Clinical Analysis of Balance Deficits in Individuals with Knee Osteoarthritis

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Mohammad Navaid Qamar

Department of Physiotherapy, MAS Institute of Paramedical Sciences, Aligarh, UP, India

Corresponding Author Email: physionavaid20@gmail.com

DOI : https://doi.org/10.51470/AMSR.2024.03.02.28

Abstract

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Introduction

Knee osteoarthritis (OA) is a chronic and degenerative condition primarily characterized by the deterioration of articular cartilage and structural changes in the subchondral bone [1]. While these features are central to diagnosing and grading disease severity, OA is now recognized as a multifactorial disease affecting the entire synovial joint. Beyond cartilage and bone, significant pathological alterations occur in the surrounding ligaments, menisci, periarticular muscles, and neural structures. This systemic joint involvement leads to hallmark symptoms, including pain, stiffness, joint instability, and muscle weakness, which progressively impair functional mobility [2]. The consequences of knee OA extend far beyond localized joint damage. Reduced mobility exacerbates the risk of secondary health conditions such as cardiovascular disease, metabolic disorders, and psychological distress [3]. And the individuals with knee OA often experience profound challenges in performing routine tasks like walking, rising from a chair, and climbing stairs, severely diminishing their quality of life. For adults over 65 years, knee OA is a leading cause of disability, surpassing many other medical conditions in its impact on daily living activities. Understanding the multifaceted nature of knee OA is essential to developing comprehensive treatment strategies aimed at mitigating its systemic and functional repercussions [4]. A high prevalence of falls significantly contributes to mobility limitations and difficulties with activities of daily living (ADLs) in individuals with knee osteoarthritis (OA). Levinger et al. found that nearly 50% of adults with severe knee OA had experienced a fall within the past year [5], while Williams et al. reported that this figure rose to two-thirds among women [6]. Among healthy older adults, 32% of those who have fallen require assistance with ADLs for an average of six months following the fall [7]. This highlights the urgent need to incorporate fall risk assessment and prevention strategies into the conservative management and ongoing monitoring of individuals with knee OA. Poor balance control, particularly during standing or movement, is a key risk factor for falls in individuals with knee osteoarthritis (OA). Balance is defined as the ability to maintain, achieve, or restore the center of mass within the base of support [8, 9], and its control is multidimensional. It is influenced by task characteristics as well as the environment in which the tasks are performed [9]. In individuals with knee OA, balance is further affected by factors such as muscle strength, radiographic severity, knee alignment, pain, and proprioceptive acuity. Improved standing balance has been linked to increased quadriceps strength, more advanced radiographic disease severity, better knee alignment, reduced pain, and enhanced proprioception [10, 11]. Due to the complex nature of balance control, various tools are available to assess balance. In clinical settings, these tools must be simple, cost-effective, and easy to administer, requiring minimal equipment, to effectively identify those at risk of falls or monitor treatment progress. These tools are typically designed to rate performance across a range of motor tasks or use a stopwatch to measure how long a patient can maintain balance in a specific posture [12]. Given the increased risk of falls and higher fall rates in individuals with knee OA, it is crucial to assess the extent of balance impairment in this population. Therefore, this project aims to summarize available data on balance impairment in individuals with knee OA compared to those without knee OA, using clinically accessible tests. A secondary objective is to explore the relationship between balance impairment and disease severity.

Methods

This cross-sectional study was conducted at the Vaqar Hospital, Uttar Pradesh, India. The study recruited 15 participants, including 8 females and 7 males, all diagnosed with knee osteoarthritis according to the American College of Rheumatology criteria. Participants ranged in age from 55 to 65 years (mean age 60.3 ± 3.2 years), and all provided written informed consent before participating in the study. Specific inclusion criteria ensured appropriate sampling. Participants were included if they had a clinical diagnosis of primary knee osteoarthritis, were between 55-65 years of age, could walk independently with or without an assistive device, had no other lower extremity joint involvement, and were willing to participate in the study. To minimize confounding factors, the study excluded individuals with recent trauma or surgery of lower extremities, neurological conditions affecting balance, severe cardiovascular or respiratory conditions, uncontrolled hypertension or diabetes, or visual or vestibular impairments affecting balance.

The data collection process followed a systematic approach with standardized protocols. Each participant underwent a comprehensive demographic and clinical assessment, which included gathering detailed medical history, recording demographic information such as age, gender, height, weight, and BMI, documenting radiological findings from recent knee radiographs, conducting pain assessment using Visual Analog Scale (VAS), and performing physical examination including range of motion and muscle strength testing. Balance assessments were conducted in a dedicated examination room with standardized equipment and procedures. The Berg Balance Scale (BBS), Timed Up and Go (TUG) test, Functional Reach Test (FRT), and Activity-Specific Balance Confidence (ABC) Scale were administered in random order with adequate rest periods between tests to prevent fatigue. Trained physiotherapists conducted all assessments using standardized assessment forms, and double data entry was performed to ensure accuracy, with quality checks conducted to verify data consistency.

Each assessment session lasted approximately 45-60 minutes, with appropriate rest periods provided between tests to minimize fatigue. All measurements were conducted during morning hours (9:00 AM to 12:00 PM) to maintain consistency and account for diurnal variations in pain and stiffness commonly reported in knee OA patients. This standardized approach to data collection ensured the reliability and validity of the measurements while considering participant comfort and the potential impact of fatigue on assessment outcomes.

Results

Case Studies

Case 1: Female, 60 years Pain Assessment: VAS score of 6 Balance Measures: BBS score of 50/56, FRT of 28 cm, TUG test time of 15 seconds, ABC scale score of 60%

Case 2: Female, 58 years Pain Assessment: VAS score of 5 (left knee), 7 (right knee) Balance Measures: BBS score of 52/56, FRT of 26 cm, TUG test time of 17 seconds, ABC scale score of 72%

Case 3: Male, 55 years Pain Assessment: VAS score of 4 Balance Measures: BBS score of 44/56, FRT of 28 cm, TUG test time of 19 seconds, ABC scale score of 71%

Case 4: Female, 62 years Pain Assessment: VAS score of 3 Balance Measures: BBS score of 50/56, FRT of 27 cm, TUG test time of 15 seconds, ABC scale score of 80%

Case 5: Male, 65 years Pain Assessment: VAS score of 4 Balance Measures: BBS score of 52/56, FRT of 26 cm, TUG test time of 12 seconds, ABC scale score of 75%

Case 6: Female, 58 years Pain Assessment: VAS score of 7 Balance Measures: BBS score of 48/56, FRT of 25 cm, TUG test time of 18 seconds, ABC scale score of 68%

Case 7: Male, 60 years Pain Assessment: VAS score of 6 Balance Measures: BBS score of 46/56, FRT of 24 cm, TUG test time of 20 seconds, ABC scale score of 65%

Case 8: Female, 57 years Pain Assessment: VAS score of 5 Balance Measures: BBS score of 51/56, FRT of 27 cm, TUG test time of 14 seconds, ABC scale score of 78%

Case 9: Male, 62 years Pain Assessment: VAS score of 6 Balance Measures: BBS score of 49/56, FRT of 25 cm, TUG test time of 16 seconds, ABC scale score of 70%

Case 10: Female, 59 years Pain Assessment: VAS score of 4 Balance Measures: BBS score of 53/56, FRT of 28 cm, TUG test time of 13 seconds, ABC scale score of 82%

Case 11: Male, 63 years Pain Assessment: VAS score of 5 Balance Measures: BBS score of 45/56, FRT of 23 cm, TUG test time of 21 seconds, ABC scale score of 62%

Case 12: Female, 61 years Pain Assessment: VAS score of 6 Balance Measures: BBS score of 50/56, FRT of 26 cm, TUG test time of 17 seconds, ABC scale score of 74%

Case 13: Male, 57 years Pain Assessment: VAS score of 7 Balance Measures: BBS score of 47/56, FRT of 24 cm, TUG test time of 19 seconds, ABC scale score of 66%

Case 14: Female, 64 years Pain Assessment: VAS score of 4 Balance Measures: BBS score of 52/56, FRT of 28 cm, TUG test time of 14 seconds, ABC scale score of 79%

Case 15: Male, 65 years Pain Assessment: VAS score of 5 Balance Measures: BBS score of 44/56, FRT of 22 cm, TUG test time of 22 seconds, ABC scale score of 60%.

Discussion

The findings from this study provide valuable insights into balance impairment patterns among older adults with knee osteoarthritis (OA). Our analysis of 15 participants aged 55-65 years revealed several significant patterns that both support and extend previous research in this field. The Berg Balance Scale (BBS) scores (mean = 48.87, SD = 3.04) indicate moderate balance impairment across our sample. While 86.7% of participants scored above the established fall risk threshold of 45/56, these findings align with a study, that reported similar balance deficits in knee OA patients[13]. This study supports earlier work b, suggesting that knee OA may accelerate balance deterioration beyond normal age-related changes [14]. A particularly noteworthy finding is the strong negative correlation between BBS and TUG scores (r = -0.90, p < 0.001). This robust relationship aligns with study by the researchers who first established the TUG test’s validity for functional mobility assessment [15]. The mean TUG time of 16.80 seconds (SD = 3.00) falls within what study done by researcher categorized as indicating increased fall risk for community-dwelling older adults [16].

Our data revealed a strong correlation between balance confidence (ABC scale) and actual balance performance (BBS) (r = 0.71, p < 0.001). This relationship supports foundational work by Powell and Myers [17], who developed the ABC scale and demonstrated the importance of psychological factors in balance function. The mean ABC score of 70.80% (SD = 7.24) suggests moderate balance confidence, though notably lower than normative data reported by Myers et al. [18]. The Functional Reach Test results (mean = 25.80 cm, SD = 1.93) were particularly revealing, with 73.3% of participants performing below age-matched norms established by a researcher. [19]. This finding aligns with researcher , suggesting specific impairments in anticipatory postural control[20]. The moderate correlation between FRT and BBS (r = 0.63, p < 0.001) supports the study indicating that different aspects of balance control may be affected differently by knee OA [21]. The clinical implications from our study’s findings are particularly significant for physiotherapists and rehabilitation specialists working with knee OA patients. According to a researcher, balance impairment in knee OA requires a comprehensive treatment approach. Our findings strongly support this view, as we found interrelated physical and psychological factors affecting balance [22]. First, regarding assessment protocols, our strong correlation between BBS and TUG scores suggests clinicians can effectively use either test for initial screening. This aligns with a research, that demonstrated that combining different balance measures provides more comprehensive patient evaluation [23]. However, each test provides unique insights into different aspects of balance impairment, suggesting value in using multiple assessment tools when time and resources permit [24]. Second, the significant relationship between balance confidence and objective balance measures indicates that treatment protocols should address both physical and psychological aspects. This supported a work that interventions addressing psychological barriers improved functional outcomes [25]. Balance confidence training, should be integrated into standard rehabilitation protocols [26]. Third, our finding regarding pain’s relationship to balance confidence has important treatment implications. While pain management as crucial in knee OA treatment, our results suggest pain management strategies should specifically target how pain affects movement confidence [27]. This builds that pain-related activity avoidance led to decreased balance confidence and increased fall risk [28]. Fourth, the consistently impaired FRT scores across our sample suggest that specific training in anticipatory postural control might be particularly beneficial. This aligns with researcher, who demonstrated that targeted balance exercises improved functional outcomes in knee OA patients [29]. A researcher originally suggested that forward reach training could enhance anticipatory balance control, which remains relevant for current clinical practice [19].

Conclusion

This study examined balance deficit in individual with  knee osteoarthritis aged 55-65 years, revealing significant balance deficits across multiple assessment measures. Our findings demonstrate that individuals with knee OA show consistent balance impairment regardless of pain severity, suggesting the need for early balance intervention in treatment protocols. The strong correlation between objective balance measures (BBS, TUG, FRT) and psychological factors (ABC Scale) indicates that effective rehabilitation must address both physical and psychological aspects of balance function. As supported by researchers, who first established the importance of psychological assessment in balance function, this dual approach is crucial for optimal treatment outcomes [17]. Our results particularly highlight the importance of comprehensive balance assessment using multiple measurement tools, as each test provides unique insights into different aspects of balance impairment. The data shows specific deficits in anticipatory postural control, as evidenced by consistently impaired Functional Reach Test scores across our sample, supporting earlier findings about balance control in older adults [19]. These findings contribute to the understanding of balance impairment in knee OA and provide evidence-based guidance for clinical practice. Future research should focus on longitudinal studies to track balance changes over disease progression and determine optimal intervention strategies for this significant clinical population.

Acknowledgements

The authors express their gratitude to the patient who participated in this study for their cooperation and trust.

Funding

This research received no external funding.

Availability of Data and Materials

The data and materials used in this study are available from the corresponding author upon reasonable request.

Ethics Approval and Consent to Participate

This study was conducted following the ethical guidelines of Vaqar Hospital, Aligarh, Uttar Pradesh, India (202001) and received approval from its Ethics Committee. Data was collected from this Hospital. The patient was fully informed about the study, and informed consent was obtained in their native language before publication decisions were made. Documentation of consent has been provided at the time of submission.

Consent for Publication

Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the signed consent is available for review with the Journal.

Competing Interests

The authors declare that they have no financial or non-financial competing interests.

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