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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by loss of articular cartilage, hypertrophy of Management of knee OA aims to control pain

bone at the margins, subchondral sclerosis and and reduce disability.30-32 A multidisciplinary
range of biochemical and morphological approach Is required with physiotherapy as the
alterations of the synovial membrane and joint main choice of conservative management;
capsule.1-5 which includes various strategies such as
Osteoarthritis is the most common form of exercises, patellar taping, manual therapy and
arthritis.6,7 It is the most frequent joint disease various electrical and thermal modalities for
with a prevalence of 22-39% in India;6,8 and pain relief. 6,31,32
one of the leading causes of pain and disability Recently, weight bearing exercises have drawn
worldwide.9-12 much attention in the management of knee
Knee is the most common site for OA13 with OA.33-34 Studies suggest that these exercises are
characteristic signs like pain during weight more effective and functional than the
bearing, limitation of knee range of motion traditionally employed non weight bearing
(ROM), crepitus, joint effusion, and local exercises.32 Weight bearing exercises for knee
inflammation.11,14-16 joint can be incorporated in many ways; one of
In knee joint, OA affects the medial them is Retro-walking.30 Retro-walking is
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compartment more frequently than the lateral. walking backwards. Since there is backward
This is attributed to higher transfer of loads propulsion, it leads to reversal of leg movement
through the medial compartment than through in Retro-walking. This requires different
the lateral, resulting in higher external knee muscle activation patterns than in forward
adduction moment.14 walking.33 Various studies have stated the
The external knee adduction moment (EKAM) effects of backward walking and backward
is the product of ground reaction force (GRF) running in strength gains and joint stress
and the moment arm with respect to knee joint reduction and facilitating rehabilitation.6 Along
17-21
center. It leads to adduction at the with a unique muscle activation pattern; Retro-
tibiofemoral joint causing compressive load at walking is leads to increased cadence,
the medial compartment of the knee joint. This decreased stride length and different joint
increase in joint forces results in a deleterious kinematics as compared to forward walking;
effect on knee cartilage and leads to offering some benefits over forward walking
development and progression of knee OA. 21-29 alone.30,32
Various studies have stated that, the first peak A growing body of evidence suggests the
knee adduction moment during walking is a importance of exercises in improvement of
strong predictor of the severity and rate of symptoms and joint function in knee OA.
progression of medial compartment of knee Precise guidelines as regards their type and
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OA. dosage have not been established. Hence,

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Retro-walking may offer additional benefits in device for ambulation were excluded.
this population. The current study aimed at Testing instruments
finding out the efficacy of Retro-walking as an For primary outcomes:
adjunct to conventional treatments on pain and (1) A 10 cm visual analogue scale (VAS) for
disability in patients with chronic knee OA. rating the intensity of perceived pain. The scale
had 0 (no pain at all) and 10 (maximum pain
MATERIALS AND METHODS: felt at this moment) at either ends. The patient
Written informed consent was obtained from all was asked to mark his/her pain where he felt it
participants prior to screening and participation would take its position in the scale.
in the study. The study was conducted at the (2) Western Ontario and McMaster Universities
Department of Physiotherapy in Terna Hospital Arthritis Index (WOMAC) of OA, a patient
and Research Center, Navi-Mumbai, India. reported scale, was used to assess pain,
Out-patients with diagnosis of knee OA stiffness and physical function levels in the
referred by a physician or an orthopedic subjects. It measures five items for pain, two
surgeon were screened for inclusion criteria. for stiffness, and 17 for functional limitation.
Physical functioning questions cover activities
Participant selection of daily living. Good test-retest reliability in
Patients having knee pain for more than 6 pain and physical function domain has been
weeks and fulfilling three out of the six clinical established for WOMAC.36
criteria listed by The American College of
Rheumatology were included in the study.34-35 For secondary outcomes:
The inclusion criteria are: Medical Research Council grading was used to
assess concentric strength of hip abductors and
• Age >50 years,
hip extensors and quadriceps muscles.
• Morning stiffness lasting <30 min,
(2) Universal Goniometer was used to assess
• Crepitus with active motion,
knee joint ROM in prone position.
• Bony tenderness,
• Bony enlargement, and
Methods
• No warmth to touch. Twelve patients (6 men, 6 women) with chronic
Exclusion criteria: knee osteoarthritis fulfilling the inclusion
Patients with bilateral involvement, a history of criteria received conventional treatment and
any lower extremity injury or underlying Retro-walking.
pathology and a history of any inflammatory Conventional treatment was in the form of deep
joint disease and balance problems, heating modality (Short Wave Diathermy)
neurological problems and using an assistive (Electro Medical Control, Electrotherm 250 W)

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for 20 minutes and exercises (static and analysis of variance with level of significance
dynamic quadriceps, knee bending exercise in set at P < 0.05; using SPSS version 17.0 for
prone lying, hip flexion exercise in supine, hip Windows.
abduction in side lying and hip extension in
prone lying position). All exercises were done RESULTS
in sets of 10 repetitions; twice a day for 3 Fifteen patients fulfilling the inclusion criteria
weeks. were screened and included in study after
Subjects also underwent two sessions of Retro- obtaining their consent.
walking per day (10 mins. per session) for 3 Three patients were lost to follow-up. The
weeks on a flat surface at their maximum pace. study population thus had 12 adults (6 men, 6
women) of mean age 64.23 ± 3.01 years [Table
Data collection: 1].
Pain and disability were the primary outcomes Scores were analyzed pre intervention, at the
and knee range of motion (ROM), hip abductor end of 1 week and at the end of 3 weeks [Table
and extensor, and quadriceps strength were the 2]. VAS and WOMAC showed highly
secondary outcomes; measured pre- significant difference over a period of time
intervention, after 1 week and after 3 weeks of [Table 3].
intervention Knee joint ROM, Strength of hip abductor
muscles and hip extensor muscles, and
Statistical-analysis: quadriceps muscles showed significant
The outcomes were analyzed using one way 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

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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 3.22 + 0.78 3.59 + 0.32 4.11 + 0.2

Strength

Hip Abductor 3.8 + 0.43 4.17 + 0.71 4.63 + 0.19

Strength

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 9.585 2 0.001 Sig

Strength

Hip Abductor 8.584 2 0.001 Sig

Strength

F value: Observed F value; df: Degrees of freedom; P value: Significance level, HS: Highly significant;
Sig: Significant

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DISCUSSION adding to its benefits. Retro-walking also has
Current pilot study examines the efficacy of effect on preventing abnormal loading at knee
Retro-walking as an adjunct to conventional joint by improving strength of hip extensors
treatment in reducing pain and disability in leading to reduced hip flexion moment during
patients with chronic knee OA. stance phase and thus and, in turn, the
Pain relief could be attributed to reduced disability. As a result of exercises and Retro-
compressive forces on medial compartment of walking there was improvement in the strength
knee joint by reduction of excess adductor of muscles at knee and hip which may have
moment due to Retro-walking. Along with helped in improving functional ability.
thermal effects causing local hypoalgesia29 and
muscle relaxation, improvement in strength of There were certain limitations in the current
musculature around knee and hip providing study. Effects of BMI, severity of knee
steadiness in the knee and giving additional deformities (for eg. genu valgum/varum), lower
joint protection from shock and stress as a limb mal-alignments (for eg. flat foot),
result of conventional treatment. footwear used, activities of daily living and
Improvement in function may be attributed to recreational activities of patients were not taken
the pain relief, improved ROM, improved into account. The compliance of patients with
muscle activation pattern and reduction in the home exercise program was not monitored.
abnormal joint kinetics and kinematics during
functional movement. Several studies have
stated that compared to forward walking; CONCLUSION
backward walking creates more muscle activity Retrowalking is an effective adjunct to
37-43
in proportion to efforts. conventional treatment in decreasing pain and
It has also shown to reduce external adductor disability in patients with chronic knee
moment at knee during stance phase of gait. osteoarthritis.
Due to a specific kinematics Retro-walking
leads to augmented stretch of hamstring muscle
groups during the stride. Other advantage of ACKNOWLEDGMENT
Retro-walking includes improvement in muscle The author would like to acknowledge Dr.
activation pattern; all of these serve in reducing Senthil P Kumar and Dr. Sujata S. Wagle for
disability thus leading to improved function. their valuable guidance in preparation of this
Since it is a weight bearing exercise, it could manuscript.
have led to proprioceptive and balance training,

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CORRESPONDENCE

*Physiotherapist at Breach Candy Hospital Trust, Mumbai, email: [email protected]

**Professor and Principal, TPCT’s Terna Physiotherpy College, Navi Mumbai. Email: [email protected]

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