ORIGINAL PAPER
A comparison of Nordic walking and treadmill walking training outcomes after total knee arthroplasty in older women: a randomized controlled trial
1
Department of Physcial Therapy, Kyungbuk College, Yeongju City, Gyeongbuk Province, Republic of Korea
2
Department of Physical Therapy, Graduate School of Daejeon University, Daejeon City, Republic of Korea
3
Department of Physical Therapy, College of Health Sciences, Kangwon National University, Samcheok City, Ganwon Province, Republic of Korea
4
Department of Physical Therapy, College of Health and Medical Science, Daejeon University, Daejeon City, Republic of Korea
Submission date: 2025-12-11
Acceptance date: 2026-05-04
Online publication date: 2026-11-05
Corresponding author
Yong-Jun Cha
Department of Physical Therapy, College of Health and Medical Science, Daejeon University, Daejeon, Republic of Korea, 62, Daehackro, Dong-Gu, Daejeon 34520, Republic of Korea
Department of Physical Therapy, College of Health and Medical Science, Daejeon University, Daejeon, Republic of Korea, 62, Daehackro, Dong-Gu, Daejeon 34520, Republic of Korea
KEYWORDS
TOPICS
ABSTRACT
Introduction:
Evidence on gait training strategies for improving function in patients with knee arthritis after total knee arthroplasty (TKA) remains limited. This study aimed to determine whether Nordic walking training yields better outcomes than treadmill walking training in patients with knee arthritis after TKA.
Methods:
This assessor-blinded trial included 38 female patients (mean age 68.7 ± 2.1 years) who had undergone TKA. Participants were randomly and equally assigned to an experimental (Nordic walking training) or a control (general treadmill walking training) group. Training consisted of 30-min sessions, five times weekly for 4 weeks. In addition, all participants received 60-min sessions of comprehensive physiotherapy five times weekly over the same 4-week period. Primary (stride length and stride, stance, and swing times) and secondary (knee flexion angle and pain score) outcomes were measured before and after the 4-week training period. The Shapiro–Wilk test was used to assess the normality of data distributions. Baseline comparability of the groups was assessed using the independent t-test (normally distributed continuous variables) and Fisher’s exact test (categorical variables). Two-way repeated-measures analysis of variance (ANOVA) was used to examine group × time interactions, and eta-squared (η2) values were calculated to quantify effect sizes.
Results:
The experimental group achieved greater increases in stride length, walking velocity, and knee flexion angle than the control group (+4.5 vs. +1.7 cm, p < 0.01, η2 = 0.62; +3.51 vs. +1.24 cm/s, p < 0.01, η2 = 0.88; +30.7 vs. +20.7°, p < 0.01, η2 = 0.87). Furthermore, the experimental group showed greater reductions in stride, stance, and swing times and in pain scores (–0.23 vs. –0.07 s, p < 0.01, η2 = 0.80; –0.11 vs. –0.09 s, p < 0.01, η2 = 0.16; –0.23 vs. –0.07 s, p < 0.01, η2 = 0.81; –2.5 vs. –1.0 score, p < 0.01, η2 = 0.87).
Conclusions:
Nordic walking training may be more effective at increasing walking function and knee flexion angles and significantly more effective at reducing knee pain than treadmill training in knee arthritis patients after TKA.
Evidence on gait training strategies for improving function in patients with knee arthritis after total knee arthroplasty (TKA) remains limited. This study aimed to determine whether Nordic walking training yields better outcomes than treadmill walking training in patients with knee arthritis after TKA.
Methods:
This assessor-blinded trial included 38 female patients (mean age 68.7 ± 2.1 years) who had undergone TKA. Participants were randomly and equally assigned to an experimental (Nordic walking training) or a control (general treadmill walking training) group. Training consisted of 30-min sessions, five times weekly for 4 weeks. In addition, all participants received 60-min sessions of comprehensive physiotherapy five times weekly over the same 4-week period. Primary (stride length and stride, stance, and swing times) and secondary (knee flexion angle and pain score) outcomes were measured before and after the 4-week training period. The Shapiro–Wilk test was used to assess the normality of data distributions. Baseline comparability of the groups was assessed using the independent t-test (normally distributed continuous variables) and Fisher’s exact test (categorical variables). Two-way repeated-measures analysis of variance (ANOVA) was used to examine group × time interactions, and eta-squared (η2) values were calculated to quantify effect sizes.
Results:
The experimental group achieved greater increases in stride length, walking velocity, and knee flexion angle than the control group (+4.5 vs. +1.7 cm, p < 0.01, η2 = 0.62; +3.51 vs. +1.24 cm/s, p < 0.01, η2 = 0.88; +30.7 vs. +20.7°, p < 0.01, η2 = 0.87). Furthermore, the experimental group showed greater reductions in stride, stance, and swing times and in pain scores (–0.23 vs. –0.07 s, p < 0.01, η2 = 0.80; –0.11 vs. –0.09 s, p < 0.01, η2 = 0.16; –0.23 vs. –0.07 s, p < 0.01, η2 = 0.81; –2.5 vs. –1.0 score, p < 0.01, η2 = 0.87).
Conclusions:
Nordic walking training may be more effective at increasing walking function and knee flexion angles and significantly more effective at reducing knee pain than treadmill training in knee arthritis patients after TKA.
REFERENCES (62)
1.
Michael JW, Schlüter-Brust KU, Eysel P. The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Dtsch Arztebl Int. 2010;107(9):152–62; doi: 10.3238/arztebl.2010.0152.
2.
Giorgino R, Albano D, Fusco S, Peretti GM, Mangiavini L, Messina C. Knee osteoarthritis: epidemiology, pathogenesis, and mesenchymal stem cells: what else is new? An update. Int J Mol Sci. 2023;24(7):6405; doi: 10.3390/ijms24076405.
3.
Shen X, Wang S, Chen J, Li J, Li C, Xiang R, Zhao C, Xu X. Inter-rater reliability and test-retest reliability of the foot posture index (FPI-6) for assessing static foot posture in elderly female patients with knee osteoarthritis and its association with quadriceps muscle tone and stiffness. Front Bioeng Biotechnol. 2024;12:1385986; doi: 10.3389/fbioe.2024.1385986.
4.
Krupka WM, Motyl G, Dmowska-Chalaba J. The gut microbiome and osteoarthritis. Reumatologia. 2025;63(1):54–60; doi: 10.5114/reum/197061.
5.
Mahmoudian A, Lohmander LS, Mobasheri A, Englund M, Luyten FP. Early-stage symptomatic osteoarthritis of the knee – time for action. Nat Rev Rheumatol. 2021;17(10):621–32; doi: 10.1038/s41584-021-00673-4.
6.
Canovas F, Dagneaux L. Quality of life after total knee arthroplasty. Orthop Traumatol Surg Res. 2018;104(1S):41–6; doi: 10.1016/j.otsr.2017.04.017.
7.
Yau LK, Henry FU, Man Hong C, Amy C, Wai Kwan Vincent C, Ping Keung C, Yuen CK. Swelling assessment after total knee arthroplasty. J Orthop Surg. 2022;30(3):10225536221127668; doi: 10.1177/10225536221127668.
8.
Łapiński M, Wyszyńska M, Buzek E, Maciąg G, Maciąg B, Adamska O, Atanasov A, Stolarczyk A. Body mass index and lower limb diameters in total knee arthroplasty outcomes and surgical planning. Reumatologia. 2025;63(6):398–404; doi: 10.5114/reum/211452.
9.
Chung MS, Kwak HS. Effects of a muscle strengthening exercise program after total knee arthroplasty. J Korean Aca Soc Nurs Edu. 2008;14(1):20–9.
10.
Toth MJ, Savage PD, Voigt TB, Anair BM, Bunn JY, Smith IB, Tourville TW, Blankstein M, Stevens-Lapsley J, Nelms NJ. Effects of total knee arthroplasty on skeletal muscle structure and function at the cellular, organellar, and molecular levels. J Appl Physiol. 2022;133(3):647–60; doi: 10.1152/japplphysiol.00323.2022.
11.
Larsen JB, Skou ST, Laursen M, Bruun NH, Arendt-Nielsen L, Madeleine P. Exercise and pain neuroscience education for patients with chronic pain after total knee arthroplasty: a randomized clinical trial. JAMA Netw Open. 2024;7(5):e2412179; doi: 10.1001/jamanetworkopen.2024.12179.
12.
Karaborklu Argut S, Celik D, Kilicoglu OI. The combination of exercise and manual therapy versus exercise alone in total knee arthroplasty rehabilitation: a randomized controlled clinical trial. PM R. 2021;13(10):1069–78; doi: 10.1002/pmrj.12542.
13.
Malviya A, Wilson G, Kleim B, Kurtz SM, Deehan D. Factors influencing return to work after hip and knee replacement. Occup Med. 2014;64(6):402–9; doi: 10.1093/occmed/kqu082.
14.
Romaniuk K, Pulik K, Kowalczyk W, Dudek S, Krzosek B, Łęgosz P, Makowski A. The survey on methods used for the assessment of patient’s satisfaction after total hip arthroplasty. Issue Rehabil Orthop Neurophysiol Sprot Promot. 2023;44(3):39–51; doi: 10.19271/IRONS-000195-2023-44.
15.
Domínguez-Navarro F, Igual-Camacho C, Silvestre-Muñoz A, Roig-Casasús S, Blasco JM. Effects of balance and proprioceptive training on total hip and knee replacement rehabilitation: a systematic review and meta-analysis. Gait Posture. 2018;62:68–74; doi: 10.1016/j.gaitpost.2018.03.003.
16.
Hsieh CJ, DeJong G, Vita M, Zeymo A, Desale S. Effect of outpatient rehabilitation on functional mobility after single total knee arthroplasty: a randomized clinical trial. JAMA Netw Open. 2020;3(9):e2016571; doi: 10.1001/jamanetworkopen.2020.16571.
17.
Huang CH, Schroeder ET, Powers C. Antigravity treadmill training during the early rehabilitation phase following unicompartmental knee arthroplasty: a case series. Physiother Theory Pract. 2019;35(5):489–94; doi: 10.1080/09593985.2018.1443535.
18.
Atan T, Bildik YE, Demir Y, Güzelküçük Ü, Tan AK. Comparison of anti-gravity treadmill training and traditional treadmill training in patients with moderate to severe knee osteoarthritis: a randomized controlled trial. Ir J Med Sci. 2024;194(1):125–36; doi: 10.1007/s11845-024-03836-w.
19.
Tarniţă D, Petcu AI, Dumitru N. Influences of treadmill speed and incline angle on the kinematics of the normal, osteoarthritic and prosthetic human knee. Rom J Morphol Embryol. 2020;61(1):199–208; doi: 10.47162/rjme.61.1.22.
20.
Candau R, Belli A, Millet GY, Georges D, Barbier B, Rouillon JD. Energy cost and running mechanics during a treadmill run to voluntary exhaustion in humans. Eur J Appl Physiol Occup Physiol. 1998;77(6):479–85; doi: 10.1007/s004210050363.
21.
Kuptniratsaikul V, Chaiworapuek W, Kovintaset K, Meesawang M, Chinsawangwatanakul P, Danoi A. Pain management and strength gains compared between pneumatic partial weight support treadmill and underwater treadmill in overweight patients with knee osteoarthritis: a randomized controlled trial. Clin Rehabil. 2022;36(9):1214–28; doi: 10.1177/02692155221097032.
22.
Tschentscher M, Niederseer D, Niebauer J. Health benefits of Nordic walking: a systematic review. Am J Prev Med. 2013;44(1):76–84; doi: 10.1016/j.amepre.2012.09.043.
23.
Willson J, Torry MR, Decker MJ, Kernozek T, Steadman JR. Effects of walking poles on lower extremity gait mechanics. Med Sci Sports Exerc. 2001;33(1):142–7; doi: 10.1097/00005768-200101000-00021.
24.
Oh YS, Kim JS, Jang WS. Effects of Nordic walking exercise on muscular strength, flexibility, balance and pain in older woman with knee osteoarthritis. J Kor Appl Sci Tech. 2019;36(4):1312–26.
25.
Mazumder O, Poduval M, Ghose A, Sinha A. Walking pole gait to reduce joint loading post total knee athroplasty: musculoskeletal modeling approach. Annu Int Conf IEEE Eng Med Biol Soc. 2021;2021:4605–10; doi: 10.1109/embc46164.2021.9630849.
26.
Bieler T, Siersma V, Magnusson SP, Kjaer M, Christensen HE, Beyer N. In hip osteoarthritis, Nordic walking is superior to strength training and home-based exercise for improving function. Scand J Med Sci Sports. 2017;27(8):873–86; doi: 10.1111/sms.12694.
27.
Revord LP, Lomond KV, Loubert PV, Hammer RL. Acute effects of walking with Nordic poles in persons with mild to moderate low-back pain. Int J Exerc Sci. 2016;9(4):507–13; doi: 10.70252/cfhc5201.
28.
Pippi R, Di Blasio A, Aiello C, Fanelli C, Bullo V, Gobbo S, Cugusi L, Bergamin M. Effects of a supervised Nordic walking program on obese adults with and without type 2 diabetes: the C.U.R.I.A.Mo. centre experience. J Funct Morphol Kinesiol. 2020;5(3):62; doi: 10.3390/jfmk5030062.
29.
Church TS, Earnest CP, Morss GM. Field testing of physiological responses associated with Nordic walking. Res Q Exerc Sport. 2002;73(3):296–300; doi: 10.1080/02701367.2002.10609023.
30.
Muroi D, Kodama K, Tomono T, Saito Y, Koyake A, Higuchi T. Upper body rotation for obstacle avoidance in individuals with stroke with different degrees of upper extremity paralysis. Motor Control. 2025;29(4):363–78; doi: 10.1123/mc.2024-0134.
31.
Konnyu KJ, Thoma LM, Cao W, Aaron RK, Panagiotou OA, Bhuma MR, Adam GP, Balk EM, Pinto D. Rehabilitation for total knee arthroplasty: a systematic review. Am J Phys Med Rehabil. 2023;102(1):19–33; doi: 10.1097/phm.0000000000002008.
32.
Boutron I, Altman DG, Moher D, Schulz KF, Ravaud P. CONSORT statement for randomized trials of nonpharmacologic treatments: a 2017 update and a CONSORT extension for nonpharmacologic trial abstracts. Ann Intern Med. 2017;167(1):40–7; doi: 10.7326/m17-0046.
33.
Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175–91; doi: 10.3758/bf03193146.
34.
Park SK, Yang DJ, Kang YH, Kim JH, Uhm YH, Lee YS. Effects of Nordic walking and walking on spatiotemporal gait parameters and ground reaction force. J Phys Ther Sci. 2015;27(9):2891–3; doi: 10.1589/jpts.27.2891.
35.
Li J, Guan T, Zhai Y, Zhang Y. Risk factors of chronic postoperative pain after total knee arthroplasty: a systematic review. J Orthop Surg Res. 2024;19(1):320; doi: 10.1186/s13018-024-04778-w.
36.
Acar A, Erden S. The effect of TENS on patient outcomes after total knee arthroplasty. Pain Manag Nurs. 2026;27(3):220–7; doi: 10.1016/j.pmn.2026.01.011.
37.
Wong CH, Lin LC, Lee HH, Liu C-F. The analgesic effect of thermal therapy after total knee arthroplasty. J Altern Complement Med. 2012;18(2):175–9; doi: 10.1089/acm.2010.0815.
38.
Chen L-H, Chen C-H, Lin S-Y, Chien S-H, Su J-Y, Huang C-Y, Wang H-Y, Chou C-L, Tsai T-Y, Cheng Y-M, Huang H-T. Aggressive continuous passive motion exercise does not improve knee range of motion after total knee arthroplasty. J Clin Nurs. 2013;22(3–4):389–94; doi: 10.1111/j.1365-2702.2012.04106.x.
39.
Pua Y-H, Poon C-L, Seah FJ-T, Mentiplay BF, Ho C-L, Leong F-L, Chong H-Ch, Lim EC-W, Clark RA. Comparative performance of isometric and isotonic quadriceps strength testing in total knee arthroplasty. Musculoskelet Sci Pract. 2018;37:17–9; doi: 10.1016/j.msksp.2018.06.008.
40.
Fortier LM, Rockov ZA, Chen AF, Rajaee SS. Activity recommendations after total hip and total knee arthroplasty. J Bone Joint Surg Am. 2021;103(5):446–55; doi: 10.2106/jbjs.20.00983.
41.
Russo L, Belli G, Blasio AD, Lupu E, Larion A, Fischetti F, Montagnani E, Di Biase Arrivabene P, De Angelis M. The impact of Nordic walking pole length on gait kinematic parameters. J Funct Morphol Kinesiol. 2023;8(2):50–71.
42.
Sivagnanam R, Krishnan R, Ramamoorthy J, Karthikeyan S, Sankaranarayanan S, Kumar G, Janet A, Sudhakar S, Govindaraj MK, Kirthika SV. Effect of bicycle ergometer training and Nordic walking training on improving functional exercise capacity in asthma patients. Cureus. 2023;15(11):e49762; doi: 10.7759/cureus.49762.
43.
Ciolac EG, Mantuani SS, Neiva CM, Verardi C, Pessôa-Filho DM, Pimenta L. Rating of perceived exertion as a tool for prescribing and self regulating interval training: a pilot study. Biol Sport. 2015;32(2):103–8; doi: 10.5604/20831862.1134312.
44.
Motti Ader LG, Greene BR, McManus K, Tubridy N, Caulfield B. Short bouts of gait data and body-worn inertial sensors can provide reliable measures of spatiotemporal gait parameters from bilateral gait data for persons with multiple sclerosis. Biosensors. 2020;10(9):128; doi: 10.3390/bios10090128.
45.
Acar S, Aljumaa H, Şevik K, Karatosun V, Ünver B. The intrarater and interrater reliability and validity of universal goniometer, digital inclinometer, and smartphone application measuring range of motion in patients with total knee arthroplasty. Indian J Orthop. 2024;58(6):732–9; doi: 10.1007/s43465-024-01129-z.
46.
Solomito MJ, Carangelo R, Makanji H. The minimal clinically important difference (MCID) for total joint arthroplasty outcome measures varies substantially by calculation method. J Bone Joint Surg Am. 2025;107(9):994–9; doi: 10.2106/jbjs.24.00916.
47.
Milanese S, Gordon S, Buettner P, Flavell C, Ruston S, Coe D, O’Sullivan W, McCormack S. Reliability and concurrent validity of knee angle measurement: smart phone app versus universal goniometer used by experienced and novice clinicians. Man Ther. 2014;19(6):569–74; doi: 10.1016/j.math.2014.05.009.
48.
Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med. 2001;8(12):1153–7; doi: 10.1111/j.1553-2712.2001.tb01132.x.
49.
Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: visual analog scale for pain (VAS pain), numeric rating scale for pain (NRS pain), McGill pain questionnaire (MPQ), short-form McGill pain questionnaire (SF-MPQ), chronic pain grade scale (CPGS), short form-36 bodily pain scale (SF-36 BPS), and measure of intermittent and constant osteoarthritis pain (ICOAP). Arthritis Care Res. 2011;63(Suppl 11):240–52; doi: 10.1002/acr.20543.
50.
Danoff JR, Goel R, Sutton R, Maltenfort MG, Austin MS. How much pain is significant? Defining the minimal clinically important difference for the visual analog scale for pain after total joint arthroplasty. J Arthroplasty. 2018;33(7S):71–5.e2; doi: 10.1016/j.arth.2018.02.029.
51.
Seamon BA, Kautz SA, Bowden MG, Velozo CA. Revisiting the concept of minimal detectable change for patient-reported outcome measures. Phys Ther. 2022;102(8):pzac068; doi: 10.1093/ptj/pzac068.
52.
Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc B. 1995;57:289–300.
53.
Pierce CA, Block RA, Aguinis H. Cautionary note on reporting eta-squared values from multifactor ANOVA designs. Edu Psychol Measur. 2004;64(6):916–24.
54.
Hansen L, Henriksen M, Larsen P, Alkjaer T. Nordic walking does not reduce the loading of the knee joint. Scand J Med Sci Sports. 2008;18(4):436–41; doi: 10.1111/j.1600-0838.2007.00699.x.
55.
Tanpure S, Phadnis A, Nagda T, Rathod C, Kothurkar R, Gad M. Effect of total knee arthroplasty on contralateral knee: a prospective comparative gait analysis of non-operated legs in the Indian population. J Clin Orthop Trauma. 2023;45:102280; doi: 10.1016/j.jcot.2023.102280.
56.
Fukui J, Matsui Y, Mizuno T, Watanabe T, Takemura M, Ishizuka S, Imagama S, Arai H. Comparison of gait analysis before and after unilateral total knee arthroplasty for knee osteoarthritis. J Orthop Surg Res. 2024;19(1):506; doi: 10.1186/s13018-024-04891-w.
57.
Aljehani MS, Christensen JC, Snyder-Mackler L, Crenshaw J, Brown A, Zeni JA, Jr. Knee biomechanics and contralateral knee osteoarthritis progression after total knee arthroplasty. Gait Posture. 2022;91:266–75; doi: 10.1016/j.gaitpost.2021.10.020.
58.
Redfern RE, Khan ST, Archibeck MJ, Peters CL, Anderson MB, Piuzzi NS. Establishing minimal clinically important difference and substantial clinical benefit thresholds for objective gait metrics after total knee arthroplasty. J Arthroplasty. 2026;41(10S1):191–7; doi: 10.1016/j.arth.2026.03.101.
59.
Kim JK, Yang SM. Analysis on body-composition change and walking type after aquatic exercise and Nordic walking exercise in patients with degenerative knee arthritis [in Korean]. Kor J Sports Sci. 2009;18(2):1379–92.
60.
Maniwa S, Michibata Y, Kawamoto K, Noguchi A, Tadenuma T, Sakai Y. Effect of Nordic walking in patients with hip osteoarthritis: a preliminary report form Japan. Shimane J Med Sci. 2022;39:63–8.
61.
Fujita R, Ota S, Yamamoto Y, Kataoka A, Warashina H, Hayashi T, Matsunaga N, Sugiura H. Factors associated with physical activity following total knee arthroplasty for knee osteoarthritis: a longitudinal study. BMC Musculoskelet Disord. 2024;25(1):178; doi: 10.1186/s12891-024-07306-3.
62.
Aoyagi K, Liew JW, Farrar JT, Wang N, Carlesso L, Kumar D, Law LF, Lewis CE, Nevitt M, Neogi T. Does weight-bearing versus non-weight-bearing pain reflect different pain mechanisms in knee osteoarthritis?: the Multicenter Osteoarthritis Study (MOST). Osteoarthritis Cartilage. 2022;30(4):545–50; doi: 10.1016/j.joca.2021.10.014.
Share
RELATED ARTICLE
| eISSN: | 2544-4395 |
We process personal data collected when visiting the website. The function of obtaining information about users and their behavior is carried out by voluntarily entered information in forms and saving cookies in end devices. Data, including cookies, are used to provide services, improve the user experience and to analyze the traffic in accordance with the Privacy policy. Data are also collected and processed by Google Analytics tool (more).
You can change cookies settings in your browser. Restricted use of cookies in the browser configuration may affect some functionalities of the website.
You can change cookies settings in your browser. Restricted use of cookies in the browser configuration may affect some functionalities of the website.
