Research Project Presentation

TITLE
Bachelor Degree in
Physiotherapy (Hons) Effect of Core Stability Exercises
Combined
with Perturbation Training on
Dynamic Balance for Knee
Osteoarthritis Patients 
STUDENT’S NAME
MOHAMAD SUHAIB BIN MOHD MAHFDZUZ
BPHP18046145
PROJECT SUPERVISOR
MADAM SONIA DUA DEWAN
 BACKGROUD OF THE STUDY
 “Knee osteoarthritis (OA), also known as degenerative joint disease, is typically
the result of wear and tear and progressive loss of articular cartilage”

World Population Economic & Social Burden

13
Worldwide musculoskeletal disease that
causes 80% to 90% of knee replacements
in the United States and the United
Kingdom (Goh S-L et al., 2019)
The frequency and chronicity of OA makes this
disease a substantial economic burden for
patients, health care systems and fitness in all
nations (O Krasilshchikov, SS Subramanian, HA
Hashim, 2018; Brillya Bhaskar, 2019)

24
Malaysia Population Impairments
Prevalence of knee OA in Malaysia was
Physical impairments associated with OA are
estimated to be 10% to 20% of the elderly. The
pain, morning stiffness, limited range of knee
knee pain problems in Malaysia affected adults
motion, reduced limb muscle power,
aged 40 years and above
proprioception, dynamic postural control and
(Chai Nien Foo et al., 2016)
ADL (Goh S-L et al., 2019)
Effect of Core Stability Exercises Combined with Perturbation Training on Dynamic Balance for Knee Osteoarthritis Patients
Knee OA Perturbation Training
Researchers reported A perturbation-based balance
greater postural sway training program works
in knee OA patients against the central nervous
as compared to their system’s and has ability to
healthy controls. predict the specific
(Jahanjoo et al, 2019) characteristics of
to use such information to
counteract the effects of a loss
of balance
(L.P. Rossi et. al 2013)
G.K Fitzegerald, 2011 first
researched studied regarding
perturbation training in OA.
Core Stability Exercise
The core can be described as
primary cylinder muscles
surrounding COG
(Akuthota V et al., 2008)
Kibler et al., 2006 defined core
stability as the ability to
control the position of trunk
over pelvic and legs that allow
optimal movement in terminal
segment in integrated kinetic
chain activities.
Dynamic Balance
Dynamic postural control
integrates two mechanisms
that determine balance
control, which is (1)ability to
maintain balance (Core)and
(2) ability to respond during
destabilizing forces given
(pertubration)
 LITERATURE REVIEW
People with early knee joint OA did reduced postural stability and altered muscle activation
patterns, specifically related to gluteus medius, quadriceps and hamstrings (L.D. Duffell et al.,
2014)
Incorporating exercises that stimulate core muscles activation into conventional treatment was more effective at
reducing short term pain in patients with knee osteoarthritis than conventional alone. Further research is needed
to confirm findings and include core exercise in management of OA (D. Hernandez et al., 2019)
Only analyzing the immediate effect.

Previous research had shown that exercise and general balance training will provide significant effect to patient
with OA in terms of pain reduction and improve functional activities (Jahanjoo et al, 2019)
Does not determine specific dynamic balance effect towards OA patient
Latest literature review found that core stability exercise had significant effect of in reducing pain and improve daily
function in OA patient (Muhammad Deyu Wisnubrata & Rahmat Sayyid Zharfan, 2020).
Not assessing in what direction affect dynamic balance – only used ADL Outcome Measure
Their results strongly suggest that trunk stabilization training using dynamic movements (perturbation training)
is necessary to elicit improvements in core control and lower limb biomechanics in active women person.
(Weltin et al., 2016)
Corelation between perturbation training with core stability exercise but no evidence in treating OA
 RATIONALE OF THE STUDY
• Latest researcher shown significant effect perturbation effect for OA (O Krasilshchikov, SS Subramanian,
HA Hashim 2018; Brillya Bhaskar, 2019) when combine into conventional treatment. Also, plenty of
literatures had been studies regarding pain effect. Thus pain effect will not be considered in this study.
However no other research study regarding effect of core stability exercise when added to perturbation
training.

• Most literatures did on both interventions used basic functional test such as TUG which is not challenging
and not specific.

• Core stability will provide more support in controlling the torso while perturbation training will provide an
ability to respond during dynamic movement. (Kiebler W.B et al.,2006)

• Interest in exercise therapy approach and to promote awareness regarding exercise as vital treatment in
OA at Malaysia (Goh S-L et al., 2019)

Questions leads to Objectives

• Does adding the core muscles can have significance improvement to dynamic balance as perturbation
training need ability to control the position of trunk over pelvic and leg which allow more neuromuscular
feedback in terminal segment during kinetic chain activity (R. Szafraniec et al., 2018)
• What effect does it provide?
OBJECTIVES
To determine the effect of core stability exercises
combined with perturbation training on dynamic
balance for knee osteoarthritis patients.
 HYPOTHESIS
H:
• There will be significance effect
on dynamic balance with core
stability exercises combined
with perturbation training
among knee osteoarthritis
patients.
Ho:
• There will not be significance
effect on dynamic balance with
core stability exercises
combined with perturbation
training among knee
osteoarthritis patients.
 METHODOLOGY
Research Design Population
 Quantitative approach  Outpatient physiotherapy referral
in private Hospital
 Quasi-experimental research designs
(pre test-post test)

Sampling Design Sampling Size

 Sample size calculation is using G
 Non-probability convenience sampling power.
 Using Calculator apps version 2.0.2
powered by Relief Apps.
 14; (7 patients in each group)
Group Allocation
 Convenience sampling. Allocate alternately in the
group which referred first
 INCLUSION & EXCLUSION CRITERIA
Inclusion
Chai Nien Foo et. al., 2016
• Age between 35 to 75 years old
• Chronicity > three months
• Visual Analogue Scale (VAS) less than 5/10
(Brillya Bhaskar, 2019)
O Krasilshchikov, SS Subramanian, HA Hashim
2018
• Have no contraindication from a personal
physician for participation in resistance and
functional exercises
• Both genders
• Having K-L Grade 1 or 2
Exclusion
Teresa et al., 2005
• The exclusion criteria of the study
included severe obesity (BMI> 30)
Brillya Bhaskar, 2019
• uncooperative patient, neurological
condition, visual and auditory problem,
uncontrolled diabetic, uncontrolled blood
pressure, recent fracture or injury to
lower limb, limb length discrepancy, hip
and ankle joint pathology and soft tissue
injury, fixed flexion contracture severe
back pain.
 MEASUREMENT TOOLS

PRIMARY RESEARCH INSTRUMENT

Y-BT seems to be a more practical and easier way to manage the test for the evaluation of the
dynamic capacity especially for OA Patient as they might get tired compared to SEBT. (Y-BT, Plisky
et al., 2009)

SCREENING RESEARCH INSTRUMENT

Demographic Profile Sheet- determine the subject’s age, sex, weight, height, BMI.
Pre VAS Scale (Brillya Bhaskar, 2019).
K-L OA Grading (O Krasilshchikov, SS Subramanian, HA Hashim 2018)
RESEARCH INTERVENTIO
DIAGRAM 18 patients walk-in by referral In
NS
Perturbation Training (Control Group)
Nov & Dec 2020
• Both group will receive perturbation
4 excluded after screening
training according to Teresa et al, 2005 and
inclusion and exclusion criteria had been applied by Brillya Bhaskar, 2019
in his studies for OA patient.
14 were divided into group A and
group B by using convenience sampling
• The duration limit at 20 minutes only

Core Stability Exercises (Experimental Group)

Pre-test measurements • Experimental group will receive core
(Y-Balance Test)
stability exercise with brochure given. The
Group B (n=7) core exercise will be based on R. Szafraniec
Group A (n=7)
Perturbation Training + Perturbation Training + et al. 2018 (procedures 1-8)
Conventional therapy
Conventional therapy
+ Core Stability
• 1 session – brief & educate. Follow up
review. As HEP.

Post-test measurements
(Post Test after 10 Sessions)
 DATA ANALYSIS

Variables Level of Central

Data Tendency

Age (Years) Ratio Mean & SD Inferential Statistics:

• Paired Sample T-Test (same group)
Gender Nominal Frequency and Independent T-Test (Comparison
Height Nominal Mean & SD between group)
• Statistical analyses : using the
Weight Nominal Mean & SD Statistical Package for Social Sciences
(SPSS) 26 software
BMI Ratio Mean & SD • Confidence Interval was set at 95
VAS Pre Test Ordinal Median percent, while p value was set at less
than 0.05.
K-L Scale Nominal Frequency
Y. Balance Test Ratio Mean & SD
 RESULTS AND INTEPRETATIONS
Table 1 : Demographic Data Collection Table

Group A Group B
Control Group(n=7) Experimental Group (n=7)
Gender, n (male: female) 3:4 4:3

Age in Years, mean (SD) 52 (9.3) 52.1. (9.1)

Weight (kg), mean (SD) 76.6 (8.9) 72.3 (7.1)

Height (cm), mean (SD) 166.4 (5.3) 162.8 (8.3)

BMI (kg/m2), mean (SD) 27.6 (4) 27.2 (0.8)

Grade of OA (K-L) Ⅰ= 4, Ⅱ = 3 Ⅰ= 2, Ⅱ = 5

VAS Pre Test 3.4 (1.3) 3.5 (0.1)

SD= Standard Deviation, kg= Kilogram, OA= Osteoarthritis, K-L= Kellgren and Lawrence, VAS= Visual Analogue Scale
 Paired T Test
Pre-test Post-test Mean
Groups difference t- value P-value
(Mean±SD) (Mean±SD)
ANTERIOR A
39.69±9.48 43.23±9.08 3.54 5.21 0.00
REACH (cm)
B
42.57±5.66 50.45±8.22 7.88 4.14 0.00

Pre-test Post-test Mean

Groups difference t- value P-value
(Mean±SD) (Mean±SD)

PM A
55.81±13.95 61.66±13.20 5.84 10.9 0.00
REACH (cm) B
59.61±2.48 72.45±8.76 12.84 4.22 0.00

Pre-test Post-test Mean

Groups difference t- value P-value
(Mean±SD) (Mean±SD)
PL
A
REACH (cm) 48.7±10.56 57.71±9.46 7.01 3.71 0.01
B
51.25±10.06 60±17.35 8.79 2.68 0.04
Independent T Test
Comparison Mean Difference Pre and Post Between Group
Variable Mean difference t-stats P-value
ANTERIOR REACH (cm)
4.34 2.88 0.02
PM REACH (cm)
6.06 1.84 0.04
PL REACH (cm)
1.63 0.43 0.68
Mean Difference BetweenGroup
GroupA
Interpretations Group B
12.84
• Both group shown significant pre and post
treatment. P<0.05.
• There are statistically significant on Anterior 7.89
8.78

and PM reach only when comparing between 7.16

5.84
group. P<0.05
• However, Group B shown higher mean value 3.54

compare to Group A in all three direction.

Anterior Posteromedial Posterolateral

 DISCUSSIONS
• The findings of the current study, coupled with previous research (L. Al-Khlaifat et.
al., 2016) provide clinicians with a method of improving dynamic balance by
improving core strength. Even though not all three reach in Y-BT show significant
improvement, all the mean difference are higher in experimental group.

• During PL, gluteus medius need to be optimum function. Patient who having early
OA had altered muscle activity that related to the reduction in postural control as
stated by L.D. Duffell et al., 2014.

• Anterior and PM reach shown significant improvement and high mean differences
probably due to core stability when combine with perturbation training provide more
stable COG and promote strength on lower abdominal as same result for patient
with early OA (Hassan Sadeghi et al., 2013).
Comparing to RCT by G.K Fitzegerald, 2011, our research gather early OA (K-L grade below 2), younger
age (mean:52), not more than 30 for BMI (mean:27) and not excluded any participant that previously
involve in recreational sport. However, this small sample size study cannot be generalized.

By assuming neuromuscular control and muscles activity of core muscles such as increased excursion
distance and knee antagonist muscles co-contraction is increased during perturbation training. Suggested
to use EMG.

Even though, both techniques had been proven before to improve dynamic balance in OA patient, this
research had proved combination of both able to bring more significant of effect even in a short duration
or as home exercise program and provide better muscle activity around COG.

LIMITATIONS
• Non- Probability sampling size
• Small sample size – cause by pandemic Covid 19
• Lack of equipment – lack of outcome measure control
• Project duration should be increase
• Findings cannot be generalized
 CONCLUSIONS
• In patient with OA, dynamic balance can be improve by providing integration between lumbopelvic
stability and terminal segment of the limb. The present study concludes that there is a clinically
significant improvement in anterior and posteromedial in dynamic balance for OA patient. Core
stability exercise regime can provide addictive effect when combined with perturbation exercise.
• However, next study need to add variables of exercise to see all the thee reach significantly
improve in Y Balance Test and include EMG as outcome measure.

IMPLICATIONS
• Provide more relevant evidence and information for the physiotherapists.
• Provide early agility intervention and delaying the process of wear and tear.
• It can be implemented in physiotherapy practice to improvise the patient progress in
dynamic balance for early OA patient.
• This study will fill the gap of evidence based practice for physiotherapy as there is still lack
of knowledge in progressing exercise for Osteoarthritis patients.
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