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EFFICACY OF RETROWALKING IN PATIENTS WITH CHRONIC KNEE

OSTEOARTHRITIS: A SINGLE GROUP EXPERIMENTAL PILOT STUDY

Gauri Arun Gondhalekar*, Medha Vasant Deo**


ABSTRACT
Background: Increased external knee adduction moment during ambulation is a strong predictor of
the severity of symptoms in patients with chronic knee osteoarthritis. Objectives: To assess the effects
of Retro-walking along with conventional treatment on pain and disability in patients with acute
exacerbation of chronic knee osteoarthritis. Methods: Twelve patients (6 men, 6 women) with chronic
knee osteoarthritis fulfilling the inclusion criteria received conventional treatment and Retro-walking.
Pain and disability were the primary outcomes and knee range of motion (ROM), hip abductor and
extensor strength were the secondary outcomes; measured pre-intervention, after 1 week and after 3
weeks of intervention. Results: One way analysis of variance was used for all the primary and
secondary outcomes. At the end of 3 weeks; the primary outcomes showed highly significant difference
(P < 0.0001), secondary outcomes showed significant difference ( P < 0.05). Conclusion:
Retrowalking is an effective adjunct to conventional treatment in decreasing pain and disability in
patients with knee osteoarthritis.
Keywords: Retrowalking, Backward-walking, Knee osteoarthritis, external knee adductor moment

INTRODUCTION
Osteoarthritis (OA) is a chronic degenerative disorder of multifactorial etiology characterized
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8
by loss of articular cartilage, hypertrophy of
bone at the margins, subchondral sclerosis and
range of biochemical and morphological
alterations of the synovial membrane and joint
capsule.
1-5

Osteoarthritis is the most common form of
arthritis.
6,7
It is the most frequent joint disease
with a prevalence of 22-39% in India;
6,8
and
one of the leading causes of pain and disability
worldwide.
9-12
Knee is the most common site for OA
13
with
characteristic signs like pain during weight
bearing, limitation of knee range of motion
(ROM), crepitus, joint effusion, and local
inflammation.
11,14-16

In knee joint, OA affects the medial
compartment more frequently than the lateral.
This is attributed to higher transfer of loads
through the medial compartment than through
the lateral, resulting in higher external knee
adduction moment.
14

The external knee adduction moment (EKAM)
is the product of ground reaction force (GRF)
and the moment arm with respect to knee joint
center.
17-21
It leads to adduction at the
tibiofemoral joint causing compressive load at
the medial compartment of the knee joint. This
increase in joint forces results in a deleterious
effect on knee cartilage and leads to
development and progression of knee OA.
21-29
Various studies have stated that, 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.
14

Management of knee OA aims to control pain
and reduce disability.
30-32
A multidisciplinary
approach Is required with physiotherapy as the
main choice of conservative management;
which includes various strategies such as
exercises, patellar taping, manual therapy and
various electrical and thermal modalities for
pain relief.
6,31,32

Recently, weight bearing exercises have drawn
much attention in the management of knee
OA.
33-34
Studies suggest that these exercises are
more effective and functional than the
traditionally employed non weight bearing
exercises.
32
Weight bearing exercises for knee
joint can be incorporated in many ways; one of
them is Retro-walking.
30
Retro-walking is
walking backwards.
6
Since there is backward
propulsion, it leads to reversal of leg movement
in Retro-walking. This requires different
muscle activation patterns than in forward
walking.
33
Various studies have stated the
effects of backward walking and backward
running in strength gains and joint stress
reduction and facilitating rehabilitation.
6
Along
with a unique muscle activation pattern; Retro-
walking is leads to increased cadence,
decreased stride length and different joint
kinematics as compared to forward walking;
offering some benefits over forward walking
alone.
30,32

A growing body of evidence suggests the
importance of exercises in improvement of
symptoms and joint function in knee OA.
Precise guidelines as regards their type and
dosage have not been established. Hence,
Scientific Research Journal of India Volume: 3, Issue: 2, Year: 2014
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Retro-walking may offer additional benefits in
this population. The current study aimed at
finding out the efficacy of Retro-walking as an
adjunct to conventional treatments on pain and
disability in patients with chronic 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 in Terna Hospital
and Research Center, Navi-Mumbai, India.
Out-patients with diagnosis of knee OA
referred by a physician or an orthopedic
surgeon were screened for inclusion criteria.

Participant selection
Patients having knee pain for more than 6
weeks and fulfilling three out of the six clinical
criteria listed by The American College of
Rheumatology were included in the study.
34-35
The inclusion criteria are:
Age >50 years,
Morning stiffness lasting <30 min,
Crepitus with active motion,
Bony tenderness,
Bony enlargement, and
No warmth to touch.
Exclusion criteria:
Patients with bilateral involvement, a history of
any lower extremity injury or underlying
pathology and a history of any inflammatory
joint disease and balance problems,
neurological problems and using an assistive
device for ambulation were excluded.
Testing instruments
For 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 five items for pain, two
for stiffness, and 17 for functional limitation.
Physical functioning questions cover activities
of daily living. Good test-retest reliability in
pain and physical function domain has been
established for WOMAC.
36


For secondary outcomes:
Medical Research Council grading was used to
assess concentric strength of hip abductors and
hip extensors and quadriceps muscles.
(2) Universal Goniometer was used to assess
knee joint ROM in prone position.

Methods
Twelve patients (6 men, 6 women) with chronic
knee osteoarthritis fulfilling the inclusion
criteria received conventional treatment and
Retro-walking.
Conventional treatment was in the form of deep
heating modality (Short Wave Diathermy)
(Electro Medical Control, Electrotherm 250 W)
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for 20 minutes and exercises (static and
dynamic quadriceps, knee bending exercise in
prone lying, hip flexion exercise in supine, hip
abduction in side lying and hip extension in
prone lying position). All exercises were done
in sets of 10 repetitions; twice a day for 3
weeks.
Subjects also underwent two sessions of Retro-
walking per day (10 mins. per session) for 3
weeks on a flat surface at their maximum pace.

Data collection:
Pain and disability were the primary outcomes
and knee range of motion (ROM), hip abductor
and extensor, and quadriceps strength were the
secondary outcomes; measured pre-
intervention, after 1 week and after 3 weeks of
intervention

Statistical-analysis:
The outcomes were analyzed using one way
analysis of variance with level of significance
set at P < 0.05; using SPSS version 17.0 for
Windows.

RESULTS
Fifteen patients fulfilling 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 12 adults (6 men, 6
women) of mean age 64.23 3.01 years [Table
1].
Scores were analyzed pre intervention, at the
end of 1 week and at the end of 3 weeks [Table
2]. VAS and WOMAC showed highly
significant difference over a period of time
[Table 3].
Knee joint ROM, Strength of hip abductor
muscles and hip extensor muscles, and
quadriceps muscles showed significant
improvement [Table 3].


Table 1: Demographic characteristics of participants
Characteristics
N 12
Age 64.23 3.01
Female % 50 %
N: Number of subjects

Table 2: Baseline parameters
Scientific Research Journal of India Volume: 3, Issue: 2, Year: 2014
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PARAMETER PRE POST 1 WEEK POST 3 WEEKS
VAS 7.79 + 1.09 6.04 + 1.03 3.75 + 1.32
WOMAC 64.72 + 15.48 52.08 + 11.34 37.16 + 14.14
Knee ROM 72.11 + 11.09 88.78 + 14.99 90.32 + 13.22
Quadriceps Strength 3.55 + 0.32 4.2 + 0.88 4.43 + 0.11
Hip Extensors
Strength
3.22 + 0.78 3.59 + 0.32 4.11 + 0.2
Hip Abductor
Strength
3.8 + 0.43 4.17 + 0.71 4.63 + 0.19
VAS: Visual Analogue Scale, WOMAC: Western Ontario and McMaster Universities Arthritis Index ,
ROM: Range of Motion
Table 3: One way analysis of variance
Parameter F value df P value Significance
VAS 37.022 2 <0.0001 HS
WOMAC 12.059 2 <0.0001 HS
Knee ROM 7.027 2 0.001 Sig
Quadriceps Strength 8.436 2 0.001 Sig
Hip Extensors
Strength
9.585 2 0.001 Sig
Hip Abductor
Strength
8.584 2 0.001 Sig
F value: Observed F value; df: Degrees of freedom; P value: Significance level, HS: Highly significant;
Sig: Significant

12
DISCUSSION
Current pilot study examines the efficacy of
Retro-walking as an adjunct to conventional
treatment in reducing pain and disability in
patients with chronic knee OA.
Pain relief could be attributed to reduced
compressive forces on medial compartment of
knee joint by reduction of excess adductor
moment due to Retro-walking. Along with
thermal effects causing local hypoalgesia
29
and
muscle relaxation, improvement in strength of
musculature around knee and hip providing
steadiness in the knee and giving additional
joint protection from shock and stress as a
result of conventional treatment.
Improvement in function may be attributed to
the pain relief, improved ROM, improved
muscle activation pattern and reduction in
abnormal joint kinetics and kinematics during
functional movement. Several studies have
stated that compared to forward walking;
backward walking creates more muscle activity
in proportion to efforts.
37-43
It has also shown to reduce external adductor
moment at knee during stance phase of gait.
Due to a specific kinematics Retro-walking
leads to augmented stretch of hamstring muscle
groups during the stride. Other advantage of
Retro-walking includes improvement in muscle
activation pattern; all of these serve in reducing
disability thus leading to improved function.
Since it is a weight bearing exercise, it could
have led to proprioceptive and balance training,
adding to its benefits. Retro-walking also has
effect on preventing abnormal loading at knee
joint by improving strength of hip extensors
leading to reduced hip flexion moment during
stance phase and thus 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
helped in improving functional ability.

There were certain limitations in the current
study. Effects of BMI, severity of knee
deformities (for eg. genu valgum/varum), lower
limb mal-alignments (for eg. flat foot),
footwear used, 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
Retrowalking is an effective adjunct to
conventional treatment in decreasing pain and
disability in patients with chronic knee
osteoarthritis.


ACKNOWLEDGMENT
The author would like to acknowledge Dr.
Senthil P Kumar and Dr. Sujata S. Wagle for
their valuable guidance in preparation of this
manuscript.


Scientific Research Journal of India Volume: 3, Issue: 2, Year: 2014
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CORRESPONDENCE
*Physiotherapist at Breach Candy Hospital Trust, Mumbai, email: gauri.physio@yahoo.com
**Professor and Principal, TPCTs Terna Physiotherpy College, Navi Mumbai. Email: medhadeoin@yahoo.com