ABSTRACT

OBJECTIVE
To find out the standing balance performance among osteoarthritis of
knee patients compared with normal age matched controls

STUDY DESIGN
Descriptive study

SAMPLING TECHNIQUE
Non Probability convenient sampling

SETTING
Department of physiotherapy,
A.C.S. General Hospital,
Chennai.

SUBJECT
20 osteoarthritis patients and 20 normal were taken for this study.

METHOD
To asses the balance performance functional research test were
administered to both osteoarthritis patients and control groups

RESULTS
Functional reach test score value, which is higher for control group
compared with osteoarthritis patients.

CONCLUSION
The results suggests that osteoarthritis of knee patients having significant
loss of (propioception) balance performance compared with normal age matched
controls.
1

INTRODUCTION
Osteoarthritis is a heterogeneous condition for which the prevalence, risk
factors, clinical manifestation, and prognosis vary according to the joints
affected. It most commonly affects knee, hips, hand and spinal apophyseal joints.
It is characterized by the focal areas of damage to the cartilage surfaces of the
synovial joints and is associated with remodeling of the underlying bone and
mild synovitis1.

Osteoarthritis is one of the most prevalent musculoskeletal complaints

worldwide. It is a major cause of impairment and disabling among the elderly.
Individual with osteoarthritis of knee suffer progressive loss of function,
displaying increasing dependency in walking, stair climbing and other lower
extremity tasks2.

Balance is a complex function involving numerous neuromuscular

mechanisms. Control of balance is dependent upon sensory input from the
vestibular, visual, and somatosensory systems. Central processing of this
information results in coordinated neuromuscular response that ensures the
center of mass remains with in the base of the support in situation when balance
is disturbed3.

Effective control of balance thus relives not only on account sensory input
but also on timely response of strong muscles. Balance is an integral component
of activities of daily living. Balance impairments are associated with an
increased risk of falls and poorer mobility in the elderly population3.

Most of our clinical practice while treating osteoarthritis patients we use

to concentrated to relieve pain and swelling and increase the muscle power and
so on. But nobody concentrated4,5,6,7 on balance performance. The recent
literatures are suggests that osteoarthritis patients having significance loss of
proprioreception that leads to imbalance. So, this study helps to find out balance
performance among osteoarthritis of knee patients compared with normal age
matched controls

OSTEOARTHRITIS AN OVERVIEW

CAUSES OF OSTEOARTHRITIS
Over weight in the main cause
Harmful stress upon the knee

CLINICAL FEATURES

Pain

Muscle spasm

Stiffness

Loss of movement

Muscle wasting and weakness

Joint enlargement

Deformity

Crepitus

Loss of function

DURING ACTIVE INFLAMMATION

Heat.

Redness.

Swelling.
4

Pain.

PAIN
The onset is of low intensity and can be described as three types.
1. Pain on weight bearing, severe aching, due to stress on the synovial
membrane and later due to the bone surfaces, which are rich in nerve
endings, coming into contact.
2. During and after exercise there is pain described as being around the
joint.
3. AT night especially after a very active day there is severe aching.

NATURE OF PAIN
1.

Aching is dominant, at first fleeting and then becoming more constant.

2.

Referred pain is described as passing down a limb distally from the

affected joint.

3.

Sharp stabbing pain is associated with a loose body becoming

impacted in the joint.

MUSCLE SPASM
This occurs over one aspect of the joint and is initially protective but
where it remains beyond the acute episode it must be treated to prevent
contractures.

STIFFNESS

This is present after rest and takes a little time to wear off with
movement. It may be due to loss of joint lubrication, chronic oedema in the
periarticular structures or swelling of the articular cartilage.

LOSS OF JOINT MOVEMENT

This is different from stiffness because it does not wear off. It may be
permanent where there is articular cartilage destruction but will respond to
physiotherapy where it is due to muscle spasm or soft-tissue contracture.

MUSCLE WASTING AND WEAKNESS

Muscle become weak often on the aspect of the joint which is opposite to
contracures. (e.g. his extensors).

JOINT ENLARGEMENT
Chronic oedema of the synovial membrane and capsule together with
muscle wasting makes the joint appear large.

DEFORMITY
Each joint tends to adopt a characteristic deformity.

CREPITUS
The flaked cartilage and eburnated bone ends grate with a characteristic
sound on movement.

LOSS OF FUNCTION

Pain, muscle, weakness, giving way lead to inability to use the limb
normally and can be severely disabling.

CLINICAL FEATURES RELATING TO KNEE JOINT

Pain is described as round and through the joint. And may be referred up
the anterior aspect of the tight or down to the ankle. Muscle spasm may be
present in the hamstring muscles. Deformity from prolonged hamstring spasm is
flexion and there is deformation of the tibia with valgus deformity. The joint is
enlarged and there is quadriceps atrophy especially vastus medialis. There is a
limp due to pain and a tendency for the joint to give way especially during
stepping down.

PATHOLOGY

This will be considered in relation to each joint structure as follows:

1. Articular Cartilage
2. Bone
3. Synovial membrane
4. Capsule
7

5. Ligaments
6. Muscles

1. ARTICULAR CARTILAGE

Erosion occurs, often central and frequently in the weight- bearing areas.
Cartilage is usually the first structure to be affected. Fibrillation which cause
softening, splitting and fragmentation of the cartilage occurs in both weight
bearing and non weight bearing areas.

Collagen fibres split and there is disorganization of the proteoglycancollagen relationship such that water is attracted into the cartilage which causes
further softening and flaking flakes of cartilage break off and may be impacted
between the join surfaces causing locking and inflammation. Proliferation occurs
at the periphery of the cartilage.

2. BONE

Eburnation the bone surfaces become hard and polished as there is loss
of protection from the cartilage

Cystic cavities form in the subcondalar bone because eburnated bone is

brittle and microfractures occur allowing the passage of synovial fluid into the
bone tissue. There can also be venour congestion in the subchondral bone.
Osteophytes form of the margin of articular surfaces where they may project
in to the joint or into the capsule and ligaments. Bone of the weight bearing
joints alters in shape- the femoral head becomes flat and mushroom shaped. The
tibial condyles become flattened.

3. SYNOVIAL MEMBRANE
This undergoes hypertrophy and becomes oedematour. Later there is
fibrour degeneration. Reduction of synovial fluid secretion results in loss of
nutrition and lubrication of the articular cartilage.

4. LIGAMENTS
This undergo the same changes as the capsule and according to the aspect
of the joint become contracted or elongated.

5. CAPSULE
This undergoes fibrous degeneration and there are low grade chronic
inflammatory changes.

6. MUSCLE
These undergo atrophy which may be related to disuse because pain limits
movement and function. Without adequate exercise the muscles may undergo
fibrous atrophy.
9

REVIEW OF LITERATURE

KORALEWICZ L.M, ENGH G.A 2000 concludes knee propriception in

middle aged and elderly persons with advanced knee arthritis are reduced
in comparison with that in middle aged and elderly persons without
arthritis.
HASSON B.S.MOCKETTS, et-all 2001 June concludes compared with
age and sex matched controls, subjects with symptomatic knee
osteoarthritis have quadriceps weakness reduced knee propriception and
increased postural sway.
DOHERTY M, et-all 2002 May concludes reduction in knee pain through
entire peripheral or central mechanisms resulted in increased maximum
voluntary contraction. This increase however, did not result in
improvement in propriception or static postural stability.
S MOCKETT, et-all 2002 concludes in subjects with knee osteoarthritis
application of an elastic bandage around the knee can reduce knee pain
and improve static postural sway. This outcome depends on the size of the
applied bandage.
10

 DIRACOGLU D, AVLIN F. et-all 2005 December concludes additive

positive effects of kinesthesia and balance exercise in knee osteoarthritis
have been demonstrated used in clinical application they should be able to
increase the functional capacities of patients. Long term studies about
efficacy and cost effective of these exercises are needed.

PAI Y.C, RYMER WZ, et-all, 2005 concludes propriception declines

with age and is further impaired in elderly patients with knee
osteoarthritis. Poor propriception may contribute to functional impairment
in osteoarthritis.

SHARMA L, PAI Y.C, 1997, concludes knee joints proprioception is

worse in knee osteoarthritis patients versus age-matched control subjects.
Functional consequences of impaired propriception may include lower
gait velocity. `Shorter stride length and slower stair walking time.
propriception worsen in hyper mobility syndrome patients versus age
matched controls.
HOLTKAMP K, et-all 1997 concludes impaired proprioception is not
exclusively a local result of disease in knee osteoarthritis. The relative
importance of impaired proprioception in the development and
progressive of knee.
KIM L, BENNELL, RANA S, HINMAN 2000 concludes proprioception
plays an integral role in neuromuscular control of the knee joint and
defects in knee joints proprioception are documented in individuals with
osteoarthritis of knee.

11

 WILLIAMS

&

WILKINS

2002,

concludes

proprioception

and

neuromuscular controls of the knee are compromised after ligament

injury and must be regained if the athlete is to return to high level sports
at normal injury risk level.

FELSON DT., HANNAN MT 1995 Oct., Concludes in Elderly persons

the new onset of knee OA is frequent and is more common in women than
men. However among the elderly age may not affect new disease
occurrence or progression.

D.V. DOYLE, DJ HART, Sept., 1994 concludes over one of middle aged
women with unilateral knee OA will progress to bilateral knee OA within
2 years. Obesity is a strong and important risk factor in the primary and
secondary prevention of OA knee.

DEBORAH, J .HART, DAVID V, 22 May 2001 concludes obesity and

aging are associated with a high risk of new knee OA developing in
women.

AL HARRISO, Sept., 2004, concludes functional Self efficiency is an

important factor affecting the functional performance out come for people
with OA knee.

12

METHODOLOGY

STUDY DESIGN
The design of the study is Descriptive study.

SETTING
Department of Physiotherapy,
A.C.S General Hospital, Chennai

SAMPLE
20 osteoarthritis Patients
20 controll Subjects

SAMPLING TECHNIQUES
Non probability convenient sampling

INCLUSION CRITERIA
Age between (45-65years)
Patient Body mass index (BMI) value between (25-30) Kg/m2
The patient who has diagnosed osteoarthritis of knee from orthopedic
department of A.C.S. General Hospital, Chennai.

13

EXCLUSION CRITERIA
H/o injuries and multiple falls
Uncorrected visual impairments
H/o stroke and cerebellar disorder
H/o hospitalization in last two months

EQUIPMENTS AND MATERIALS

Inch tape
Weight machine
Wooden Scale

14

METHOD:

The functional reach test is developed as a quick screen for balance

problems in older adults. For performing this test subjects stand with feet
shoulder distance apart and with the arm raised to 90 flexion without moving
their feet, subjects reach as for forward as they can, while still maintaining their
balance. The distance reached is measured and compared to age-related norms 3.

Twenty osteoarthritis knee patients and twenty normal subjects were

participated in this study. To asses the balance performance the functional reach
test is administered to both the groups. Before applying the test, the procedure
was clearly explained to the patient.

To perform the functional reach test subjects stand with feet shoulder
distance apart and with the arm raised to 900 flexion without moving their feet,
subjects reach as for forward as they can, while still maintaining their balance.
The measuring scale is placed on the wall.

SAMPLE
The sample consists of 20 Osteoarthritis, patients and 20 control subjects.

15

FUNCTIONAL REACH TEST BY PATIENT

16

FUNCTIONAL REACH TEST BY PATIENT

17

TABLE -1
FUNCTIONAL REACH SCORES OF MALE SUBJECTS (45-65 YRS)
OA KNEE
11.2
10.5
9.5
10.4
11
8.9
9.3
10.6
8.5
9.2

CONTROL
16.3
15.6
15.2
16
17
14.8
15.6
16.8
16.5
16.7

18

19

TABLE 2 (MALES)
BETWEEN GROUP ANALYSIS USING PAIRED T-TEST FOR MALES

OA KNEE

CONTROL

SIGNIFICANT

16.05
Mean

9.91

Mean

(p <0.001)
SD

0.9409

S.D

0.7337

RESULTS:
Table 2 shows the value of mean and S.D functional reach test score
between OA knee patients and control subjects. For OA patients mean value is
9.91 and standard deviation (S.D) 0.9409. For control subjects mean value 16.05
and S.D 0.7337. In order to find out the level of significance. I used paired Ttest. The results shows that level of significance p value <0.001.

20

BAR DIAGRAM

21

TABLE 3
FUNCTIONAL REACH SCORES OF FEMALE SUBJECTS (45-65YRS)
OA KNEE
9.3
8.5
9.4
10.5
8.9
9.2
10.1
9.5
8.5
10.2

CONTROL
14.6
13.3
12.6
14.5
13.3
14
14.2
12.5
13.9
14.5

TABLE 4 (FEMALES)
BETWEEN GROUP ANALYSIS OF FEMALE USING PAIRED T-TEST

OA KNEE

CONTROL

22

SIGNIFICANT

Mean

9.4

Mean

13.74
(p <0.005)

SD

0.688

S.D

0.7763

RESULTS:
Table 4 shows the value of mean and standard deviation of functional
reach test score between OA patients and control subjects. For OA patients mean
value 9.4 and SD 0.688. For control subjects mean value 13.74 and SD 0.7763.
In order to find out the level of significance I used paired t-test. The results
shows that the level of significance p-value < 0.005.

23

BAR DIAGRAM

24

DISCUSSION
The aim of this study is to identify the standing balance performance
between OA knee patients and age matched normal controls.

Table -1 Shows that value of functional reach test score for male. The
value of functional reach score which is high for control subjects compared with
AO patients.

Table 2 shows the value of mean and S.D functional reach test score
between OA knee patients and control subjects. For OA patients mean value is
9.91 and standard deviation (S.D) 0.9409. For control subjects mean value 16.05
and S.D 0.7337. In order to find out the level of significance. I used paired Ttest. The results shows that level of significance p value <0.001.

Table 3 Shows that the value of functional reach test score for female.
The value of functional reach test score which is high for control subjects
compared with OA patients.

Table 4 shows the value of mean and standard deviation of functional

reach test score between OA patients and control subjects. for OA patients mean
value 9.4 and SD 0.688. For control subjects mean value 13.74 and SD 0.7763.

25

In order to find out the level of significance I used paired t-test. The results
shows that the level of significance p-value < 0.005.

KORALEWICZ12 et-all 2000 concludes knee proprioception in middle

aged and elderly persons with advanced knee arthritis are reduced in comparison
with that in middle aged and elderly persons without arthritis.

HASSON11 et-all 2001 June concluded compared with age sex mateched
controls, subjects with symptomatic knee osteoarthritis have quadriceps
weakness reduced knee proprioception and increased postural way.

PAI Y.C.6 et-all 2005 concludes proprioception declines with age and is
further impaired in elderly patients with knee osteoarthritis poor proprioception
may contribute to functional impairment in osteoarthritis.

Based on the results it is suggests that OA knee patients having significant

loss of (Proprioception) balance performance compared with normal controls.
While comparing the functional reach test score value between male and female,
male obtaining more value than female. It suggests that female having more risk
of imbalance than man.

26

CONCLUSION

To conclude from the results of this study osteoarthritis knee patients

having significant loss of (Proprioception) balance performance compared with
normal age matched controls.

27

RECOMMENDATION

This study can be carried out large sample size

This study can be carried out different BMI

28

BIBLIOGRAPHY

1. Tidys physiotherapy 4th Edition Page No. 107-109 Author TIDYS and
THOMSON.
2. Orthropaedics and Traumatology 6th Edition Author - NATARAJAN
3. Motor control theory and practical applications Page No.208-209 Author
ANNE SHUMWAY, MARJORIE WOOILACOTT
4. Effects of kinesthesia and balance exercises in knee ostheoarthristis
2005 Dec., DIRACOGLU .D, AYDIN. R
5. Effects of age and osteoarthritis on knee propriception 12th Dec., 2005
PAI.Y.C
6. Impaired proprioception and osteoarthritis 1997 May SHARMA .L,
PAI.Y.C
7. Is knee joint proprioception worse in the arthritic knee versus the
unaffected knee in unilateral knee osteoarthritis 1997 August- HOLT
KAMP .K,

RYMER WZ

8. Relationship of knee joint proprioception to pain and disability in

individuals with knee osteoarthritis 2000- KIM.L, BENNELL, RANA.S.
9. Static postural sway, proprioception and maximal voluntary quadriceps
contraction in patterns with knee osteoarthritis and normal control
subjects, January 2001, HASSAN B.S. , MOCKETT.S
29

10. Effect of pain reduction on postural sway. Proprioception and quadriceps

strength in subjects with knee osteoarthritis 2002 May- HASSAN B.S.,
DOHERTHY. S.A.
11. Influence of elastic bandage on knee pain. Proprioception and postural
sway in subjects with knee osteoarthritis 2002- B. HASSAN, S.
MOCKETT
12. Comparison of proprioception in arthritic and age matched normal knees
2000- KORALEWICZ L.M. ENGH. G.A.
13. The incidence and neutral history of knee osteoarthritis in the elderly1995, OCT., FILSON D.T. , ZHANQ.Y
14. Incidence and progression of osteoarthritis in women with unilateral knee
disease in the general population the effect of obesity Sept., 1994- D.V.
DOYLE, D.J. HART
15. Incidence and risk factor for radiographic knee osteoarthritis in middle
aged women 22 May 2001- KIM.D., DEBORAH, J. HART.
16. The influence of pathology pain balance and self efficacy on function in
women with osteoarthritis of the knee sept., 2004 A.L. HARRISON.
17. Strategies for enhancing proprioception and neuromuscular control of the
knee 2002 Sep., - WILLIAMS AND WILKINS.

30

APPENDIX I

PROFORMA

Name

: __________________________

Age

: ________

Sex

: ________

Occupation

: __________________________

Height (Cms)

: ________

Weight(kgs)

: ________

BMI

: ________

Group

: Control / Experimental

FRT Score

31

APPENDIX II
DATA I
FUNCTIONAL REACH TEST SCORE

Age Group 45-65 Years (Male)

S.No.

OA

1
2
3
4
5
6
7
8
9
10

PATIENTS
11.2
10.5
9.5
10.4
11.0
8.9
9.3
10.6
8.5
9.2

BMI

CONTROL

BMI

27
30
28
29
25
26
28
27
30
25

GROUP
16.3
15.6
15.2
16.0
17.0
14.8
15.6
16.8
16.5
16.7

25
29
27
28
29
25
27
25
29
28

32

DATA II
FUNCTIONAL REACH TEST SCORE

Age Group 45-65 Years (Female)

S.No.

OA

BMI

CONTROL

BMI

1
2
3
4
5
6
7
8
9
10

PATIENTS
9.3
8.5
9.4
10.5
8.9
9.2
10.1
9.5
8.5
10.2

28
29
30
26
29
25
27
28
28
26

GROUP
14.6
13.3
12.6
14.5
13.3
14.0
14.2
12.5
13.9
14.5

27
30
28
27
30
27
25
29
26
28

33