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Efficacy of Combined Proprioceptive Exercises and Conventional Physiotherapy

in Patients with Osteoarthritis Knee Joint: A Double-Blinded Two-Group
Pretest–Posttest Design

Article · June 2018

DOI: 10.4103/jotr.jotr_40_17

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Original Article

Efficacy of Combined Proprioceptive Exercises and

Conventional Physiotherapy in Patients with Knee Osteoarthritis:
A Double‑Blinded Two‑Group Pretest–Posttest Design
Veena Kirthika, S. Sudhakar1, K. Padmanabhan2, S. Ramachandran3, Mohan Kumar2
Department of Neuro Physiotherapy, Department of Sports Physiotherapy, 2Department of Ortho Physiotherapy, 3Department of Cardiopulmonary Physiotherapy,
1

Faculty of Physiotherapy, Dr. MGR Educational and Research Institute University, Chennai, Tamil Nadu, India

Abstract
Background: Osteoarthritis  (OA) is a chronic degenerative condition of the joint. Current physiotherapy interventions for OA focus on
pain reduction, improve knee range of motion, and muscle strength. OA of knee impairs quadriceps function which affects balance and gait
reducing patient’s mobility and function. Therefore, there is a need to find out the effect of combined proprioceptive exercises with conventional
physiotherapy in Patient with knee osteoarthritis (PKOA). Aim: The aim of this study is to analyze the effect of combined proprioceptive
exercises and conventional physiotherapy in PKOA. Methods: A total of 40 female POAK were recruited for the study and were divided
into two groups as follows: Group A (conventional group) and Group  B  (experimental group). Group  B in addition to the conventional
treatment received proprioceptive exercises. Both the groups were instructed to perform exercises for 5 days in a week for 3 months. Visual
analog scale (VAS) for pain and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were noted pre‑ and
post‑intervention. Results: On comparing the mean values of Group A and Group B on VAS and WOMAC scores, both the groups showed a
significant decrease (P < 0.001) in the posttest mean, but Group B (experimental group) was more effective than Group A (conventional group).
Conclusion: The present study concluded that 3 months duration of combining proprioceptive exercises with conventional physiotherapy is
more effective than conventional physiotherapy alone in PKOA.

Keywords: Conventional physiotherapy, osteoarthritis, proprioceptive exercise, visual analog scale, Western Ontario and McMaster
Universities Osteoarthritis Index

Introduction Unilateral OA of knee has impaired proprioceptive accuracy

Osteoarthritis (OA) is one of the most common musculoskeletal
disorders in the world affecting 2693 of every 100,000 women
and 1770 of every 100,000 men. The overall prevalence of
knee OA was found to be  (22%–39%) 28.7% in India.[1]
Knee OA is the most common type of arthritis. While it can
occur even in young people, the chance of developing OA
increases after the age of 45 years. With the knee being one
of the most commonly affected joints, women (31.6%) are
more likely to have OA than men.[1] OA is a joint disease that
causes the cushion layer between one’s bones or cartilage
to wear away.[2] Symptoms include pain, tenderness in the
knee, stiffness when standing or walking, loss of flexibility,
and grating sensations that can be heard when the knee joint
is used.[3,4]
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DOI: exercises and conventional physiotherapy in patients with knee
10.4103/jotr.jotr_40_17
in both the knees. Impaired proprioceptive accuracy could be
a risk factor for progression of both knee pain and activity
limitations in patients with knee osteoarthritis  (PKOA).[4]
Proprioception is the process by which the body can vary
muscle contraction in immediate response to incoming
information regarding external force. Any pathology that
Address for correspondence: Dr. S. Sudhakar,
Department of Sports Physiotherapy, Faculty of Physiotherapy,
Dr. MGR Educational and Research Institute University, Maduravoyal,
Chennai ‑ 600 095, Tamil Nadu, India.
E‑mail: drsudhakar.acs@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com
How to cite this article: Kirthika V, Sudhakar S, Padmanabhan K,
Ramachandran S, Kumar M. Efficacy of combined proprioceptive
osteoarthritis: A double-blinded two-group pretest–posttest design. J Orthop
Traumatol Rehabil 2018;10:94-7.

94 © 2018 Journal of Orthopaedics, Traumatology and Rehabilitation | Published by Wolters Kluwer - Medknow
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Kirthika, et al.: Efficacy of combined proprioceptive exercises and conventional physiotherapy
adversely affects muscle function may impair force generation
and proprioceptive activity system is essential for maintenance
of balance, and production of smooth stable gait.[5]
OA of the knee impairs quadriceps functions which, in turn,
impair the patient’s balance and gait reducing their mobility
and function.[4] The intent of proprioceptive exercises is to
expose people to activities that challenge the stability of the
knee and balance in a controlled manner during rehabilitation.
Current physical therapy interventions for knee OA focus on
decreasing pain and improving knee range of motion, muscle
strength, balance, and functional mobility.[6,7] It is necessary
to focus on proprioceptive accuracy of the knee which when
neglected can have a deleterious effect during rehabilitation.
The present study was intended to find the effectiveness
of combining proprioceptive exercises with conventional
treatment to reduce pain and improve functional ability in
female PKOA.
Methodology
Procedure
The study protocol was approved by the Institution Research
and Ethics Committee, and the study was performed according
to the guidelines laid by the Declaration of Helsinki, revised
2013. A total of 40  female PKOA were recruited for the
two group’s pretest–posttest experimental study by the
Figure 1: Consolidated standards of reporting trials of the study
Journal of Orthopaedics, Traumatology and Rehabilitation  ¦  Volume 10  ¦  Issue 2  ¦  July-December 2018
simple random sampling method. Before the data collection,
duly signed informed consent was obtained. They were
randomly allocated into two even groups as follows: Group A
(conventional group) and Group B (experimental group) by the
block randomization (4 × 5 blocks).
Treatment protocol in Group A
Totally 20 PKOA were given isometric quadriceps exercises,
high sitting knee extension, straight leg raise, hamstring
stretching, hip abduction, hip extension, along with short‑wave
diathermy (crossfire method) wider spacing, and thermal dose
for 15 min. All the exercises were performed once in a day,
with 10 repetitions for each exercise.
Treatment protocol in Group B
Twenty PKOA were given proprioceptive exercises in addition
to the conventional treatment. Pelvic tilts and knee flexion and
extension using Swiss ball, sliding lunge, stepping lunge, step
up and down in a footstool, stand up and sit down in a stool,
squatting, and single leg squat were given as proprioceptive
exercises. All the exercises were performed once in a day, with
10 repetitions for each exercise.
Both the groups followed the above‑mentioned exercise
protocol for 5 days/week for 3  months. Visual analog
scale (VAS) for pain and the Western Ontario and
McMaster Universities OA Index (WOMAC) score
were noted pre‑  and post‑intervention. The therapist
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Kirthika, et al.: Efficacy of combined proprioceptive exercises and conventional physiotherapy

who supervised the intervention and outcome assessor between pretest and posttest in VAS and WOMAC scores
was blinded to the groups. Hence, the study was among both the groups, which are displayed in Tables 2 and 3.
double‑blinded. Detailed study layout was displayed in Between group analysis revealed significant difference among
the standardized format, consolidated standards of reporting the groups. PKOA in Group  B demonstrated significant
trials [Figure 1]. improvement (P < 0.001) in VAS and WOMAC scores when
compared with Group A, [Figures 1‑3].
Data analysis
The collected data were assessed for their normality using
Shapiro–Wilk test. As the data follow normal distribution, all Discussion
the descriptive were expressed in mean ± standard deviation. PKOA faces problems with reduced quadriceps muscle
Paired t‑test was adopted to find out the effectiveness within strength and a decline in balance and proprioception. Reduced
Group A and Group  B in participants with stress‑induced proprioception in participants with OA knee weakens their
asthma, and independent t‑test  (Student’s t‑test) was used thigh muscles and may limit their walking ability and
to compare the changes in mean values of all parameters dynamic balance. Joint pain associated with knee OA also
between Group A and Group B. The data were analyzed has a direct impact on the muscle activation and strength
using statistical software, statistical package for the social of the thigh muscles and proprioception. Therefore while
science  (SPSS), and IBM SPSS version  22.0  (IBM Corp. treating PKOA, an exercise program that could concentrate
Armonk, NY, USA). Value of P ≤ 0.05 was considered to be on strengthening exercise of the muscles in and around knee
statistically significant. joint and proprioceptive exercise which could have an effect
in improving joint proprioception should be considered.
Results Current therapy for rehabilitation of PKOA focuses on reducing
A total of 40 female PKOA were recruited for this experimental pain and improving knee joint range of motion. Proprioception
study. The demographic characteristic of the patient recruited which could be gradually affected during the disease in PKOA
was given in Table  1. Three PKOA  (one  –  Group A and has to be given importance during rehabilitation. Proprioception
two – Group B) who lost to follow‑up were analyzed using responses allow compensatory adjustments in the lengths
intention to treat analysis. There exists significant difference of various muscles, muscle tension, and joint position to
facilitate joint movements.[6] Proprioceptive activation exercises
have a direct effect on mobility and pain, and restoration of
Table 1: Demographic characteristics between the groups proprioception is essential during the rehabilitation of PKOA.[8]
Demographic characteristic Group‑A Group‑B P
Diminished knee proprioception highly correlates with the
Age (years) 58.8±5.3 58.2±5.7 0.08
level of pain[9] and the relationship between proprioception and
Height (cm) 156.5±10.6 156.1±11.1 0.7
muscle strength is closely related to functional movements.[4]
Weight (kg) 81.5±7.2 80.9±6.9 0.5
The intention of this study was to combine proprioceptive
BMI (kg/cm2) 34.2±3.1 34.1±3.4 0.9
BMI: Body mass index
exercises with conventional physiotherapy in participants
suffering from knee OA. This study shows that proprioceptive
exercises are helpful in reducing pain and improving physical
Table 2: Comparison of visual analog scale and Western function related to knee joint.[7]
Ontario and McMaster Universities Osteoarthritis Index
Thus, the study demonstrates that combining proprioceptive
scores of pre‑ and post‑intervention in Group A
exercises with conventional physiotherapy program are an
Outcome Preintervention Postintervention P effective treatment protocol to enhance knee joint functions
measure scores scores and improve pain control in PKOA.
VAS 6.5±1 4.0±1 <0.001
WOMAC 55.3±3.1 45.9±3.4 <0.001
VAS: Visual analog scale, WOMAC: Western Ontario and McMaster
Universities Osteoarthritis Index

Table 3: Comparison of visual analog scale and Western

Ontario and McMaster Universities Osteoarthritis Index
scores of pre‑ and post‑intervention in Group B
Outcome Preintervention Postintervention P
measure scores scores
VAS 6.4±1 2.0±0.7 <0.001
WOMAC 54.7±3.9 33.9±4.7 <0.001
VAS: Visual analog scale, WOMAC: Western Ontario and McMaster
Universities Osteoarthritis Index Figure 2: Pre‑post‑visual analog scale changes between Group A and Group B

96 Journal of Orthopaedics, Traumatology and Rehabilitation  ¦  Volume 10  ¦  Issue 2  ¦  July-December 2018
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Kirthika, et al.: Efficacy of combined proprioceptive exercises and conventional physiotherapy
Figure 3: Pre‑post‑Western Ontario and McMaster Universities
Osteoarthritis Index score changes between Group A and Group B
Conclusion
Three months combined proprioceptive exercises with
conventional physiotherapy program might be an effective
rehabilitation option over the convention physiotherapy
program alone.
Acknowledgment
The authors are very thankful to Dr. Asir John Samuel, MPT,
(PhD), Associate Professor, Maharishi Markandeshwar
Institute of Physiotherapy and Rehabilitation, Maharishi
Markandeshwar University, Mullana, India, for providing
logistic and technical support in manuscript editing.
Financial support and sponsorship
Nil.
Journal of Orthopaedics, Traumatology and Rehabilitation  ¦  Volume 10  ¦  Issue 2  ¦  July-December 2018
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Conflicts of interest
There are no conflicts of interest.
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