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 Table of Contents  
Year : 2021  |  Volume : 15  |  Issue : 2  |  Page : 98-102

Correlation between balance performance and perception about the knee in patients with osteoarthritis knee

1 Department of Physiotherapy, BPTH, Sancheti Institute College of Physiotherapy, Pune, Maharashtra, India
2 Department of Neuro Physiotherapy, Sancheti Institute College of Physiotherapy, Pune, Maharashtra, India
3 Department of Orthopaedic, Sancheti Institute of Orthopaedic and Rehabilitation, Pune, Maharashtra, India

Date of Submission09-Aug-2021
Date of Decision09-Jan-2022
Date of Acceptance15-Jan-2022
Date of Web Publication15-Feb-2022

Correspondence Address:
Dr. Manish Ray
Sancheti Institute College of Physiotherapy, Thube Park, Shivajinagar, Pune - 411 005, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pjiap.pjiap_23_21

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BACKGROUND: Static and dynamic balance impairment is seen in multiple cases of knee osteoarthritis (OA). The affection of body perception has also been observed. Balance and body perception are an integral part while performing daily activities. The affection of these further leads to fear of fall. The aim of this study was to find the relation between balance and knee body perception in primary OA knee patients.
METHODS: This was a correlational study. Seventy-three patients with primary knee OA were recruited from tertiary care hospitals. Kellgren–Lawrence Grading system (I-IV) was used to assess the severity of knee OA. Patients having pain on the Visual Analog Scale 6/10 or below were included. The Fremantle Knee Awareness Questionnaire was used to assess a patient's body perception about the osteoarthritic knee. Static balance was assessed using four-stage balance test. Dynamic balance was assessed using the Timed Up and Go test.
RESULTS: Statistical analysis was performed using Spearman's Correlational test to investigate the correlation between balance performance and knee body perception. The study included 73 patients within 45–80 years (59.4 ± 9.0). An overall strong positive correlation was obtained between balance performance and knee perception (r = 0.76, P = 0.00). Based on the OA grades, this correlation was moderate (r = 0.62, P = 0.00) in mild OA, moderate (r = 0.47, P = 0.05) in moderate OA, and strong (r = 0.71, P = 0.02) in severe OA.
CONCLUSION: In knee OA patients, positive correlation exists between balance performance and knee body perception. As the severity of the disease increases, there is more impairment in balance and body perception. This affects the physical performance, quality of life in knee OA patients.

Keywords: Body perception, dynamic balance, osteoarthritis, proprioception, timed up and go

How to cite this article:
Bhole H, Ray M, Shyam A, Sancheti P. Correlation between balance performance and perception about the knee in patients with osteoarthritis knee. Physiother - J Indian Assoc Physiother 2021;15:98-102

How to cite this URL:
Bhole H, Ray M, Shyam A, Sancheti P. Correlation between balance performance and perception about the knee in patients with osteoarthritis knee. Physiother - J Indian Assoc Physiother [serial online] 2021 [cited 2023 Jun 3];15:98-102. Available from: https://www.pjiap.org/text.asp?2021/15/2/98/337718

  Introduction Top

Osteoarthritis (OA) is a chronic degenerative joint disease characterized by loss of articular cartilage, synovial inflammation, sclerosis of the bone, and osteophyte formation. Nearly 45% of women over the age of 65 years have symptoms while 70% of those over 65 years show radiological evidence of OA.[1] OA ranks as the fifth-highest cause of years lost to disability and ninth-highest in low- and middle-income countries.[2]

OA is manifested by joint pain and reduced physical performance and is one of the major risk factors for fall and injuries in older adults. This leads to fear of fall which is associated with reduced functional status and quality of life.[3] Loss of confidence is observed while performing any activity leading to activity limitations and participation restriction. A study reported that in people with arthritis, risk of fall is 2.5 times higher than people without arthritis.[4] Therefore, it is necessary to identify people who have OA and are exposed to a higher risk of fall.

Knee joint instability is seen in patients with knee OA resulting in episodes of knee buckling, giving away.[5] This may be one of the contributing factors for altered knee body perception. Proprioception is the perception of the body position. In the lower extremity, proprioception provides feedback about joint position and limb orientation. This contributes to static and dynamic postural stability.[4] There is reduced proprioception in people with knee OA. It is histologically inspected that the number of mechanical sensory receptors that are normally present around the ligaments of the knee joint are reduced in knee OA.[6] Hence, knee OA is a risk factor for fall and injuries.

Balance is a complex function that requires proper feedback from the sensory system about the position of the body and appropriate motor response to perform body movement.[7],[8] In people with knee OA, decreased balance confidence is associated with more difficulty while performing activities of daily living, and lower quality of life.[9] Recent systematic reviews have demonstrated that pain associated with knee OA involves various contributors which include lifestyle, cognitive factors, and peripheral/central sensitization.[10],[11]

Patients with knee OA exhibit impaired body perception. There is limited evidence on how this affects the balance. Hence, it is necessary to evaluate knee body perception while managing people with knee OA.[12] The primary objective of the study was to assess balance performance and knee body perception in knee OA patients and evaluate the relationship between these two variables and also study grade-wise correlation.

  Methods Top

The present study was a correlational study. Before beginning the research work, permission was taken from the Ethical Committee and Head of the orthopedics department for performing the assessment on knee OA patients. The patients were diagnosed with knee OA by the Orthopedic consultants. Convenience sampling technique was used. Patients having knee OA were identified. The purpose of the research study was explained to them. They were asked to rate their pain on the Visual Analog Scale (VAS)[13] and patients having pain of 6/10 or below were included in the study. The procedure that would be followed was thoroughly explained to the patients. Informed written consent was obtained from the patients who were willing to participate voluntarily in the study. Patients who had any history of trauma to the lower extremity and who had undergone any surgery of the lower extremity were excluded from the study. Seventy-three patients; consisting of 53 females and 20 males between the age of 45–80 years were included in the study. Demographic data (age, gender) of the patients was collected [Table 1]. Knee X-rays in anteroposterior and lateral view were taken and patients were further classified by the orthopedic consultant into four grades of knee OA based on the Kellgren–Lawrence Grading system.[14] Further, they were divided into mild OA (Grade 1 and 2), moderate OA (Grade 3), and severe OA (Grade 4). Fremantle Knee Awareness Questionnaire was used to assess patients awareness and body perception about the osteoarthritic knee.[12] Balance[15] was assessed using the Timed Up and Go test (TUG).[16],[17]
Table 1: Demographic data of subjects

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(Intraclass correlation coefficients: 0.97, MDC: 1.10 sec, validity: pearson r = 0.75).

  Results Top

Seventy-three patients of knee OA within the age group of 45–80 years were recruited for the study. The severity of the disease was assessed using KL grades for knee OA.

Statistical method

Spearman's correlational test.

Statistical analysis was performed using IBM SPSS software version 26 IBM Corp. (2019). IBM SPSS Statistics for Windows, Version 26.0.Armonk, NY: IBM Corp. [Computer software].

TUG test was used to assess the balance performance. Grade-wise evaluation showed that the balance impairment was more in moderate (Grade 3) and severe (Grade 4) OA. It was clinically correlated with increased TUG test scores; which were recorded in seconds.

Similarly, altered body perception was seen; which increased according to the grade of knee OA.

An overall strong positive correlation was obtained between balance performance and knee perception (r = 0.76, P = 0.001). Grade-wise correlation was studied. The correlation was moderate (r = 0.62, P = 0.001) in Grade 1 and 2 OA; moderate (r = 0.47, P = 0.05) in Grade 3 OA and strong (r = 0.71, P = 0.02) in Grade 4 OA; respectively [Table 2].
Table 2: Mean and standard deviation in timed up and go test score and Fremantle score

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  Discussion Top

In this study, the relationship between balance performance and knee body perception was studied. The results showed a strong positive correlation between balance performance and knee body perception. Correlation was also studied according to the grades of knee OA to investigate how this relationship varies according to the severity of knee OA. A moderate positive correlation was exhibited in the mild OA (Grade 1 and 2) as well as moderate OA (Grade 3) group. A strong positive correlation was found in severe OA (Grade 4).

In the present study, alteration in body perception was seen. As the severity of the disease increases, there is more damage to the articular cartilage of the knee leading to reduced proprioceptive acuity. This is one of the contributing factors for alterations in knee body perception. There is evidence that brain structure is altered in chronic pain conditions. This can be another factor associated with body perception. In a study done to investigate brain structure in people with knee OA, grey matter atrophy was seen in several regions of the brain which are involved in nociceptive processing. This was mainly seen in patients with end-stage knee OA.[18]

In the present study, based on the Fremantle knee awareness questionnaire; considering some of its components; like-'To move my knee the way I want to, I feel like I have to concentrate all my nerves there' it was seen that patients felt that a greater amount of concentration and effort was required to move the knee in the way they wanted it to. Furthermore, while performing ADLs they do not know how much their knee is moving and sometimes they feel that the knee moves without any connection to what they intend it to do so. The factors that contribute can be reduced proprioceptive acuity, reduced muscle strength, and neurological factors.

Similarly, the results of a study suggested that there would be a link between cortical changes in the brain and modified motor behavior in patients of knee OA. They used Functional magnetic resonance imaging to investigate the possible differences that may exist in the organization of the motor cortex in knee OA patients. A 4.1 mm of the anterior shift in the representation of the knee in the motor cortex was seen and also there was switching of the arrangement of knee and ankle representation.[19]

Postural instability results into balance deficits. In the present study postural sway was observed, which gradually increased as there was the progression of the disease. Reduced proprioception is the contributing factor. A study concluded that patients with symptomatic knee OA had reduced proprioception, increased postural sway and had quadriceps weakness compared to the normal age- and sex-matched controls. They suggested that joint pain and muscle strength may affect the postural sway.[20]

In the present study, it was seen that in test TUG, the time required to cover a distance of 3 m increased as the severity of the disease increased. Furthermore, some patients with moderate-to-severe OA complained of fear of fall while performing some activities. It was clinically correlated with an increased scores of the TUG test. Other factors which contributed were reduced muscle strength, altered gait pattern, decreased balance confidence. A study assessed postural control using Tetrax, Berg Balance Scale (BBS), and TUG and concluded that more deficits in balance were seen in moderate-to-severe OA than those with mild OA.[6] It was seen that a significant difference was seen in the TUG scores between healthy, mild and moderate knee OA groups and they concluded that in the moderate OA knee group there was increased risk of fall.[21]

Pain is another main factor which alters the physical performance of the patient. It was observed that as the severity of the disease increases and higher the grade of knee OA, pain also increases. This may be due to the neuromuscular changes that happen as a result of the disease process. A study stated that functional deficits observed in knee OA may be correlated with pain and somatosensory alterations that are commonly associated with OA.[22]

In the present study, it was seen that in many patients pain was present on the medial aspect of the knee and medial joint line. This is due to medial compartmental OA which is more commonly seen where degenerative changes are seen within the medial compartment of the joint. This depends on the ground reaction forces and the load that is placed on the knee joint. As the amount of load increases, there is an increase in joint pain. A study on pathophysiology and mechanical perspective of knee OA concluded that knee kinematics have a major role in articular cartilage degradation and once there is alteration in the normal kinematics of the joint, there is the shift of loading to areas which are not suitable enough to accommodate that increased amount of stress.[23]

Strength of the study

  • Evaluation was done based on Kellgren–Lawrence grades of knee OA and correlation was studied between balance performance and knee body perception.
  • Patients having pain on VAS 6/10 or below were only included so that severe pain is not the factor which can affect balance.

Limitation of the study

  • The age group included in the study is 45–80 years, which is a wide age group. The age group was not further divided.

Clinical implication

Reduced balance performance and altered body perception affect the physical performance of the patient. Assessment of these components in the initial stage of the disease will help us prevent further deterioration of patient's performance. This will help us to effectively plan Physiotherapy treatment strategies which would also focus on balance and proprioceptive training. It will help us to counsel patients about their altered knee body perception and how physiotherapy would improve their condition and Quality of life. It will help us in the prevention of fall and injury which would help increase the balance confidence of patients while performing activities. This will reduce the psychological consequences of fall which include fear of fall and depression.

Future research directions

  • To find whether there is any association between altered body perception and depression
  • Assessment of body perception prerehabilitation and postrehabilitation
  • Stratification can be done according to age using the stratified sampling method.

  Conclusion Top

In Knee OA patients, a strong positive correlation was found between balance performance and knee body perception in severe knee OA patients. This suggests that as the severity of knee OA increases, there is more impairment in balance performance and knee body perception is more altered. Therefore, it is essential to assess balance and body perception in the initial stage of the disease to prevent further impairments.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Osteoarthritis – National Health Portal of India. Available from: https://www.nhp.gov.in/disease/musculo-skeletal-bone-joints-/osteoarthritis. [Last accessed on 2021 Aug 03].  Back to cited text no. 1
Background Paper 6.12 Osteoarthritis – World Health Organization. Available from: https://www.who.int/medicines/areas/priority_medicines/BP6_12Osteo.pdf. [Last accessed on 2021 Aug 03].  Back to cited text no. 2
Ng CT, Tan MP. Osteoarthritis and falls in the older person. Age Ageing 2013;42:561-6.  Back to cited text no. 3
Hoops ML, Rosenblatt NJ, Hurt CP, Crenshaw J, Grabiner MD. Does lower extremity osteoarthritis exacerbate risk factors for falls in older adults? Womens Health (Lond) 2012;8:685-96.  Back to cited text no. 4
Fitzgerald GK, Piva SR, Irrgang JJ. Reports of joint instability in knee osteoarthritis: Its prevalence and relationship to physical function. Arthritis Care Res 2004;51:941-6.  Back to cited text no. 5
Kim HS, Yun DH, Yoo SD, Kim DH, Jeong YS, Yun JS, et al. Balance control and knee osteoarthritis severity. Ann Rehabil Med 2011;35:701-9.  Back to cited text no. 6
Hill KD, Williams SB, Chen J, Moran H, Hunt S, Brand C. Balance and falls risk in women with lower limb osteoarthritis or rheumatoid arthritis. J Gerontol Geriatr 2013;4:22-8.  Back to cited text no. 7
Sturnieks DL, St George R, Lord SR. Balance disorders in the elderly. Neurophysiol Clin 2008;38:467-78.  Back to cited text no. 8
Bobić Lucić L, Grazio S. Impact of balance confidence on daily living activities of older people with knee osteoarthritis with regard to balance, physical function, pain, and quality of life – A preliminary report. Clin Gerontol 2018;41:357-65.  Back to cited text no. 9
Lluch E, Torres R, Nijs J, Van Oosterwijck J. Evidence for central sensitization in patients with osteoarthritis pain: A systematic literature review. Eur J Pain 2014;18:1367-75.  Back to cited text no. 10
Urquhart DM, Phyomaung PP, Dubowitz J, Fernando S, Wluka AE, Raajmaakers P, et al. Are cognitive and behavioural factors associated with knee pain? A systematic review. Semin Arthritis Rheum 2015;44:445-55.  Back to cited text no. 11
Nishigami T, Mibu A, Tanaka K, Yamashita Y, Yamada E, Wand BM, et al. Development and psychometric properties of knee-specific body-perception questionnaire in people with knee osteoarthritis: The Fremantle knee awareness questionnaire. PLoS One 2017;12:e0179225.  Back to cited text no. 12
Alghadir AH, Anwer S, Iqbal A, Iqbal ZA. Test-retest reliability, validity, and minimum detectable change of visual analog, numerical rating, and verbal rating scales for measurement of osteoarthritic knee pain. J Pain Res 2018;11:851-6.  Back to cited text no. 13
Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957;16:494-502.  Back to cited text no. 14
Stevens JA, Phelan EA. Development of STEADI: A fall prevention resource for health care providers. Health Promot Pract 2013;14:706-14.  Back to cited text no. 15
Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the timed up & go test. Phys Ther 2000;80:896-903.  Back to cited text no. 16
Alghadir A, Anwer S, Brismée JM. The reliability and minimal detectable change of timed up and go test in individuals with grade 1-3 knee osteoarthritis. BMC Musculoskelet Disord 2015;16:174.  Back to cited text no. 17
Lewis GN, Parker RS, Sharma S, Rice DA, McNair PJ. Structural brain alterations before and after total knee arthroplasty: A longitudinal assessment. Pain Med 2018;19:2166-76.  Back to cited text no. 18
Shanahan CJ, Hodges PW, Wrigley TV, Bennell KL, Farrell MJ. Organisation of the motor cortex differs between people with and without knee osteoarthritis. Arthritis Res Ther 2015;17:164.  Back to cited text no. 19
Hassan BS, Mockett S, Doherty M. Static postural sway, proprioception, and maximal voluntary quadriceps contraction in patients with knee osteoarthritis and normal control subjects. Ann Rheum Dis 2001;60:612-8.  Back to cited text no. 20
Khalaj N, Abu Osman NA, Mokhtar AH, Mehdikhani M, Wan Abas WA. Balance and risk of fall in individuals with bilateral mild and moderate knee osteoarthritis. PLoS One 2014;9:e92270.  Back to cited text no. 21
Courtney CA, O'Hearn MA, Hornby TG. Neuromuscular function in painful knee osteoarthritis. Curr Pain Headache Rep 2012;16:518-24.  Back to cited text no. 22
Vincent KR, Conrad BP, Fregly BJ, Vincent HK. The pathophysiology of osteoarthritis: A mechanical perspective on the knee joint. PM R 2012;4:S3-9.  Back to cited text no. 23


  [Table 1], [Table 2]


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