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Scientific, Research, Journal, India, Scientific Research Journal of India, SRJI, Vol- 2, Issue- 4, Year- 2013
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53
A COMPARATIVE STUDY OF STANDING BALANCEPERFORMANCE
BETWEEN OA KNEE PATIENTS COMPARED WITH NORMAL AGE
MATCHED CONTROLS
Alagappan Thiyagarajan.T MPT (Sports)*, DY, PGDFWM; Prem Karthik .GS MPT (Ortho)
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, Pallava Hospital, Chennai.
SUBJECT: 20 osteoarthritis patients and 20 normal were taken for this study. METHOD: To assess 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 (proprioception) balance performance compared with normal age matched controls
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
remodelling of the underlying bone and mild
synovitis1.
Osteoarthritis is one of the most
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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 within 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 concentrated4,5,6,7on balance
performance. The recent literatures are
suggests that osteoarthritis patients having
significance loss of proprioception 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. � 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.
Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013
55
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 MOVEMENTThis 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 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.
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Collagen fibres split and there is
disorganization of the proteoglycan- collagen
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. BONEEburnation – 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.
METHODOLOGY
STUDY DESIGN - The design of the study is
Descriptive study.
SETTING - Department of Physiotherapy,
A.C.S General Hospital, Chennai
SAMPLE - 20 osteoarthritis Patients20
control 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.
EXCLUSION CRITERIA
� H/o injuries and multiple falls
� Uncorrected visual impairments
Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013
57
� H/o stroke and cerebellar disorder
� H/o hospitalization in last two months
EQUIPMENTS AND MATERIALS
� Inch tape
� Weight machine
� Wooden Scale
METHOD:
The functional reach test is developed as a
quick screen for balance problems in older
adults. For performing this test subject’s 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 norms3.
Twenty osteoarthritis knee patients and
twenty normal subjects were participated in
this study. To assess 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.
Functional Reach Test By Patient
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Functional Reach Test By Patient
TABLE -1
FUNCTIONAL REACH SCORES OF
MALE SUBJECTS (45-65 YRS)
OA KNEE CONTROL
11.2 16.3
10.5 15.6
9.5 15.2
10.4 16
11 17
8.9 14.8
9.3 15.6
10.6 16.8
8.5 16.5
9.2 16.7
TABLE 2 (MALES)
BETWEEN GROUP ANALYSIS USING
PAIRED T-TEST FOR MALES
OA KNEE
CONTROL
SIGNIFICANT
Mean
9.91
Mean 16.05
(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
Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013
59
(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 T- test. The
results shows that level of significance p value
<0.001.
BAR DIAGRAM
0
5
10
15
20
BETWEEN GROUP ANALYSIS USING PAIRED T-TEST FOR MALES
OA (MALE) CONTROL(MALE)
TABLE 3
FUNCTIONAL REACH SCORES OF FEMALE SUBJECTS (45-65YRS)
OA KNEE CONTROL
9.3 14.6
8.5 13.3
9.4 12.6
10.5 14.5
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60
8.9 13.3
9.2 14
10.1 14.2
9.5 12.5
8.5 13.9
10.2 14.5
FUNCTIONAL REACH TEST SCORES OF FEMALES(45 TO 65 YRS)
0
2
4
6
8
10
12
14
16
SUBJECTS
FR
T S
CO
RES
OA CONTROL
TABLE 4 (FEMALES)
BETWEEN GROUP ANALYSIS OF FEMALE USING PAIRED T-TES T
RESULTS:
Table 4 shows the value of mean and standard
deviation of functional reach test score
between OA patients and control subjects. For
OA KNEE
CONTROL
SIGNIFICANT
Mean
9.4
Mean
13.74
(p <0.005)
SD 0.688 S.D 0.7763
Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013
61
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.
BAR DIAGRAM
0
5
10
15
BETWEEN GROUP ANALYSIS OF FEMALE USING PAIRED T-TEST
OA KNEE CONTROL
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 T- test. 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. In order to find out the level of
significance I used paired t-test. The results
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shows that the level of significance p-value <
0.005.
KORALEWICZ 12et-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.
HASSON11et-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.6et-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.
CONCLUSION
To conclude from the results of this study
osteoarthritis knee patients having significant
loss of (Proprioception) balance performance
compared with normal age match controls.
RECOMMENDATION
This study can be carried out large sample
size. This study can be carried out different
BM.
REFRENCES
1. Tidy’s physiotherapy 4th Edition Page No. 107-109 Author – TIDYS and THOMSON.
2. Orthopaedics 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 kinaesthesia and balance exercises in knee osteoarthritis – 2005 Dec., DIRACOGLU .D, AYDIN. R
5. Effects of age and osteoarthritis on knee proprioception 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
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.
Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013
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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 elderly- 1995, 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.
CORRESPONDING AUTHOR:
* Department of physiotherapy Pallava hospitals
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