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Falls Risk and Utilization of Balance Training by Physical Therapists for Adults with Symptomatic Knee Osteoarthritis: A Retrospective Data Analysis

 

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Balance Exercise

Falls Risk and Utilization of Balance Training by Physical Therapists for Adults with Symptomatic Knee Osteoarthritis: A Retrospective Data Analysis

Monica Anderson, SPT

 

Background

This past year I had the unique opportunity to perform a retrospective analysis using data from the PATH-IN (physical therapy vs. internet-based exercise training for patients with knee osteoarthritis) trial. With the guidance of my capstone advisor Carla Hill, PT, DPT, OCS, Cert MDT and researchers from the Thurston Arthritis Research Center, Kelli Allen, PhD and Yvonne Golightly, PT, MS, PhD, I determined the extent to which physical therapy was provided during the PATH-IN trial was consistent with evidence for balance training in falls risk individuals. Components of my capstone project included performing a chart review for participants allocated to the standard physical therapy intervention group of the PATH-IN trial, classifying and coding performed physical therapy interventions as balance training or not, and determining appropriate thresholds for falls risk in this patient population. The findings from this data analysis cumulated as an abstract to be submitted to the 2018 Combined Sections Meeting (CSM) and an academic paper summarizing the background literature and findings of the analysis. It is my intent to revise this paper into a manuscript to be submitted to a peer-reviewed journal.

 

Overview

Knee osteoarthritis (OA) is a degenerative joint disease that involves the breakdown of cartilage and bone within the knee joint which can result in significant pain, swelling and stiffness (1). This progressive deterioration within the joint capsule is further exacerbated during the aging process or after injury to the knee joint (2). Knee OA is a highly prevalent joint disorder in the United States, with symptomatic knee OA occurring in 10% of men and 13% of women over the age of 60 (3). Risk factors strongly associated with the incidence of knee OA include age over 50 years, female gender, obesity (body mass index over 30), and prior trauma to the knee (4). Due to the aging population and rising obesity rates in the United States, the prevalence of individuals affected by this disease will likely increase (3,5). An estimated 26% of adults over the age of 18 in the United States will have a diagnosis of arthritis by 2040 (5).

Patients with knee OA frequently experience a loss of proprioception and kinesthesia sensation due to increased articular damage and decreased quantity of joint mechanoreceptors (7,8). These deficits contribute to inadequate neuromuscular control which decreases an individual’s ability to safely perform functional activities such as walking, negotiating stairs, reaching for objects, and rising from a chair. These musculoskeletal and neuromuscular impairments increase an individual’s risk for falls (6). Falls are responsible for a substantial sum of health care costs since they frequently result in injury and hospital admission (9). Patients with physician-diagnosed arthritis are approximately twice as likely to have two or more falls compared to healthy older adults (11). The falls for individuals with knee OA are also likely to be more severe, with 29.23% of the falls resulting in injury or fracture (6). Additionally, patients who report a history of falls with a diagnosis of knee OA are more likely to have a poorer health-related quality of life compared to individuals with a history of falls or knee OA alone (12). The rapidly aging population and increasing prevalence of arthritis will likely compound this public health problem.

Due to the increased risk for falls in this patient population, balance training and falls prevention programs may be important management strategies for individuals with symptomatic knee OA. However, there is currently limited evidence and controlled trials of individuals with knee OA participating in balance training programs to reduce falls risk. Several studies have demonstrated the additive effects of balance training interventions to standard exercise programs for individuals with knee OA (7,15,16,17). Furthermore, balance training interventions have been demonstrated to improve both quality of life and fear of movement within this patient population (10,18). Despite the increased falls risk for individuals with knee OA, the American College of Rheumatology (ACR) and the EULAR recommendations for nonpharmacologic therapies do not currently include recommendations for balance exercises for individuals with knee OA due to lack of evidence indicating a need to further explore the potential of this intervention to be integrated into management for this population (19,20).

 

Statement of Need 

My capstone project aimed to determine the prevalence of participants at risk for falling in the PATH-IN (physical therapy vs. internet-based exercise training) trial for patients with knee osteoarthritis, as well as the frequency in which participants allocated to PT and classified as high falls risk participated in balance training interventions (21).  In addition, my capstone assessed the frequency and type of balance training interventions utilized by the study physical therapists. Assessment of current physical therapy practice patterns for individuals with knee OA may offer insight into physical therapy treatment approaches to address symptomatic knee OA, specifically for individuals who are considered high falls risk. Highlighting these practice patterns may help physical therapists harness untapped potential to integrate balance training into a comprehensive plan of care for patients with knee OA, and potentially prevent future falls in this patient population.

 

Products

In preparation for this capstone project, I completed a Critically Appraised Topic (CAT) to answer a clinical question related to the effectiveness of balance training vs. therapeutic exercise as a treatment strategy for patients with symptomatic knee osteoarthritis and balance impairments.

Critically Appraised Topic – Monica Anderson

Extended Literature Review

The products that emerged from my capstone project include an abstract to be submitted to the 2018 Combined Sections Meeting (CSM) and an academic paper summarizing the findings of the retrospective data analysis. It is my intent to modify the paper into a manuscript to submit to a peer-reviewed journal. My products are intended for an audience of physical therapists and other health care professionals who treat patients with symptomatic knee osteoarthritis. Please click the links below to review my research project and the results of the data analysis.

CSM Abstract – Monica Anderson

Capstone Paper and Analysis of Findings – Monica Anderson

 

Self-Assessment and Reflection

To evaluate my abstract, I appraised and aligned my abstract to the CSM guidelines for quality abstract submissions. Additionally, I appraised the Journal of Geriatric Physical Therapy guidelines and instructions to authors in anticipation of preparing my academic paper into a manuscript for submission to a peer-reviewed journal. Substantial assessment, guidance, and feedback was provided by my faculty advisor, Carla Hill, and my project committee members, Kelli Allen and Yvonne Golightly, who offered insight and expertise to this research topic. I could not have asked for better mentors to help develop my research skills. Because of this project, I can say with certainty that I have a strong interest in clinical research. I have nothing but admiration for the dedication researchers contribute to advancing the value of care for our patients and the physical therapy profession as a whole.

 

Acknowledgements

I would like to offer immense gratitude to my capstone project advisor Carla Hill, PT, DPT, OCS, Cert MDT for her commitment to making my project a success. The guidance, encouragement, and expertise she provided throughout this capstone experience undoubtedly advanced my research abilities and analytical and clinical reasoning skills. It has been a privilege to learn from you! I would also like to thank Yvonne Golightly, PT, MS, PhD and Kelli Allen, PhD for their investment in my capstone project. I could not have completed this project without their expertise of data analysis for clinical research, knowledge of this patient population, and their dedication to help my products come to completion. I am thankful I had the opportunity to work alongside you both. Thank you for coordinating with Liubov S Arbeeva, MS (a talented and helpful statistician) to ensure I had all the data I needed to complete my analysis. In addition, thank you to Vicki Mercer, PT, PhD and Carol Giuliani, PT, PhD for offering their expertise and suggestions related to classifying balance training interventions and determining thresholds for falls risk for this patient population. Finally, I would like to thank the UNC Division of Physical Therapy for their dedication to my education these past three years. My appreciation is truly beyond words.

 

 

References

  1. Arthritis Foundation website. http://www.arthritis.org/about-arthritis/types/osteoarthritis/ Accessed April 5, 2017.
  2. Vincent KR, Conrad BP. Fregly BJ, Vincent HK. The pathophysiology of osteoarthritis a mechanical perspective of the knee joint. PH R. 2012;4(50):S3-S9.
  3. Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Clin Geriatr Med. 2010; 26(3):355-369.
  4. Zhang W, Doherty M, Peat G, Bierma-Zeinstra SMA, et al. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis. 2010; 69:483-489.
  5. Hootman JM, Helmick CG, Barbour KE, Theis KA, Boring MA.  Updated projected prevalence of self-reported doctor-diagnosed arthritis and arthritis-attributable activity limitation among US adults, 2015-2040.  Arthritis & Rheumatology. 2016; 68(7):1582-1587.
  6. Tsonga T, Michalopoulou M, Malliou P, Godolias G, et al. Analyzing the history of falls in patients with severe knee osteoarthritis. Clinics in Orthopedic Surgery. 2015; 7:449-456.
  7. Diracoglu D, Aydin R, Baskent A, Celik A. Effects of kinesthesia and balance exercises in knee osteoarthritis. Journal of Clinical Rheumatology. 2005;11(6):303-310.
  8. Duman I, Taskaynatan MA, Hohur H, Tan AK. Assessment of the impact of proprioceptive exercises on balance and proprioception in patients with advanced knee osteoarthritis. Rheumatol Int. 2012; 32:3793-3798.
  9. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed April 5, 2017.
  10. Burns EB, Stevens JA, Lee RL. The direct costs of fatal and non-fatal falls among older adults—United States. J Safety Res. 2016; (58):99-103.
  11. Barbour KE, Stevens JA, Helmick CG, Luo YH, Murphy LB, Hootman JM, et al. Falls and fall injuries among adults with arthritis–United States, 2012. MMWR Morb Mortal Wkly Rep. 2014;63(17):379–383.
  12. Vennu V, Bindawas SM. Relationship between falls, knee osteoarthritis, and health-related quality of life: data from the Osteoarthritis Initiative study. Clinical Interventions in Aging. 2014; 9:793-800.
  13. Important Facts About Falls. Centers for Disease Control and Prevention website. https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.htmlUpdated February 10, 2017. Accessed April 5, 2017.
  14. AGS/GBS Clinical Practice Guideline: Prevention of Falls in Older Persons. The American Geriatrics Society website. Accessed April 5, 2017. http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/prevention_of_falls_summary_of_recommendations
  15. Fitzgerald GK, Piva SR, Gil AB, Wisniewski SR, et al. Agility and perturbation training techniques in exercise therapy for reducing pain and improving function in people with knee osteoarthritis: a randomized clinical trial. Physical Therapy. 2011; 91(4):452-469.
  16. Golightly YM, Allen KD, Caine DJ. A comprehensive review of the effectiveness of different exercise programs for patients with osteoarthritis. The Physician and Sportsmedicine.2012;40(4):52-65.
  17. Diracoglu D, Baskent A, Celik A, Issever H, Aydin R. Long-term effects of kinesthesia/balance and strengthening exercises on patients with knee osteoarthritis: A one-year follow-up study. Journal of Back and Musculoskeletal Rehabilitation. 2008;21:253-262.
  18. Takacs J, Krowchuk NM, Garland SJ, Carpenter MG, Hunt MA. Dynamic balance training improves physical function in individuals with knee osteoarthritis: a pilot randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2017;[Epub ahead of print].
  19. Hochberg MC, Altman RD, April KT, Benkhalti M, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care & Research. 2012; 64(4):465-474.
  20. Fernandes L, Hagen KB, Bijlsma JWJ, Andreassen O, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013; 72:1125-1135.
  21. Williams QI, Gunn AH, Beaulieu JE, Benas BC, et al. Physical therapy vs. internet-based exercise training (PATH-IN) for patients with knee osteoarthritis: study protocol of a randomized controlled trial. BMC Musculoskeletal Disorders. 2015; 16:264.

 

6 Responses to “Falls Risk and Utilization of Balance Training by Physical Therapists for Adults with Symptomatic Knee Osteoarthritis: A Retrospective Data Analysis”

  1. Monica Anderson

    Hi Carla,

    Good suggestion to post my additional review of literature. The initial extension of my literature review aimed to assess current evidence related to the effectiveness of balance training for falls prevention for individuals with knee osteoarthritis. As I quickly learned, there is limited evidence on this topic. Therefore, my literature review expanded to explore falls risk among individuals with osteoarthritis in a more general manner.

    As you noted, the proportion of individuals at falls risk decreased over time for patients allocated to the standard PT intervention (36.2% at the baseline assessment, and 21.7% at the 12-month follow-up). However, the proportion of individuals at falls risk also decreased for all PATH-IN participants, so for individuals who were allocated to the internet-based exercise treatment as well, though to a slightly lesser degree (25.7% at the 12-month follow-up). From this information we can conclude that individuals with knee OA have the ability to reduce their risk for falls with physical therapy intervention, internet-based or with standard care. However, due to the small size of this study and potential cofounding variables, we cannot conclude that there is a direct effect of balance training for falls prevention in individuals with knee OA. Therefore, a larger scale study is necessary to assess the efficacy of balance training in preventing falls.

    Thank you for the feedback and questions!

    Monica

    Reply

  2. Monica Anderson

    Hi Dr. Givens,

    Thresholds were established based on the best available current evidence for falls risk relevant to this patient population. Two different falls risk thresholds were utilized to assess both static and dynamic balance abilities. Two studies were particularly helpful in determining the 13.5 second threshold for the TUG. Shumway-Cook et al. reported a time of greater than, or equal to, 13.5 seconds could predict falls in community dwelling older adults 90% of the time (1). A TUG time of 13.5 was also confirmed by Zasadska et al. as an indicator for falls in older adults with lower extremity osteoarthritis (2). The other metric used to classify falls risk was a participants’ inability to maintain unilateral stance for at least five seconds, as research as also shown this threshold is a predictive marker for injurious falls in older adults (3).

    Thank you for your inquiry!

    Monica

    1.Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Physical Therapy. 2000;80(9):896-903.
    2.Zasadzka E, Borowicz AM, Roszak M, Pawlaczyk M. Assessment of risk of falling with the use of timed up and go test in elderly with lower extremity osteoarthritis. Clinical Interventions in Aging. 2010;10:1289-1297.
    3.Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, et al. One-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45(6):735-738.

    Reply

  3. Debby Givens

    Nice work. I was curious about the metrics to determine high fall risk. I believe it was 13.5 sec or more on the TUG. What was the basis of this cut-off score for this population?

    Reply

  4. Carla Hill

    Monica,
    Great job with your Capstone project! I really appreciate the effort you dedicated and professional communication throughout all phases. Your final products are great and I look forward to helping with final revisions then submission to CSM/journal.

    I believe you did additional review of evidence this semester related to fall risk among individuals with osteoarthritis, but I don’t see it linked here, so may want to consider adding it.

    Since the proportion of individuals at falls risk decreased over time (baseline>4 months>12 months) in the participants allocated to the PT intervention, what can you conclude and not conclude about the benefit of balance training based on your analysis? What type of research could be proposed next to determine if balance training can reduce falls in this population?
    Carla

    Reply

  5. Monica Anderson

    Hannah,

    Thank you for your thoughtful feedback, I appreciate it. I agree that this arthritic disease has a profound and far-reaching impact on our society, sometimes in ways we never even considered (i.e. falls risk and prevalence). My experiences working with patients with knee OA are similar, in that a majority of the time these patients are seeking some form of pain-relief. Something pretty fascinating that resonated with me while completing my CAT and the background for my capstone, was that several studies demonstrated balance training has a therapeutic effect on pain outcomes.1,2,3

    And excellent question about the feasibility of balance training for this patient population. You are right, in that many balance activities require patients to be able to tolerate weight-bearing in stance or single-leg stance in order to adequately challenge their balance systems. This may be difficult for patients with significant knee pain. In these instances, physical therapists may choose to first focus on pain-relieving modalities or strengthening exercises, and then address balance deficits as tolerated. Another low-level balance activity that may place less force through the knee would be having patients perform activities while maintaining balance sitting on a stability (i.e. yoga) ball. Though not as functionally applicable as sit-to-stand exercises with SLS, this exercise may help improve postural control and core stability.

    Thank you again,

    Monica

    1.Fitzgerald GK, Piva SR, Gil AB, Wisniewski SR, et al. Agility and perturbation training techniques in exercise therapy for reducing pain and improving function in people with knee osteoarthritis: a randomized clinical trial. Physical Therapy. 2011; 91(4):452-469. Doi: 10.2522/ptj.20100188.
    2.Chaipinyo K, Karoonsupcharoen O. No difference between home-based strength training and home-based balance training on pain in patients with knee osteoarthritis: a randomised trial. Australian Journal of Physiotherapy. 2009;55:25-30. Doi: 10.1016/S0004-9514(09)70057-1.
    3.Duman I, Taskaynatan MA, Hohur H, Tan AK. Assessment of the impact of proprioceptive exercises on balance and proprioception in patients with advanced knee osteoarthritis. Rheumatol Int. 2012; 32:3793-3798. Doi: 10.1007/s00296-011-2272-5.

    Reply

  6. Hannah Leshin

    Monica,

    I am so impressed by your work. Your data analysis is both thorough and easy to interpret. Given the high prevalence of knee OA, I would wager that nearly every student in our class has treated a patient with knee OA on clinical rotation, providing more justification for the utility of your research. Your discussion of comorbidities and clinical manifestations of knee OA elucidate the increased risk of falls for this patient population. On my clinical rotation in outpatient orthopedics, patients with knee OA were often in search of pain relieving modalities. As clinicians, we are responsible for management of the current condition and for evaluation of potential secondary risks. The injury that could occur as a result of a fall has potential to be much more damaging to a patient’s functional mobility and independence than the presence of knee pain. Your paper demonstrates that there is a considerable percentage of patients with knee OA who are at risk of falls, but who do not receive adequate balance training.

    Did you find anything regarding feasibility of balance training for this patient population? I could see a potential problem for some of these patients performing challenging balance tasks due to increased knee pain. For example, single leg stance would clearly increase the force through the knee, causing an increase of pressure and, therefore, pain in the knee with OA. I imagine that the low-level activity of sit-to-stand with SLS (in Table 1) would be really difficult and painful for some of these patients.

    Once again, great work on this project. I am looking forward to hearing about the results of your submission to CSM 2018!

    Best,
    Hannah

    Reply

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