|Year : 2016 | Volume
| Issue : 1 | Page : 62-67
To study effectiveness of progressive relaxation on balancing exercises in functional outcome of osteoarthritis knee in postmenopausal females
Arunima Chaudhuri1, Manjushree Ray2, Samir Kumar Hazra3
1 Department of Physiology, Burdwan Medical College, Burdwan, West Bengal, India
2 Department of Anesthesiology, National Medical College, Kolkata, West Bengal, India
3 Department of Gynecology and Obstetrics, Burdwan Medical College, Burdwan, West Bengal, India
|Date of Web Publication||7-Jan-2016|
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
Background: Postmenopausal females with osteoarthritis (OA) of knee joint often report episodes of knee instability limiting their daily activities and this causes an added stress. Aims: To evaluate the effects of progressive muscle relaxation (PMR) on balancing exercises to improve functional ability in postmenopausal females with OA of knee. Materials and Methods: This interventional study was conducted on 60 postmenopausal females in a tertiary care hospital of Eastern India after taking Institutional Ethical Clearance and informed consent of the subjects. Perceived stress scores of the subjects were assessed. Patients were randomly allocated into two groups and they received either balancing exercises and PMR (Group A) or balancing exercises (Group B). Both of the groups received transcutaneous electrical nerve stimulation and treatment was given for 4 days a week for 4 weeks. The outcome measures were Visual Analogue Scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Results: After 4 weeks of treatment, significant reduction in the WOMAC score and VAS was found in both Groups. The results showed that improvement was more in Group A than Group B. Perceived stress scores significantly decreased in Group A (27.8 ± 1.95 vs. 20.16 ± 3.33; P < 0.000**) but the change was not significant in Group B (28.2 ± 1.4 vs. 27.46 ± 1.45; P value: 0.53). Perceived Stress Scale (PSS) was positively correlated with WOMAC and VAS scores at R value of 0.68 and 0.81, respectively. Conclusion: The results of the study indicates that balancing exercise when practiced along with stress relaxation exercises is more effective in improving the functional ability of OA knee.
فعالية الاسترخاء التدريجي و تدريبات التوازن الرياضية في نتائج الوظيفية للإناث المصابات بهشاشة عظام مفصل الركبة (Osteoarthritis- OA)بعد انقطاع الحيض
خلفية البحث: الإناث اللاتي يعانين من هشاشة عظام مفصل الركبة (OA) بعد انقطاع الحيض (OA) يظهر لديهن عدم الاستقرار في الركبة مما يحد من حركتهن اليومية وهذا يسبب توترا إضافيا.
الأهداف: تقييم فعالية الاسترخاء التدريجي للعضلات وتدريبات التوازن الرياضية لتحسين القدرة الوظيفية للإناث المصابات بهشاشة عظام مفصل الركبة (OA) بعد انقطاع الحيض
المواد والوسائل: أجريت الدراسة على 60 من الإناث بعد انقطاع الحيض في مستشفى الرعاية التخصصي في شرقي الهند وبعد أخذ الموافقة الأخلاقية وإخطار أفراد عينة الدراسة الذين خضعوا لتمارين الإجهاد. وقد قسم أفراد العينة عشوائيا إلى مجموعتين، وأخضع أفراد المجموعة (أ) لتمارين التوازن وأخضع أفراد المجموعة (ب) لتمارين الاسترخاء التدريجي. وأخضعت المجموعتان وعبر الجلد الى تحفيز العصب كهربائيا ولفترة 4 أيام في الأسبوع لمدة 4 أسابيع. كانت وسائل مقاييس النتائج هي المقياس البصري مقياس التناظري (Visual Analogue Scale - VAS) و مقياس ويسترن أونتاريو و مؤشر ما كماستر (WOMAC).
النتائج: بعد 4 أسابيع من العلاج، ظهر انخفاض على في النتيجة WOMAC و VAS في كل من المجموعات. وأظهرت النتائج أن التحسن كان أكثر في المجموعة الأولى أ من المجموعة الثانية ب وقد انخفضت معدلات الإجهاد بصورة ملحوظة في المجموعة (أ) 1.95 ± 27.8) A مقابل 20.16 ± 3.33؛ P <0.000**) ولكن كان التغيير غير ملحوظ في المجموعة (ب) 1.4 ± 28.2) B مقابل 27.46 ± 1.45؛ P القيمة: 0.53).
الخلاصة: أشارت نتائج الدراسة إلى أن ممارسة تمارين التوازن جنبا إلى جنب مع تمارين الاسترخاء التدريجي للعضلات لها تأثير واضح في تحسين القدرة الوظيفة للركبة المصابة بهشاشة عظام مفصل الركبة (OA).
Keywords: Balancing exercise therapy, knee osteoarthritis, progressive muscle relaxation, stress
|How to cite this article:|
Chaudhuri A, Ray M, Hazra SK. To study effectiveness of progressive relaxation on balancing exercises in functional outcome of osteoarthritis knee in postmenopausal females. Saudi J Sports Med 2016;16:62-7
|How to cite this URL:|
Chaudhuri A, Ray M, Hazra SK. To study effectiveness of progressive relaxation on balancing exercises in functional outcome of osteoarthritis knee in postmenopausal females. Saudi J Sports Med [serial online] 2016 [cited 2022 Jan 26];16:62-7. Available from: https://www.sjosm.org/text.asp?2016/16/1/62/167758
| Introduction|| |
Menopause is a substantial life event and causes women to reflect on the past, think about future, and come to terms with some issues of their own mortality, and this increases stress levels among postmenopausal females. Postmenopausal women have increased the risk of metabolic syndrome, including dyslipidemia, insulin resistance, hypertension, and cardiovascular diseases. Osteoarthritis (OA) of knee resulting in physical disability is a major public health problem in postmenopausal females.,, Sixty million women in India are above the age of 65 years. The average lifespan for Indian women is 65 years while in developed countries it is 80 years, so women of our country deserve special attention.
Women are more likely to have OA than men and have more severe OA. The definite increase in OA in women around the time of menopause has led investigators hypothesize that hormonal factors may play a role. Results on the effect of estrogen, either endogenous or exogenous, on OA from observational studies have been conflicting.,,, In a randomized clinical trial in a group of older postmenopausal women with heart disease, no significant difference was found in the prevalence of knee pain or its associated disability between those taking estrogen plus progestin therapy or those taking placebo. Data from the Women's Health Initiative showed that women on estrogen replacement therapy were 15% less likely to require total knee or hip arthroplasty than those not taking such therapy.,
OA is the most common joint disorder in the United States. Symptomatic knee OA occurs in 10% men and 13% in women aged 60 years or older. Old age, female gender, overweight and obesity, knee injury, repetitive use of joints, bone density, muscle weakness, and joint laxity all play roles in the development of joint OA, particularly in the weight-bearing joints. Modifying these factors may reduce the risk of OA and prevent subsequent pain and disability. OA is characterized by loss of articular cartilage, hypertrophy of bone at the margins, subchondral sclerosis, the range of biochemical and morphological alterations of the synovial membrane and joint capsule.,,,,,,,, The pathological changes that occur in OA are the result of the action of biomechanical forces coupled with multiple autocrine, paracrine, and endocrine cellular events that lead to a breakdown of the normal balance in tissue turnover within the joint.
In OA in addition to exercises that improve lower extremity strength, range of motion, and cardiovascular endurance it is now being recommended that exercise therapy programs should also include techniques to improve balance and coordination, and provide patients with an opportunity to practice various skills that they will likely encounter during normal daily activities.
Stress management programs such as meditation, yoga, hypnosis, imagery, muscle relaxation, etc., have shown improvement in positive coping skills and has been used in the treatment of various disease as an adjuvant therapy. Progressive muscle relaxation (PMR) Technique developed by Dr. Edmund Jacobson is a technique for reduction of stress and anxiety. Muscle tension accompanies anxiety; one can reduce anxiety by learning how to relax the muscular tension. This technique is easy to learn and requires no constant guidance.
Evolving definitions of OA, improvement in risk factor measurement, by utilizing advanced imaging, systemic and local biomarkers, and improved methods for measuring symptoms and their impact, can help to elucidate mechanisms and identify potential areas for intervention and prevention. The present study was conducted to identify the effectiveness of balancing exercises versus balancing exercises along with PMR to improve the functional ability of OA knee in postmenopausal females.
| Materials and Methods|| |
This pilot study was conducted in a time span of 1-year on 60 postmenopausal females in a tertiary care hospital of eastern India after taking Institutional ethical clearance and informed consent of the subjects. Women with history of amenorrhea for consecutive 12 months or more were considered as menopausal. Postmenopausal females in the age group of 50–65 years with knee pain in or around the joint for most days in last one month were selected.
American College of Rheumatology criteria for the classification and reporting of OA of the knee was used for inclusion of patients.
Clinical and laboratory diagnostic criteria:
- Knee pain plus at least 5 of the following 9 criteria: Age >50 years; stiffness <30 min; crepitus; bony tenderness; bony enlargement; no palpable warmth; erythrocyte sedimentation rate <40 mm/h; RF <1.40; synovial fluid signs of OA.
Clinical and radiographic diagnostic criteria:
- Knee pain plus osteophytes, plus at least 1 of the following 3 criteria: Age >50 years; stiffness <30 min; crepitus.
Subjects with rheumatoid arthritis, polyarthritis or systemic inflammatory arthropathy were excluded. Patients with history of total knee arthroplasty or major knee trauma injury, corticosteroid injection to the quadriceps or patellar tendon in the last month, suffering from neurological and psychological disorder, unresolved balance disorder, hip or ankle instability, excessive weakness, surgery or major trauma injury, high-risk health status such as uncontrolled hypertension, diabetes, and CAD, were not included.
Subjects with a musculoskeletal problems such as fractures, tendonitis or bursitis, or any significant symptoms affecting the whole lower limb or back that would interfere with the exercise program were excluded.
On the first appointment; histories of the subjects were carefully recorded. Subjects were asked to tally a list of 43 life events based on a relative score. The stress level in the subjects was assessed according to the presumptive life event stress scale (PSLES). Accordingly, they were categorized into no stress, less/moderate stress and severe stress. Score stress up to 40: No-stress; 41–200: Less/moderate stress; more than 200: Severe stress. Finally, 60 females with scores above 200 were chosen for the study, as they had a higher risk of developing the illness. They were randomly allocated into two groups using an online randomizer and received either balanced exercises and PMR (Group A) or balancing exercises (Group B). Dietary habits of both groups were comparable, all were nonvegetarian. Both of the groups received transcutaneous electrical nerve stimulation (TENS) and took treatment for 4 days a week for 4 weeks. The outcome measures were Visual Analogue Scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). VAS was used to measure knee pain intensity, and WOMAC was used to assess perceived pain, stiffness, and functional ability.
The Western Ontario and McMaster Universities Osteoarthritis Index
Self-administered WOMAC  index is the most common used clinical tools for evaluating patients with knee OA. The WOMAC is a disease-specific measure of pain, stiffness, and physical function for individuals with knee OA, which includes 5 items related to pain, 2 related to stiffness, and 17 related to physical function. Each item is scored on a 5-point Likert scale. Reliability and validity of WOMAC has been established with higher scores representing greater limitations in functions.
Visual Analogue Scale
The VAS  was used to measure the intensity of subjective pain sensation. The VAS consisted of 10 cm horizontal line, anchored with “no pain” at the left end (i.e., threshold intensity) and “pain as bad as it could be” at the right (i.e., maximally tolerable intensity). The subjects were requested to put a mark on the scale at the point which approximates to the relative intensity of his/her pain experienced.
The PSS of Cohen, the most widely used psychological instrument for measuring the perception of stress, was used to measure perceived stress scores. It is a measure of the degree to which situations in one's life are appraised to be stressful. Items were designed to find how unpredictable, uncontrollable, and overloaded respondents find their lives. The scale also includes a number of direct queries about current levels of experienced stress. The questions in the PSS ask about feelings and thoughts during the last month. It comprises of 10 items, four of which are reverse-scored, measured on a 5-point scale from 0 to 4. PSS scores are obtained by reversing responses (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1, and 4 = 0) to the four positively stated items (items 4, 5, 7, and 8) and then summing across all scale items. Total score ranges from 0 to 40.
Before starting the treatment in day one detail assessment according to assessment, the format was taken, and assessment of the parameters such as VAS and WOMAC were taken and recorded for both the groups as pretreatment data. Both Group A and B received TENS treatment.
The balance exercise programs were as follows:
- One leg balances: It involved standing on affected foot with relaxed, upright posture, and the other leg raised to the back (flexed at 90°). This position was held for 30 s, followed by rest for 10 s. It was repeated three times with each leg
- Blind advanced one leg balances: It was same like one leg balance, except that the patient was asked to keep her eyes completely closed while performing the exercise
- Cross body leg swings: Patients were asked to lean slightly forward with hands on a wall for support and whole body weight on affected leg, other leg was allowed to swing in front of the body, pointing toes upward as foot reached its farthest point of movement. Then the same leg was allowed to swing backward as far as comfortably possible. This was repeated for 15 times. After 10 s of rest 15 similar repetition of movements were done with the other leg
- Tandem walking: The subjects were asked to walk, placing the heel of one foot directly in front of the toe of the opposite foot (tandem walking) along a three-meter line marked on the floor
- Rocker board exercise: At first the rocker board was placed on a mat near a wall. Then the patient was asked to stand on it just trying to maintain the balance. Then asked to slowly rock it back and forth by hinging at the ankles and trying to avoid bending at the waist. Then rocking was done with the feet facing either corner.
Instruction in both active interventions included an introductory presentation and discussion, brief personal interview, personal instruction meeting, and three follow-up small group seminars. The instructional meetings lasted about 1.5 h each and took place over the course of 1-week. Participants of PMR were instructed to practice their respective techniques for 20 min twice daily (morning and evening) while seated comfortably with eyes closed. Training involved tensing the specific muscle groups of the body for 7–10 s, followed by releasing them for 15–20 s.
All participants were also requested not to reveal details of their program to individuals outside their treatment group. Assessments of patients were done by doctors who were blind to the study. Patients were reevaluated after 4 weeks of treatment.
The computer software “Statistical Package for the Social Sciences” (SPSS) version 16 (SPSS Inc. released 2007. SPSS for Windows, version 16.0. Chicago, SPSS Inc.) was used to analyze the data. The difference between the groups was considered significant and highly significant if the analyzed probability values (P value) were P < 0.05* and P < 0.01**, respectively.
| Results|| |
Sixty postmenopausal females were included in the study. There was no difference in age (56.03 ± 2.09 vs. 55.63 ± 2.9; P value: 0.54), BMI, PSLES, and PSS scores (27.86 ± 1.95 vs. 28.2 ± 1.4; P value 0.31), WOMAC and VAS scores between the two groups on first day of assessment (Group A WOMAC SCORE 44.06 ± 12.43 vs. Group B 43.93 ± 18.17; P value: 0.97 and Group A VAS SCORE 5.67 ± 1.21 vs. Group B 6.2 ± 1.35 P value: 0.11). There was significant improvement in WOMAC and VAS scores after 4 weeks of treatment in both groups (Group A WOMAC SCORE on day 1 44.06 ± 12.43 vs. Group A 18.6 ± 5.4 after 1-month of treatment; P < 0.000** and Group A VAS SCORE 5.67 ± 1.2 on day 1 vs. Group A 1.5 ± 0.68 after 4 weeks of treatment; P < 0.000** and Group B WOMAC SCORE 43.93 ± 18.17 on day 1 vs. Group B 22.13.3 ± 4.47; after 1-month of treatment; P < 0.000** and Group B VAS SCORE 6.2 ± 1.35 on day 1 vs. Group B 2.4 ± 0.89 after 4 weeks of treatment; P < 0.000). There was significant difference in WOMAC and VAS scores between the two groups following treatment (Group A WOMAC SCORE 18.6.1 ± 5.4 vs. Group B 22.13 ± 4.47; P value: 0.008** and Group A VAS SCORE 1.5 ± 0.68 vs. Group B 2.4 ± 0.89 P < 0.000**). Changes in WOMAC and VAS SCORE are shown in [Table 1] and [Table 2]. Perceived stress scores significantly decreased in Group A (27.8 ± 1.95 vs. 20.16 ± 3.33; P < 0.000**) but the change was not significant in Group B (28.2 ± 1.4 vs. 27.46 ± 1.45; P value: 0.53). PSS was positively correlated with WOMAC and VAS scores at R value of 0.68 and 0.81, respectively.
|Table 1: WOMAC and VAS scores of Group A (at first day and end of 4th week of treatment)|
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|Table 2: WOMAC and VAS scores of Group B (at first day and end of 4th week of treatment)|
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| Discussion|| |
Progressive structural and functional changes on articular structures commence at early menopause and persist postmenopause, leading to an increase in the prevalence of OA in the latter population and representing a big impact on health costs worldwide. The dramatic rise in OA prevalence among postmenopausal women, which is associated with the presence of estrogen receptors in joint tissues, suggests a link between OA and loss of ovarian function. This association indicates a potential protective role for estrogens against the development of OA.,,, The present study was conducted to evaluate the effects of PMR on balancing exercises to improve functional ability in postmenopausal females with OA of the knee. Sixty postmenopausal females were included in the study. Patients were randomly allocated into two groups, and they received either balancing exercises and PMR (Group A) or balancing exercises (Group B). There was no difference in age, PSLES, PSS scores, WOMAC, and VAS scores between the two groups on the first day of assessment. There was a significant improvement in WOMAC and VAS scores after 4 weeks of treatment in both groups. There was a significant difference in WOMAC and VAS scores between the two groups following treatment. PSS scores were significantly decreased in group A and were found to be positively correlated with WOMAC and VAS scores.
Management of OA pain involves nonpharmacologic modes of therapy as well as pharmacologic agents. Nonpharmacologic therapeutic modalities include osteopathic manipulative treatment, physical therapy (PT), exercise, use of assistive devices, and weight reduction. Pharmacologic options, categorized as topical, intra-articular, or oral, include acetaminophen, nonsteroidal anti-inflammatory agents, and cyclooxygenase type 2 inhibitors. Patients often benefit from use of a combination of these therapeutic modalities.,
Mind-body therapies may have particular promise for alleviating the distressful symptoms associated with OA of the knee. Eight studies, representing a total of 267 participants, were reviewed by Selfe and Innes in 2009. Interventions included tai chi, qigong, and yoga. Collectively, these studies suggested that specific mind-body practices may help alleviate pain and enhance physical function in adults suffering from OA of the knee. However, sample sizes were small, rigorous investigations were few, and the potential benefits of several mind-body therapies have not yet been systematically tested. In the present study, similar results were also observed.
The most widely used remedy for knee OA is rehabilitation and PT. PT has proved to be useful in helping patients with pain and mobility. Fitness walking, aerobic exercise, and strength training have all been reported to result in functional improvement in patients with OA of the knee. Having a clinical PT program has the benefits of onsite direction and availability of sophisticated equipment. Various studies have shown that having these added benefits contributes to program adherence and overall higher outcomes while in the care of the PT. Balancing exercises and TENS were found to significantly decrease WOMAC and VAS scores in the present study.
A longitudinal, randomized clinical trial pilot study was conducted by Baird and Sands in 2004 to determine whether Guided Imagery with PMR would reduce pain and mobility difficulties of women with OA. Twenty-eight older women with OA were randomly assigned to either the treatment or the control group. A significant difference between the two groups in the amount of change in pain and mobility difficulties they experienced over 12 weeks was observed. The treatment group reported a significant reduction in pain and mobility difficulties at week 12 compared to the control group. Members of the control group reported no differences in pain and nonsignificant increases in mobility difficulties. The present study also shows similar results, and we used a larger sample size and PT along with PMR for managing of our patients.
We had earlier conducted four studies to demonstrate effects of PMR on cardiovascular profile in postmenopausal females, PCOS patients, female health care professionals  and young adult males  and observed positive influence of PMR on cardiovascular profile. This study was conducted to study effects of PMR on pain management in OA patients and PSS were significantly decreased in subjects practicing PMR and outcome of treatment in this group was significantly better as compared to the other group.
Limitations, strength and future scope
The sample size was small in this pilot project, and long-term follow-up was not done, but results indicate a positive effect of stress management programs in the management of OA knee.
The application of stress relaxation exercises as an adjuvant in the treatment of OA process holds promise for the development of new, potentially disease-modifying nonpharmacologic therapies.
| Conclusion|| |
The results of the study indicate that balancing exercise when practiced along with stress relaxation exercises is more effective in improving the functional ability of OA knee.
We hereby acknowledge the West Bengal University of Health Sciences for helping us to conduct the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]