Effectiveness of Exercises Performed on an Unstable surface on Pain, Lower Extremity Function, Balance and Strength in Post- Menopausal Female Patients with Tibio Femoral Osteoarthritis – A Literature Review

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  June 30, 2022 |  admin |  Physiotherapy, Publications

Akhila K1, Saji. V.T2

Co-Author:

2Saji. V.T, Professor and Principal,  Cooperative Institute of Health Sciences, Thalassery, Kannur, Kerala, India.

Corresponding Author:

1Akhila K, MPT Student, Cooperative Institute of Health Sciences, Thalassery, Kannur, Kerala, India. Email Id: akhilasuresh1997@gmail.com

ABSTRACT

Background of the study: Osteoarthritis is one of the most common disease causing disability and functional problems. Exercise therapy has recently become popular. It can improve the general function of the body and activities of daily living by enhancing the range of motion (ROM) and muscle strength of patients having osteoarthritis. Objective of the study was to establish or review existing studies evaluating the effectiveness of exercises performed on unstable surfaces on pain, lower extremity function, balance and strength in post-menopausal female patients with tibiofemoral osteoarthritis.

Methodology: Various articles from databases like Pub Med, Google scholar, science direct, research gate has been collected for analysis. It has retried through search by using keywords of osteoarthritis, post menopausal women, manual muscle test, pain and balance. Total 20 articles were included in the study and based on their findings a review was made.

Result: Strengthening of the hamstring in addition to strengthening of the quadriceps is beneficial for improving subjective knee pain, range of motion, and decreases the limitation of functional performance of patients with knee osteoarthritis.

Conclusion: The present literature review concludes that exercise using unstable surface improved the symptoms of patient with osteoarthritis

Keywords: Osteoarthritis; Range of motion; Lower extremity function; Balance

Received on 20th April  2022, Revised on 19th May 2022, Accepted on 24th May  2022 DOI:10.36678/IJMAES.2021.V08I02.001

INTRODUCTION

OA is the most common form of arthritis. Osteoarthritis is a progressive degenerative joint disease involving the cartilage and surrounding tissues. It results in damage and loss of articular cartilage, remodelling of subarticular bone, osteophyte formation, ligamentous laxity, weakening of periarticular muscles and synovial inflammation.

OA is a non-inflammatory progressive disorder of movable joints, particularly weight bearing joints1.  Hip and knee OA is the most prevalent forms of OA with the overall prevalence of knee OA is 28.7%. In addition, OA knee patients may also experience poor neuromuscular control, slower walking speed, decreased functional activity and   walking.

 The prevalence of knee osteoarthritis is 22% – 32%   in India; commonly females are more affected than males as the age progress. More than half of those with arthritis are under 65 years of age. OA knee increases with age (older than 50 years), especially in women2.

It has a multifactorial etiology. The etiology of OA is related to repetitive mechanical loads and aging. The knee is the most common weight-bearing joint affected by OA, with the disease predominantly affecting the medial compartment of the tibiofemoral joint. Patients with knee OA frequently report symptoms of knee pain and stiffness as well as difficulty with activities of daily living such as walking, stair-climbing and housekeeping3. The principle contributors to disability are believed to include pain, reduced range of joint movement, and muscle weakness 4. Degenerative OA is more common in women than in men and grows worse with age, if left untreated, the disease may increase the risk of falls and decrease longevity. As degenerative OA affects the ligaments, articular capsules, muscles and tendons 5.

Lower extremity muscle weakness may play an important role in knee osteoarthritis. Quadriceps weakness is common in patients with knee osteoarthritis and may contribute to the substantial functional deficits that occur with disease progression6.Dynamic stability at the knee joint is provided by the muscles that surround the knee joint. Many muscles acting on the thigh have their insertions around the knee. The quadriceps femoris muscle is the principal muscle involved in knee extension.

The principle muscles involved in knee flexion are the hamstring muscle group. quadriceps weakness is one of the most common and disabling impairments seen in individuals with knee osteoarthritis. Sufficient quadriceps and hamstrings strength, both isometric and dynamic, is essential for undertaking basic activities of daily living, such as standing and walking.

Strengthening the hamstring muscle has been found to enhance the functional ability of deficient knees. This is probably due to overall increases in both hamstring and quadriceps strength, increase in the hamstring to quadriceps ratio (H: Q), and minimization of anterior-lateral subluxation of the tibia.4

It is evident that lower extremity strength has a major role in knee joint during weight bearing activities There are three types of basic therapeutic exercise: isotonic, isokinetic, and isometric exercise. Of these three, isometric exercise might be the most appropriate and easy to understand by the patients and can be easily and safely performed at home because it requires no or minimal apparatus. “isometric exercises” are simple and inexpensive to perform and that they rapidly improve strength7.

Straight leg raises and mini-squats are very commonly prescribed to increase the strength and control of the knee muscles. [ Straight leg raises are a movement with a free distal extremity that improves the strength of the knee muscles and protects the knee joint. Mini-squats target only the knee joint and are performed under weight-bearing or simulated weight bearing conditions with a fixed distal extremity8.

Retro-walking is sometimes referred to as backward walking, improve sport performance, promote balance and also to stay mentally fit. Back ward walking increases stride rate, decreases stride length and increases support time. Muscular structure supporting ankle and knee reversed their role during retro-walking. Backward walking produces significantly lower patellar compressive force than forward walking and helps to reduce maximal vertical force and impulsive force on knee in comparison to forward walking.

Retro-walking significantly lowers peak patellofemoral joint compressive force and a significantly slower rate of loading has been found during backward walking. Consequently, trauma to the articular cartilage is reduced during retro-walking. Retro-walking could be an effective tool to increase quadriceps strength1.

Literature review unveils that that the prevalence of knee joint osteoarthritis shows an upward trend in females during perimenopausal period and continues to soar up throughout menopause. Studies suggest that declining levels of estrogen during menopause increases a women’s risk of acquiring osteoarthritis.9 Patients who have knee osteoarthritis have difficulty in walking and going up and down stairs. These daily activities are related to balance. Balance training is more effective way for knee osteoarthritis. Balance exercise is effective for the decline of knee stability. Improving stability and exercise techniques with conversion of direction, beginning and end of unexpected exercise by using balance board or inclination board helps protect knee joints from noxious loads.

Performing balance exercise can help the stability of knee joints, as well as performance of harder movement in daily activity. Balance exercise on rehabilitation of knee or ankle is essential to restore muscles power and ligament and damaged tissues around the joint.10

Objective: To establish or review existing studies evaluating the effectiveness of exercises performed on unstable surfaces on pain, lower extremity function, balance and strength in post- menopausal female patients with tibio- femoral osteoarthritis

METHODOLOGY

Data bases searched were from Pubmed, Google Scholar, and Research Gate. Queries used were Osteoarthritis, post menopausal women, manual muscle test, pain and balance. To review the literatures that describe and evaluate “the effectiveness of exercises performed on unstable surfaces on pain, lower extremity function, balance and strength in post- menopausal female patients with tibio- femoral osteoarthritis” Relevant articles in english were received through search of pub med, google scholar, research gate. Total 20 articles were taken and studied out of which experimental studies, comparative study, cross sectional study, review literature; uncontrolled study and longitudinal study were included.

The inclusion criteria were patient  of age group between 55-60 years of post menopausal female diagnosed with osteoarthritis exclusion criteria were  Acute/ chronic neurological abnormalities, Recent cerebrovascular accident or myocardial infarction, Illiterate, Previous fracture of lower extremities, Participants with balance problem, systemic inflammatory disease, Congenital or acquired deformity of lower extremity, Patients with unstable vital signs. The purpose of the review was to gain an understanding about the benefits of  exercises performed on an unstable surfaces on pain, lower extremity function, balance and strength in post- menopausal female patients with tibio femoral osteoarthritis  The following key words are used in combinations : Osteoarthritis, post menopausal women , manual muscle test, pain and balance

RESULT

Total 20 articles were taken and studied. The review study is tabulated in Table 1. About author, title of the study and final conclusion of the study were described below in the Table

Authors   Title Conclusion
Balraj AM et al.   Impact of Retro-Walking on Pain and Disability Parameters among Chronic Osteoarthritis Knee Patients Retro-walking leads to a significant improvement in reduction of pain and disability of the subjects under study.
K.Hrishikesh Yadav et al. Effectiveness of retrowalking in osteoarthritis of knee – a review article   Retro walking as an exercise in rehabilitation of  OA Knee patients can reduce excessive abnormal adduction torque on knee joint and also improve functional activities.   
Ashraf  ramadan hafez1 et al. Treatment of Knee Osteoarthritis in Relation to Hamstring and Quadriceps Strength Strengthening the hamstring muscles in addition to strengthening the quadriceps muscles proved to be beneficial for perceived knee pain, range of motion, and decreasing the limitation of functional performance of patients with knee OA
Ahmedh Al-Johani et al. Comparative Study of Hamstring and Quadriceps Strengthening Treatments in the Management of Knee Osteoarthritis Strengthening of the hamstring in addition to strengthening of the quadriceps is beneficial for improving subjective knee pain, range of motion, and decreases the limitation of functional performance of patients with knee osteoarthritis
Taesung  KO et al. Manual therapy and exercises for OA knee: Effects on muscle strength , proprioception and functional performance Manual therapy together with resistive exercises appears to be more effective at improving muscle strength, proprioception and functional
Michael D. Lewek et al. Quadriceps femoris muscle weakness and activation failure in patients with symptomatic knee osteoarthritis Patients with knee osteoarthritis would exhibit quadriceps weakness
Shahnawaz anwer et al. Effect of Isometric Quadriceps Exercise on Muscle Strength, Pain, and Function in Patients with Knee Osteoarthritis: A Randomized Controlled Study The 5-week isometric quadriceps exercise program showed beneficial effects on quadriceps muscle strength, pain, and functional disability in patients with osteoarthritis of the knee.
Arzu daşkapan  et al. Comparison of Mini-squats and Straight Leg Raises in Patients with Knee Osteoarthritis: A Randomized Controlled Clinical Trial The effectiveness of straight leg raises or mini-squats when they were added to a traditional physical therapy program in patients with knee OA. Both types of exercises exhibited that they can be used to reduce pain and disease-related OA
M. Koch et al. Prevalence of knee joint osteoarthritis among perimenopausal and post-menopausal women in Guwahati, Assam, India The prevalence rate of knee OA was estimated to be 28.3% among women in the age group of 40-65 years and   Prevalence was more in postmenopausal women
Young Dae Yuna et al. The Effects of Resistance Exercise and Balance Exercise on Proprioception and WOMAC Index of Patients with Degenerative Knee Osteoarthritis Resistance exercise and balance exercise are effective on degenerative knee osteoarthritis and resistance exercise is the most effective for improving proprioception and WOMAC index.
Kristin R. Baker et al. Quadriceps Weakness and Its Relationship to Tibiofemoral and Patellofemoral Knee Osteoarthritis in Chinese There is a relationship between quadriceps weakness and knee OA in all compartments, with the strongest association in mixed disease. Pain may contribute to some of this weakness
Chan-Woo Nam et al. The Influence of Exercise on an Unstable Surface on the Physical Function and Muscle Strength of  Patients with Osteoarthritis of the Knee Exercise using    unstable surface improved the symptoms of patient with osteoarthritis. Exercise on an unstable surface might be helpful for improving the muscle    strength and alignment of the lower extremities               
K. Kotteeswaran et al. A comparative study to find the effectiveness of weight bearing exercises on stable platform versus wobble board, to improve balance and functional outcome of individuals with knee osteoarthritis patients with knee osteoarthritis had improvement in balance and functional outcome through weight bearing exercises given on wobble board along with interferential therapy compared to the patients who were given weight-bearing exercises on stable platform along with interferential therapy
Vijaya Krishnan et al. Effect of retro walking versus balance training on pain and disability in patients with osteoarthritis of the knee: a randomized controlled trial The 6-week rehabilitation protocol comprising retro walking as an adjunct to conventional therapy resulted in greater pain reduction and enhanced functional performance of patients with OA knee
Dr. Sneha Sameer Ganu et al. Effect of Retrowalking on Pain, Functional Disability and Functional Mobility in Patients with Chronic Knee Osteoarthritis Retrowalking was more effective than conventional closed kinematic chain exercises in reducing symptom, improving functional mobility, overcoming physical dysfunction and increasing strength of hip muscles in osteoarthritis of knee after 4 weeks of rehabilitation.
Nehal Shah et al. Role of Interferential Therapy in Osteoarthritis Knee – A Narrative Review Studies show both positive and negative findings of the effects of interferential therapy in osteoarthritis knee.
Yun Lak Choi et al. Effects of isometric exercise using biofeedback on maximum voluntary isometric contraction, pain, and muscle thickness in patients with knee osteoarthritis Results suggest that USBF training is similar to EMGBF training in terms of its effectiveness and is helpful for treating patients with knee OA.
Olagbegi OM, Adegoke BOA et al. Effectiveness of combined chain exercises on pain and function in patients with knee osteoarthritis CCEs are better than OKCEs and CKCEs for pain reduction in though all three exercise regimens are singly effective. CCEs are recommended for improving treatment outcome for pain in patients with knee osteoarthritis
Mahima Mukharjee et al. Comparative Effect of Burst Transcutaneous Electrical Nerve Stimulation (Tens) Versus Interferential Therapy (Ift) Along With Exercise In Reducing Pain and Functional Impairtment in Subjects with Knee Osteoarthritis The study concluded that Interferential Therapy along with Exercises is more effective than Burst Transcutaneous Electrical Nerve Stimulation along with Exercise.
Jun Iwamoto et al. Effectiveness of exercise for osteoarthritis of the knee: A review of the literature   Muscle strengthening and aerobic exercises are effective in reducing pain and improving physical function in patients with mild to moderate OA of the knee

Table 1. Data collected from authors of articles from different Journals

DISCUSSION

This study was to investigate the influence of exercises on unstable surfaces along with conventional therapy and conventional therapy alone on pain, lower extremity function, balance and strength in post- menopausal female patients with tibio- femoral osteoarthritis. Of the many movements of the body needed for ADL, the movements of the lower extremities are related to gait performance. Especially, knee joint movement is involved in many activities of daily living. For this reason, osteoarthritis commonly occurs in the knee and pelvic joints which are responsible for weight bearing.

If there is a problem in the knee joint, gait is easily impaired in activities of daily living such as stair-climbing,        sit-to-stand and standing Exercise using unstable surface proved the symptoms of patient with osteoarthritis .Exercise on an unstable surface might be helpful for improving the muscle strength and alignment of the lower extremities as well as positively affecting physical function related to the knee joint12

Subjects with OA knee have impairment of proprioception within the joint or weakness in the quadriceps muscles as compared with those without OA knee. These impairments associated with the disease may explain poorer balances within these individuals, evidences suggest the possibility that quadriceps weakness is the primary risk factor for knee pain, disability, balance and progression of joint damage in individuals with osteoarthritis of knee13

Individual with OA knee walked more slowly, with less knee excursion, increased adduction moment and with more joint stiffness. These secondary compensatory gait adaptations in OA knee patients helps in reducing pain by decreasing ground reaction loading on knee. This prolonged usage of secondary gait compensation creates greater imbalance of muscle, progressively reduces muscle strength, endurance, flexibility and later ending to deformity.

During forward walking knee joint flexes, extends and then flexes in support phase, whereas in backward walking knee initially extends, flexes and extends in support phase, prior to flexing and extending during swing. However support swing ratio of retrowalking is similar to forward walking with 60% support and 40% swing. Retrowalking produce significantly lower patellar compressive force than forward walking.

Retrowalking helps to reduce maximal vertical force and impulsive force on knee compare to forward walking because of toeheel contact pattern. According to a study by Neptune and Kautz (2000), backward walking allows increased hamstrings activation which generates reduced patello- femoral and lower tibiofemoral compression load stress and ACL strain, and therefore BW reverses the shear forces in the knee joint.15

Muscle plays a major role in the structure and function of joints, as demonstrated by the disuse atrophy of the quadriceps femoris muscle that accompanies knee joint pain. Weakness of the quadriceps muscle has been noted by the American Academy of Orthopedic Surgeons as a risk factor structural damage of the knee joint. Muscle weakness affects the antero posterior stability of the knee joint and makes patients feel unstable, leading to decreased personal confidence and decreased performance and independence in daily activities, causing disability and dysfunction in patients with knee OA.

The ratio of the quadriceps to hamstring muscle strength is important for the stability of the knee and for protection from excessive stress3 Quadriceps weakness is one of the most common and disabling impairments seen in individuals with knee osteoarthritis (OA). Sufficient quadriceps and hamstrings strength, both isometric and dynamic, is essential for undertaking basic activities of daily living, such as standing and walking4isometric quadriceps exercise brought significant improvements in all the parameters after the 5-week training program.

The prevalence rate of knee OA was estimated to be 28.3% among women in the age group of 40-65 years. The prevalence of knee OA increased with increasing age. Prevalence was more in postmenopausal women. Sedentary lifestyle and greater BMI also emerged as factors associated with knee OA.9

Ethical clearance: There was no risk of conducting this study.Ethical clearance was obtained from the ethical Institutional ethical committee of Cooperative Institute of Health Sciences, Thalasseri, Kerala with letter Reference Number: 5, MSK/CR/ NEU/MPT/ CIHS/ 2020, Dated 17/05/2021.

Conflicts of Interest: There is no conflict of interest to conduct this study.

Fund for the study: This is self-funded study.

CONCLUSION

The present literature review concludes that  exercises performed on an unstable surfaces reduces  pain,  improves lower extremity function, balance and strength in post- menopausal female patients with tibio femoral osteoarthritis.

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Citation:  
Akhila K, Saji. V.T (2022).  Effectiveness of exercises performed on an unstable surfaces on pain, lower extremity function, balance and strength in post- menopausal female patients with tibio femoral osteoarthritis – A literature review, ijmaes; 8 (2); 1238-1247.