Rheumatology International

, Volume 32, Issue 11, pp 3339–3351 | Cite as

The effectiveness of proprioceptive-based exercise for osteoarthritis of the knee: a systematic review and meta-analysis

  • Toby O. Smith
  • Jonathan J. King
  • Caroline B. Hing
Review Article


Osteoarthritis (OA) is a leading cause of functional impairment and pain. Proprioceptive defects may be associated with the onset and progression of OA of the knee. The purpose of this study was to determine the effectiveness of proprioceptive exercises for knee OA using meta-analysis. A systematic review was conducted on 12th December 2011 using published (Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, PubMed, PEDro) and unpublished/trial registry (OpenGrey, the WHO International Clinical Trials Registry Platform, Current Controlled Trials and the UK National Research Register Archive) databases. Studies were included if they were full publications of randomized or non-randomised controlled trials (RCT) comparing a proprioceptive exercise regime, against a non-proprioceptive exercise programme or non-treatment control for adults with knee OA. Methodological appraisal was performed using the PEDro checklist. Seven RCTs including 560 participants (203 males and 357 females) with a mean age of 63 years were eligible. The methodological quality of the evidence base was moderate. Compared to a non-treatment control, proprioceptive exercises significantly improved functional outcomes in people with knee OA during the first 8 weeks following commencement of their exercises (p < 0.02). When compared against a general non-proprioceptive exercise programme, proprioceptive exercises demonstrated similar outcomes, only providing superior results with respect to joint position sense-related measurements such as timed walk over uneven ground (p = 0.03) and joint position angulation error (p < 0.01). Proprioceptive exercises are efficacious in the treatment of knee OA. There is some evidence to indicate the effectiveness of proprioceptive exercises compared to general strengthening exercises in functional outcomes.


Joint position sense Tibiofemoral Patellofemoral Degenerative changes Rehabilitation Conservative management 


Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Stillman BC (2002) Making sense of proprioception. The meaning of proprioception, kinaesthesia and related terms. Physiother 88:667–676CrossRefGoogle Scholar
  2. 2.
    Olsson L, Lund H, Henriksen M, Rogind H, Bliddal H, Danneskiold-Samsoe B (2004) Test-retest reliability of a knee joint position sense measurement method in sitting and prone position. Adv Physiother 6:37–47CrossRefGoogle Scholar
  3. 3.
    Kinzey SJ, Armstrong CW (1998) The reliability of the star-excursion test in assessing dynamic balance. J Orthop Sports Phys Ther 27:356–360PubMedGoogle Scholar
  4. 4.
    Jerosch J, Prymka M (1996) Knee joint proprioception in patients with posttraumatic recurrent patella dislocation. Knee Surg Sports Traumatol Arthrosc 4:14–18PubMedCrossRefGoogle Scholar
  5. 5.
    Jerosch J, Prymka M (1996) Proprioception and joint stability. Knee Surg Sports Traumatol Arthrosc 4:171–179PubMedCrossRefGoogle Scholar
  6. 6.
    Baker V, Bennell K, Stillman B, Cowan S, Crossley K (2002) Abnormal knee joint position sense in individuals with patellofemoral pain syndrome. J Orthop Res 20:208–214PubMedCrossRefGoogle Scholar
  7. 7.
    Duncan R, Peat G, Thomas E, Hay EM, Croft P (2001) Incidence, progression and sequence of development of radiographic knee osteoarthritis in a symptomatic population. Ann Rheum Dis 70:1944–1948CrossRefGoogle Scholar
  8. 8.
    Woolf AD, Pfleger B (2003) Burden of major musculoskeletal conditions. Bull World Health Organ 81:646–656PubMedGoogle Scholar
  9. 9.
    Bayramoglu M, Toprak R, Sozay S (2007) Effects of osteoarthritis and fatigue on proprioception of the knee joint. Arch Phys Med Rehabil 88:346–350PubMedCrossRefGoogle Scholar
  10. 10.
    Felson DT, Gross KD, Nevitt MC, Yang M, Lane NE, Torner JC, Lewis CE, Hurley MV (2009) The effects of impaired joint position sense on the development and progression of pain and structural damage in knee osteoarthritis. Arthritis Rheum 61:1070–1076PubMedCrossRefGoogle Scholar
  11. 11.
    Lund H, Juul-Kristensen B, Hansen K, Christensen R, Christensen H, Danneskiold-Samsoe B, Bliddal H (2008) Movement detection impaired in patients with knee osteoarthritis compared to healthy controls: a cross-sectional case-control study. J Musculoskelet Neuronal Interact 8:391–400PubMedGoogle Scholar
  12. 12.
    Bennell KL, Hinman RS, Metcalf BR, Crossley KM, Buchbinder R, Smith M, McColl G (2003) Relationship of knee joint proprioception to pain and disability in individuals with knee osteoarthritis. J Orthop Res 21:792–797PubMedCrossRefGoogle Scholar
  13. 13.
    van Dijk GM, Dekker J, Veenhof C, van den Ende CH, Carpa Study Group (2006) Course of functional status and pain in osteoarthritis of the hip or knee: a systematic review of the literature. Arthritis Rheum 55:779–785PubMedCrossRefGoogle Scholar
  14. 14.
    Hassan BS, Doherty SA, Mockett S, Doherty M (2002) Effect of pain reduction on postural sway, proprioception, and quadriceps strength in subjects with knee osteoarthritis. Ann Rheum Dis 61:422–428PubMedCrossRefGoogle Scholar
  15. 15.
    Hinman RS, Bennell KL, Metcalf BR, Crossley KM (2002) Balance impairments in individuals with symptomatic knee osteoarthritis: a comparison with matched controls using clinical tests. Rheumatology 41:1388–1394PubMedCrossRefGoogle Scholar
  16. 16.
    van der Esch M, Steultjens M, Harlaar J, Knol D, Lems W, Dekker J (2007) Joint proprioception, muscle strength, and functional ability in patients with osteoarthritis of the knee. Arthritis Rheum 57:787–793PubMedCrossRefGoogle Scholar
  17. 17.
    Knoop J, Steultjens MP, van der Leeden M, van der Esch M, Thorstensson CA, Roorda LD, Lems WF, Dekker J (2011) Proprioception in knee osteoarthritis: a narrative review. Osteoarthritis Cartilage 19:381–388PubMedCrossRefGoogle Scholar
  18. 18.
    Hurley MV (1997) The effects of joint damage on muscle function, proprioception and rehabilitation. Man Ther 2:11–17PubMedCrossRefGoogle Scholar
  19. 19.
    Zech A, Hübscher M, Vogt L, Banzer W, Hänsel F, Pfeifer K (2010) Balance training for neuromuscular control and performance enhancement: a systematic review. J Athl Train 45:392–403PubMedCrossRefGoogle Scholar
  20. 20.
    Tsauo JY, Cheng PF, Yang RS (2008) The effects of sensorimotor training on knee proprioception and function for patients with knee osteoarthritis: a preliminary report. Clin Rehabil 22:448–457PubMedCrossRefGoogle Scholar
  21. 21.
    Lephart SM, Pincivero DM, Giraldo JL, Fu FH (1997) The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med 25:130–137PubMedCrossRefGoogle Scholar
  22. 22.
    Fransen M, McConnell S (2009) Land-based exercise for osteoarthritis of the knee: a metaanalysis of randomized controlled trials. J Rheumatol 36:1109–1117PubMedCrossRefGoogle Scholar
  23. 23.
    Devos-Comby L, Cronan T, Roesch SC (2006) Do exercise and self-management interventions benefit patients with osteoarthritis of the knee? A metaanalytic review. J Rheumatol 33:744–756PubMedGoogle Scholar
  24. 24.
    Farrar EK, Mitchell H (2009) Osteoarthritis and exercise: a review of the literature. J S C Med Assoc 105:8–11PubMedGoogle Scholar
  25. 25.
    Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (1988) Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 15:1833–1840PubMedGoogle Scholar
  26. 26.
    Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD (1998) Knee injury and osteoarthritis outcome score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther 28:88–96PubMedGoogle Scholar
  27. 27.
    Macedo LG, Elkins MR, Maher CG, Moseley AM, Herbert RD, Sherrington C (2010) There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials. J Clin Epidemiol 63:920–925PubMedCrossRefGoogle Scholar
  28. 28.
    de Morton NA (2009) The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother 55:129–133PubMedCrossRefGoogle Scholar
  29. 29.
    Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M (2003) Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 83:713–721PubMedGoogle Scholar
  30. 30.
    Hurley MV, Scott DL (1998) Improvements in quadriceps sensorimotor function and disability of patients with knee osteoarthritis following a clinically practicable exercise regime. Br J Rheumatol 37:1181–1187PubMedCrossRefGoogle Scholar
  31. 31.
    Chaipinyo K, Karoonsupcharoen O (2009) No difference between home-based strength training and home-based balance training on pain in patients with knee osteoarthritis: a randomised trial. Aust J Physiother. 55:25–30PubMedCrossRefGoogle Scholar
  32. 32.
    Fitzgerald GK, Piva SR, Gil AB, Wisniewski SR, Oddis CV, Irrgang JJ (2011) Agility and perturbation training techniques in exercise therapy for reducing pain and improving function in people with knee osteoarthritis: a randomized clinical trial. Phys Ther 91:452–469PubMedCrossRefGoogle Scholar
  33. 33.
    Lin DH, Lin CH, Lin YF, Jan MH (2009) Efficacy of 2 non-weight-bearing interventions, proprioception training versus strength training, for patients with knee osteoarthritis: a randomized clinical trial. J Orthop Sports Phys Ther 39:450–457PubMedGoogle Scholar
  34. 34.
    Jan MH, Lin CH, Lin YF, Lin JJ, Lin DH (2009) Effects of weight-bearing versus nonweight-bearing exercise on function, walking speed, and position sense in participants with knee osteoarthritis: a randomized controlled trial. Arch Phys Med Rehabil 90:897–904PubMedCrossRefGoogle Scholar
  35. 35.
    Lin DH, Lin YF, Chai HM, Han YC, Jan MH (2007) Comparison of proprioceptive functions between computerized proprioception facilitation exercise and closed kinetic chain exercise in patients with knee osteoarthritis. Clin Rheumatol 26:520–528PubMedCrossRefGoogle Scholar
  36. 36.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502PubMedCrossRefGoogle Scholar
  37. 37.
    Diracoglu D, Aydin R, Baskent A, Celik A (2005) Effects of kinesthesia and balance exercises in knee osteoarthritis. J Clin Rheumatol 11:303–310PubMedCrossRefGoogle Scholar
  38. 38.
    Jaeschke R, Singer J, Guyatt GH (1989) Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials 10:407–415PubMedCrossRefGoogle Scholar
  39. 39.
    Bland M (2000) Introduction to medical statistics, 3rd edn. Oxford University Press, OxfordGoogle Scholar
  40. 40.
    Campbell R, Evans M, Tucker M, Quilty B, Dieppe P, Donovan JL (2001) Why don’t patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee. J Epidemiol Community Health 55:132–138PubMedCrossRefGoogle Scholar
  41. 41.
    Bouët V, Gahéry Y (2000) Muscular exercise improves knee position sense in humans. Neurosci Lett 289:143–146PubMedCrossRefGoogle Scholar
  42. 42.
    Hewett TE, Paterno MV, Myer GD (2002) Strategies for enhancing proprioception and neuromuscular control of the knee. Clin Orthop Relat Res 402:76–94PubMedCrossRefGoogle Scholar
  43. 43.
    Hazneci B, Yildiz Y, Sekir U, Aydin T, Kalyon TA (2005) Efficacy of isokinetic exercise on joint position sense and muscle strength in patellofemoral pain syndrome. Am J Phys Med Rehabil 84:521–527PubMedCrossRefGoogle Scholar
  44. 44.
    Schaible HG, Grubb BD (1993) Afferent and spinal mechanisms of joint pain. Pain 55:5–54PubMedCrossRefGoogle Scholar
  45. 45.
    Hellström F, Thunberg J, Bergenheim M, Sjölander P, Pedersen J, Johansson H (2000) Elevated intramuscular concentration of bradykinin in jaw muscle increases the fusimotor drive to neck muscles in the cat. J Dent Res 79:1815–1822PubMedCrossRefGoogle Scholar
  46. 46.
    Capra NF, Ro JY (2000) Experimental muscle pain produces central modulation of proprioceptive signals arising from jaw muscle spindles. Pain 86:151–162PubMedCrossRefGoogle Scholar
  47. 47.
    Johansson H, Sjölander P, Sojka P (1991) A sensory role for the cruciate ligaments. Clin Orthop Relat Res 268:161–178PubMedGoogle Scholar
  48. 48.
    Ashton-Miller JA, Wojtys EM, Huston LJ, Fry-Welch D (2001) Can proprioception really be improved by exercises? Knee Surg Sports Traumatol Arthrosc 9:128–136PubMedCrossRefGoogle Scholar
  49. 49.
    Coleman S, McQuade J, Rose J, Inderjeeth C, Carroll G, Briffa NK (2010) Self-management for osteoarthritis of the knee: does mode of delivery influence outcome? BMC Musculoskelet Disord 11:56PubMedCrossRefGoogle Scholar
  50. 50.
    Evcik D, Sonel B (2002) Effectiveness of a home-based exercise therapy and walking program on osteoarthritis of the knee. Rheumatol Int 22:103–106PubMedCrossRefGoogle Scholar
  51. 51.
    Carvalho NA, Bittar ST, Pinto FR, Ferreira M, Sitta RR (2010) Manual for guided home exercises for osteoarthritis of the knee. Clinics (Sao Paulo) 65:775–780CrossRefGoogle Scholar
  52. 52.
    Tunay VB, Baltacı G, Atay AO (2010) Hospital-based versus home-based proprioceptive and strengthening exercise programs in knee osteoarthritis. Acta Orthop Traumatol Turc 44:270–277PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Toby O. Smith
    • 1
  • Jonathan J. King
    • 2
  • Caroline B. Hing
    • 3
  1. 1.Faculty of Medicine and Health Sciences, Queen’s BuildingUniversity of East Anglia, Norwich Research ParkNorwichUK
  2. 2.Physiotherapy DepartmentNorfolk and Norwich University HospitalNorwichUK
  3. 3.Department of Orthopaedics and TraumaSt George’s HospitalLondonUK

Personalised recommendations