INTRODUCTION:

Sherrington (1906)^[1] coined the term Proprioception. Proprioception is defined as the perception of joint position and movement as well as “the afferent information arising from internal peripheral areas of the body (located predominantly in the muscles, tendons, joint capsules and ligaments) that contribute to postural control (postural equilibrium), joint stability (segmental posture), and several conscious sensations (muscle sense)”^[2][3]. Proprioception is the sense the body has with regard to the relative position and movement of its constituent parts. It is the unconscious perception of movement and spatial orientation arising from stimuli within the body itself. Osteoarthritis of knee reduces the joint position sense of the knee joint and reduced joint position sense is an initiator of joint damage, consequently leading to osteoarthritis^[4][5][6]. The entire structure of the joint is affected in osteoarthritis. The pathology of the disease doesnot restrict itself to the cartilage but the soft tissues such as capsule and muscles are also involved. Few individuals present with inflammation of synovium,ligament laxity and bone marrow lesions. Elderly people are most commonly disabled by osteoarthritis. The inability of the cartilage to repair itself causes more disability and the treatment for OA is limited with no long term solution. Poor proprioception was found to be associated with pain,stiffness and physical function^[7]. Low energy, load-bearing exercise is beneficial for joint health. A lack of regular physical activity is a risk factor for functional decline and is associated with increased health care costs^[8]. Exercise therapy aims to improve patients' overall function and to help them meet the demands of daily living. It can be defined as a range of activities involving the prescription of muscular contraction and bodily movement^[9]. Isokinetic exercise is a mode of speed-constant training. The velocity of the joint motion is constant, excluding acceleration to and deceleration from the designated speed, and the force depends on how hard the individual pushes against the load cell. The exercise can be used at low, moderate and high velocity for different evaluations and rehabilitation programs and provides reliable data. Isokinetic exercise is actually used to quantify muscle strength, treatment and rehabilitation efficacy with mechanical or neurological instability of the knee or ligament injury^[10]. Isokinetic training has been found to significantly improve the strength of quadriceps femoris in patients with osteoarthritis of knee (Raj etal.,2018)^[11]. EMG biofeedback training is used as an supplementary in training for various forms of ailments^[12]. It has been used in fibromyalgia syndrome^[13]. The effect of EMG aided on pain in osteoarthritis of knee was studied by Raeissadat (2018)^[14] who revealed that the there was additional impact of EMGBF. However the effect of it on proprioception has not been identified. This study aimed to investigate the effects of physiotherapy, isokinetic training and EMG Biofeedback training on improving the proprioception of knee in patients with osteoarthritis of knee.

METHODOLOGY:

Participants:

About 60 participants was chosen for the study based on the sample size calculation using G power version (3.1). The subjects were chosen after they were assessed for eligiblity and inclusion criteria (American college of rheumatology criteria, severity of Grade II and Grade III according to Kellgren-Lawrence criteria^[11][15], unilateral osteoarthritis and females who have attained menopuase) while those with secondary osteoarthritis, bilateral osteoarthritis, could not attend the training session were excluded from the study. All participants were requested to sign the informed consent form prior to the study. The procedure of the study was in accordance with the Helsinki Declaration^[16] of 1975 as revised in 1983.The male participants were about 14 in number and the female participants amounted to 46 participants. The age range of the participants was 50 - 66 years. The study was conducted at Exercise and Sports Science laboratory, School of Health Sciences and Skills laboratory, School of Medical Sciences, Universiti Sains Malaysia.The present study was undertaken after the approval of the ethical committee of Universiti Sains Malaysia. An orthopedic surgeon who is blinded to the research recruited the subjects after X ray evaluation following which the participants were brought to the exercise and sport science laboratory for the baseline assessments.

Outcome measurements:

Anthropometric measurements:

The weight, height and BMI of the participants were measured and recorded using stadiometer.

Measurement of Proprioception:

Proprioception of knee was measured using BIODEX 4 isokinetic device. The measurement of proprioception of the knee joint was done using the protocol described by Koralewicz and Engh (2000)^[17]. The proprioception of knee joint was analyzed by the following methods: Participant was positioned in a high sitting position. The back rest of the seat was adjusted so that the trunk is inclined at an angle of 80 degrees. The participant was firmly secured to the seat with the help of straps to avoid any compensatory movements. The height of the seat was adjusted accordingly. An inflated pneumatic air splint was attached to the ankle to prevent any tactile feedback from the dynamometer and the limb. The pressure of the air inside the splint was maintained at 40 millimeters of mercury. The participants were blindfolded and wore headphones playing white noise to prevent any visual and auditory cues respectively. They wore less clothing to negate any extraneous skin sensation from clothing touching the knee area. The tibial pad was secured to the shank of the leg 3cm superior to the lateral malleolus^[17]. In the same seated conditions, the participant actively moved the limb to the target angle of 60°, 45° and 30° of flexion. The leg was held there for 10 seconds, so the participant could remember the position, and then returned to 90° of knee flexion. After a pause of 5 seconds, the participant moved the lower limb by active contraction at an angular velocity approximating 0.5°/second and stopped when he or she thought that the target angle had been reached. Participants were not permitted to correct the angle. The absolute difference between the perceived angle and the target angle was calculated for each trial. A maximum of three trials was performed^[17].

Figure 1. Measurment of Proprioception

The participants were chosen from a population based on simple random sampling. After the sampling was performed randomization was done using Research Randomizer (Version 4.0) [Computer software]^[18] to categorize the subjects into four groups – 1) Group A – Control group (received Conventional Physiotherapeutic intervention) (n = 18); 2) Group B – Experimental Group I, received Isokinetic Training (n = 18) consisting of 3 males and 15 females; 3) Group C – Experimental Group II, received EMG Biofeedback training (n = 18); 4) Group D – Experimental Group IV received a combined intervention of isokinetic training and EMG biofeedback (n = 18). All the allocation was concealed ina opaque envelope. Participants of the control group received Conventional Physiotherapy exercise program following the standardized physiotherapeutic intervention protocol which were progressed after 2 weeks.

S. No

Protocol

Exercises performed

Conventional Physiotherapy Deyle et al.,(2005)^[19]

1. Strengthening exercise

a. Static quadriceps

b. Standing terminal knee extension

c. Seated leg press

d. Partial squat weight lessened with arm support

e. Step-up

2. Stretching exercise

a. Standing calf stretch

b. Supine hamstring muscle stretch

c. Prone quadriceps femoris stretch

3. Range of motion exercise

a. mid-flexion to full-extension

b. mid-flexion to full-flexion

c. modified cycling motion

Isokinetic training Huang et al.,(2005)^[20]

Warm up session of 3-5 minutes cycling on a stationary bicycle without resistance or modified cycling motion, stretching of the quadriceps and hamstrings for 3 repetitions and 30 seconds hold during each repetition

5-Concentric and eccentric contraction for knee extensors,

5-Eccentric and concentric for knee flexors at (90°/sec and 150°/sec) of 60% average peak torque progressed to

20-Concentric and eccentric contraction for knee extensors,

20-Eccentric and concentric for knee flexors at (90°/sec and 150°/sec) of 60% average peak torque

Twice per week for 10 weeks resulting for about 20 sessions

30 seconds of rest between sets.

EMG Biofeedback training Yilmaz et al., 2010 ^[21]

Prior preparation of the skin was done. Electrodes were placed on vastus lateralis and vastus medialis muscle. Participant was required to hold each contraction for 10 seconds, rest 20 seconds in between contraction for five repetitions.

a. Quadriceps isometric contraction,

b. Hip adduction isometric,

c. Four ways straight leg raise and

d. 45 º knee extension

Combined intervention (Huang et al., 2005 and Yilmaz et al., 2010)^[20][21]

Isokinetic training

10 repetitions (5 repetitions at 90°/second and 5 repetitions at 150 °/second at 60%peak torque)

The training was progressed to reach 40 repetitions by the 10th week.

EMG Biofeedback

2 repetitions of Isometric quadriceps, Hip adductor isometric, four way Straight leg raise (supine lying, prone lying, side lying on right, side lying on left ), terminal knee extension in lying.

The training was progressed to 5 repetitions by the 10th week of training.

EMG biofeedback was given using Mega ME 6000. All the intervention was given for approximately 25 – 30 minutes/day, 2 days/week for 5 weeks. A mid term assessment was performed at 5th week and post intervention assessment was carried out at the end of 10 th week of intervention. A follow up assessment was carried at 14 th week followed by another assessment at 18th week. During the follow up period the participants were advised not to participate in any form of training. At the end of the 18 th week the data of the final participants after drop out were taken for analysis to find out the mean differences across groups at various time. The data were analysed using SPSS version 23.0. Descriptive statistics and repeated measures ANOVA, within and between interactions was done to compute the results of the study following analysis.

RESULTS:

The data were obtained from 60 participants since there was drop out of about 12 patients from the groups which is shown in the CONSORT diagram. The demographic data of the participants is depicted in Table 1. Female participants outnumbered the male counterpart. The number of females were about 46 and the male subjects acouted to 14. Out of the 60 participants only 7 were observed to be of normal body mass index whereas 20 subjects were obese and the remaining 33 were overweight were observed to be of normal BMI whereas the other 41 subjects were on the overweight and obese category. Table 2 depicts the mean difference in proprioception across various interventions and phases. It could be observed that the active reposiioning error decreased across all the intervention groups. The normality of the data was established by Kolomogrov-Smirnov test. Mauchly’s test of Sphericity was done to evaluate the variances of difference among the groups followed by Greenhouse Geisser corrections due to the violation of the sphericity. Table 3 shows the comparison of the active repositioning error with each treatment group based on time. There were significant reduction in the active repositioning error (P<0.05) at 5, 10,14 and 18 weeks. Repeated measures ANOVA within group analysis was applied followed by pairwise comparison with 95% confidence interval adjustment by Shefe correction. The results show that there were significant differences in conventional physiotherapy and combined intervention groups (P<0.05).The results of the intervention effect (Table 4) after repeated measures anova analysis followed by post hoc multiple comparisons using Shefe correction depicts that combined intervention was significantly better than conventional physiotherapy (P<0.05) whereas there were no significant difference amongst other groups. Pairwise comparison of group analysis with regard to time (Table 5) highlights the difference in the active repositioning error values across the intervention groups. It is evident that the combined intervention was superior to physiotherapy and isokinetic training at the end of 10 weeks of intervention and at the end of 18 weeks combined intervention was found to be signifiantly better in reducing the active repsoitioning error compared to that of conventional physiotherapy and isokinetic training (P<0.05).

Table 1. Demographic characters of the participants

	Conventional Physiotherapy	Isokinetic Training	Emg Biofeedback Training	Combined Intervention
GENDER
Male	3	3	4	4
Female	11	12	12	11
Age (years)	56.57±3.67	53.67±2.63	56.00±3.52	56.80±4.18
Weight (kg)	62±6.39	69.53±5.77	71.94±9.53	70.13±9.17
Height (cm)	153.14±5.13	151.80±3.10	155.25±5.70	155.93±5.70
BMI (kg/m²)
Normal	3	1	0	3
Overweight	11	6	9	7
Obese	0	8	7	5

Table 2. Mean differences in proprioception

	Groups	Number of Measurements	Active repositioning error@ 45 degree
	Groups	Number of Measurements	Mean	SD
Active repositioning error at 45degree of knee flexion	CP	Pre	8.00	3.28
		Mid	3.50	1.87
		Post	1.86	1.70
		Fu1	0.57	1.45
		Fu 2	1.21	1.63
	ISO	Pre	10.00	5.62
		Mid	5.07	4.57
		Post	1.87	1.19
		Fu1	2.00	1.46
		Fu 2	1.60	1.06
	EMG BIOFEEDBACK	Pre	11.44	4.03
		Mid	6.38	5.10
		Post	4.00	3.71
		Fu1	2.00	1.83
		Fu 2	1.19	0.91
	COMBINED	Pre	9.47	4.88
		Mid	7.53	5.89
		Post	5.33	3.79
		Fu1	4.07	2.66
		Fu 2	3.07	1.44

Table 3. Comparison of the active repositioning error at 45 degree with each treatment group based on time (Time effect)

Comparison	Physiotherapy		Isokinetic		Emg Biofeedback		Combined Emg+Iso
Comparison	MD(95%CI)	P-value	MD(95%CI)	P-value	MD(95%CI)	P-value	MD(95%CI)	P-value
PRE-MID	4.50(0.79,8.2)	0.01	4.93(0.87,8.99)	0.01	5.06(-0.29,10.42)	0.07	1.93(-4.20,8.07)	1.00
PRE- POST	6.41(2.81,9.4)	0.98	8.13(3.46,12.80)	0.00	7.43(3.56,11.31)	0.00	4.13(-0.52,8.79)	0.10
PRE TO FU1	7.42(3.79,11)	0.00	8.00(3.71,12.28)	0.00	9.43(5.75,13.12)	0.00	5.40(1.08,9.71)	0.01
PRE-FU2	6.78(3.35, 10.)	0.00	8.40(3.29,13.50)	0.00	10.25(7.18,13.31)	0.00	6.40(2.33,10.46)	0.00
MID-POST	1.64(-0.49,3.78)	0.22	3.20(-0.44,6.84)	0.11	2.37(-2.00,6.75)	0.94	2.20(-1.08,5.48)	0.42
MID-FU1	2.92(0.27,5.5)	0.02	3.06(-1.24,7.37)	0.33	4.37(0.61,8.13)	0.01	3.46(-0.76,7.69)	0.16
MID-FU2	2.28(0.64,3.9)	0.00	3.46(-0.30,7.23)	0.08	5.18(0.82,9.54)	0.01	4.46(-0.50,9.44)	0.09
POST-FU1	1.28(0.75,3.33)	0.53	-0.13(-1.58,1.31)	1.00	2.00(-0.95,4.95)	0.41	1.26(-0.77,3.30)	0.57
POST-FU2	0.64(-1.24,2.54)	1.00	0.26(-0.87,1.41)	1.00	2.81(0.15,5.46)	0.03	2.26(-0.73,5.26)	0.24
FU1-FU2	-0.64(-2.78,1.49)	1.00	0.40(-1.40,2.20)	1.00	0.81(-0.75,2.37)	1.00	1.00(-0.97,2.97)	1.00

Based on estimated marginal means

*. The mean difference(MD) is significant at the .05 level.

b. Adjustment for multiple comparisons: Bonferroni.

Table 4. Overall mean differences of proprioception among three intervention groups (Intervention effect)

Comparison	MD(95%CI)	P-value
Physiotherapy-Isokinetic	-1.07(-3.24,1.08)	0.56
Physiotherapy-Biofeedback	-1.97(-4.10,0.15)	0.08
Physiotherapy-Combined	-2.86(-5.02, -0.70)	0.00
Isokinetic –Biofeedback	-0.89(-2.98,1.19)	0.68
Isokinetic-Combined	-1.78(-3.91,0.33)	0.13
Biofeedback-Combined	-0.89(-2.98,1.19)	0.68

Table 5. Comparison of the proprioception among three different treatment groups based on time (Time-treatment interaction)

	Comparison	MD(95%CI)	P-value
PRE	Physiotherapy-isokinetic	-2.00(-6.62,2.62)	1.00
	Physiotherapy-biofeedback	-3.43(-7.99,1.11)	0.26
	Physiotherapy-combined	-1.46(-6.09,3.15)	1.00
	Isokinetic –biofeedback	-1.43(-5.91,3.03)	1.00
	Isokinetic-combined	0.53(-4.01,5.07)	1.00
	Biofeedback-combined	1.97(-2.50,6.44)	1.00
MID	Physiotherapy-isokinetic	-1.56(-6.29,3.16)	1.00
	Physiotherapy-biofeedback	-2.87(-7.53,1.78)	0.58
	Physiotherapy-combined	-4.03(-8.76,0.69)	0.14
	Isokinetic –biofeedback	-1.30(-5.88,3.26)	1.00
	Isokinetic-combined	-2.46(-7.11,2.18)	0.91
	Biofeedback-combined	-1.15(-5.73,3.41)	1.00
POST	Physiotherapy-isokinetic	-0.01(-2.93,2.91)	1.00
	Physiotherapy-biofeedback	-2.14(-5.02,0.74)	0.28
	Physiotherapy-combined	-3.47(-6.40, -0.54)	0.01
	Isokinetic –biofeedback	-2.13(-4.96,0.69)	0.26
	Isokinetic-combined	-3.46(-6.34, -0.58)	0.01
	Biofeedback-combined	-1.33(-4.16,1.49)	1.00
FU 1	Physiotherapy-isokinetic	-1.42(-3.38,0.52)	0.30
	Physiotherapy-biofeedback	-1.42(-3.35,0.49)	1.00
	Physiotherapy-combined	-3.49(-5.44, -1.54)	0.02
	Isokinetic –biofeedback	0.00(-1.88,1.88)	1.00
	Isokinetic-combined	-2.06(-3.98, -0.14)	0.02
	Biofeedback-combined	-2.06(-3.95, -0.18)	0.02
FU 2	Physiotherapy-isokinetic	-0.38(-1.68,0.91)	1.00
	Physiotherapy-biofeedback	-0.02(-1.25,1.30)	1.00
	Physiotherapy-combined	-1.85(-3.15, -0.55)	0.00
	Isokinetic –biofeedback	0.41(-0.84,1.66)	1.00
	Isokinetic-combined	-1.46(-2.74, -0.19)	0.01
	Biofeedback-combined	-1.87(-3.13, -0.62)	0.00

DISCUSSION:

The findings of the active repositioning error at 45º evidentially indicate that, there was an overall reduction in the repositioning error by participants across the different phases of assessment amongst the different intervention groups. A thorough analysis of the comparison amongst the group across the interventions revealed that, during the mid-term intervention assessment phase, only the participants of the Isokinetic Training group (M=5.07, SD=4.57) was observed to effectively reduce the errors compared to that of their counterparts in the combined intervention group (M=7.53, SD=5.89) (P<.05). In the post intervention assessment phase, the errors committed by the participants of the EMG biofeedback and the combined intervention group were more compared to that of the participants in the Conventional Physiotherapy group (M=1.86, SD=1.70) (P<.05). Participants of the Isokinetic Training group were observed to commit less errors in repositioning compared with that of the trainees in the EMG biofeedback training group (P<.05) and combined intervention group (P<.01). The participants of the combined intervention group were noticed to have more errors than that of their counterparts of the EMG biofeedback training group (P<.05). During the follow up assessment phase, the participants of the Conventional Physiotherapy group were observed to commit fewer errors than the participants of the other intervention groups. The trainees of the combined intervention group were observed to have more error in repositioning compared to that of their counterparts in the Isokinetic Training group (P<.01) and EMG biofeedback training group (P<.01). When the final follow up phase assessment was performed, we observed that the participants of the combined intervention group were unable to sustain the effect of the combined intervention training thereby not significantly reducing the errors committed when compared to that of the participants in the Conventional Physiotherapy (M=1.21, SD=1.63) (P<.01), Isokinetic Training (M=1.60, SD=1.06) (P<.01) and EMG biofeedback training group (M=1.19, SD=0.91) (P<.01). Combined intervention was superior to physiotherapy and isokinetic training at the end of 10 weeks of intervention and at the end of 18 weeks combined intervention was found to be signifiantly better in reducing the active repsoitioning error compared to that of conventional physiotherapy and isokinetic training (P<0.05). The finding of the current study in proposing that, participants with osteoarthritis of knee were observed to have reduced proprioception is supported by that of Barrett, Cobb and Bentley (1991)^[4], Koralewicz and Engh (2000)^[17]. Barrett, Cobb and Bentley (1991)^[4] reported a 5-10 degree of inaccuracy in the reproduction of the angle. The beneficial effect of Isokinetic Training in improving the joint position sense has been demonstrated by the work of Hazneci and co-researchers (2005)^[22] but this research was undertaken on participants with patellofemoral pain syndrome (PFPS). Hazneci et al., (2005)^[22] reported a decrease in the proprioceptive error at 50 degree extension (M=1.29, SD=0.57) and at 40 degree knee flexion (M=2.15, SD=0.97). This is in line with the finding of our study in which, Isokinetic Training produced significant improvement in the joint position sense compared with that of other intervention groups. This could be due to the fact that patellofemoral pain syndrome (PFPS) occurs in younger population who have a comparatively good strength of the muscle of the knee joint whereas in our study it was done on elderly population with osteoarthritis, super-scribed with weakness of muscle. But when the same Isokinetic Training was coupled with EMG biofeedback, the joint position sense improvement was significant among the participants with osteoarthritis of knee. Numerous studies investigating the effect of proprioceptive exercises on participants with knee OA have observed an overall beneficial effect compared with that of the strength training exercises^[23][24][25]. The aforementioned studies have included proprioceptive exercises in weight bearing position which may increase the symptoms of pain, whereas the present study has introduced a combined intervention protocol which is performed in non-weight bearing position hence the chance of aggravating the pain or symptoms could be minimal compared to that of other proprioceptive exercises. This finding is supported by the findings of Lin and co-researchers (2007)^[26], Jan and associates (2009)^[27] where they observed that proprioception can be trained in non-weight bearing positions too. Lin et al., (2007)^[26] reported an increase in the proprioceptive acuity in the range of 40.4-42.9% in both the computerised proprioceptive facilitation exercises group and the closed kinetic chain exercises group. Even though many researchers^[27][21] have used EMG aided training for the purpose of improving strength and reducing pain in the participants with knee OA, none of them have measured theeffect of EMG aided training on proprioception. Liza et al., (2018)^[28] observed that that proprioception improved in female patients with osteoarthritis of knee following isokinetic exericise training and a combination of isokinetic exercise training and conventional physiotherapy. It coulde be observed that conventional physiotherapy, isokinetic training and isometric EMG aided training were effective in reducing the repositioning error of the participants. It could also be observed from our discussion earlier that combined intervention group had improved peak torque values, improved activation of vastus medialis, reduction in the imbalances between vastus medialis and lateralis and reduction in the knee joint force and all these help in the reduction of the proprioceptive errors committed. Another factor that could possibly be attributed to the beneficial effect of the intervention is that of the activation of muscle spindle and golgi tendon organs present in the muscle and tendon. These structures do play an important role in proprioception of joint. These structures are stimulated by changes in velocity of movement. All these factors could have possibly resulted in the improvement of joint position sense of the knee joint.

LIMITATIONS:

Our study has few limitations such as smaller sample size,more female participants,participants recruited mainly from one hospital,non inclusion of other grades of knee osteoarthritis and absence of no treatment control group.These shortcomings should be considered for future researches.

CONCLUSION:

Conventional physiotherapy,isokinetic training and EMG biofeedback were effective in improving the proprioception of knee. But a combined intervention of isokinetic training and EMG biofeedback evidentially proved to be superior in enhancing the proprioception of knee in patients with knee osteoarthritis.

CONFLICT OF INTEREST:

Declared none.

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Received on 18.06.2019 Modified on 20.07.2019

Research J. Pharm. and Tech 2019; 12(9):4379-4386.

DOI: 10.5958/0974-360X.2019.00753.4