IJCRR - 7(20), October, 2015
Pages: 45-54
Date of Publication: 20-Oct-2015
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A COMPARATIVE STUDY OF EFFECTS OF A STATIONARY CYCLE AND MOTORIZED TREADMILL AS AN ADJUNCT TO CONVENTIONAL EXERCISES IN IMPROVING THE FUNCTIONAL STATUS OF PATIENTS
WITH KNEE OSTEOARTHRITIS
Author: Shivani Vaid (P.T.)
Category: Healthcare
Abstract:Objective: To determine the effectiveness of different interventions: conventional exercises, and a stationary cycle and motorized treadmill as an adjunct to it in improving the functional status of patients with knee osteoarthritis. Method: Experimental study (RCT type of study). 95 patients with knee osteoarthritis fulfilling the inclusion and exclusion criteria of the study were studied. Patients were randomly allotted by envelope method to any of the three groups. All patients were subjected to a standardized assessment including the detailed demographic details, Visual Analogue Scale (VAS) for assessing pain, 36, 61 The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for pain, stiffness and physical function, 33, 62 Timed Up and Go test (TUG) for assessing physical function and balance, 63, 64, 65 and Single Leg Standing test (SLST) for assessing balance, 65 were taken post 1 week and post 2 weeks of the intervention. The intervention was given on thrice a week schedule for total two weeks follow up. Difference between the three groups was compared by statistical methods.
Result: The study shows that irrespective of the demographic characteristics and the other parameters (OA grade, leg dominance, U/L or B/L, etc.), all the three intervention groups A, B and C are homogenous and comparable and effective intervention types showing statistically significant difference. Conclusion: The study shows a statistically highly significant result of Group C, i.e. motorized treadmill within sub maximal limits should be used as an adjunct to conventional exercises for treating Grade I and Grade II knee osteoarthritis patients in improving their functional status.
Keywords: Knee osteoarthritis, Conventional exercises, Stationary cycle, Motorized treadmill
Full Text:
INTRODUCTION
There are more than hundred types of arthritis. The most common type of arthritis is osteoarthritis (OA) or degenerative joint disease. It is a leading cause of disability and commonly affects the middle aged and elderly, although younger people may be affected as a result of injury or overuse. It is often more painful in weight bearing joints such as knee, hip and spine than the wrist, elbow and shoulder joints. Knee OA is a degenerative disease of knee joint, more common in people older than 40 years, predominantly considered a wear and tear process, where there is gradual degradation of the hyaline cartilage that covers the articulating surfaces of the bones of the knee joint. Symptoms may include joint pain, tenderness, stiffness, effusion, decreased movement secondary to pain, muscle weakness, ligament laxity, and radiological changes such as loss of joint space and osteophytes.17 Activities like walking, squatting and stair climbing are affected the most. The incidence of knee OA in India is as high as 12%. According to the International Journal of Rheumatic Disease 2011, the Community Program for Control of Rheumatic Disease (COPCORD) studies conducted in India revealed a significantly higher prevalence of knee pain in the rural (13.7%) compared to urban (6%) community.18, 20 According to The European League against Rheumatism (EULAR) committee report 2012, knee OA is likely to become the 4th most important global cause of disability in women and the 8th most important in men. Moreover, studies over the years have suggested that postural stability and balance control are also altered in people with OA, increasing their risk to falls.12, 14 These findings suggest that modification of traditional rehabilitation programs may improve the overall effectiveness of exercise therapy for people with knee OA. The management of OA is broadly divided into non pharmacological, pharmacological and surgical. Surgical management is generally reserved for failed medical management where functional disability affects the patient’s quality of life. Exercises are considered one of the major interventions in the conservative or non pharmacological treatment of patients with knee osteoarthritis.1, 35 Stationary cycle, a low impact aerobic exercise, proves to be beneficial to improve general fitness, pain and function in patients with knee OA by unloading compressive forces on the knee joints.1, 26 Motorized treadmill, though considered a high impact aerobic exercise, if the speed and inclination is kept within the submaximal limits, 15 may prove to be a better low impact exercise for patients with knee osteoarthritis, as the person is required to walk in the functional position, which is required for the activities in daily living. The present study compares the effects of a stationary cycle and motorized treadmill as an adjunct to conventional exercises in improving the functional status of patients with knee osteoarthritis.
MATERIALS
• Plinth
• Chair with arm rest
• Measuring tape - small - Large (30 m)
• Weighing scale – manual with 1 kg increment
• Stadiometer instrument
• Stop watch application available in mobile
• Pillows
• Sandbag or cloth pad
• Motorized treadmill (Kamachi company)
• Stationary cycle (Body Gym company) • Climbing stool • Parallel bars • Pen, pencil, eraser and sharpener • Ruler and stapler • Notebook • Written informed consent • Patient information sheet • Data collection sheet • Exercise handouts
METHOD STUDY DESIGN: Experimental study (RCT type of study)
SETTING OF THE STUDY: This study was conducted in Physiotherapy department, SSG Hospital, Vadodara.
DURATION OF THE STUDY: Study was completed over a period of four months i.e. December 2013 to March 2014.
SAMPLE SIZE: The difference between means of TUG of group A and group B is 0.76 and S.D (standard deviation) of group A is 0.48 and group B is 0.91 (from pilot study done on 30 knee OA patients referred to OPD 16, S.S.G Hospital, Vadodara, Gujarat, India fulfilling the inclusion and exclusion criteria of the study). With α risk 5% and power 90, the minimum expected sample size in each group came to 20, considering non responsive rate 20%, the minimum total sample size came to 72. [Ref: Med Cal C Version 12.50] 95 patients with knee osteoarthritis fulfilling the inclusion and exclusion criteria of the study were studied.
STUDY POPULATION: Patients coming to Outpatient department and being referred to OPD-16, College of Physiotherapy, S.S.G Hospital, Vadodara, Gujarat, India, at morning time, as new patients with knee OA, fulfilling the inclusion and exclusion criteria of the study.
SAMPLING METHOD: Patients were randomly allotted by envelope method to either of the Three groups: Group A: Conventional Exercises
Group B: Conventional Exercises + Stationary Cycle (voluntary speed) Group
C: Conventional Exercises + Motorized Treadmill (sub maximal speed, 0 inclinations)
SELECTION CRITERIA:
Inclusion criteria: 1
. Age: 40-75 years;
2. Grade I or II on Lawrence and Kellegren Radiological Classification;
3. Osteoarthritis knee (OA Knee) diagnosed according to the American College
Exclusion criteria:
1. Pace maker use or used;
2. Unstable heart conditions;
3. Going to participate in another physical activity program;
4. Inability to pedal a stationary cycle;
5. Inability to walk;
6. Previous knee or hip arthroplasty;
7. Epilepsy;
8. Presence of tumor or cutaneous lesion that could interfere with the procedure;
9. Previous traumatic history;
10. Other significant neurological and musculoskeletal disorders.
DATA COLLECTION AND METHODOLOGY
A written and informed consent about enrolment in the interventional study and maintaining adequate privacy and confidentiality was taken from all the patients included in the study. All patients were subjected to a standardized assessment including the detailed demographic details, Visual Analogue Scale (VAS) for assessing pain, 36,61 The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for assessing pain, stiffness and physical function,33,62 Timed Up and Go test (TUG) for assessing physical function and balance,63,64,65 and Single Leg Standing test (SLST) for assessing balance in patients.65 A detailed clinical, past, personal and family history was taken to rule out any other cause other than idiopathic or primary knee osteoarthritis. Subcommittee on Osteoarthritis of the American College of Rheumatology has defined OA as “A heterogeneous group of conditions that lead to joint symptoms and signs which are associated with defective integrity of articular cartilage, in addition to related changes in the underlying bone at the joint margins.”19 Patients of knee OA were taken from the new cases referred to OPD-16, College of Physiotherapy, S.S.G Hospital, Vadodara. They were randomly allotted by envelope method to any of the three groups: Group A: Conventional Exercises Group B: Conventional Exercises + Stationary Cycle (voluntary speed) Group C: Conventional Exercises + Motorized Treadmill (sub maximal speed, 0 inclinations)
![](https://ijcrr.com/admin/public/uploads/1/myfiles/1_1516002979683.PNG)
Group A patients were given Conventional exercises according to the American Academy of Orthopedic Surgeons (AAOS) guidelines and protocol for knee conditioning, which includes:
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Group B patients were given stationary cycle as a form of exercise adjunct to the conventional exercises. It was given for 10 minutes after the conventional exercises at patient’s voluntary speed.1 (Figure 11.1 and 11.2)
![](https://ijcrr.com/admin/public/uploads/1/myfiles/1_1516003103909.PNG)
Group C patients were given motorized treadmill as a form of exercise adjunct to the conventional exercises. It was given for 10 minutes after the conventional exercises at sub maximal speed according to Modified Bruce Protocol, 37 starting with the default lowest speed of treadmill being 0.8 miles per hour and gradually increasing, but not exceeding the speed of 1.7 miles per hour, and at 0 degree inclination level. (Figure 12.1 and 12.2)
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Each group and each patient was given the same attention by the physiotherapist and the exercises were given with same care and precaution. Patients were allowed to follow the orthopedic advices and the prescribed medication. The assessment was done using the outcome measures VAS, WOMAC, TUG and SLST taken on the date of admission to OPD-16. These outcome measures were again taken post 1 week and post 2 weeks of the intervention. The intervention was given on thrice a week schedule for total two weeks follow up. Difference between the three groups was compared by statistical methods.
RESULT
The result states that irrespective of the demographic characteristics (age, sex, BMI, etc.) and the other parameters (OA grade, leg dominance, U/L or B/L, etc.), all the three intervention groups A, B and C are homogenous, comparable and effective intervention types showing statistically significant difference.
![](https://ijcrr.com/admin/public/uploads/1/myfiles/1_1516003162804.PNG)
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The study shows a statistically significant result of Group A, i.e. conventional exercises as an intervention type, in improving VAS and TUG scores, and a highly significant result in improving WOMAC scores, but there was statistically no significant result in improving SLST scores, in patients with knee osteoarthritis. (Table 2)
![](https://ijcrr.com/admin/public/uploads/1/myfiles/1_1516003207799.PNG)
The study shows a statistically significant result of Group B, i.e. stationary cycle adjunct to conventional exercises as an intervention type, in improving VAS and SLST scores, and a highly significant result in improving WOMAC and TUG scores, in patients with knee osteoarthritis. (Table 3)
![](https://ijcrr.com/admin/public/uploads/1/myfiles/1_1516003227830.PNG)
The study shows a statistically highly significant result of Group C i.e. motorized treadmill adjunct to conventional exercises, as an intervention type, in improving all the four outcome measures scores VAS, WOMAC, TUG and SLST scores, in patients with knee osteoarthritis.(Table 4)
![](https://ijcrr.com/admin/public/uploads/1/myfiles/1_1516003247208.PNG)
DISCUSSION
Osteoarthritis (OA) also called as degenerative joint disease (DJD) is the most common of all joint diseases to affect mankind. Although joint inflammation is implied by the suffix ‘itis’, in osteoarthritis, inflammation is typically found only after there has been substantial articular degeneration.38 Approximately 40% of adults older than the age of 70 suffer from OA of the knee, 80% of people with OA knee have limitation of movement, and 25% cannot perform their major daily activities of living.39 Predisposition to knee OA increases in Asians, especially Indians as there is a common thread that binds millions of inhabitants in near similar lifestyles ranging from squatting and kneeling to sitting cross legged on ground for prayers.40 Knee OA is associated with considerable disability and functional limitation is an inevitable consequence. Studies over the years have suggested that postural stability and balance control are also altered in people with OA, increasing their risk to falls, 12, 14 the need for a specific intervention type hence becomes important. Oliveria AM, Peccin MS, Silva KN, Teixeira LE, Trevisani VF. (2012) studied the impact of exercise on the functional capacity and pain of patients with knee osteoarthritis on a thrice a week intervention for 8 weeks comparing the exercise group which included stationary cycle along with exercises and an instruction group and concluded Quadriceps strengthening exercises for eight weeks are effective to improve pain, physical function, and stiffness of patients with knee OA. Strengthening exercises combined with stretching and stationary bike should be implemented in rehabilitation programs of patients with knee OA.1 The present study compared the conventional exercises and stationary cycle as an adjunct to conventional exercises as two different intervention groups A and B, and found that group B gives more significant results than group A (table 2 and 3), which supports the conclusion of the above study, that strengthening exercises combined with stretching and stationary bike should be implemented in rehabilitation programs of patients with knee OA. Moreover the present study also compared motorized treadmill as an adjunct to conventional exercises i.e. group C with the other two groups A and B, and found that group C gives the most significant results out of the three groups, with pvalue <0.001 for VAS, WOMAC, TUG and SLST suggesting the highly significant results (table 4), which states that conventional exercises along with motorized treadmill as an adjunct should be implemented in rehabilitation programs of patients with knee OA for improving their functional status. Damiano DL, Norman TL, Stanley CJ, Park HS. (2011) studied the kinetics and kinematics analysis of elliptical training, stationary cycling, treadmill walking and over ground walking and found that treadmill walking excursion, position, gait deviation index (GDI) and variability were very similar to those of over ground walking showing kinematic and coordinative similarity, whereas elliptical training and stationary cycling showed unique patterns of differences from over ground walking. In stationary cycling the three joints hip, knee and ankle were highly coupled and constrained to move in unison. The study concluded that if kinematic similarity was the sole determinant of skill transfer, then a treadmill would be the universally preferred device. However, other devices may promote different aspects of the target task that may be even more important for transfer, particularly in varied rehabilitation applications.2
In the present study, motorized treadmill shows more significant results as an adjunct to conventional exercises than stationary cycle in improving the functional status of knee OA patients (table of 3 and 4), but supporting the above study conclusion stationary cycle may give better results in improving the range of movement of the knee joint wherein the range is limited following specific disorders. Hunt MA, McManus FJ, Hinman RS, Bennell KL. (2010) studied the predictors of Single Leg Standing balance in individuals with medial knee osteoarthritis and concluded that given the reduced balancing ability in this patient population, interventions targeting these factors are necessary.11 Another study by Kim HS, Yun DH, Yoo SD, Kim DH, Jeong YS, Yun JS, Hwang DG, Jung PK, Choi SH. (2011) on balance control and knee osteoarthritis severity and concluded that evaluation of balance control and education aimed at preventing falls would be useful to patients with knee OA.8 Supporting the above studies conclusion, the present study showed group C i.e. motorized treadmill as an adjunct to conventional exercises, as more significant intervention for knee OA patients in improving their functional status (table 4), As walking on a motorized treadmill is in a functional position for the patient where he bears equal weight on both legs because of the moving belt. And when within the sub maximal limits, the stance phase is same for both legs increasing the balance and reducing the risk to fall, as well as reduces the lurching or leaning to one side, a common finding in knee OA patients. The results from the statistical analysis of the present study support the alternative hypothesis which suggests that there is a significant difference between the effects of a stationary cycle and motorized treadmill as an adjunct to conventional exercises in improving the functional status of patients with knee osteoarthritis.
CONCLUSION
The study shows a statistically highly significant result of Group C i.e. motorized treadmill adjunct to conventional exercises, as an intervention type, in improving all the four outcome measures scores VAS, WOMAC, TUG and SLST scores, in patients with knee osteoarthritis. Thus, Group C i.e. motorized treadmill adjunct to conventional exercises, is more effective intervention type for improving the functional status of patients with knee osteoarthritis. Hence, motorized treadmill within sub maximal limits should be used as an adjunct to conventional exercises for treating Grade I and Grade II knee osteoarthritis patients in improving their functional status.
ACKNOWLEDGEMENT
Any accomplishment cannot be performed single handed but requires the efforts of many individuals. Firstly, I am thankful to GOD who always kept my faith inbuilt in me as a constant force of encouragement, support and trust. I have been privileged to have the direction and guidance from my P.G. Guide Beena Kodnani, Senior Lecturer, College of Physiotherapy, Vadodara, who has remained generous with her time and guided me with her resourceful knowledge. I acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. I am also grateful to the authors, editors and publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. I thank Dr. A.T.Leuva, Dean, Faculty of Medicine, M.S.University of Baroda and Dr. R.N. Daveshwar, Medical Superintendent, S.S.G.Hospital, Vadodara for permitting me to carry out the study in the hospital. I would like to thank Dr Vikas Doshi, Assistant Professor in PSM department, Baroda Medical College, for helping me in statistical analysis of the results of this study. My heartfelt appreciation goes to all the patients who generously volunteered to participate in the study; they deserve my utmost respect for keeping faith in me. I am thankful to my colleagues in Master of Physiotherapy, for being with me always and helping me continuously in all manners. Finally, I owe to my parents Dr. Sanjiv Vaid and Jyoti Vaid and my brother Ankit Vaid for always believing in me and encouraging me to achieve my goals.
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