Impact Of Knee Osteoarthritis On Balance Perceived Fear

Impact Of Knee Osteoarthritis On Balance, Perceived Fear Of Fall And Quality Of Life Dr. Garima Gupta (PT) HOD, Assistant professor Department of Physiotherapy, Saaii College of Medical Science & Technology Kanpur, India.

INTRODUCTION Osteoarthritis (OA) is a degenerative joint disease, occurs when the cushiony cartilage between two bones becomes worn down, and the bones begin to rub against each other. This often leads to pain, swelling, stiffness, decreased ROM or the formation of bone spurs. __________________________ Krishanu Sengupta, Krishnaraju V Alluri, et al. A double blind, randomized, placebo controlled study of the efficacy and safety of 5 -Loxin ® for treatment of osteoarthritis of the knee. Arthritis Research & Therapy 2008; 10: 1186 -2461. 2

INTRODUCTION With advancing age osteoarthritis (OA) of the hips and the knees is a major disabling disorder due to its restricting effect on mobility. OA knee is one of the most prevalent musculoskeletal complaints worldwide, affecting 30– 40% of the population by the age of 65 year. Individuals with OA suffer progressive loss of function, displaying increasing dependency in walking, stair climbing and other lower extremity tasks. ______________________________________ Ming-Chien Chyu, Veravon Bergen, Jean-Michel Brismee, Yan Zhang, James K. Yeh, and Chwan-Li Shen. Complementary and Alternative Exercises for Management of Osteoarthritis. Hindawi Publishing Corporation Arthritis 2011; 1 - 10. R. S. Hinman, K. L. Bennell, et al. Balance impairments in individuals with symptomatic knee osteoarthritis: a comparison with matched controls using clinical tests. Rheumatology 2002; 41: 1388 -1394. 3

INTRODUCTION Balance is an integral component of mobility and many activities of daily living. Control of balance is essential in all static and dynamic postures situations. It is dependent upon sensory input from the vestibular, visual and somato-sensory systems. ____________________________ Afaf A. M. Shaheen and Khaled Ayad. Impact of Chronic Osteoarthritis of Knee Joint on Postural Stability and Functional Mobility in Women. Bull. Fac. Ph. Th. Cairo Univ 2008; 13: 317 -318. R. S. Hinman, K. L. Bennell, et al. Balance impairments in individuals with symptomatic knee osteoarthritis: a comparison with matched controls using clinical tests. Rheumatology 2002; 41: 1388 -1394. 4

INTRODUCTION Various researches in the elderly population have documented that balance impairments may results in an increased risk of falls and poorer mobility measures, which could lead to ADL restriction and social isolation. __________________________ Maria H Nilsson, Anna-Maria Drake, et al. Assessment of fall-related self-efficacy and activity avoidance in people with Parkinson’s disease. BMC Geriatrics 2010; 10: 78. Carol S Burckhardt, Kathryn L Anderson. The Quality of Life Scale (QOLS): Reliability, Validity, and Utilization. Health and Quality of Life Outcomes 2003; 1: 60. 5

INTRODUCTION Effects of balance deficits have been widely documented in elderly population but much less has been studied about the presence of balance deficits and their effect on osteoarthritic population. Even if few studied most of the studies have used force platform, or balance master as their tool. Present study is designed to use cost effective clinical tool: sway meter, for assessing the balance in osteoarthritis population. 6

INTRODUCTION Postural sway is used as an indicator of static standing balance where bodily movement in both the anterio-posterior (AP) and transverse direction are analyzed. ______________________________________ R. S. Hinman, K. L. Bennell, et al. Balance impairments in individuals with symptomatic knee osteoarthritis: a comparison with matched controls using clinical tests. Rheumatology 2002; 41: 1388 -1394. 7

INTRODUCTION Sway-meter � The Swaymeter is a reliable tool for assessing postural sway. � The device consisted of an inflexible 40 -cm-long rod with a vertically mounted pen at its end. � The pen record participant’s postural sway on a sheet of millimeter graph paper, fastened to the top of an adjustable-height table. � AP, transverse and total postural sway is calculated under following four conditions: on floor eyes open and closed and on foam eyes open and closed. ________________________________ Afaf A. M. Shaheen and Khaled Ayad. Impact of Chronic Osteoarthritis of Knee Joint on Postural Stability and Functional Mobility in Women. Bull. Fac. Ph. Th. Cairo Univ 2008; 13: 317 -318. Diana L Sturnieks, Ria Arnold, Stephen R Lord. Validity and reliability of the Swaymeter device for measuring 8 postural sway. BMC Geriatrics 2011; 11: 63.

AIMS AND OBJECTIVES To study the presence of balance deficits in people of 50 -70 years with knee OA: using a cost effective sway meter. To study and correlate the disease severity and fear of fall in people with knee osteoarthritis. To study and correlate the previous falls, perceived fear of fall and quality of life in people with knee osteoarthritis. 9

METHODOLOGY A sample of 60 people of 50 -70 years took part in the present study. The subjects who were ready to participate were recruited from the orthopedics department of Lala Lajpat Rai Hospital (Hallet) Kanpur. _________________________ Krishanu Sengupta, Krishnaraju V Alluri, et al. A double blind, randomized, placebo controlled study of the efficacy and safety of 5 -Loxin ® for treatment of osteoarthritis of the knee. Arthritis Research & Therapy 2008; 10: 1186 -2461. K L Bennell, R S Hinman, et al. Efficacy of physiotherapy management of knee joint osteoarthritis: a randomized, double blind, placebo controlled trial. Ann Rheum Dis 2005; 64: 906– 912. 10

INCLUSION CRITERIA Age of the participants (Male or female) was between 50 to 70 years. Diagnosed case of knee OA as confirmed by an orthopedic. Participants with OA were included if they had knee pain on most days of previous month (average pain > 3 cm on a 10 cm VAS) and experienced pain or difficulty when getting up from sitting or climbing stairs. People having MMSE SCORE > 24 were included. 11

EXCLUSION CRITERIA Participants <50 & >70 years were excluded from the study. Participants those who were having neurological, cardiovascular problems were excluded from the study. If consultation of a physiotherapist for treatment of the knee problems. __________________________________________ Afaf A. M. Shaheen and Khaled Ayad. Impact of Chronic Osteoarthritis of Knee Joint on Postural Stability and Functional Mobility in Women. Bull. Fac. Ph. Th. Cairo Univ 2008; 13: 317 -318. Diana L Sturnieks, Ria Arnold, Stephen R Lord. Validity and reliability of the Swaymeter device for 12 measuring postural sway. BMC Geriatrics 2011; 11: 63.

EXCLUSION CRITERIA Control participants were excluded if they have any sign and symptoms of OA any deformity, pathology or injury in past year. Also excluded if they reported any deformity in knee or any lower limb pathology or any injury to or pain in either knee in the past year or displayed abnormality on physical examination of the knee (flexion ROM ≤ 125°, effusion, palpable warmth, ligamentous laxity). ______________________________________ R. S. Hinman, K. L. Bennell, et al. Balance impairments in individuals with symptomatic knee osteoarthritis: a comparison with matched controls using clinical tests. Rheumatology 2002; 41: 1388 -1394. 13

INSTRUMENTATION Sway-meter: Graph paper, Pen, Adjusting table, Rod, Velcro Belt Scales: � Arthritis Impact Measurement Scale 2 Short Form (AIMS 2 -SF) � Index of Severity for Osteoarthritis of the knee (ISK) � Fall Efficacy Scale (FES) __________________________________________ E Taal, J J Rasker, et al. Sensitivity to change of AIMS 2 and AIMS 2 -SF components in comparison to M -HAQ and VAS-pain. Ann Rheum Dis 2004; 63: 1655– 1658. Thomas Rosemann, Gunter Laux and Joachim Szecsenyi. Osteoarthritis: quality of life, comorbidities, medication and health service utilization assessed in a large sample of primary care patients. Journal of Orthopaedic Surgery and Research 2007; 2: 12. Thomas Rosemann, Stefanie Joos, et al. Comparison of AIMS 2 -SF, WOMAC, x-ray and a global physician assessment in order to approach quality of life in patients suffering from osteoarthritis. BMC Musculoskeletal Disorders 2006; 7: 6. Lequesne M Mery C et al. Indexes of severity for osteoarthritis of the hip and knee. Scand J Rheumatology. 1987; Supplement 65: 85 -89. Legters K. Fear of falling. Phys. Ther. 2002; 82: 264 – 272. 14

PROTOCOL & PROCEDURE Sample of 60 people of Kanpur city Participants were assessed : Inclusion & Exclusion criteria. Signed consent form was obtained Initial assessment: Demographic details , observations and examination Patient was given instruction and procedure was explained. 15

Assessments of the postural sway were performed in bipedal stance with bare feet (10 cm apart). Total 4 conditions: on floor and on foam with EYES OPEN & EYES CLOSED. Conditions was randomly presented and 3 trails of 30 seconds were conducted per condition, for a total of 12 trails per participants. Participants were instructed to stand still without talking for a period of 30 seconds, looking ahead and slightly down at a blank wall 1. 5 m away. Participants were offered a seat and rested for at least 1 minute in between trails. 16 Testing under each condition was performed with no practice permitted

ASSESSMENT OF POSTURAL SWAY USING SWAY METER 17

If the loss of balance was about to happen, testing was ceased for that particular condition Tracings of the pen on graph paper yielded the following measures of postural sway: maximal sway in the (i) AP and (ii) Transverse or Medio-lateral directions and then (iii) total sway area was calculated. A ruler was used to locate the outer borders of the AP and lateral directions used to determine the respective maximal sway measures. Readings were recorded. The details required for responding to rest of the scales (AIMS 2 -SF, ISK, FES, Number of falls in previous year ), were given to the subject. 18

CALCULATION OF MEDIAL-LATERAL, ANTERIOPOSTERIOR &TOTAL BODY SWAY FROM PEN TRACING 19

RESULTS Basic characteristics of the participants: Subjects Control group Age(years): Mean+ SD N= 30 OA group Age (years): Mean+ SD N=30 Characteristic 56. 1+ 5. 97 55. 67 + 6. 52 Control group Weight (Kg) : Mean+ SD N= 30 OA group Weight (Kg): Mean+ SD N=30 62. 2 + 9. 53 62. 71 + 15. 6 SD= Standard deviation, N = Number. of Participants, OA= Osteoarthritis 20

RESULTS Balance deficits Mean body sway in the AP direction in OA and control participants across the four testing conditions: Floor eyes open AP SWAY Mean CONTROL GROUP tvalue 18 Mean tvalue pvalue 19. 73 2. 39** OA GROUP pvalue Floor eyes closed 0. 019 21. 43 Mean t- value p-value 27. 7 2. 43** 25. 11 Foam eyes open 0. 018 Mean t- value pvalue 3. 352** . 001 37. 82 2. 926** 34. 78 Foam eyes closed . 005 46. 07 **= Significant at ≤ 0. 01 level 21

Mean body sway in the AP direction in OA and control participants across the four testing conditions 50 45 40 AP SWAY (mm) 35 30 CONTROL GROUP 25 OA GROUP 20 15 10 5 0 Floor eyes open Floor eyes closed Foam eyes open Foam eyes closed 22

RESULTS Balance deficits Mean body sway in the lateral direction in OA and control participants across the four testing conditions: Floor eyes open Floor eyes closed Foam eyes open Foam eyes closed TRANSVERS E SWAY Mean CONTROL GROUP t- value 12. 82 Mean t- value p-value 10. 84 3. 54** OA GROUP p-value 0. 0008 21. 57 **= Significant at ≤ 0. 01 level t- value pvalue 15. 56 4. 64** 23. 65 Mean 0. 0001 t- value p-value 3. 501** . 001 18. 23 4. 519** 29. 55 Mean . 0001 19. 1 23

Mean body sway in the transverse direction in OA and control participants across the four testing conditions 35 30 Transverse sway (mm) 25 20 CONTROL GROUP OA GROUP 15 10 5 0 Floor eyes open Floor eyes closed Foam eyes open Foam eyes closed 24

RESULTS Balance deficits Mean total body sway in OA and control participants across all four testing conditions. Floor eyes open TOTAL SWAY CONTROL GROUP Mean t- value 236. 65 Mean t- value p-value 213. 13 3. 894** OA GROUP p-value Floor eyes closed . 0001 461. 13 Mean t- value Foam eyes closed p-value 450. 02 3. 986** 659. 18 Foam eyes open . 0001 t- value p-value 3. 724** . 0001 708. 38 4. 479** 1083. 54 Mean . 0001 1395. 33 **= Significant at ≤ 0. 01 level 25

Mean total body sway in OA and control participants across all four testing conditions 1600 1400 1200 Total Sway (mm) 1000 CONTROL GROUP 800 OA GROUP 600 400 200 0 Floor eyes open Floor eyes closed Foam eyes open Foam eyes closed 26

IMPACT OF BALANCE DEFICITS ON KNEE DISABILITY Pearson’s correlational analysis showed significant correlation between balance deficits and degree of knee disability in both eyes open and eyes close on floor conditions in people of 50 -70 years of age group. r value = 0. 45** , p value = 0. 01 (eyes open, on floor) r value = 0. 44** , p value = 0. 01 (eyes closed, on floor) r value = 0. 47**, p value = 0. 01 (eyes open, on foam) r value = 0. 31*, p value = 0. 05 ( eyes closed, on foam) 27

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IMPACT OF PREVIOUS NUMBER OF FALLS ON PERCEIVED FEAR OF FALL Pearson’s correlation analysis showed highly significant correlation between participant’s perceived fear of fall and their number of fall in last 12 months. r value = 0. 86**, � p value = 0. 01 � 30

IMPACT OF PERCEIVED FEAR OF FALL ON QUALITY OF LIFE Pearson’s correlation analysis showed highly significant correlation between participant’s perceived fear of fall and their quality of life. r value = 0. 40**, � p value = 0. 01 � 31

DISCUSSION The key finding of the present study is that the people with OA have significant balance deficits as compared to control group. The amount of anterio posterior , transverse and total sway suggests that people with OA significantly increase their sway displacement as compared to the people who had no symptoms of OA. The results of the study agree with Hinman et al (2002) findings which showed that osteoarthritic population had significant balance deficits in both anterio posterior and transverse direction under eyes open and eyes close. ____________________________________________ R. S. Hinman, K. L. Bennell, et al. Balance impairments in individuals with symptomatic knee 32 osteoarthritis: a comparison with matched controls using clinical tests. Rheumatology 2002; 41: 1388 -1394.

DISCUSSION Findings of the Ratzlaf et al (2010) also suggests that any injury or pathology to knee have definite neuromuscular impairments such as decreased quadriceps strength , poor lower limb positioning, proprioceptive deficits and impaired postural control. The magnitude of postural sway is the amount of movement of center of pressure (COP). Previous literature suggests that when the COP displacement falls outside the limits of stability (LOS) the person’s balance get lost. Hence greater the postural sway more will be the chances of person to loose their balance. __________________________ Yung-Hui Tien, Kuei-Fu Lin. The Relationships between Physical Activity and Static Balance In elderly People. J Exerc Sci Fit 2008; 6: 1: 21. Charles R Ratzlaf, Matthew H Liang. Prevention of injury-related knee osteoarthritis: opportunities for the primary and secondary prevention of knee osteoarthritis. Ratzlaf and Liang Arthritis Research & Therapy 2010; 12: 215. 33

DISCUSSION Balance deficits could lead to fall hence; when we studied how previous falls affect person’s ability to carry out day to day activities we found that previous falls have a significant impact on person’s perceived fear of fall. Excessive fear of fall can lead to needless restriction in participation in physical and social activities, resulting in physical deconditioning, social isolation, depression and distress. 34

DISCUSSION The result of the study confirms that the previous episodes of fall strongly correlate with person’s fear of fall. Activities restrictions, associated physical deconditioning and social isolation can in turn affects the quality of life. __________________________ Thomas Rosemann, Stefanie Joos, et al. Comparison of AIMS 2 -SF, WOMAC, x-ray and a global physician assessment in order to approach quality of life in patients suffering from osteoarthritis. BMC Musculoskeletal Disorders 2006; 7: 6. 35

VISCOUS CYCLE CREATED DUE TO VARIOUS PHYSIOLOGICAL AND PSYCHOLOGICAL FACTORS Balance deficits in osteoarthritis Social isolation Loss of balance/ Fall Depression & Distress Fear of fall Physical deconditioning Activity restrictions 36

FUTURE RESEARCHES Future studies are recommended to study the gender base difference of balance deficits in people with osteoarthritis. Future studies are recommended to establish the relationship between balance deficits, muscle strength, pain and disability in osteoarthritic population. Future studies are also recommended to calculate the amount of dynamic balance deficits in osteoarthritis. 37

CONCLUSION The findings of the present study suggested that people with osteoarthritis presents with increase postural sway and hence has significant balance deficits. The secondary findings revealed that balance deficits have strong impact on person’s perceived fear of fall and quality of life. In clinical terms the results of the present study could be concluded as: “While attending any person with osteoarthritis importance should be given not only to pain and physical deficits but also to their balance deficits, their fear of fall and quality of life affected due osteoarthritis. ” 38

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