|Year : 2016 | Volume
| Issue : 4 | Page : 220-226
Comparison of effectiveness of forward and backward walking on pain, physical function, and quality of life in subjects with osteoarthritis of knee
Priya Singh Rangey, Megha Sandeep Sheth, Neeta J Vyas
Department of Physiotherapy, S. B. B. College of Physiotherapy, V. S. Hospital Campus, Ellisbridge, Ahmedabad, Gujarat, India
|Date of Web Publication||15-Nov-2016|
(Lecturer) Priya Singh Rangey
Department of Physiotherapy, S. B. B. College of Physiotherapy, V. S. Hospital Campus, Ellisbridge, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
Context: Walking, both forward and backward, is found to be effective for reducing pain in subjects with osteoarthritis (OA) of the knee and improving physical function and quality of life (QOL). Aims: This study aims to determine and compare the effects of forward walking (FW) and backward walking (BW) on pain, physical function, and QOL in subjects with OA knee. Settings and Design: Quasi-experimental study set up at general hospital, Ahmedabad, India. Subjects and Methods: Thirty subjects >40 years diagnosed as having bilateral OA knee according to American College of Rheumatology criteria having indoor and outdoor walking ability without aids were included in this study. Group A and B subjects received FW and BW respectively for 10 min in addition to conventional treatment thrice daily for 2 weeks. Group C received conventional treatment in the form of hot water fomentation and exercises. Exercises comprised of static quadriceps, short arc terminal extension of the knee, ankle toe movements, straight leg raises, knee flexion and extension, proprioceptive exercises in the form of lunges, weight shifts, partial squats and balance training on the balance board and stretching of hamstrings, tendo-Achilles and rectus femoris muscles. Statistical Analysis Used: SPSS 16.0 (IBM Corporation). Parametric tests were used. The level of significance was 5%. Results: The results showed improvement in all the outcome measures within all the three groups. However, there was no statistically significant difference between the groups except Western Ontario and McMaster Universities Arthritis Index (WOMAC). Visual analog scale (VAS) at rest on the right side in all three groups and on the left side in Group A as well as in scores of VAS at activity on both the sides (P < 0.05) and no improvement in VAS at rest on the left side in Groups B and C (P > 0.05). Improvement in WOMAC scores within all the 3 groups (P < 0.05) and SF-36 (P < 0.05). No statistically significant difference between the groups for VAS at rest (left P = 0.919, right P = 0.823) or activity (left P = 0.706, right P = 0.052) on both the sides and SF-36 scores (P > 0.05). Statistically significant difference between the groups for WOMAC (P = 0.043), Group A was better than Group C (P = 0.043). Conclusions: FW and BW along with conventional therapy are equally effective and not better than conventional treatment alone in reducing pain and improving physical function and QOL.
Keywords: Backward walking, forward walking, knee, osteoarthritis, pain, physical function, quality of life
|How to cite this article:|
Rangey PS, Sheth MS, Vyas NJ. Comparison of effectiveness of forward and backward walking on pain, physical function, and quality of life in subjects with osteoarthritis of knee. Int J Health Allied Sci 2016;5:220-6
|How to cite this URL:|
Rangey PS, Sheth MS, Vyas NJ. Comparison of effectiveness of forward and backward walking on pain, physical function, and quality of life in subjects with osteoarthritis of knee. Int J Health Allied Sci [serial online] 2016 [cited 2020 Aug 14];5:220-6. Available from: http://www.ijhas.in/text.asp?2016/5/4/220/194085
| Introduction|| |
Osteoarthritis (OA) of the knee is a major cause of mobility impairment, particularly among females.  The prevalence of OA knee in rural and urban India is 3.9% and 5.5%, respectively. ,,
Knee OA is associated with symptoms of pain and functional disability. Physical disability arising from pain and loss of functional capacity reduces the quality of life (QOL) and increases the risk of further morbidity and mortality. 
Osteoarthritis Research Society International (OARSI) guidelines recommend that patients with OA knee should be encouraged to undertake regular aerobic walking exercises.  Walking is the most common form of exercise employed by older adults, and walking-based exercise programs improve pain and functional limitation in people with symptomatic knee OA.  Graded walking provides a functional exercise that improves muscular activity around the affected joints, employs an appropriate range of motion, and provides a controlled environment which minimizes the possibility of further damage. 
Shankar et al. in 2013 found that retro-walking is highly effective in reducing pain and extension lag and improving physical function and dynamic balance in knee OA patients.  Gondhalekar and Deo in 2013 concluded that retro-walking is an effective adjunct to conventional treatment in decreasing disability in patients with knee OA. 
Recently, the investigation of backward locomotion has received particular attention from researchers. From a physical therapist perspective, backward walking (BW) on a treadmill is a common tool employed for injury prevention and lower extremity rehabilitation in the clinical setting since it has been demonstrated that BW is associated with less biomechanical strain on the knee joint rather than forward walking (FW).
The previous studies have examined the differences between FW and BW terms of several biomechanical parameters.  Comparison of FW and BW has also been done more in normal subjects.  However, FW and BW have not been compared clinically to see their effectiveness in a particular population. Furthermore, there are a limited number of studies comparing the effect of FW and BW in OA of the knee. Hence, this study aims to determine and compare the effectiveness of FW and BW on pain, physical function, and QOL in subjects with OA of the knee.
The alternative hypotheses were that there is statistically significant difference between FW and BW for pain, physical function, and quality life for the same.
| Subjects and Methods|| |
A quasi-experimental study was conducted among the general population of Ahmedabad, India. The study was set in the Physiotherapy Department of V. S. General Hospital, Ahmedabad. Ethics approval was taken from the hospital's review board. All the subjects were referred from the orthopedic out-patient department of the General Hospital. The study was conducted from May 2014 to October 2014. The total duration of the study was 2 weeks. The subjects were treated in the physiotherapy department for 2 weeks except Sunday and public holidays. Informed written consent was taken from each subject.
Males and females aged >40 years with a diagnosis of bilateral OA of the knee according to American College of Rheumatology Criteria and referred by the orthopedic out-patient department and ability to walk indoor and outdoor without assistive aid were included in this study. Those having a history of any lower extremity injury or underlying pathology, any inflammatory joint disease, any cardiac or neurological disorder, soft tissue injury of the knee, or previous history of knee surgery were excluded from this study.
The pain was measured using visual analog scale (VAS), Physical Function using Western Ontario and McMaster Universities Arthritis Index (WOMAC) of OA and QOL using SF36.
Group A subjects received FW along with conventional treatment. Each patient was asked to perform FW on level ground for 10 min at their comfortable speed up to a rate of perceived exertion (RPE) of 11-13 in the department. The subjects were asked to walk at a similar speed at home in two sessions of 10 min each.
Group B subjects received BW and conventional treatment. Each patient was asked to perform BW on level ground for 10 min at their comfortable speed up to RPE of 11-13. Since BW is not a part of our routine lives and the subjects were not accustomed to walking backward, they were given training on day 1 before the actual intervention in the parallel bars. Only when they had gained confidence in walking backward, were they allowed to walk backward without support. The subjects were asked to walk at a similar speed at home in one or two sessions for 20 min but since BW is an unaccustomed activity they were asked to do so with supervision.
Group C subjects received conventional treatment alone consisting of exercises and hot water fomentation for 10 min. Exercises in the form of static quadriceps exercises, short arc terminal extension, ankle and toe movements, straight leg raise, knee extension in a high sitting, prone knee bending, lunges, weight shifts, and partial squatting. Along with this stretching of the hamstrings, tendo-Achilles and rectus femoris was also done.
The patients were assessed again at the end of 2 weeks and then the data were collected.
| Results|| |
Data were analyzed using SPSS 16.0 (IBM Corporation). Level of significance was kept at 5%.
All the outcome measures along with age and gender were tested for normal distribution using Kolmogorov-Smirnov test. The data for all tested measures were found to be normally distributed, and hence parametric tests were applied. Paired t-test was applied for within group analyses, and one-way ANOVA was used for between-group analyses. Tukey's test was applied for post-hoc analysis.
[Table 1] shows demographic details of the subjects.
There was no statistically significant difference between the three groups (F = 0.827, P = 0.448) with respect to age and gender (χ2 = 2.522, P = 0.283).
There was no statistically significant difference between the groups for all the measures at baseline except VAS on activity on the left side as shown in the [Table 2].
There was statistically significant difference for VAS at rest within Group A on both sides (left P = 0.046, right P = 0.044), Group B on right side (P = 0.041) and Group C on right side (P = 0.042). There was no statistically significant difference within Group B on the left side (P = 0.293) and Group C on the left side (P = 0.170) [Table 3].
There was statistically significant difference for VAS at activity on both the sides within Group A (left P = 0.005, right P = 0.002), Group B (left P = 0.005, right P = 0.005), and Group C (left P = 0.008, right P = 0.005) [Table 4].
There was no statistically significant difference between the groups for VAS at rest (left P = 0.919, right P = 0.823) as well as on activity (left P = 0.706, right P = 0.052) on both the sides. Results are presented in [Table 5] and [Table 6].
Statistically significant difference within all the three groups was observed for WOMAC (Group A P < 0.01, Group B P < 0.01, Group C P = 0.005) [Table 7].
There was statistically significant difference between the groups WOMAC score (0.043). Group A was found to be statistically better than Group C (P = 0.043). There was no statistically significant difference between Groups A and B (P = 0.822) and Groups B and C (P = 0.145) [Table 8] and [Table 9].
|Table 9: Post-hoc multiple comparison of mean difference in womac score between the groups |
Click here to view
SF-36 scores were analyzed according to the different components: Physical functioning, role physical, role emotional, vitality, mental health, social functioning, bodily pain, and general health. There was statistically significant difference within all the 3 groups for all the components of SF-36 [Table 10.1] and [Table 10.2].
There was no statistically significant difference between the groups for any of the SF-36 component scores as shown in [Table 11].
| Discussion|| |
The purpose of this study was to evaluate and compare the effects of FW and BW on pain, physical function and QOL.
There was a significant improvement in the VAS scores both at rest and at activity in all the three groups except VAS at rest on the left side in Groups B and C. However, in these groups, the post VAS at rest was 0. Hence, there was an improvement compared to the pre VAS, but the difference could not be statistically significant.
The results of this study are consistent with the findings of Evcik and Sonel  who evaluated the effects of home-based exercise program and walking program on pain, physical function, and QOL in subjects with OA of the knee. They concluded that walking reduces pain in subjects with OA of the knee but it is not better in comparison to home-based exercise program. The pain relief in the FW group may be attributed to the aerobic effects that they cause. Aerobic walking programs are effective with individuals diagnosed with OA of the knee because they help relieve pain and promote nutrition and remodeling without increasing stress in the affected joint. Aerobic exercise can increase endorphin production, generating an analgesic effect, which gradually induces a decrease in pain. 
The findings in Group B are similar to the findings of Flynn and Soutas-Little  who concluded that BW may provide a greater benefit for certain conditions such as overuse injuries in the lower extremities and patellofemoral dysfunctions. Shankar et al.  and Kedia and Sharma  also concluded a similar findings in chronic OA and patellofemoral pain syndrome, respectively. The pain relief occurs because, during backward locomotion, patellofemoral joint reaction forces, and eccentric loading of the patellar tendon are both reduced. Specifically, peak patellofemoral joint compressive forces are significantly lower and occur significantly later in the stance phase in backward locomotion in comparison to forward locomotion. Furthermore, pain relief may be seen due to a reduction in excess adductor moment at knee joint which decreases the compressive forces on medial compartment of knee joint. 
Pain relief after conventional treatment could be attributed to the thermal effects associated with heating modality, strengthening exercises for hip and knee helping to steady the knee and giving additional joint protection from shock and stress. 
There was a statistically significant difference within all the three groups for the WOMAC scores. Martin et al.  suggested that a 6-month weight loss and walking program improved measures of physical functioning as determined by WOMAC, up and go test and 6 min walk test and pain measured by WOMAC in overweight and obese postmenopausal women with knee OA. The intervention included weekly nutrition classes and an exercise walking program.
Gondhalekar and Deo  postulated that as advantages of retro-walking include improvement in muscle activation pattern, reduction in adductor moment at the 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. Furthermore, there is a possibility that proprioceptive and balance training may have occurred during retro-walking adding to its benefits. They also found improvement in physical function following conventional treatment comprising deep heating modality (Short Wave Diathermy) for 20 min for pain relief and free exercises. For the conventional treatment, the improvement in function may be attributed to the reduction of pain, reduction in abnormal joint kinetics and kinematics during functional movements and improved muscle activation pattern.
All the groups showed a statistically significant difference for all the SF-36 scores, but there was no difference between the groups. Evcik and Sonel  too found a statistically significant improvement in the QOL scores in the walking group when compared to the control group in the subjects with OA knee. Dias et al.  concluded that walking program had a positive effect on QOL of elderly individuals with knee OA. Aerobic walking programs improve joint stability. This stability of the affected joint assists persons with OA to be more functional in everyday living, which progressively improves their QOL. The significant improvements in QOL may be in relation with physical activity, by helping patients reduce fatigue, anxiety, and recover their self-esteem, motivation, and mental health. 
According to Skevington  who investigated the relationship between pain and discomfort and QOL, when QOL is assessed, negative feelings are most closely associated with reports of pain and discomfort than any other facet. Those who are pain-free have significantly better QOL than those in pain. A longer duration of pain is associated with increasingly poorer QOL. Intense affective pain is particularly detrimental to a good QOL. Hence, the improvement in the QOL scores might be attributed to the reduction in pain and improved physical function and disability in all the three groups.
There was no statistically significant difference between the groups for VAS at rest as well as on activity and any of the SF-36 component scores on both the sides.
No difference between the groups might be due to the duration of the walking. It could be possible that the duration was not sufficient to get additional effects of walking. To the authors' knowledge, no study till date has compared the effects of FW and BW on pain, physical function, and QOL. The present study shows that all the three interventions: FW, BW, and Conventional treatment are equally effective in the short term. However, studies researching the effects of these interventions in the long-term need to be done. Most of the studies regarding the effectiveness of aerobic exercises in OA of knee have continued the intervention for 8 weeks or more. Also, for BW most of the studies that have been done have been performed on the treadmill. There might be a possibility that the subject learns the activity better over treadmill than on the ground. In addition, the speed that was used in the present study was limited by the pain of the subject. Due to pain and altered gait pattern, there would have been the possibility that the subject did not walk up to a speed required to gain the therapeutic effects of BW. In general, higher intensity training programs lead to greater improvements; however, higher-intensity exercise programs also result in increased rates of injury and lower compliance. 
There was statistically significant difference between the groups for WOMAC scores. FW group was found to be better than control in improving physical function as measured by WOMAC. These results are consistent with the findings of Kovar et al.  who also found that a program of supervised fitness walking and patient education can improve functional status without worsening pain or exacerbating arthritis-related symptoms in patients with OA of the knee.
OA of the knee is a condition that leads to a lot of disability and reduction of physical activity. The incidence of OA is quite large in the Indian population, and the pain it causes leads to further disability. Walking is an activity that can be performed at any time and even at home without the need of any specialist.
This study proves that both forward and backward lead to a reduction of pain and improvement of physical function and QOL. This may eventually lead to a lessened burden of life and the individual can perform his ADLs without any complaints. Also, as the individual gets better he is able to fulfill his role in the society being an active participant.
Thus, FW and BW can be used to increase the functional independence of the individual with OA of the knee.
- The speed of walking was not monitored for both FW and BW groups
- Long-term follow-up was not taken
- Assessor blinding was not done
- The compartment of involvement was not noted- whether it was tibiofemoral or patellofemoral
- Footwear was not taken into consideration.
- Future studies with long-term follow-up can be undertaken
- Studies monitoring the intensity of walking can be done
- Studies with longer duration of walking can be done.
| Conclusion|| |
FW and BW along with conventional treatment and conventional treatment alone lead to a reduction of pain and improvement of physical function and QOL after 2 weeks of intervention.
There is no difference between FW and BW along with conventional treatment and conventional treatment alone for pain and QOL.
FW along with conventional treatment is more effective in improving physical function compared to conventional treatment alone.
There is no difference between FW and BW along with conventional treatment for pain, physical function, or QOL.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Symmons D, Mathers C, Pfleger B. Global Burden of Osteoarthritis in the Year 2000. Global Burden of Disease 2000. Geneva: WHO; 2006.
Chopra A, Patil J, Billempelly V, Relwani J, Tandle HS; WHO-ILAR COPCORD study. WHO international league of associations from rheumatology community oriented program from control of rheumatic diseases. Prevalence of rheumatic diseases in a rural population in western India: A WHO-ILAR COPCORD Study. J Assoc Physicians India 2001;49:240-6.
Chopra A, Saluja M, Patil J, Tandale HS. Pain and disability, perceptions and beliefs of a rural Indian population: A WHO-ILAR COPCORD study. WHO-International League of Associations for Rheumatology. Community oriented program for control of rheumatic diseases. J Rheumatol 2002;29:614-21.
Joshi VL, Chopra A. Is there an urban-rural divide? Population surveys of rheumatic musculoskeletal disorders in the Pune region of India using the COPCORD Bhigwan model. J Rheumatol 2009;36:614-22.
Tok F, Aydemir K, Peker F, Safaz I, Taskaynatan MA, Ozgül A. The effects of electrical stimulation combined with continuous passive motion versus isometric exercise on symptoms, functional capacity, quality of life and balance in knee osteoarthritis: Randomized clinical trial. Rheumatol Int 2011;31:177-81.
Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al
. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008;16:137-62.
White DK, Tudor-Locke C, Felson DT, Gross KD, Niu J, Nevitt M, et al
. Walking to meet physical activity guidelines in knee osteoarthritis: Is 10,000 steps enough? Arch Phys Med Rehabil 2013;94:711-7.
Khyatee, Mittal K, Gupta SK. Retrotreadmill walking as a rehabilitative in knee pain and quadriceps insufficiency. Int J Res Sci Technol 2013;2(4).
Shankar P, Bhandiwad RM, Pai H. Effectiveness of retrowalking in chronic osteoarthritis of knee joint. Innov J Med Health Sci 2013; 3:19-22.
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. N Am J Med Sci 2013;5:108-12.
Zampeli F, Stergiou N, Xergia S, Georgoulis AD. Backward walking alters the stride-to-stride variability for hip, knee and ankle joints. J Orthop 2011.
Evcik D, Sonel B. Effectiveness of a home-based exercise therapy and walking program on osteoarthritis of the knee. Rheumatol Int 2002;22:103-6.
Loew L, Brosseau L, Wells GA, Tugwell P, Kenny GP, Reid R, et al
. Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis. Arch Phys Med Rehabil 2012;93:1269-85.
Flynn TW, Soutas-Little RW. Patellofemoral joint compressive forces in forward and backward running. J Orthop Sports Phys Ther 1995;21:277-82.
Kedia S, Sharma S. Effect of retro-treadmill ambulation training in patellofemoral pain patients. Physiother Occup Ther J 2012;5:59
Kisner C, Colby LA. Therapeutic Exercise: Foundations and Techniques. 5 th
ed. Philadelphia: F.A. Davis Company; 2007.
Martin K, Fontaine KR, Nicklas BJ, Dennis KE, Goldberg AP, Hochberg MC. Weight loss and exercise walking reduce pain and improve physical functioning in overweight postmenopausal women with knee osteoarthritis. J Clin Rheumatol 2001;7:219-23.
Dias RC, Dias JM, Ramos LR. Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee. Physiother Res Int 2003;8:121-30.
Skevington SM. Investigating the relationship between pain and discomfort and quality of life, using the WHOQOL. Pain 1998;76:395-406.
Kovar PA, Allegrante JP, MacKenzie CR, Peterson MG, Gutin B, Charlson ME. Supervised fitness walking in patients with osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med 1992;116:529-34.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10.1], [Table 10.2], [Table 11]