A Comparative Study of Standing Balance Performance Between Oa Knee Patients Compared With Normal Age Matched Controls. Alagappan Thiyagarajan.t Prem Karthik .Gs Srji Vol 1 Issue 4

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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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54

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.

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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


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� 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


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(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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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


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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


62

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.


63

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

Documents

A Comparative Study of Standing Balance Performance Between Oa Knee Patients Compared With Normal Age Matched Controls. Alagappan Thiyagarajan.t Prem Karthik .Gs Srji Vol 1 Issue 4