Enhancing postural stability in knee osteoarthritis patients through targeted training: a randomized control trial using the WOMAC assessment tool
Article information
Abstract
[Purpose]
Knee osteoarthritis (KOA) is a common joint condition in older adults that causes pain, disability, and reduced quality of life. Although there is no known cure for KOA, exercise therapy is strongly recommended as a primary non-drug treatment. This study aimed to assess the effect of combining proprioceptive training with physical therapy on pain, balance, and osteoarthritis symptom severity in patients with KOA.
[Methods]
A total of 34 patients with primary KOA (aged 50-65) were assigned to either intervention or control groups (n = 17 each). The intervention group received conventional physical therapy combined with proprioceptive training for 3 days a week for 8 weeks. The Tampa Scale for Kinesiophobia (TSK), Timed Up and Go (TUG) test, and Modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire were administered before and after 8 weeks intervention.
[Results]
After the intervention, the TUG and TSK scores improved significantly more in the intervention group than in the control group (p < 0.05). Significant differences were also observed in Numerical Rating Scale and WOMAC scores (pain, stiffness, function, and total WOMAC scores).
[Conclusion]
The integration of proprioceptive training with physical therapy resulted in significant improvements in balance, reduced fall risk, and decreased movement-related fear after 8 weeks of intervention.
INTRODUCTION
Bone and joint diseases are significant health concerns because of their increasing incidence. Osteoarthritis is a prevalent musculoskeletal disorder that often develops with age and leads to joint deterioration [1]. This degenerative condition has a chronic and progressive course, with an increasing prevalence in many countries worldwide. In the United States, osteoarthritis ranks among the top five conditions that severely limit the daily activities of patients [2]; moreover, it is one of the leading causes of disability among the elderly in Thailand [3]. A study on the health status of older adults in Thailand revealed that 43.9% suffered from knee joint pain, with osteoarthritis being the primary cause. It is the most common joint condition, accounting for 66.23% of cases [4]. The knee, a sizable weight-bearing joint that is heavily involved in daily activities, is particularly vulnerable. Osteoarthritis progresses slowly and worsens over time with continued use.
Osteoarthritis is a condition characterized by the deterioration in articular cartilage structure and changes in the composition of synovial fluid. These alterations cause deformities in the knee joint, reducing its ability to bear weight and impairing function [5]. Symptoms include knee pain, stiffness, swelling, and creaking sounds in the joints. Weakness and contraction of the muscles around the knee can lead to abnormal movements, causing further joint deformities that prevent proper knee extension, often resulting in bowed or crooked legs in older adults. Furthermore, these deformities affect posture, walking patterns, balance, and standing ability [2].
Weaknesses in the muscles surrounding the knee, coupled with joint and ligament deterioration, lead to reduced joint mobility, slower reaction times, and impaired balance compared to those in the general population [6]. Consequently, individuals with osteoarthritis face difficulties in performing daily activities and have a heightened risk of falling. Some falls can lead to hip fractures, necessitating long-term surgical intervention. Hip fractures are associated with a mortality rate of 20-30% and a loss of daily function in 25-75% of cases, often resulting in permanent disability in the elderly [7]. This leads to physical and emotional distress, decreased life satisfaction, and a sense of burden on others, all of which contribute to depression. Additionally, fear and lack of confidence in accomplishing daily tasks have become common, further diminishing the quality of life.
Although there are various approaches for treating osteoarthritis, they can generally be divided into three main categories: pharmacological therapy (using medications), surgical treatment, and non-pharmacological therapy (nondrug interventions). Physical therapy is a non-pharmacological treatment that involves multiple techniques that can be applied simultaneously for more effective results [1,5,8]. A patient-centered approach has been shown to enhance treatment outcomes. However, balance and proprioception training are often overlooked when treating elderly patients with osteoarthritis. These patients frequently experience poor perception of joint position and reduced mobility, resulting in poor balance and an increased risk of falls compared with healthy people of the same age. Recent studies have emphasized the importance of incorporating balance training, agility exercises, and muscle strengthening techniques to improve the mobility of patients with osteoarthritis [6]. Since balance is essential for movement and daily functioning, focusing on this aspect can significantly enhance the overall quality of life.
To the best of our knowledge, few studies have investigated the effects of balance and proprioception training combined with physical therapy in patients with knee osteoarthritis (KOA). The current research was conducted to educate and raise awareness among osteoarthritis patients and physical therapists about the benefits of balance training along with physical therapy treatment. The objective of this study was to evaluate the effects of balance and proprioception training combined with physical therapy on pain, balance ability, and the severity of osteoarthritis symptoms in patients with KOA. This was a quasi-experimental study with a research design of two groups measuring the results before and after the experiment. The hypothesis was that balance and proprioception training combined with physical therapy could reduce pain, increase balance ability, and effectively reduce the severity of osteoarthritis symptoms in patients with KOA. The results of this study can serve as guidelines for physical therapists for the treatment of KOA.
METHODS
Research design
This study was an 8-week randomized control trial with one intervention group and one control group. Participants were asked to measure their outcomes before and after completing 8-week intervention. This study aimed to explore the effects of balance training combined with physical therapy on pain, balance ability, and osteoarthritis severity in patients with KOA.
Participants
Thirty-four participants (age 58 ± 2.53 years) with symptoms of KOA, according to the osteoarthritis diagnostic criteria of Altman et al. [9] and diagnosed by a physician as having primary osteoarthritis of the knee, were recruited at outpatient services at Ban Thaen Hospital, Chaiyaphum province, Thailand. They were divided into two different groups, an intervention group (n = 20) and a control group (n = 20), using a simple random technique by the assistant researcher (matched participants in both groups by age and sex before randomization of the intervention group). Figure 1 shows a flowchart of the participant selection.
A flow-chart of participant selection.
Inclusion and exclusion criteria
The inclusion criteria were as follows: (1) aged 50-65 years with mild-to-moderate KOA, as assessed by the Oxford Knee Score; (2) able to walk 10 m without the aid of a walking device; and (3) willingness to participate in the research [9]. The exclusion criteria were as follows: (1) musculoskeletal issues or underlying conditions affecting postural control; (2) severe or acute KOA; (3) leg deformities such as prolonged joint stiffness or muscle contracture; (4) a history of leg fractures within the past 6 months; (5) a history of falls within the last year; or (6) any comorbidities or contraindications that would prevent participation in physical therapy, such as severe cardiovascular disease, advanced asthma, neurological disorders, or skin infections [6].
Sample size calculation
This study involved male and female participants aged 50-65 years with KOA. The sample size was calculated using the G-Power program (version 3.0), with a confidence level of 0.05, effect size of 1.10, and test power of 0.80, based on Wang et al. in 2018 [11]. Based on the calculation, a minimum of 32 participants was required. To account for potential dropouts, the sample size was increased by 20%. As a result, 40 participants were recruited and divided into two groups: 20 participants in the balance training group (receiving balance and proprioception training combined with physical therapy) and 20 participants in the control group (receiving conventional physical therapy).
Research tools
There were two types of instruments used in this study as follows:
1) The screening tool used is the Osteoarthritis Severity Screening Form (Oxford Knee Score), consisting of 12 questions. Each response is rated on a 5-point scale ranging from 4 points for the most severe symptoms to 0 points for no symptoms. The total score is interpreted as follows: 0-19 points indicate severe level, 20-29 points indicate moderate level, 30-39 points indicate mild level, and 40-48 points indicate no significant symptoms [10].
2) The data collection tools include:
a) The Personal Information Record Form is used to capture general details about the participants, including sex, age, body mass index (BMI), marital status, occupation, pre-existing conditions, history of falls or knee-related accidents, dominant leg, and osteoarthritis-specific information such as the duration of KOA and any treatments received in the past 6 months [11].
b) The Pain Assessment Form using the Numerical Rating Scale (NRS) is a tool that uses numbers to measure pain severity. A score of 0 on the far left indicates no pain, whereas a score of 10 on the far right indicates the most intense pain. The NRS is divided into four levels: 0 indicates no pain, 1-3 indicates mild pain, 4-6 indicates moderate pain, and 7-10 indicates severe pain [1].
c) The Movement Fear Assessment Form uses the Thai version of the Tampa Scale for Kinesiophobia to evaluate the pain-related fear of movement. This questionnaire consists of 17 questions, each with four response options: Strongly Disagree (1 point), Disagree (2 points), Agree (3 points), and Strongly Agree (4 points). The total score ranges from 17 to 68 points, with higher scores indicating a greater fear of pain-related movements [6].
d) Balance control is assessed using the Timed Up and Go (TUG) test, which measures the time required to perform basic daily movements such as rising from a chair, walking 3 m, turning, and sitting back down. The test is conducted twice, with a 2-min rest period between trials, and the best time is used for analysis. A shorter test time indicates excellent balance control, whereas a longer test time suggests impaired balance control [6].
e) The Modified Western Ontario and MacMaster University (WOMAC) Osteoarthritis Severity Assessment Scale- The Thai version consists of 22 questions assessing 5 pain points, 2 measures of knee stiffness, and 15 aspects of knee function. The scale uses a numerical system ranging from 0 to 10, where 0 indicates no pain and 10 represents the most severe pain. The research participants complete the questionnaire twice-once before starting treatment and again at the end of the treatment period-to evaluate the severity of their osteoarthritis [12].
Experimental treatments
1. Hydrocollator or hot pack: The participants were placed in a hot pack wrapped in a towel with 6-8 layers of thickness applied to the affected knee and any tense or painful muscle area. Each session lasted 20 min, during which the participants felt comfortable and warm.
2. Ultrasound therapy: This therapy was applied to the painful area using a continuous mode with a frequency of 1 MHz and intensity of 1.2 W/cm² for approximately 10 min. This treatment was intended to produce a warm sensation without causing burns or pain.
3. Education on osteoarthritis: This session covered the disease’s pathology, causes or risk factors, signs and symptoms, and treatment guidelines. The participants were advised to manage their conditions. The information was based on a distributed manual and took approximately 20 min.
4. Stretching exercise: This involved stretching the leg muscles, including the quadriceps and hamstrings. (a) For the quadriceps muscle, the participants were in a prone lying position with their knees bent while their ankles were passively held by a physical therapist. The physical therapist applied pressure in such a way as to bring the heels closer to the buttocks until the patient felt tightness in the front of the thigh. (b) For the hamstring muscle, the participants were in a long sitting position on a bed. The physical therapist held the bottom of both feet and applied pressure on the toes forward so that the patient felt tightness at the back of the thigh (under the crook of the knee and calf). Passive stretching was performed by the physical therapist. Each stretch was held for 30 s and repeated 10 times per position for approximately 10 min in total.
5. Strengthening exercise: Four positions were used for the strengthening exercises. (a) For the muscles at the front of the thighs (quadriceps muscles), the starting position was supine, and the knee was slightly bent at 30-40° using a cylindrically shaped rolled cloth under the knee joint. The participant was then instructed to apply pressure toward the rolled cloth by straightening the knee so that the heel was off the floor (hold for 5 s, then relax). (2) For muscles inside the thighs (adductor muscles), the participant was positioned in the supine position with the knee flexed at approximately 90°. A ball or pillow was placed between the knees. The patient was then instructed to squeeze against the pillow for 5 s and then release. (3) For muscles at the back of the thighs (hamstring muscles), the patient was positioned in the prone position and asked to bend the knees in an upright position, hold for 5 s, and then release. (4) Progressive resistance exercise (PRE) was used to increase the strength of the muscles in the front of the thigh (quadriceps muscles). The participant was in a standing position against the wall and then asked to bend the knees at approximately 15-30° without pain, hold for 5 s, and then stretch straight up. They were then instructed to perform self-active exercises with slow movement and hold tight for 5 s (counting from 1 to 5), 10 times per round, for 2 rounds. The rest period between the positions and rounds was 2 min. The total duration of these exercises was approximately 10-20 min.
6. Balance training: This session involved practicing standing on a balance pad, with exercises adapted from Jahantigh et al. [13]. The exercise consisted of 4 positions: (a) maintaining a standing balance position on a balance pad with both hands folded across the chest and feet shoulder-width apart; (b) standing with feet together for 10 s, repeated 10 times; (c) standing straight with your arms at your waist and feet shoulder-width apart. They were instructed to slowly bend their knees so that they were slightly in front of the ankles, maintain for 1-2 seconds, and then return to the starting position. They were asked to perform this exercise 10 times; and (d) standing on one leg on a balance pad for 10 s and repeating it 10 times before switching legs and repeating it another 10 times. Prior to the exercise, assistive devices (such as standing or walking support) could be requested if needed. However, the participants were asked to balance independently without using any support aids. This balance session lasted approximately 20-30 min with a 2-min rest period between each position. The physical therapists ensured the safety of the participants throughout the session [6].
Data collection procedure
The researchers explained the methods for completing the assessments used in this study and collected personal information. Physical assessments and evaluations were conducted before treatment (for the first time) to ensure completeness of the record form. This included personal information, pain level (measured using the NRS), fear of movement (assessed using the Thai version of the Tampa Scale for Kinesiophobia), balance level (evaluated using the TUG test), and severity of osteoarthritis symptoms (scored using the Modified WOMAC questionnaire-Thai version).
The experimental balance training group received conventional physical therapy combined with balance training exercises for 8 weeks, 3 times a week. The program included educational sessions and a home-based exercise program. Each session began with 20 min of hot-pack compression, followed by 10 min of ultrasound therapy. The exercise routine consisted of stretching exercises and balance training. From the second until final day of treatment, the balance training group continued with the same balance training and physical therapy program, including educational sessions and a home program.
The control group received conventional physical therapy for 8 weeks, 3 times a week, including educational sessions and a home exercise program. Each session began with 20 min of hot-pack compression followed by 10 min of ultrasound therapy. The exercise routine consisted of stretching and strengthening exercises. From the second day until the end of the treatment period, the control group continued with the same physical therapy as that provided on the first day, excluding the educational sessions and home programs. At the end of the treatment period, the researchers re-evaluated the participants to assess their post-treatment results, as was done initially (Table 1). This study was approved by the Human Research Ethics Committee of the Chaiyaphum Provincial Public Health Office (EC 35/2563), following the principles of the Declaration of Helsinki, and registered prospectively with the Thai Clinical Trial Registry (TCTR20241219001).
Intervention program for knee osteoarthritis
Statistical analysis
Upon completion of the experiment, all data collected before and after the experiment as well as the basic statistical agreement were examined and verified by the researchers for completeness. The data were then analyzed using statistical software. Descriptive statistics, including numbers, percentages, means, and standard deviations, were used to analyze the general characteristics of the sample. To evaluate the changes within the sample, a paired t-test was used to compare the mean values before and after treatment. Differences between the samples were assessed using an independent sample t-test. The variables studied included pain level (NRS), Tampa Scale for Kinesiophobia score, mean balance test time (TUG), WOMAC pain score, WOMAC joint stiffness score, WOMAC knee function score, and overall WOMAC score. Statistical significance was set at p < 0.05.
RESULTS
This study aimed to investigate the effects of balance training combined with physical therapy on pain, balance ability, and severity of osteoarthritis symptoms in individuals with KOA. The results of the data analysis are presented in Table 2.
The number and percentage of baseline data between the balance training and control groups
As shown in Table 2, the basic information on the volunteers in the intervention and control groups revealed that most participants were female, comprising 76.47% of each group. Both groups were aged between 50 and 65 years, with an average age of 57.07 years for both groups, indicating similar age distributions. The mean BMI was 25.97 for the control group and 25.98 for the balance training group. Most volunteers in both groups reported having knee pain for 1-3 years. Congenital diseases were present in 35.29% of the control group and 41.18% of the balance training group, including conditions such as high blood pressure, diabetes, and thyroid disorders.
A history of falls was reported in 64.72% of the control group and 47.06% of the balance training group. Participants lived in single-story houses. There were 88.24% and 70.59% farmers in the control and balance training groups, respectively. However, the control group predominantly used flush toilets (88.23%), whereas the balance training group primarily used cesspools or squat toilets (52.94%). Additionally, they were all regularly engaged in physical activities such as walking and gardening at least 3-4 times a week.
Table 3 shows the mean values of the variables studied (NRS, TUG, and Tampa Scale) for both groups before treatment. No statistically significant differences were found between the two groups before treatment (p > 0.05). After treatment, both groups showed a significant decrease in mean NRS and TUG scores (p < 0.05). In the balance training group, the results revealed a decrease in mean Tampa Scale scores after treatment. In contrast, no significant changes were found in the Tampa Scale scores before and after treatment in the control group. Comparing the results between groups, the balance training group experienced a greater reduction in mean TUG test time and Tampa Scale score compared to the control group (p < 0.05).
Means and standard deviations (Mean ± SD) of the study variables between the balance training group and the control group pre and post treatment
The control group underwent conventional physical therapy, whereas the balance training group underwent balance and proprioception training combined with physical therapy. Table 4 illustrates that after treatment, both groups experienced significant reductions in mean WOMAC pain, WOMAC stiffness, WOMAC function, and overall WOMAC scores (p < 0.05). However, when comparing the results between the two groups, there were no significant differences in mean pain score (NRS), WOMAC pain score, WOMAC stiffness, WOMAC function, or overall WOMAC score.
Means and standard deviations (Mean ± SD) of the WOMAC variables between the balance training group and the control group pre and post treatment
DISCUSSION
This was a quasi-experimental study with a two-group design that measured the outcomes before and after intervention. This study aimed to evaluate the effects of balance and proprioception training combined with physical therapy on pain scores, balance ability, and severity of osteoarthritis in individuals with KOA. Overall, the findings support our initial hypothesis that combining balance and proprioception training with a physical therapy program can effectively reduce pain scores, improve balance ability, and decrease the severity of knee joint osteoarthritis symptoms. After treatment, both groups showed significant reductions in pain scores (NRS), timing of the TUG test, Tampa Scale scores, and WOMAC scores (including pain, stiffness, function, and total scores) compared to before treatment (p < 0.05). However, the control group showed no significant change in mean Tampa Scale scores before and after intervention. Overall, the findings indicated that both groups improved after intervention. Nonetheless, the group receiving balance and proprioception training combined with physical therapy showed greater improvements in balance ability, leading to a reduced risk of falls and decreased fear of movement compared with the group receiving the conventional physical therapy program.
The study found that both the control and balance training groups predominantly consisted of females (92.86%), aligning with the findings of Patsika et al. in 2011, who reported a higher prevalence of KOA in women compared to men. The female-to-male ratio for this condition is approximately 4 1, and its prevalence notably increases in women after menopause [14]. The increase in osteoarthritis among women post 50-years-old has been attributed to decreased estrogen levels during menopause. Estrogen plays a crucial role in tissue repair, particularly in inflamed joint tissues, and supports parathyroid hormone function, which helps maintain bone mass. Lower estrogen levels lead to more rapid degeneration of the knee joints [14].
The research results indicate that both balance and proprioception training combined with physical therapy and a conventional physical therapy program effectively reduced pain scores, improved balance ability, and alleviated the severity of osteoarthritis symptoms at the knee joint. However, the group receiving balance and proprioception training combined with physical therapy demonstrated greater improvement in balance ability than the group receiving the conventional physical therapy program alone. The combined treatment approach included hot packs, ultrasound therapy, stretching exercises, educational and home programs, and balance and proprioception training. In contrast, the conventional physical therapy regimen consisted of hot packs, ultrasound therapy, education and advice, stretching exercises, and muscle-strengthening exercises. Consistent with the study by Abdel-Fattah et al., a balance exercise program was found to improve pain, physical function, and dynamic balance in patients with KOA, regardless of severity [15].
The study revealed that using hot compression for 20 min effectively reduced pain intensity (NRS) and severity of osteoarthritis symptoms (WOMAC pain). Hot compression provides superficial heat that alleviates knee joint pain by reducing muscle spasticity and tightness, enhancing blood circulation, and stimulating the temperature receptors in the skin [1]. This process inhibits the pain signals transmitted by small nerve fibers, resulting in fewer pain signals reaching the brain. Additionally, heat increases tissue temperature and boosts chemical reactions and metabolic rates within cells, which aids in tissue repair and reduces knee stiffness. By enhancing oxygen use and reducing knee joint congestion, hot compresses improve collagen tissue flexibility and facilitates easier knee joint movement [16]. This is consistent with a previous study by Heidari et al. in 2011, which demonstrated that moist heat improved hamstring flexibility compared with static stretching [9].
Ultrasound therapy uses high-frequency sound waves to penetrate tissue layers and provides deep heat energy that extends approximately 3-5 cm below the skin surface. This vibration of molecules within the tissue helps reduce both acute and chronic pain and inflammation and accelerates tissue repair. Boonsiripipat et al. reviewed the literature on ultrasound therapy for osteoarthritis and found that 10 of 11 studies reported that ultrasound therapy effectively reduced pain and improved knee joint mobility [17].
The present study also found that exercise therapy, which strengthens the muscles around the knee joint, effectively reduces knee pain. Strengthening these muscles enhances joint stability and reduces load on the knee joints, leading to decreased pain. Additionally, exercising the thigh muscles alters nerve fiber transmission from the brain, stimulates the pain-relieving endorphin system, and increases blood flow and nutrient supply to the knee cartilage. This also helps to reduce swelling by improving venous blood return and lymphatic drainage, further alleviating pain. These findings align with the 2018 study by Wang et al., which reported that exercise therapy improved clinical symptoms and knee joint function in osteoarthritis patients [11]. Similarly, Mat et al. demonstrated that both strength and balance training at home effectively reduced pain in individuals with osteoarthritis [6].
The current study on balance ability revealed that both balance and proprioception training combined with physical therapy and conventional physical therapy can reduce the timing of the TUG test after 8 weeks. However, the group that received balance and proprioception training combined with physical therapy showed a significantly greater decrease than the group that received conventional physical therapy alone (p < 0.05). These results indicate that balance and proprioception training combined with physical therapy enhances balance more effectively than conventional physical therapy alone. Our findings also agree with a previous research by Jahanjoo et al. in 2019, which compared the effects of conventional physical therapy (including hot packs, ultrasound, and transcutaneous electrical neuromuscular stimulation (TENS)) with physical therapy combined with balance training using the Biodex balance system [18]. Another study revealed that the combined approach significantly improved balance, as evidenced by a lower TUG test time compared with the conventional physical therapy group [18].
Balance and proprioception training in the current study involved positions that stimulated the proprioceptive senses, which helped individuals become more aware of their body’s position and movement. Proprioceptive training enhances the ability to recognize limb positions and movements while maintaining balance. Furthermore, effective balance requires the coordination of leg muscles to support the body’s center of gravity. These findings are consistent with those of the study by Pan et al. (2023), which showed that combining joint awareness training with exercise significantly improved balance compared with traditional exercise alone. Poor neuromuscular function is a well-established risk factor for falls. However, balance training has been shown to enhance sensory input, stabilize postural control, and promote neural adaptations in pathways related to joint perception [19]. Therefore, integrating balance training into rehabilitation programs for individuals KOA is essential to improve balance and reduce the risk of falls.
The results of the current study indicate that balance and proprioception training combined with physical therapy and conventional physical therapy effectively reduced the severity of KOA. These treatments reduce knee pain during activities, decrease joint stiffness, and improve the overall physical activity levels. Reduction in knee pain during activity can be attributed to mechanisms similar to those involved in pain reduction and muscle strengthening around the knee joint.
Knee joint stiffness, a common symptom of osteoarthritis, typically occurs in the morning or during initial movements but usually resolves within 30 min. This stiffness is exacerbated by prolonged periods of inactivity because aging leads to more viscous synovial fluid, which impairs cartilage nourishment and accelerates cartilage degeneration. Prolonged immobility can lead to stiffness and loss of flexibility in the knee joint [2]. Hot compresses can alleviate joint stiffness by increasing the temperature of the knee joint, which enhances flexibility and reduces resistance. Heat also improves the elasticity of the contracted collagen tissue in the knee joint. In addition, hamstring-stretching exercises can further enhance joint mobility, as patients with osteoarthritis often experience tightness in these muscles [2].
Both treatment groups used hot compresses and muscle stretching around the knee joint, which helped reduce stiffness and improve knee mobility. People with osteoarthritis often experience decreased physical activity due to knee pain and muscle weakness, which limits their daily activities. These treatments may have increased the muscle strength around the knee, improving the ability to perform daily tasks. Such findings are consistent with those obtained by Cetin et al. in 2008, where physical therapy combined with various modalities, such as hot compresses, shortwave diathermy, electrical stimulation, or ultrasound therapy, was found to effectively reduce knee joint pain and symptom severity [20].
This study has some limitations. The current study focused on individuals with KOA of low to moderate severity. Therefore, the findings may not be generalizable to patients with varying degrees of severity, as determined by radiographic assessments. Moreover, this study has limitations in assessing the long-term effects of the treatment programs. Further studies are needed to evaluate the duration of the residual effects and the sustainability of treatment outcomes over an extended period. Future research should include larger sample sizes, ensure representation across all severity levels of KOA, and conduct long-term studies to evaluate the sustained effects of treatment over extended periods. This will enhance the credibility of the findings and provide a more robust basis for future applications and dissemination.
In conclusion, our findings provide insights into the design of physical therapy exercise programs in which balance and proprioception training combined with physical therapy significantly reduces pain scores, improves balance ability, reduces the risk of falls, and decreases the fear of movement after 8 weeks of treatment. This improvement enhances mobility, boosts confidence in daily activities, and lowers the risk of falls, which is crucial for individuals approaching elderly age. Promoting balance and proprioception training emphasizes that joint awareness in the pre-aging population can help slow knee joint deterioration, alleviate osteoarthritis symptoms, and reduce fall risk. Such interventions benefit long-term health, improve the quality of life, and decrease direct and indirect healthcare costs. Patients should be encouraged to use technology to promote health, such as leg and knee exercise programs or knee pain tracking technology, to record their injury histories.
Acknowledgements
This research was supported by the Ban Thaen Hospital, Chaiyaphum, Thailand. The authors would like to thank all research and administrative assistants who contributed to data gathering and all participants for their enthusiastic support.