Retrowalking as an Adjunct to Conventional Treatment Versus Conventional Treatment Alone on Pain and Disability in Patients with Acute Exacerbation of Chronic Knee Osteoarthritis: A Randomized Clinical Trial

Abstract

Increased external knee adduction moment during walking alters the joint biomechanics; which causes symptoms in chronic knee osteoarthritis patients.
To assess additional effects of Retro-walking over conventional treatment on pain and disability in patients with acute exacerbation of chronic knee osteoarthritis.
Thirty chronic knee osteoarthritis patients were randomly assigned into 2 groups. Group 'A' (7 men, 8 women) received conventional treatment. Group 'B' (8 men, 7 women) received conventional treatment and Retro-walking. Pain, assessed through visual analogue scale (VAS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were the primary outcomes and knee range of motion (ROM), hip abductor and extensor strength were secondary outcomes; measured pre-intervention, after 1 week and after 3 weeks of intervention.
Two factors analysis of variance for repeated measures was used for all outcomes. At the end of 3 weeks; WOMAC score showed highly significant difference within (P < 0.0001) and significant difference between groups (P = 0.040) also by Time × group interaction (P = 0.024), VAS showed highly significant difference within groups (P < 0.0001). Knee ROM showed significant difference within groups. Hip abductor and extensor strength showed significant difference by Time × group interaction (P < 0.05).
Retrowalking is an effective adjunct to conventional treatment in decreasing disability in patients with knee osteoarthritis.

Full text

North American Journal of Medical Sciences | February 2013 | Volume 5 | Issue 2 |
108
Original Article
Introduction
A chronic degenerative joint disease, osteoarthritis (OA)
is a leading cause of disability, affecting 15‑40% of
people aged 40 and above; and 60‑70% of the population
older than 60 years.[1,2] It has a multifactorial etiology
characterized by wear and tear of articular cartilage,
hypertrophy of bone at the margins and a host of
biochemical and morphological alterations of the
synovial membrane and joint capsule.[3] It is the most
frequent joint disease with a prevalence of 22‑39% in
India.[4] Although most joints of the lower extremity may
be involved, the knee is the most common site for OA
with characteristic signs like pain during weight bearing,
limitation of knee range of motion (ROM), crepitus, joint
effusion, and local inammation.[3] If left untreated,
it may result in a reduction in physical function and
independence.
In knee OA, the medial compartment is more frequently
affected than the lateral. This is due to higher transfer
of loads through the medial compartment than through
the lateral, resulting in higher external knee adduction
Retrowalking as an Adjunct to Conventional
Treatment Versus Conventional Treatment Alone
on Pain and Disability in Patients with Acute
Exacerbation of Chronic Knee Osteoarthritis:
A Randomized Clinical Trial
Gauri Arun Gondhalekar, Medha Vasant Deo
Department of Musculoskeletal Physiotherapy, Terna Physiotherapy College, Navi‑Mumbai, Maharashtra, India
Abstract
Background: Increased external knee adduction moment during walking alters the joint biomechanics; which causes symptoms in chronic
knee osteoarthritis patients. Aims: To assess additional effects of Retro‑walking over conventional treatment on pain and disability in patients
with acute exacerbation of chronic knee osteoarthritis. Materials and Methods: Thirty chronic knee osteoarthritis patients were randomly
assigned into 2 groups. Group ‘A’ (7 men, 8 women) received conventional treatment. Group ‘B’ (8 men, 7 women) received conventional
treatment and Retro‑walking. Pain, assessed through visual analogue scale (VAS), and Western Ontario and McMaster Universities Arthritis
Index (WOMAC) were the primary outcomes and knee range of motion (ROM), hip abductor and extensor strength were secondary
outcomes; measured pre‑intervention, after 1 week and after 3 weeks of intervention. Results: Two factors analysis of variance for repeated
measures was used for all outcomes. At the end of 3 weeks; WOMAC score showed highly signicant difference within (P<0.0001) and
signicant difference between groups (P=0.040) also by Time×group interaction (P=0.024), VAS showed highly signicant difference
within groups (P<0.0001). Knee ROM showed signicant difference within groups. Hip abductor and extensor strength showed signicant
difference by Time×group interaction (P< 0.05). Conclusion: Retrowalking is an effective adjunct to conventional treatment in decreasing
disability in patients with knee osteoarthritis.
Keywords: Backward‑walking, Knee osteoarthritis, Pathomechanics, Retrowalking
Address for correspondence: Miss. Gauri A Gondhalekar, Postgraduate Student, Department of Physiotherapy, Kasturba Medical College,
Manipal University, Mangalore, India. E‑mail: gauri.physio@yahoo.com
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DOI:
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Gondhalekar and Deo: Efcacy of retrowalking in knee osteoarthritis
North American Journal of Medical Sciences | February 2013 | Volume 5 | Issue 2 | 109
moment. According to studies, the first peak knee
adduction moment during walking is a strong predictor
of the severity and rate of progression of medial
compartment of knee OA.[3]
Management of knee OA necessitates a multidisciplinary
approach with physiotherapy as the main choice of
conservative management; which includes various
strategies such as manual therapy, exercises, patellar
taping and electrical modalities with or without thermal
modalities as measures for pain reduction.[2]
Recently, closed kinematic chain exercises have drawn
much attention in the management of knee OA.[5]
Studies suggest that these exercises are more effective
and functional than the traditionally employed open
kinematic chain exercises.[6] Closed kinematic chain
exercises for knee joint can be incorporated in many
ways; one of them is Retro‑walking.[5] Retro‑walking
is walking backwards.[2] Since there is propulsion in
backward direction and reversal of leg movement in
Retro‑walking, different muscle activation patterns from
those in forward walking are required.[7] The effects of
backward walking and backward running in strength
gains and joint stress reduction and hence in facilitating
rehabilitation are discussed in several studies.[2] Along
with a unique muscle activation pattern; Retro‑walking
is associated with increased cadence, decreased stride
length and different joint kinematics as compared to
forward walking and hence may offer some benets over
forward walking alone.[5,6]
Though a growing body of evidence suggests the role of
exercises in improvement of symptoms and joint function
in knee OA; precise guidelines as regards their type
and dosage have not been laid. Hence, Retro‑walking
may offer additional benets in this population. The
current study aimed at nding out the effectiveness of
Retro‑walking as an adjunct to conventional treatments
on pain and disability in patients with knee OA.
Materials and Methods
Written informed consent was obtained from all
participants prior to screening and participation in the
study. The study was conducted at the Department of
Physiotherapy, Navi‑Mumbai Municipal Corporation
Hospital, and Department of Physiotherapy in Terna
Hospital and Research Center, Navi‑Mumbai, India.
It is difficult to differentiate acute and chronic knee
pain in clinical settings as patients often present with
acute exacerbation of chronic problem.[8] Out‑patients
referred by a physician or an orthopedic surgeon to the
aforementioned departments for acute knee pain were
screened for clinical and radiological diagnosis of knee OA.
Participant selection
The participants fullling three out of the six clinical
criteria listed by The American College of Rheumatology
were diagnosed as knee OA which was confirmed
using radiological investigations.[9] The criteria are
(1) Age>50 years, (2) Morning stiffness lasting<30 min,
(3) Crepitus with active motion, (4) Bony tenderness,
(5) Bony enlargement, and (6) No warmth to touch.
Patients having knee pain for more than 6 weeks were
included. Patients with bilateral involvement, a history
of any lower extremity injury or underlying pathology,
a history of any inammatory joint disease and balance
problems or using an assistive device for ambulation
were excluded.
Testing instruments
The tools used for measurement of the two primary
outcomes: (1) A 10 cm visual analogue scale (VAS) for
rating the intensity of perceived pain. The scale had
0 (no pain at all) and 10 (maximum pain felt at this
moment) at either ends. The patient was asked to mark
his/her pain where he felt it would take its position in
the scale. (2) Western Ontario and McMaster Universities
Arthritis Index (WOMAC) of OA, a patient reported
scale, was used to assess pain, stiffness and physical
function levels in the subjects. It measures ve items for
pain, two for stiffness, and 17 for functional limitation.
Physical functioning questions cover activities of daily
living. Its Psychometric properties have been established.
It has good test‑retest reliability in pain and physical
function domain.[10]
The tool used for measurement of the secondary
outcome: Medical Research Council grading was used
to assess concentric strength of hip abductors and hip
extensors muscles and a Universal Goniometer was used
to assess knee joint ROM in prone position.
Methods
The subjects were randomly allocated to either of the
two treatment groups.
GroupA(conventional treatment group)
Subjects in this group received deep heating
modality (Short Wave Diathermy) (Electro Medical
Control, Electrotherm [250 W]) for 20 min for pain relief
and free exercises (static and dynamic quadriceps, knee
bending exercise in prone lying, hip exion exercise in
supine, hip abduction in side lying and hip extension
in prone lying position). All exercises were done in sets
of 10 repetitions; 1 set of all exercises twice‑a‑day for
1st week and progressed to 2 sets twice‑a‑day in 2nd week
and 3 sets twice‑a‑day in 3rd week.
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Gondhalekar and Deo: Efcacy of retrowalking in knee osteoarthritis
North American Journal of Medical Sciences | February 2013 | Volume 5 | Issue 2 |
110
GroupB(conventional treatment and retro‑walking group)
Subjects underwent three sessions of Retro‑walking per
day (10 mins. per session) for 3 weeks on a at surface at
their maximum pace along with conventional treatment
as mentioned above.
Data collection
The two patient reported outcomes were taken before
treatment, after 1 week of treatment and after 3 weeks
of treatment as shown in Figure 1.
Statistical analysis
The outcomes were analyzed using two factors analysis
of variance for repeated measures and Bonferroni test
with level of signicance set at P < 0.05; using SPSS
version 13.0 for Windows.
Results
Thirty three patients fullling the inclusion criteria
were screened and included in study after obtaining
their consent. Three patients were lost to follow‑up.
The study population thus had 30 adults (15 men, 15
women) of mean age 63.43±6.202 years. Scores were
analyzed pre intervention, at the end of 1 week and at
the end of 3 weeks in both the groups [Table 1]. VAS
showed highly signicant difference within the groups,
but no signicant difference was seen between the two
groups and with Time × group interaction [Tables 2
and 3].
WOMAC score showed highly signicant difference
within and signicant difference between both the groups
and with Time×group interaction [Tables 2 and 4]. Knee
joint ROM showed significant improvement within
group but not between the groups and with Time×group
interaction [Table 5]. Strength of hip abductor muscles
and hip extensor muscles did not show significant
improvement within or between the groups but
showed signicant improvement with the Time× group
interaction [Table 5].
Discussion
Present study examines the efcacy of Retro‑walking as
an adjunct to conventional treatment in reducing pain
and disability in patients with acute exacerbation of knee
OA. Group × time interaction analysis revealed that
Retro‑walking is more effective in reducing disabilities
as compared to conventional treatment. However, both
are equally effective in relieving pain.
Pain relief after conventional treatment could be
attributed to the thermal effects associated with
deep heating modality, strengthening exercises for
Table1: Primary and secondary outcomes (with respect
to groups and time interval)
Parameter Group Time
Pre After
1 week
After
3 weeks
VAS Group A 7.53±1.06 5.70±0.80 4.07±1.18
Group B 7.70±0.99 5.83±1.08 3.53±1.33
WOMAC Group A 67.26±14.67 60.00±13.24 52.60±13.29
Group B 62.80±14.95 51.33±11.57 37.13±12.68
Knee ROM Group A 111.7±6.45 113.0±5.60 117.0±4.14
Group B 112.3±10.50 118.0±6.50 125.2±5.40
Hip
abductors
strength
Group A 3.86±0.35 4.00±0.00 4.26±0.59
Group B 3.53±0.51 3.80±0.42 4.60±0.50
Hip
extensors
strength
Group A 3.93±0.25 3.933±0.25 4.467±0.51
Group B 3.80±0.41 4.13±0.35 4.93±0.25
VAS:Visual analogue scale; WOMAC:Western ontario and Mcmaster
universities arthritis index; Knee ROM:Knee range of motion
Figure 1: Methodology ow chart
hip and knee helping to steady the knee and give
additional joint protection from shock and stress. In
addition to this, Retro‑walking may have effect on
pain relief by reducing excess adductor moment at
knee joint decreasing the compressive forces on medial
compartment of knee joint.
Statistically, signicant improvement in function is seen
in both the groups and between the groups. However,
the improvement in Group B is greater than that of
Group A. Improvement in function may be attributed
to the reduction of pain, reduction in abnormal joint
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Gondhalekar and Deo: Efcacy of retrowalking in knee osteoarthritis
North American Journal of Medical Sciences | February 2013 | Volume 5 | Issue 2 | 111
kinetics and kinematics during functional movements
and improved muscle activation pattern. Studies have
shown that compared to forward walking; backward
walking creates more muscle activity in proportion
to efforts.[11] As advantages of Retro‑walking include
improvement in muscle activation pattern, reduction in
adductor moment at knee during stance phase of gait
and augmented stretch of hamstring muscle groups
during the stride; all of these may have helped in
reducing disability thus leading to improved function.
There is a possibility that proprioceptive and balance
training may have occurred during Retro‑walking
adding to its benets. Retro‑walking also has effect on
improving strength of hip extensors leading to reduced
hip flexion moment during stance phase and thus
preventing abnormal loading at knee joint and, in turn,
the disability. As a result of exercises and Retro‑walking
there was improvement in the strength of muscles
at knee and hip which may have reduced functional
disability.
There were certain limitations in the current study.
Medications of patients, activities of daily living and
recreational activities of patients were not taken into
account. The compliance of patients with the home
exercise program was not monitored.
Conclusion
Retro‑walking as an adjunct to conventional treatment
is more effective than conventional treatment alone, in
reduction of disability in patients with knee OA.
Acknowledgement
The author wants to thank all the patients for their participation
in the study, Mr. Senthil P Kumar for being a great source
of inspiration, Miss Karishma H Keswani for her valuable
contribution and biostatistician Mrs. Sucharitha Suresh for
data analysis work.
References
1. Kugler LM, Amstrong CW, Moleski B. Comparative analysis
of the kinematics and kinetics of forward and backward
human locomotion. ISBS 1988;6:451‑64.
2. Nor AM, Lyn KS. Effects of passive joint mobilization on
patients with knee osteoarthritis. Sains Malays 2011;40:1461‑5.
Table5: Two factor ANOVA for repeated measures
for knee range of motion, hip abductors and extensors
strength
Parameter Source F
value
Df P
value
Signicance
Knee ROM Time 13.981 2, 56 0.033 Sig
Group 13.872 1, 28 0.062 NS
Time×group
interaction
2.177 2, 56 0.119 NS
Hip
abductors
strength
Time 0.040 2, 56 0.841 NS
Group 16.121 1, 28 0.6 NS
Time×group
interaction
3.885 2, 56 0.024 Sig
Hip
Extensors
strength
Time 3.205 2, 56 0.076 NS
Group 31.467 1, 28 0.111 NS
Time×group
interaction
4.383 2, 56 0.015 Sig
F value:Observed F value; df:Degrees of freedom; P value:Signicance
level; HS:Highly signicant at P<0.05; NS:Not signicant at P<0.05,
Sig:Signicant at P<0.05; Knee ROM:Knee range of motion
Table3: Pairwise comparisons, parameter: VAS
Group Time Mean
difference
Standard
error
P value
A Pre‑1 week 1.83 0.26 NS
Pre‑3 week 3.46 0.36 NS
1‑3 week 1.63 0.20 NS
B Pre‑1 week 1.86 0.23 NS
Pre‑3 week 4.16 0.30 NS
1‑3 week 2.30 0.26 NS
VAS: Visual analogue scale; NS: Not signicant
Table4: Pairwise comparisons, parameter: western
ontario and McMaster universities arthritis index
Parameter Dependent
variable group
Mean
difference
Standard
error
P
value
WOMAC Pre‑1 week
Group A
Group B
4.20 3.32 0.216
Pre‑3 week
Group A
Group B
11.00 4.56 0.022*
1‑3 week group
A group B
6.80 2.89 0.025*
P value: Signicance level; *Signicant at P<0.05; WOMAC: Western ontario
and Mcmaster universities arthritis index
Table2: Two factor ANOVA for repeated measures
for visual analogue scale and Western Ontario and
McMaster universities arthritis index
Parameter Source F
value
df P
value
Signicance
VAS Time 187.795 2, 56 <0.0001 HS
Group 0.136 1, 28 0.057 NS
Time×group
interaction
2.010 2, 56 0.144 NS
WOMAC Time 60.750 2, 56 <0.0001 HS
Group 4.626 1, 28 0.040 Sig
Time×group
interaction
4.595 2, 56 0.024 Sig
F value: Observed; F value, df: Degrees of freedom; P value: Signicance
level; HS: Highly signicant at P<0.05; NS: Not signicant at P<0.05;
Sig: Signicant at P<0.05; VAS: Visual analogue scale; WOMAC: Western
ontario and Mcmaster universities arthritis index
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Gondhalekar and Deo: Efcacy of retrowalking in knee osteoarthritis
North American Journal of Medical Sciences | February 2013 | Volume 5 | Issue 2 |
112
3. Mündermann A, Dyrby CO, Andriacchi TP. Secondary
gait changes in patients with medial compartment knee
osteoarthritis: Increased load at the ankle, knee, and hip
during walking. Arthritis Rheum 2005;52:2835‑44.
4. Mahajan A, Verma S, Tandon V. Osteoarthritis. J Assoc
Physicians India 2005;53:634‑41.
5. Chen LY, Su FC, Chiang PY. Kinematic and EMG analysis
of backward walking on treadmill. Conf Proc IEEE Eng Med
Biol Soc 2000;2:825‑7.
6. Cipriani DJ, Armstrong CW, Gaul S. Backward walking at
three levels of treadmill inclination: An electromyographic
and kinematic analysis. J Orthop Sports Phys Ther
1995;22:95‑102.
7. Kumar TR, Ashraf M. The effect of backward walking
treadmill training on kinematics of the trunk and lower limbs.
Serb J Sports Sci 2009;3:121‑7.
8. Jackson JL, O’Malley PG, Kroenke K. Evaluation of acute knee
pain in primary care. Ann Intern Med 2003;139:575‑88.
9. Brotzman BS, Manske RC. The arthritic lower extremity.
Clinical Orthopedic Rehabilitataion: An Evidenced Based
Approach. 3rd ed. USA: Elsevier MOSBY; 2011. p. 380‑1.
10. McConnell S, Kolopack P, Davis AM. The Western Ontario
and McMaster Universities Osteoarthritis Index (WOMAC):
A review of its utility and measurement properties. Arthritis
Rheum 2001;45:453‑61.
11. Yang YR, Yen JG, Wang RY, Yen LL, Lieu FK. Gait outcomes
after additional backward walking training in patients
with stroke: A randomized controlled trial. Clin Rehabil
2005;19:264‑73.
How to cite this article: Gondhalekar GA, Deo MV. Retrowalking as an
adjunct to conventional treatment versus conventional treatment alone
on pain and disability in patients with acute exacerbation of chronic
knee osteoarthritis: A randomized clinical trial. North Am J Med Sci
2013;5:108-12.
Source of Support: Nil. Conict of Interest: None declared.
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