The Indian Journal of Occupaikmal Therapy : Vol. XU : No.

2 (May 2009 August 2009}

+A STUDY ON EFFECT OF PROPRIOCEPTIVE TRAINING IN PATIENTS

WITH OSTEOARTHRITIS KNEE WEARING ELASTIC BANDAGES
* Sheeta Gangaram Joijode, M.O.Th., Co-Author: **Stephen 6.A. Sams, M.Sc.O.T., F A.C.O.T (India)
Abstract :
Oslciuilhns is hecaniing an ever iucraisifJi; healfli care problem , affec!ii\}^fiiiu:ona .ilas of un iiulivihu! ami pt'ifonnance.
The limnan knee perhaps susfains high forces and as is siituiied hdween the body's two longest lever arm. nmki-.s ii sii.scepiihle
to weight hearing stre>ses. These forces lead to an increase in the stress forces on the propriocepiors. Proprioceptors provide
information about the rate of movement, as a result there is deterioration in joint position sense and fear of falling n patients.
llw raiionale of using Elastic bandage around the knee is to maximize cutaneous sensation contribution to joint position
sense. Ii provides mechanical support to the knee .improves disease specific quality of life.
Oincome measures used was WOMAC scale which as.^esses pain, .'itiffness and functional ability. Proprioception testing was
done using an Elecirogoniometer. Twenty-eight patients were assessed and randomly dstrbuied in Experimental and Control
groups. The assessment was done initially pre-exercise and then at the end of 2nd, 4th and 6th week of training program for
both patient groups.
This program showed that Experimental group training improved joint proprioception following proprioceptive training and
patients had reduced symptoms like pain, stiffness and improved physical functional ability, which provided comfort in
performing ADL. thus, improving Quality of Life of these patients.
Key Words:- O.sieoarthritis, Proprioception. Knee ji)int, Elastic bandage. Proprioceptive iriiining. Quality f life.

INTRODUCTION
The Human knee, withstands extreme weight bearing
stresses, when we walk or run, Osleoarthritis is a
dcgeneralive process characterized by variable degree of
joint pain, tenderness, decrease R.O.M, crepitus. occasional
effusions & inllammation. This affects the functional status
of an individual with osteoarthritis knee. Ail this leads toan
increase in the stress forces on the proprioceptors.
Proprioceptors provide information about the rale of
nuivemeiu & degree of joint angulation. Thus Proprioceplive
Training is an important component of osteoartbrllis knee
rehabilitalion, PropritK'cption increases the state ot readiness
0 the jDint. decreasing ihe chance of re-injury on return to

daily activities. Elastic bandages provide tactile stimuli to skin

receptors & any movement of the elastic bandage on skin
influence proprioceptive acuity & maximise cutaneous
sensation around knee joint subsequently improving
proprioception and self-efficacy during performance of daily
activities.
AIMS & OBJECTIVES OF THE STUDY
Aim of the present study was to compare the effectiveness
of proprioceptive training along with conventional
occupational therapy treatment versus conventional
oecupational therapy treatment alone by providing [uhuar
elastic bandages to both the group of patients having knee
osteoarthritis,
HYPOTHESIS

' Occupalionai Tiierapist

I'tiice of Sttid> : (),T School & Came.. SeUi (i S, Med, Coilege &
K H M flospiial, Munihat - 4(HH)i2

Oinespoiideuce :

Dr. Miss. Shweta Gangaram Joijode

-53. Supreme Park. Opp Vijay Park. Near Janyid Coiiipicx.
Mita Road (-JSI. Muinbai - 401 107,
Tel. : +'-)\ ^(-i<)K24511
E-mail: sjO!J<idc(>yiihoo,com

i" Paper was presented in 46th Annual National Conference of

lO EMC0NV9 in .hin. 2009 at Jaipur and awarded with
KEMOT Youtlt Talem Award.

H O : Proprioceptive training in conjunction with conventional

occupational therapy is not effective in pahcnts with
knee osteoarthritis,
H

Proprioceptive training in conjuncticnwilli conventional

occupational therapy is effective in patients wiih knee
osteoarthritis.

MATERIALS & METHODS

This prospective, randomized & comparative study was done
on 28 female subjects wilh Bilateral Osteoarthritis of

wbich proprioception training was started at 3"' week and

were continued, with progress recorded at the end o 4 '
week and 6'" week. Proprioception was tested using
Electrogoniometer. With subjects in supine position.
Electrogoniotneter was tied to subjects' knee to test
proprioception. It was placed on the lateral aspect of the
joint tested. Electrogoniometer was designed with visual cue
in the form of red light. As soon as the patient would achieve
the predetermined position (i.e criterion angle) of knee flexion,
the red light would provide visual cue regarding accurate
angle of knee flexion has been achieved. The knee was moved
passively and positioned at a certain predetermined position
(criterion angle). These criterion angles were 0-15, 0-3{F.
Qo_45o^ O^-tf and held there for 5 seconds. The knee was
then returned passively by the therapist to the original position
and the subject was asked to reproduce the criterion angle.
The difference between the criterion angle and reproduced
angle was taken as a measure of proprioceptive acuity. This
procedure is performed with eyes closed. The proprioception
testing was performed four times. The first was a trial one
to familiarize the subject with the procedure. The average
of the last 3 trials was regarded as the proprioceptive acuity
for that knee joint.

knt-e joint: between age group of 35-60 years. The subjects

were divided equally into two groups i.e control group &
experimental group. The study was a randomized controlled
tnul based on an outpatient setting. The patients were asked
to wear tubular Elastic Bandages during the daytime, when
ambulatory & performing daily activities, that require knee
joint motions/movements, which places stress forces over
the joint. The tubular Elastic Bandages could be removed
when patient rested.
The inclusion criteria were:
1.

Patient diagnosed as a case of knee osteoartbritis.

2.

Biiateral knee joint involvement.

3.

Radiographic evidence of Grade II or III of Kellgren

and Lawrence criteria for knee osteoarthritis.

4.

Female subjects:-e"35 & d"60 years of age.

The exclusion criteria were:

1.

Patients with symptoms, signs or X-ray findings to

suggest co-exislent inflammatory or other locomotor
disease.

2.

Any significant peripheral and C.N.S disease.

3.

Limitation of R.O.M of the knee joint or any other

musculoskeletal problem.

4.

Any other join involvement.

.S.

Uncontrolled hypertension or cardiac problems.

6.

Secondar> osteoarthritis:-

MATERIALS USED:
I>Measuring Tape, 2>BIectrogoniometer, 3>Therabands,
4>Weighted Cuffs, 5>Elaslic Bandages.
EXERCISE PROTOCOL
Both Control and Experimental groups were treated with
regular exercise training program and tubular Elastic
Bandages as per the size of their knee joints. Experimental
group received Proprioceptive Training from 3"' week of the
Exercise Protocol.

Trauma during last 3 months.

Axiai deviation >15'' in valgus/varus.
Clinically significant anteroposterior or mediolateral
instability.

STANDARD KNEE OSTEOARTHRITIS

REHABILITATION PROTOCOL

Once the subject was selected; detailed subjective and

objective orthopaedic evaluation was carried out.

Static quadriceps

>\VOMAC Index [Western Ontario And Me. Master

Universities Osteoarthritis Index]

Active Ankle Pumps

Hamstring .setting exercises

Perceived pain, knee stiffness and functional ability was

assessed by WOMAC Index, done initially, then at end of
2"^ . 4'** and 6"^ week after the training program.

EuU arc knee flexion & extension

Straight leg raising

The individual completing the scale, rated her perceived pain,

stiffness and functional ability on a 5-point Likert's scale
which is scored from 0-4 i.e:-

Hip abducion-adduction, extension exercises

Dynamic hamstring exercises

"

Dynamic quadriceps exerci.ses

O-None, 1-Slight, 2-Moderate, 3-Severe, 4-Extreme

Hamstring curls

>Proprioception Testing done initially, then at the end of

2''* . 4''^ and 6''' week of training program. Proprioception
testing was done initially, then at the end of 2"'* week; after

O|xn chain dynamic quadriceps exercises with weighed

cuffs

iJOT ; Vol. XLI : No. 2

38

May 2009 - Augusi 2009

Open chain ham.string curls exercises with weighted

cuffs
Medicine ball kicking exercises in sitting
Stationary bicycle exercises

PROPRIOCEPTIVE TRAINING: (starting from 3'^

week only for experimental group)
Weight Bearing & Weight Shifts

Slepup's

Leg presses

Timed single leg stance

Wallslides

Both the groups were assessed for proprioception initially

pre-exercise & then at the end of 2"^,4'^ & &* weeks post
exercise respectively.
Subjects had lo rate their perceived pain, stiffness & physical
functional ability using the WOMAC Scale; which was also
assessed initially pre-exercise & then at the end of 2''^'.4'" &
6'^ weeks post exercise.
To analyze 28 female patients of Experimental & CoiUroi
groups following steps were carried out. Mean & Standard
Deviation of each of the variable in proprioception &
WOMAC Scale for bilateral knee osteoarthritis patients was
found out & then unpaired t-test was applied.
Un-paired 't' test was applied to determine the comparative
effects of both the groups for proprioception & WOMAC
Scale variables. Significant main was determined & any vahie
of p< 0.05 indicated that it Is statislicaliy significant.

Closed chain isometric exercise against the resistance

of theraband.
.All exercises were given thrice a week and without elastic
bandages worn by the patient.

Table 1
Average mean age of Experimental & Control
Group.

DATA ANALYSIS & RESULTS

The Expeririienlal group consisted of 14 patients which were
given proprioceptive training along with Conventional
Occupational therapy & application of tubular Elastic
Bandages at the knees. The control group which consisted
o( 14 patients were given Convencional Occupationai therapy
A; application of tubular Elastic Bandages around the knees.

Groups

N (no. of
female patients)

Mean

Experimental group

14

51.29

Control group

14

54.36

Table 2
Pre-exercise & Post-exercise mean scores of WOMAC scale.
WOMAC SCALE
VARIABLE
Pain
Stiffness
Physical inctioiial
ability

PRE EXERCISE
INITIAL
Exp
Control
15.64
15.64
7.93
8.57

2"'*week
Exp
Control
13.00
12.07
5.50
7.21

57.07

39.57

57.07

42.07

POST EXERCISE
4'^*' week
Exp
Control
6.57
6.71
2.93
5.64
27.36

33.50

6"^ week
Exp
Control
1.36
2.86
0.50
2.50
814

[\2l

Table 3
Pre-exercise & Post-exercise Standard Deviation values of WOMAC Scale.
WOMAC SCALE
VARIABLE
Fain
Stiffness
Physical Junctional
ability
tJOT : Vot. XLI : No. 2

PRE EXERCISE
INITIAL
Exp
CiHitroi
1.151
1.277
i.328
1.158

1.301
1.454

1.439

2 269

4.183

2.999

1,979

r'week
Exp
Control
.188

39

POST EXERCISE
4"' week
Exp
Control
1.222
J.383
1.141
1.447
2,061

3.111

6" week
Exp
Control
0.842
] 099
0.760
1 092
1.956

2.455

May 2009 - August 2009

Table 4
Unpaired "t"test values of WOMAC scale.
WOMAC SCALE PRE EXERCISE
VARIABLE
INITIAL
0.000
Pain
1365
Shtness
Physical functional
0.000
ability
^HS=: Highly significant.

POST EXERCISE
4'^ week
6'^ week
0.290
4.053
1.791
5.626
3.45
5.511
1.817

5.341

df(degree
of freedom)

p value

26
26

0.000 HS ^
0,000 HS*

26

0,001 HS*

3.661

Il shows that on comparing experimental v/s control group p<0.05 which indicates that il is statistically significant, which
means that the reduction in pain, stiffness & physical functional ability as shown in the experimental group is highly significant
than that of control group.
Assessment of Proprioception (Table 5, 6 & 7) for right Knee joint.
Table 5
Pre-exercise & Post-exercise mean scores of Proprioception for the right Knee joint.
Predeterniiued
angles of right
knee flexion
()"-15"
ff-30
^-45"
0"-60"

PRE EXERCISE
INITIAL
Exp
Control
21.407
20.757
38.664
37.879
51,450
51.279
68.757
68,500

2'"'week
Exp
Control

20.264
37.250
50.093
66.943

18.207
35.321
48.879
66.071

POST EXERCISE
4'"* week
Exp
Control
16.529
18.471
32.671
35.486
47.050
48,571
64.679
63.436

6'" week
Exp
Control
14.907
16.300
30.407
33.357
45.500
45.629
61.271
60,864

Table 6
Pre-exercise & Post-exercise Standard Deviation values of Proprioception for the right Knee joint.
PRE EXERCISE
INITIAL
Control
Exp
2.1033
1.9747
1.4672
1.3136
2.0034
2.7186
1.2472
1.2113

Predetermined
angles of right
knee flexion
0*^-150*^-45"

2""* week
Control
Exp
1.3012
2.0121
1.I7U
1.2745
1.9313
1.5798
1.2296
0.9285

POST EXERCISE
4'*' week
Control
Exp
1.4736
0.8119
0,9848
1,4570
1.1223
1.8006
1.2699
0,9270

6"' week
('ontrol
Exp
0.3990
0.9047
0.6944
1,2062
0.5831
0.6900
0.8352
0,7099

Table 7
Unpaired "t" test values of Proprioccptiou for the right Knee joint.
POST EXERCISE

Predetermined
angles of right knee
flexion

PRE EXERCISE
INITIAL

2"''week

4* week

6'^ week

df(degree
of freedom)

(f-15"

0,843

3.212

4,321

5,271

26

0"^30"

1.493

4.154

5.988

7.930

26

O''-45

0.217

1.821

2,683

0.533

26

Cr-60"

0,553

2.116

2.958

1.390

26

p value
0.000
HS*
0.000
HS'^
0.599
NS*

0,176

*HS= Highly significant, NS=Non significant.

IJOT ; Vol. XL! : No, 2

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May 2D09 - August 2009

Assesstnen of Proprioception (Table 8, 9 & 10) for left Knee joint:Table 8

Pre-exercise & Post-exercise mean scores of Proprioception for the left Knee joint.
Predetermined
angks of left
knee flexion
(f-15"

PRE EXERCISE
INITIAL
Exp
Control
19.77!
20.693
37.707
38.643
51.300
51.071
68.64
67.671

0"-45"

ir-6(r

2"*^ week
Exp
Control
17.750
19,M3
15,329
37.571
49.607
49,286
65,950
66.636

POST EXERCISE
4"' week
Exp
Control
16.493
18.029
32,.'i71
36.09.
47.743
48.329
63.714
65,143

6'^ week
Exp
Control
14,900
16..264
.4.664
.0.60
45-186
45.629
60,986
61.493

Table 9
Pre-exercise & Post-exercise Standard Deviation values of Proprioception for the left Knee joint.
Predetermined
angles of Idt
knee Hexion
0"-15"
ir-Mf
)"-45"

PRE EXERCISE
INITIAL
Exp
Control
1.5779
1.9269
1.7127
i.3012
1.9I8
1.7063
L7637
2.0 ! 93

o"-6(r

2"" week
Exp
Control
i.0932
1.8186
1.3820
1.6909
1.7497
I.S574
i .4981
1.9805

POST EXERCISE
4'" week
Exp
Control
0.9352
1.4751
1.0440
1,5061
1.3637
1.7539
1.5231
1.8105

6'" week
Control
i.[784
0.5948
0.7158
1.4841
0.6347
0.6069
0.8986
0.8965
Exp

Table 10
Unpaired "t" test values of Proprioception for the left Knee joint.
Predetermined
angles of left knee
flexion

PRK EXERCISE
INITIAL

2"%eek

4'" week

6"' week

df(degree
of freedom 1

if' ! 5"'

..S84

3A62

.1290

3.867

26

(T-Mf

1.628

3.500

7.19)

9.230

26

0--4.S"

0.33.5

0.471

0986

1,887

26

0"-6(f

1316

1.033

2,259

1.495

26

POST EXERCISE

p value
O,K)1
O.O(K)
HS^^
0.070
NS^^
0.147

'1iS= High!) significant, NS~Non signicant.

Hence, HI is accepted only at 15'^ & 30" perceived angle o\'
hilaeral knee Oexion. Tiowever. HO is accepted at 45" & 60"

As persialistical analysis shown in Table 5 , 6 . 7 . 8 . 9 , & 10 it

was ibiitui thai expLTimciUa! group showed highly significant
iiiprovement at 15" & 30" perceived angle of bilateral knee
flexion as compared lo control group. At 4 5 " & 60" perceived
angle of bilateral knee flexion showed non significant results.
The experimental group had an increase in perceived angle
of hi latera! knee ilex ion a t 4 5 " & ; 60"(i.e proprioception) but
ihe difference was not slatislically significant when both
experimental & control groups were c o m p a r e d .

perceived angle of bilateral knee flexion.

DISCUSSION
In this study proprioceptive training was given lo iiiiprt)ve
joint position sense (orjoint pr[>prioception). Propriocept[\c
training involves use of weight bearing exercises; closed
kinclic chain exercises which decrease shear forces on the
extremity & iereby belps in improving proprioeepion &
muscle group eo-ordinaiion. Also, it has been documenied
thai proprioceplive training increases the state of readiness
of the knee joini & decrease chances of re-in jury upon rcuirn
0 daily activities. ^^^

T h e proprioceptive exercises wei'e beneficial in improving

proprioception at 15" & 30" angle of the propritcepiion as
compared u> pre-exercise therapy values ibr experimental
g r o u p as compared lo eonlro! group.

IJOT : Voi, XLi : No. 2

41

May 2009 AugusI 2009

Our study shows that after proprioceptive training for the

experimental group there was significant change in the
perception of the joint angle i.e position sense. The perception
of the joint angle i.e position sense was highly significant
statistically (p d" 0.001 )at 15 & 30 & was statistically non
significant at 45 & 60 (p> 0.05)for both the knee joints.
Although proprioception did not improve totally in
experimental group after proprioception training it was
improving faster as compared to control group.(Table 7 &
10).

CONCLUSION
It can be said that the effects of tubular Elastic Bandages on
patients with bilateral knee osteoarthritis by providing
Proprioceptive Training along with Conventional Occupational
Therapy protocol is the effective mode of treating patients
with knee osteoarthritis than treatment with Conventional
Occupational Therapy protocol alone.
Thereby it can be said that as proprioception improved
following Proprioceptive Training & use of tubular Elastic
Bandages. Patients had improved disease specific quality of
life, reduced pain, swelling, stiffness & improvement in the
physical functional ability associated with performing
Activities of Daily Living like ascending & descending stairs,
ambulation & risjng from the chair.

In our study WOMAC scale was used. Both, the

Experimental & Control Group showed reduced perceived
pain subscale as seen in (Table no.2). But the reduction
observed in the Experimental Group was statistically highly
significant as compared to the control group, (table no.4)
The findings of the present study suggest that the exercise
intervention along with tubular elastic bandage produced
decrease perceived pain in the Experimental Group compared
to the Control Group.

Thus overall functional status of patients with Knee

Osteoartritis was improved, as is the goal of Occupational
Therapy Intervention is to enhance independence in
functional performance.
However, it is recommended that further studies replicating
the present one be conducted with a larger Indian population
as sample size to substantiate the findings of this study.

Perceived stiffness on WOMAC was reduced in both the

groups as evident from (Table no.2). However, a highly
statistically significant reduction of perceived stiffness was
noted in the Experimental Group as compared to Control
Group (Table no,4).

ACKNOWLEDGEMENT
We would like to extend our acknowledgement to
Dr.M.E.Yeolekar, Dean, Seth G.S.Medical College & K.E.M
Hospital for granting us permission to carryout the study.

Both, Experimental & Control groups reported improvement

in physical functional ability (Table no.2); However, the
Experimental Group showed statistically highly significant
improvement on physical functional ability subscale of
WOMAC as compared to control group (Table no.4).

We would also like to thank all our patients who participated

in this study.

REFERENCES

Our findings suggest that the present study's exercise

intervention decreases perceived pain & stiffness & increase
in physical functional ability. The goal of rehabilitative bracing
is to provide controlled motion, which has been shown to be
beneficial to articular cartilage nourishment & collagen
orientation in ligamentous healing & remodeling. ''''
A tubular elastic bandage around the knee improved the
performance of patients with poor joint position sense, f^'
Subjects with knee OA who use tubular elastic bandages
report pain relief & diminution of feeling of "giving way" &
fear of falling. A tubular elastic bandage improves knee
proprioception through skin sensory input, which in turn may
improve sensation & thus lead to improved co-ordination "'
Hence, the present study's aim in using tubular Elastic
Bandages along with exercises is justified. The results of
the current study showed that a tubular elastic bandage does,
on the average, improve proprioception, disease-specific
quality of life, reduces pain, stiffness & improves the physical
functional ability associated with activities of daily living in
patients with knee osteoarthritis.
IJOT : Vol. XU : No. 2

42

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May 2009 - August 2009

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