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Gauri Arun Gondhalekar*, Medha Vasant Deo**


Background: Increased external knee adduction moment during ambulation is a strong predictor of the severity of symptoms in patients with chronic knee osteoarthritis. Objectives: To assess the effects of Retro-walking along with conventional treatment on pain and disability in patients with acute exacerbation of chronic knee osteoarthritis. Methods: Twelve patients (6 men, 6 women) with chronic knee osteoarthritis fulfilling the inclusion criteria received conventional treatment and Retro-walking. Pain and disability were the primary outcomes and knee range of motion (ROM), hip abductor and extensor strength were the secondary outcomes; measured pre-intervention, after 1 week and after 3 weeks of intervention. Results: One way analysis of variance was used for all the primary and secondary outcomes. At the end of 3 weeks; the primary outcomes showed highly significant difference (P < 0.0001), secondary outcomes showed significant difference ( P < 0.05). Conclusion:

Retrowalking is an effective adjunct to conventional treatment in decreasing pain and disability in patients with knee osteoarthritis.

Keywords: Retrowalking, Backward-walking, Knee osteoarthritis, external knee adductor moment


Osteoarthritis (OA) is a chronic degenerative


disorder of multifactorial etiology characterized

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by loss of articular cartilage, hypertrophy of bone at the margins, subchondral sclerosis and range of biochemical and morphological alterations of the synovial membrane and joint capsule. 1-5 Osteoarthritis is the most common form of arthritis. 6,7 It is the most frequent joint disease with a prevalence of 22-39% in India; 6,8 and one of the leading causes of pain and disability worldwide. 9-12 Knee is the most common site for OA 13 with characteristic signs like pain during weight bearing, limitation of knee range of motion (ROM), crepitus, joint effusion, and local inflammation. 11,14-16 In knee joint, OA affects the medial compartment more frequently than the lateral. This is attributed to higher transfer of loads through the medial compartment than through the lateral, resulting in higher external knee adduction moment. 14 The external knee adduction moment (EKAM) is the product of ground reaction force (GRF) and the moment arm with respect to knee joint center. 17-21 It leads to adduction at the tibiofemoral joint causing compressive load at the medial compartment of the knee joint. This increase in joint forces results in a deleterious effect on knee cartilage and leads to development and progression of knee OA. 21-29 Various studies have stated that, the first peak knee adduction moment during walking is a strong predictor of the severity and rate of progression of medial compartment of knee OA. 14

Management of knee OA aims to control pain and reduce disability. 30-32 A multidisciplinary approach Is required with physiotherapy as the main choice of conservative management; which includes various strategies such as exercises, patellar taping, manual therapy and various electrical and thermal modalities for pain relief. 6,31,32 Recently, weight bearing exercises have drawn much attention in the management of knee OA. 33-34 Studies suggest that these exercises are more effective and functional than the traditionally employed non weight bearing exercises. 32 Weight bearing exercises for knee joint can be incorporated in many ways; one of them is Retro-walking. 30 Retro-walking is walking backwards. 6 Since there is backward propulsion, it leads to reversal of leg movement in Retro-walking. This requires different muscle activation patterns than in forward walking. 33 Various studies have stated the effects of backward walking and backward running in strength gains and joint stress reduction and facilitating rehabilitation. 6 Along with a unique muscle activation pattern; Retro- walking is leads to increased cadence, decreased stride length and different joint kinematics as compared to forward walking; offering some benefits over forward walking alone. 30,32 A growing body of evidence suggests the importance of exercises in improvement of symptoms and joint function in knee OA. Precise guidelines as regards their type and dosage have not been established. Hence,


Scientific Research Journal of India ● Volume: 3, Issue: 2, Year: 2014 Retro-walking may offer

Scientific Research Journal of India Volume: 3, Issue: 2, Year: 2014

Retro-walking may offer additional benefits in this population. The current study aimed at finding out the efficacy of Retro-walking as an adjunct to conventional treatments on pain and disability in patients with chronic knee OA.


Written informed consent was obtained from all participants prior to screening and participation in the study. The study was conducted at the Department of Physiotherapy in Terna Hospital and Research Center, Navi-Mumbai, India. Out-patients with diagnosis of knee OA referred by a physician or an orthopedic surgeon were screened for inclusion criteria.

Participant selection Patients having knee pain for more than 6 weeks and fulfilling three out of the six clinical criteria listed by The American College of Rheumatology were included in the study. 34-35 The inclusion criteria are:

Age >50 years,

Morning stiffness lasting <30 min,

Crepitus with active motion,

Bony tenderness,

Bony enlargement, and

No warmth to touch. Exclusion criteria:

Patients with bilateral involvement, a history of any lower extremity injury or underlying pathology and a history of any inflammatory joint disease and balance problems, neurological problems and using an assistive

device for ambulation were excluded. Testing instruments For primary outcomes:

(1) A 10 cm visual analogue scale (VAS) for rating the intensity of perceived pain. The scale had 0 (no pain at all) and 10 (maximum pain felt at this moment) at either ends. The patient was asked to mark his/her pain where he felt it would take its position in the scale. (2) Western Ontario and McMaster Universities Arthritis Index (WOMAC) of OA, a patient reported scale, was used to assess pain, stiffness and physical function levels in the subjects. It measures five items for pain, two for stiffness, and 17 for functional limitation. Physical functioning questions cover activities of daily living. Good test-retest reliability in pain and physical function domain has been established for WOMAC. 36

For secondary outcomes:

Medical Research Council grading was used to assess concentric strength of hip abductors and hip extensors and quadriceps muscles. (2) Universal Goniometer was used to assess knee joint ROM in prone position.

Methods Twelve patients (6 men, 6 women) with chronic knee osteoarthritis fulfilling the inclusion criteria received conventional treatment and Retro-walking. Conventional treatment was in the form of deep heating modality (Short Wave Diathermy) (Electro Medical Control, Electrotherm 250 W)


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for 20 minutes and exercises (static and dynamic quadriceps, knee bending exercise in prone lying, hip flexion exercise in supine, hip abduction in side lying and hip extension in prone lying position). All exercises were done in sets of 10 repetitions; twice a day for 3 weeks. Subjects also underwent two sessions of Retro- walking per day (10 mins. per session) for 3 weeks on a flat surface at their maximum pace.

Data collection:

Pain and disability were the primary outcomes and knee range of motion (ROM), hip abductor and extensor, and quadriceps strength were the secondary outcomes; measured pre- intervention, after 1 week and after 3 weeks of intervention


The outcomes were analyzed using one way

analysis of variance with level of significance set at P < 0.05; using SPSS version 17.0 for Windows.

RESULTS Fifteen patients fulfilling the inclusion criteria were screened and included in study after obtaining their consent. Three patients were lost to follow-up. The study population thus had 12 adults (6 men, 6 women) of mean age 64.23 ± 3.01 years [Table


Scores were analyzed pre intervention, at the end of 1 week and at the end of 3 weeks [Table 2]. VAS and WOMAC showed highly significant difference over a period of time [Table 3]. Knee joint ROM, Strength of hip abductor muscles and hip extensor muscles, and quadriceps muscles showed significant




Table 1: Demographic characteristics of participants






64.23 ± 3.01

Female %

50 %

N: Number of subjects

Table 2: Baseline parameters


Scientific Research Journal of India ● Volume: 3, Issue: 2, Year: 2014 PARAMETER PRE POST

Scientific Research Journal of India Volume: 3, Issue: 2, Year: 2014







+ 1.09


+ 1.03


+ 1.32



+ 15.48


+ 11.34


+ 14.14

Knee ROM


+ 11.09


+ 14.99


+ 13.22

Quadriceps Strength


+ 0.32

4.2 + 0.88


+ 0.11




+ 0.78


+ 0.32


+ 0.2





3.8 + 0.43


+ 0.71


+ 0.19



VAS: Visual Analogue Scale, WOMAC: Western Ontario and McMaster Universities Arthritis Index , ROM: Range of Motion

Table 3: One way analysis of variance


F value


P value












Knee ROM





Quadriceps Strength



















F value: Observed F value; df: Degrees of freedom; P value: Significance level, HS: Highly significant; Sig: Significant


DISCUSSION Current pilot study examines the efficacy of Retro-walking as an adjunct to conventional treatment in reducing pain and disability in patients with chronic knee OA. Pain relief could be attributed to reduced compressive forces on medial compartment of knee joint by reduction of excess adductor moment due to Retro-walking. Along with thermal effects causing local hypoalgesia 29 and muscle relaxation, improvement in strength of musculature around knee and hip providing steadiness in the knee and giving additional joint protection from shock and stress as a result of conventional treatment. Improvement in function may be attributed to the pain relief, improved ROM, improved muscle activation pattern and reduction in abnormal joint kinetics and kinematics during functional movement. Several studies have stated that compared to forward walking; backward walking creates more muscle activity in proportion to efforts. 37-43 It has also shown to reduce external adductor moment at knee during stance phase of gait. Due to a specific kinematics Retro-walking leads to augmented stretch of hamstring muscle groups during the stride. Other advantage of Retro-walking includes improvement in muscle activation pattern; all of these serve in reducing disability thus leading to improved function. Since it is a weight bearing exercise, it could have led to proprioceptive and balance training,

adding to its benefits. Retro-walking also has effect on preventing abnormal loading at knee joint by improving strength of hip extensors leading to reduced hip flexion moment during stance phase and thus and, in turn, the disability. As a result of exercises and Retro- walking there was improvement in the strength of muscles at knee and hip which may have helped in improving functional ability.

There were certain limitations in the current study. Effects of BMI, severity of knee deformities (for eg. genu valgum/varum), lower limb mal-alignments (for eg. flat foot), footwear used, activities of daily living and recreational activities of patients were not taken into account. The compliance of patients with the home exercise program was not monitored.

CONCLUSION Retrowalking is an effective adjunct to conventional treatment in decreasing pain and disability in patients with chronic knee osteoarthritis.

ACKNOWLEDGMENT The author would like to acknowledge Dr. Senthil P Kumar and Dr. Sujata S. Wagle for their valuable guidance in preparation of this manuscript.



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*Physiotherapist at Breach Candy Hospital Trust, Mumbai, email: **Professor and Principal, TPCT’s Terna Physiotherpy College, Navi Mumbai. Email: