip abductor muscle, our findings would indicate

that turning motion may be more vulnerable to hip abductor muscle impairment. As turning

accounts for as much as 50% of the steps taken in daily life(Glaister et al., 2007) and poses an

increased risk of falling(Pati et al., 2017), characterizing turning motion is essential for a deeper

understanding of mobility limitation and potential fall risks in individuals with knee OA who have

weak hip abductor muscles.

The effects of weak hip abductor muscles on knee OA has been less investigated than the effects

of the quadriceps muscle in clinical trials. A few body of evidences from randomized controlled

trials have shown that hip abductor muscle strengthening exercise may improve knee pain, self-

reported physical function, and objectively measured physical function such as stair climbing and

sit-to-stand abilities(Bennell et al., 2010; Sled et al., 2010). If our findings are replicated in a larger

trial, the results may be a first step in justifying the need to specifically target the hip abductors

during rehabilitation to improve turning motion, which has not been focused on by previous

randomized controlled trials(Bennell et al., 2010; Sled et al., 2010). Before hip abductor strength

training becomes a fundamental component of physical therapy in patients with knee OA,

14
longitudinal studies are needed to determine whether an increase in hip abductor strength will

improve turning motion.

4.3 Study Limitations

First, the cross-sectional nature of the study limits our ability to assess causality between hip

abductor muscle strength and slowed turning. Therefore, our results should be cautiously

interpreted. Weaker hip abductors may be a consequence of slowed turning, and our findings do

not necessarily highlight the need for muscle strengthening exercises. Second, this study did not

exclude patients with chronic hip pain, hip OA, and femoroacetabular impingement, which may

also contribute to hip muscle weakness in patients with knee OA(Arokoski et al., 2002; Diamond

et al., 2016; Harris-Hayes et al., 2014). Third, electromyography data of the hip abductors are

lacking. Weaker isometric hip abductor muscle while in a side-lying position may not imply lower

hip abductor muscle activity during turning. Finally, it should also be noted that even the largest

contributor to the explained variance in covariates only contributed approximately 4.2–16.6% on

TUG performance. Even with the addition of lower-limb muscle strength investigated in the

present study, the total amount of explained variance was only approximately 7.2–21.3%. Further

studies are needed to identify other potential contributors to mobility limitation in TUG.

5. Conclusion

Participants with weaker hip abductor muscles had a slowed turning speed, but not in the forward

and return phases, indicating hip abductor muscle specificity in turning. This study may provide

15
mechanistic insights into knee OA-related mobility limitation. Turning motion may be more

sensitive to aggravated hip abductor muscle weakness and may show better response to hip

abductor muscle strengthening exercises. Longitudinal studies are warranted to elucidate this issue.

Acknowledgments

The authors thank the members of Aoyama Laboratory (Kyoto University, Kyoto) for assisting

with the data collection. We also thank Editage (www.editage.jp) for English language editing.

Role of the Funding Source

This study was supported in part by a Grant-in-Aid from the Japan Society for the Promotion of

Science (https://www.jsps.go.jp/) for Research Fellows to HI.

Conflict of interest

The authors did not receive financial support or other benefits from commercial sources for the

work reported in this manuscript, or any other financial support that could create a potential

conflict of interest or the appearance of a conflict of interest concerning the work.

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Table 1. Patients’ characteristics (n = 165)

Age, years 68.6 ± 9.32

Female, no. (%) 116 (70.3)
Height, m 1.58 ± 0.08
Mass, kg 57.3 ± 11.3
BMI, kg/m2 22.8 ± 3.61
Index knee corrected AAA, ° 177.4 ± 3.90
Alignment, no. (%)
Neutral (corrected AAA ≥179° but <182°) 34 (20.6)
Valgus (corrected AAA ≥182°) 19 (11.5)
Varus (corrected AAA <179°) 112 (67.9)
Index knee K&L grade, no. (%)
Grade 1 73 (44.2)
Grade 2 73 (44.2)
Grade 3 17 (10.3)
Grade 4 2 (1.2)
Bilateral knee OA, no. (%) 52 (49.1)
Bilateral knee pain, no. (%) 24 (22.2)
GDS score, points 2.45 ± 2.34
PCS score, points 16.1 ± 11.7
JKOM pain subscale, points 4.80 ± 4.40
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 JKOM ADL subscale, points 2.44 ± 3.30
JKOM total score, points 10.9 ± 8.86
Quadriceps strength, Nm/kg
Index knee 1.30 ± 0.46
Non-index knee 1.33 ± 0.45
Hip abductor strength, Nm/kg
Index knee 0.93 ± 0.35
Non-index knee 0.93 ± 0.36
Time to perform TUG test, s 5.89 ± 1.21
TUG performance speed, m/s 1.25 ± 0.20
TUG subtask
Sit-to-walk time, s 0.43 ± 0.18
Gait speed in forward phase, m/s 1.43 ± 0.21
Gait speed in turning phase, m/s 1.21 ± 0.21
Gait speed in return phase, m/s 1.16 ± 0.24
AAA: anatomical axis angle; ADL: activity of daily living; BMI: body mass index; GDS:

Geriatric Depression Scale; JKOM: Japanese Knee Osteoarthritis Measure; K&L: Kellgren and

Lawrence; PCS: Pain Catastrophizing Scale; TUG: timed up and go.

Unless otherwise indicated, values are mean ± standard deviation index-knee .

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Table 2. Multiple linear regression analysis for muscle strength predicting TUG subtasks (n = 165)

Unique Regression coefficient

Dependent variable Step Independent variable R2 ΔR2 variance (95% CI) p-value
Overall TUG task
Time to perform TUG 1 Covariate† 0.097 ¬ ¬ ¬ ¬
Quadriceps strength
2 0.144 0.047 0.035 -0.645 (-1.086, -0.203) 0.005
(per Nm/kg)
Hip abductor strength
3 0.150 0.006 0.006 -0.301 (-0.870, 0.269) 0.298
(per Nm/kg)
TUG performance speed 1 Covariate† 0.138 ¬ ¬ ¬ ¬
Quadriceps strength
2 0.183 0.045 0.028 0.105 (0.033, 0.177) 0.004
(per Nm/kg)
Hip abductor strength
3 0.200 0.017 0.017 0.083 (-0.009, 0.175) 0.075
(per Nm/kg)
TUG subtask
Sit-to-walk time 1 Covariate† 0.042 ¬ ¬ ¬ ¬
Quadriceps strength
2 0.069 0.027 0.030 -0.074 (-0.145, -0.004) 0.039
(per Nm/kg)
Hip abductor strength
3 0.072 0.003 0.003 0.036 (-0.055, 0.126) 0.442
(per Nm/kg)
Gait speed in forward phase 1 Covariate† 0.115 ¬ ¬ ¬ ¬
Quadriceps strength
2 0.153 0.038 0.022 0.098 (0.023, 0.172) 0.010
(per Nm/kg)
Hip abductor strength
3 0.171 0.018 0.018 0.088 (-0.008, 0.183) 0.072
(per Nm/kg)
Gait speed in turning phase 1 Covariate† 0.166 ¬ ¬ ¬ ¬
Quadriceps strength
2 0.192 0.026 0.013 0.082 (0.009, 0.155) 0.028
(per Nm/kg)
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Gait speed in return phase
TUG: timed up and go; 95% CI: 95% confidence interval.
Hip abductor strength
3 0.213 0.021 0.021 0.095 (0.001, 0.188) 0.047
(per Nm/kg)
1 Covariate† 0.135 ¬ ¬ ¬ ¬
Quadriceps strength
2 0.176 0.041 0.029 0.119 (0.033, 0.205) 0.007
(per Nm/kg)
Hip abductor strength
3 0.185 0.009 0.009 0.070 (-0.041, 0.180) 0.216
(per Nm/kg)

† Covariates included age, sex, index knee Kellgren and Lawrence grade, Japanese Knee Osteoarthritis Measure pain score, Geriatric

Depression Scale score, and Pain Catastrophizing Scale score.

Bold type represents a statistically significant result.

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Figure 1. Primary outcome measures calculated using laser range sensor-based timed up-

and-go test

Definition of each outcome measure was provided as an illustration with description.

Figure 2. Flowchart of the study and laser range sensor-based timed up-and-go (laser-

TUG)

A, Flowchart of this study. B, Representative image of laser-TUG. Individuals with relatively

stronger (left panel) and weaker (right panel) hip abductor muscle. C, Laser-TUG-calculated

outcome measures as described in Fig. 1. Horizontal and vertical bars display the means and

95% confidence intervals.

Figure 3. Graphic abstract

The relationship between hip abductor muscle strength and speed of timed up-and-go test

performance may depend on the task. Weaker hip abductor muscle strength was a significant

factor associated with a slowed turning speed. Effect size (ES) and 95% confidence interval (CI)

are provided.

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