Physiotherapeutic Intervention Techniques for Knee Osteoarthritis: A Systematic Review

Globally, knee osteoarthritis (KOA) is the leading cause of disability. The most prevalent complaints associated with KOA are knee pain, joint stiffness, and weakness in the muscles of the lower limbs. These symptoms impede movement and result in functional limitations. As a result, people with KOA have a lower quality of life. For all patient groups with knee OA, an effective rehabilitation program focuses on improving knee range of motion, isometric quadriceps strength, and productivity level while reducing discomfort. The American College of Rheumatology (ACR) categorization criteria for KOA, research on KOA physiotherapy, and reviews covering various physical therapy interventions, including exercise, physical modalities, and patient education, were used to narrow down the pool of 180 systematic reviews to 15 articles. Google Scholar, PubMed, the Cochrane Library, and EMBASE were the databases that were used. The following keyword combinations were included in our search: KOA and physiotherapy or interventions or exercises, strengthening and stretching, concentric and eccentric training. Through our analysis, we identified a few methods that, in addition to standard therapy, could be used in clinical settings for people with osteoarthritis in the knee. It has been shown that Mulligan, Pilates, Kinesiotaping, Aquatic Therapy, and other current therapies are effective. The study employed a broad range of results. This review concludes that rather than relying solely on conventional therapy, it is preferable to combine a number of the most current physiotherapy techniques with it.


Introduction And Background
Osteoarthritis of the knee is the main reason for disability worldwide [1].It is a chronic deteriorating condition that affects the knee joint.It is signified by anatomical and physiological abnormalities that cause bone tissue to change position, osteophytes to form, synovial membrane inflammation, ligament damage, and loss of normal joint movement [2].People with KOA experience a reduction in quality of life as a result [1].The most common KOA-related complaints are knee pain, joint stiffness, and lower limb muscle weakness, all of which limit movements and cause functional restrictions [1].As people live longer around the world, there is an increase in the prevalence of knee osteoarthritis (KOA) [3].The combined worldwide prevalence of KOA was 22.9% in those over 40 and 16.0% in those over 15 years of age.Accordingly, the global population with KOA in 2020 will be around 654.1 million people (40 years of age and older).The combined worldwide incidence of KOA in those 20 years of age and older was 203 per 10,000 person-years (95% CI, 106,331) [4].By 2050, the number of cases of osteoarthritis (OA) is expected to rise from 2020 to 74.9% (59.4-89.9)for the knee, 48.6% (35.9-67.1)for the hand, 78.6% (57.7-105.3)for the hip, and 95.1% (68.1-135.0)for other types [5].The literature indicates that women experience KOA more frequently.In these investigations, the overall proportion of KOA varied from 27.1% to 66.1%, depending on the lower age limit of the study group [3].KOA has a number of reasons.The following categories apply to knee osteoarthritis based on their causes such as idiopathic, which can be both localized and generalized KOA, or secondary OA, which can result from diseases such as calcium deposition, congenital or developmental disorders, post-traumatic OA, or developmental disorders [6].

Pathophysiology of KOA
The diarthrodial joint unites two adjacent bones and is protected by a synovial bursa and a unique layer of articular cartilage [7].More than half of undetectable people over the age of 50 have subchondral bone marrow lesions (SBMLs), which are caused by aberrant and chronic mechanical assaults and result in cellular and biomolecular reactions to microfractures, reported by abnormal MRI signals below the calcified cartilage [8].
Matrix metalloproteinase (MMP) synthesis is diminished by macrophage reduction and neutralization of macrophage-derived TNF and IL-1, which associate synovial macrophages with cartilage deterioration [9].Transforming Growth Factor (TGF), Bone Morphogenetic Proteins (BMP-2), and BMP-4, macrophage-derived growth factors that are involved in chondrogenesis and bone formation and are indicative of wound recovery responses, were found to have a negative impact on pathologic bone formation in OA [9].This indicates that the impact of inflammation in OA is multifaceted and regulated by the triggering stimuli.Still, it also influences macrophage-mediated inflammatory activity in the pathologic cartilage and bone responses associated with OA [9].
It has been established that the development of OA includes the wear and tear of the cartilage extracellular matrix (ECM), which, along with bone remodeling, causes progressive degradation of the joints and structural failure [10].The conclusion that MMPs mediate the breaking down of type II collagen and that aggrecan is destroyed by related metalloproteinases called adamalysins with thrombospondin motifs (ADAMTSs) is supported by a substantial body of evidence [10].

Clinical features of KOA
KOA is characterized by apprehension decreased range of motion (ROM), stiffness and edema of the joint, weak muscles, and joint instability [11].Joint discomfort that worsens with movement and is reduced by rest is one of the typical signs of OA, as is momentary joint stiffness that appears after inactivity.Physical evaluations of people with OA may reveal "knobby" joints as a result of the reorganization of bone and cartilage [12].According to the latest research, knee crepitus is a quick and reliable test that predicts the progression of symptomatic KOA over time.

Diagnostic investigations
Rather than clinical characteristics, radiographic appearance is frequently used to make the diagnosis of KOA.In 1957, Kellgren and Lawrence advocated the use of radiographic appearance [6].Five grades (0, normal to 4, severe) were used by Kellgren and Lawrence to categorize OA.According to this scale, grade 1 demonstrates that there are no bony growths and normal joint space; grade 2 demonstrates that there may be a slight narrowing of the joint space and the emergence of bony growths; grade 3 demonstrates that there is a narrowing of the joint space and mild bony growth formation; and grade 4 demonstrates that there is moderate bony growth formation, a narrowing of the joint space, and sclerosis of the subchondral bone [13].

Physical therapy management
All KOA groups respond well to a condition-specific rehabilitation program that reduces discomfort severity while enhancing knee range of motion, isometric quadriceps strength, and level of functional efficiency [14].In those with KOA, systematic quadriceps isometric contraction exercise successfully reduced pain and enhanced knee joint function [15].Interferential therapy with the specified parameters is proved to be very effective in improving pain [16].People with KOA may find stretching procedures helpful for managing their pain, especially when done on their own [17].In this way, numerous studies have demonstrated the significance of conventional physical therapy rehabilitation programs for individuals with KOA.
People with KOA have been established to greatly advantage from a variety of modern physiotherapy intervention options.Aquatic therapies, mulligan mobilization, pilates, closed-chain exercises, task-specific perturbation training, etc., are a few techniques.These strategies, as well as others that have been demonstrated to be extremely useful in such groups, are supported by a wealth of evidence.In this review, we have studied the many novel methods that, when used in conjunction with standard treatment, can benefit people with KOA.

Review
The approach of searching strategy through electronic databases for English language literature studies in which different physiotherapeutic regimens were used in individuals with KAO.The databases utilized were Google Scholar, PubMed, Cochrane Library, and EMBASE.We searched for the following combinations of keywords: KAO and physiotherapy or interventions or exercises, concentric and eccentric training, stretching, and strengthening.Numerous physiotherapeutic studies on KAO were included in the searches, but randomized control trials (RCTs), taking the year of publication into account, received more attention.Out of 180 systematic reviews, 15 articles were selected from the timeframe year 2019 to July 2023 based on the eligibility criteria as follows.

Eligibility criteria
The articles that needed to be examined were chosen based on the inclusion and exclusion criteria stated underneath.The inclusion criteria were as follows: studies included participants who met the American College of Rheumatology (ACR) categorization criteria for KAO, research on KAO physiotherapy, the reviews that covered various varieties of physical therapy interventions, such as exercise, physical modalities, and patient education, the key outcomes for this overview are pain and physical function, but we have also included psychological outcomes (such as scales of psychological disability or self-efficacy) because patients may find this information to be significant.The exclusion criteria were as follows: studies conducted that were not available in English; studies conducted without using human participants; studies for which there was no full text accessible; studies whose objectives were not related to the review; studies whose interventions were not clearly explained; studies based on the medications and studies whose outcome measures used were not reliable.

Discussion
The systematic literature review focuses on a number of research analyses that assess the effects of different types of training programs on KAO.These study methods include randomised control trials, experimental studies, comparative studies, and prospective studies to assess features such as pain, range of motion, strength, physical function, and psychological consequences.We discovered that the variation in misalignment is influenced by additional parameters such as meniscal degeneration and position, bone attrition, osteophytes, and ligament injury [33].Knee pain, its severity, and greater physical functional limits are all correlated cross-sectionally with poor proprioceptive acuity as measured by joint position awareness [34].Based on the KL scoring criteria, there is systematic shift in the knee joint muscle recruitment sequence are changed during gait in a systematic manner as structural KOA severity increases.These changes in muscle activation patterns have been associated with systematic temporal response delays, higher demand for active stiffness throughout the gait cycle and particularly during mid-stance, and diminished medial compartment joint loading with increased structural severity [35].
The elderly with KOA who participated in the structured aquatic physiotherapy program demonstrated increases in functional capacity (FC) and mobility when compared to conventional physiotherapy.These findings are consistent with our review, which suggests that aquatic therapy is more effective in boosting and enhancing the individual's strength and performance capacity in daily life than conventional physiotherapy [22].In comparison to Muscle Energy Technique with conventional therapy, Kinesio taping significantly improved pain on the VAS, increased range of motion on the Goniometer, and increased hamstring flexibility on the Active Knee Extension Test [18].For adults with initial medial KOA, a sensorbased gait retraining program was more effective than walking exercises at reducing medial knee loading, relieving knee discomfort, and improving indicators of OA [26].The kinematics associated with the recovery stepping response in women with KOA were dramatically enhanced by a single trip-specific perturbation training session [31].Both pilates exercises and closed kinematic chain exercises significantly improved pain reduction, muscle strength, and functional performance after six weeks of intervention.As compared to the closed kinematic chain exercises the pilates approach boosts mechanoreceptor sensitivity, which amplifies reflex neuromuscular protection mechanisms.Pilates training has been tailored to improve general body coordination, increase skeletal muscle recruitment, encourage muscular co-contraction, and activate proprioception throughout the knee joint.These exercises precisely minimize pain and improve lower limb muscle strength, coordination, and adaptability, hence improving the individual's general well-being life.However, it was discovered that pilates exercises were more efficient than closed kinematic chain exercises [23].
This review suggests that people with KAO respond well to conventional physiotherapy rehabilitation programs.However, these programs can be improved, and their quality of care can be increased by using other strategies.Through this research, we gathered strong evidence for few new intervention strategies such as kinesiotaping, non-thrust manuplation to reduce pain, muscle energy technique to increase the end range knee extention, blood flow restriction therapy, eccentric exercises, pilates, aquatic therapy enchances the muscular strength which leads to improve balance and sensor based gait traning is very effective to give the virtual feedback to the patients this would be extremely beneficial for people with KAO.In order to improve patients' standard of living, this study gives a brief overview of therapies that can be used in addition to regular physiotherapy.