The Effect of exercise program on balance, gait speed, and knee

pain among obese people

Mohammad Amro1 *
1
Faculty of Allied Medical Sciences, Arab American University, Palestine.
Abstract
Background: Obesity is associated with a range of disabling musculoskeletal conditions
in adults as knee and hip pain which account for a great deal of activity limitation. The
purpose of this study was to investigate the effect of exercise program on balance, gait
speed, and knee pain among obese people. Methods: A quasi-experimental trial with two
groups, experimental and control groups post-test. A total of 40 adult obese patients with
knee pain were randomly assigned to the control group (n=20) or experimental group
(n=20). Participants in the experimental group received exercise program. Results: A
total of 40 patients were enrolled. There were significant differences between the
experimental and control group regarding balance, speed gait, and knee pain (P< 0.005)
with favor to experimental group. Conclusions: the study confirmed the effect of
exercise on decrease knee pain, improved balance, and increase speed gait
.
Keywords: Obese patients, Exercise, Knee pain, Balance, Speed gait
1. Introduction

Obesity represents a major public health problem and carries with it the risk of
developing significant medical problems [1]. The global burden of obesity is rising at an
alarming rate. [2] In 2016, more than 1.9 billion adults aged 18 years and older were
overweight. Of these over 650 million adults were obese. [3] Obesity is a multifactorial
pathology that can be related to an altered nutritional behavior or secondary to genetic,
hypothalamic, iatrogenic or endocrine diseases [4] According to the classification based
on body mass index (BMI), the ratio between weight in kilograms and height in meters
squared (kg/m2) [5], a patient is considered overweight for BMI values greater than 25
kg/m2 and obesity is classified when BMI is greater than 30 kg/m2 [6]

Obesity is associated with a range of disabling musculoskeletal conditions in adults as

knee and hip pain which account for a great deal of activity limitation. Knee osteoarthritis
is a common comorbid condition associated with aging and obesity and over time can
lead to pain, stiffness, immobility, and possible joint replacement therapy [7]. Increase in
body weight puts a significant amount of stress and strain on the weight bearing joints,
especially lower back, hip, and knee, thus increasing the severity of MSD in older adults.
Obese individuals are also at higher risk for injuries to other joints, such as shoulders and
wrist, due to biomechanical compromises linked with higher body weight while
performing daily activities [8]. In a major study, Andersen et al. [4] compared the
relationship between body mass index (BMI) to knee and hip pain in elderly adults, 60
years and older. They reported the prevalence for knee, hip, and back pain as 21%, 14%,
and 22%, respectively, with an increase associated with higher BMI values [8].

The combination of an aging society and increase obesity levels make the
development of interventions for improving the physical independence of an aging
society is an issue of high importance. Current recommendations suggest that low
functioning obese older adults should receive weight loss treatments that minimizes
muscle and bone loss. [9] This recommendation has been empirically supported as obese
older adults who follow diet and exercise therapy are able to lose weight while
maintaining their muscle mass and improving their physical function. [10] However,
systematic reviews of randomized controlled trials (RCTs) indicate that exercise therapy
reduces pain and patient‐reported disability in patients with knee osteoarthritis (OA), but
to date, the optimal exercise regimen has not been identified [11, 12]) The effects of
exercise programs in clinical trials are likely to vary, since the interventions differ
substantially in type of exercise (aerobic, strengthening, etc.), intensity of exercise,
duration of intervention, and number of sessions per week. Therefore, the purpose of this
study was to investigate the effect of exercise program on balance, gait speed, and knee
pain among obese people.

1.1 Research Hypothesis

1) There is a significant difference in balance between the experimental group and the
intervention group post exercise program in the obese people
2) There is a significant difference in gait speed between the experimental group and
the intervention group post exercise program in the obese people
3) There is a significant difference in knee pain between the experimental group and the
intervention group post exercise program in the obese people
2. Methods

2.1 Research design

The study utilized an experimental controlled design with post- test.

2.2 Population and sampling

The population in this study included obese people with knee pain from several regions in
Palestine who attended the physiotherapy center at Arab American University. The study
conducted in the period June and September, 2019. All obese patients with knee pain and
their age above 18 years were invited to participate in the study. A total of 40 patients
agreed to participate in the study. The participants were distributed randomly into
experimental group (n=20) and control group (n=20).

2.3 Instruments

The questionnaire composed of four parts; the first part involved demographic
characteristics which include age, gender, marital status, in addition to anthropometric
measurements as height and weight. The second part involved gait speed test to measure
the speed for each person. The third part involved Berg balance scale to evaluate the level
of balance for each person. It composed of 14 item scale with 0-4 point and its total point
is 56. Finally, the fourth part involved visual analog scale to assess severity of the pain.
The scale from (0) the lowest degree to (10) the highest degree of pain and the partcipants
choose the most appropriate for him or her.

2.4 Procedure and data collection

The approval to conduct the study was obtained from the university. All obese patients
with knee pain who attended the physiotherapy center invited to participate. The
researcher explained to them the purpose of the study and they have the opportunity to
refuse or to withdraw from the study at any time. Then, the partcipants who agreed to
participate assigned the informed consent. Before staring the exercise program the
participants blood pressure assessed. The partcipants distributed randomly to
experimental or control group. The experimental group demonstrated the exercise
program. The exercise program composed of strength exercise, balance exercise, stretch
exercise. The exercise program applied individually for the participants and took place
one hour. The researcher asked to do it twice a day for a week. Then, after one week all
participants completed the questionnaire. Also, the participants tested the gait speed by
using gait speed test. Appropriate and safe area to walk was chosen. The distance was
20m and put out marker. The participant was instructed to walk normally within the
marked distance. When she/he started walk, the researcher begin timing by timer and stop
it just as participant pass the end marker of walking area. This test performed 3 times to
get most accurate result, then the average of the results got to calculate the gait speed by
the equation (total distance/time). Then the participants evaluated by Berg balance scale
to assess the level of balance for each of them. The control group received routine care
physiotherapy.

3. Results
3.1 Descriptive of the participants

A total of 40 obese patient with knee pain participated in the study. Approximately half
of the participants were between 46-55 years old (n=18; 45.0%), and more than half of
them were male (n=22; 55.0%). Also, the analysis of the experimental group revealed
that 8 (40.0%) while 9 (45%) of the control group aged between 46-55 years old.
Additionally, the experimental group had equal male and female 10 (50%) while the
control group 12 (60%) were male, as seen in table 1

Table 1: Socio-demographic characteristics of the study subjects (n=40).

Variable Experimental Control group Total

group
n)%( n)%( n(%)
Age 20-25 years 2 (10.0) 4 (20.0) 6 (15.0)
26-35 years 3 (15.0) 1 (5.0) 4 (10.0)
36-45 years 7 (35.0) 6 (30.0) 12(30.0)
46-55 years 8 (40.0) 9 (45.0) 18(45.0)
Gender Male 10 (50.0) 12 (60.0) 22(55)
Female 10 (50.0) 8 (40.0) 18(45)

The analysis showed that 22(55%) suffering from knee pain since less than 5 years.
Additionally, more than half of respondents suffering from pain in both knees 24
(60.0%), as seen in table 2.
Table 2: Participants’ history of knee pain (n=40).

Variable Experimental Control group Total

group
n(%) n(%) n(%)
Period of less than 5 years 10 (50.0) 9 (45.0) 22(55.0)
pain 5-10 years 7(35.0) 6 (30.0) 12(30)
10-15 years 2 (10.0) 2 (10.0) 4(10)
more than 15 1 (5.0) 3 (15.0) 2(5.0)
years
Place of pain Both knees 12 (60.0) 10 (50.0) 24(60.0)
Right knee 4 (20.0) 4 (20.0) 6(15.0)
Left knee 4 (20.0) 6 (30.0) 10(25.0)

3.2 Testing hypothesis

The analysis revealed that there is significant difference in balance scores between the
control (M=40, SD= 8.8) and the experimental group (M=45.4, SD=7.6) among obese
patients post exercise program (P< 0.05). Also, the analysis revealed that there is
significant difference in Gait speed test scores between the control (M=0.57, SD= 0.18)
and the experimental group (M=0.64, SD=0.26) among obese patients post exercise
program (P< 0.05). Moreover, there is significant difference in severity of pain between
both groups post exercise program. The mean severity of pain was (5.60) in the control
group, while severity of pain has declined into (4.80) post exercises in the experimental
group. Table 3 represented the analysis
Table 3: the difference of balance, gait speed, and pain among obese people between
the control and the experimental groups post exercise program (N=40)

Variable Experimental group Control group Statistical test P. Value

M(SD) M(SD)
Balance 45.40 (7.6) 40.60 (8.8) 5.46 0.001
Gait speed 0.65 (0.26) 0.57 ( 0.18) 2.22 0.004
Severity of pain 5.60 (1.71) 4.80 (2.15) 4.00 0.003

4. Discussion
The current study aimed to investigate the effect of exercise program on balance, gait
speed, and knee pain among obese people.

The current study showed that the larger age group was between 46-55 years old
(45.0%), and the number of respondents of the males was (55%). About 55% of the
respondents reported that they had pain since less than 5 years. Moreover, more than half
of respondents indicated that their pain in both knees (60.0%).

Hypothetically, there was a significant relationship between exercises and balance

among obese people, they became more balanced with more exercises. There was an
effect of exercises on knee pain severity among obese people, pre and post exercises.

The obese people display more balance with exercises. Jadelis et al. study results [13] had
shown that obesity is associated with attenuated dynamic balance performance and that
poorer balance is associated with higher pain scores in the presence of weaker knees. The
stronger knees, however, pain does not appear to be related to balance but it was found that
the mean standard of "reaching forward with outstretched arm" task had the lowest mean
before achieving this task, while raised up post undertaking this task. "Standing with eyes
closed" task achieved the highest mean score before performing this task, while raised up
post achieving this task. Grossly, by achieving this Berg Balance test by the experimental
group, it was concluded that exercises have positive impact on subjects by displaying more
balance.

Decreased balance and mobility are the main cause of falls in elderly people [14]. Falls
are serious adverse events for elderly people, which may cause disability or even death.
According to Arnold’s research [15], an exercise intervention can improve balance and
mobility, and prevent falls by elderly patients. Exercise can increase the muscle strength
of the lower limbs to stabilize the knees and coordinate gait [16]. In our study, the
exercise intervention decreased pain intensity and joint stiffness in patients, and increased
their physical functioning, including lower-limb muscle strength, balance, and mobility.
Therefore, the improvement in patients’ quality of life may due to the improvements in
pain intensity, stiffness, and physical functioning. The study recommended replication of
the study in other areas of Palestine to make generizablity for findings. Strength of the
study was randomized control study.
5. Conclusions
This study confirmed that obese people exhibit lower gait speeds, more balanced, and
reduced knee pain with more exercises.

References:
[1]. Jastreboff AM, Kotz CM, Kahan S, Kelly AS, Heymsfield SB. Obesity as a disease:
the obesity society 2018 position statement. Obesity. 2019 Jan;27(1):7-9.
[2]. World Health Organization. (2016). Obesity and overweight [Internet]. Fact sheet,
311.
[3]. Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ, et al.
National, regional, and global trends in body-mass index since 1980: systematic analysis
of health examination surveys and epidemiological studies with 960 country-years and 9·
1 million participants. Lancet. 2011;377(9765):557–567
[4]. Vallgårda S, Nielsen ME, Hansen AK, Cathaoir KÓ, Hartlev M, Holm L,
Christensen BJ, Jensen JD, Sørensen TI, Sandøe P. Should Europe follow the US and
declare obesity a disease?: a discussion of the so-called utilitarian argument. European
journal of clinical nutrition. 2017 Nov;71(11):1263-7.
[5]. WHO Expert Committee, 1995. Physical status: the use and interpretation of
anthropometry. http://helid. digicollection. Org/en/d/Jh0211e/.
[6]. Flegal KM. Commentary: the quest for weight standards. International journal of
epidemiology. 2010 Aug 1;39(4):963-7.
[7]. Powell A, Teichtahl AJ, Wluka AE, Cicuttini FM (2005) Obesity: a preventable risk
factor for large joint osteoarthritis which may act through biomechanical factors. Br J
Sports Med 39: 4-5.
[8]. Andersen RE, Crespo CJ, Bartlett SJ, Bathon JM, Fontaine KR (2003) Relationship
between body weight gain and significant knee, hip, and back pain in older Americans.
Obes Res 11: 1159-1162.
[9]. Villareal DT, Apovian CM, Kushner RF, Klein S. Obesity in older adults: technical
review and position statement of the American Society for Nutrition and NAASO, The
Obesity Society. Obes Res. 2005; 13:1849–63. [PubMed: 16339115]
[10]. Villareal DT, Banks M, Sinacore DR, Siener C, Klein S. Effect of weight loss and
exercise on frailty in obese older adults. Arch Intern Med. 2006; 166:860–6.
[11]. Jansen MJ, Viechtbauer W, Lenssen AF, Hendriks EJ, de Bie RA. Strength training
alone, exercise therapy alone, and exercise therapy with passive manual mobilization
each reduce pain and disability in people with knee osteoarthritis: a systematic review. J
Physiother2011;57:11–20.
[12]. Fransen M, McConnell S. Exercise for osteoarthritis of the knee. Cochrane
Database Syst Rev2008:CD004376.

[13]. Jadelis. K, Miller. M. E, Ettinger. W.H, Messier. S.P, Strength, Balance, and the
Modifying Effects of Obesity and Knee Pain, JOURNAL AMERICAN GERIATRICS
SOCIETY (2001) ,7(7) , 884-891.

[14]. Keskin D, Borman P, Ersoz M, Kurtaran A, Bodur H, Akyuz M. The risk factors
related to falling in elderly females. Geriatr Nurs. 2008;29:58–63.

[15]. Arnold CM, Gyurcsik NC. Risk factors for falls in older adults with lower extremity
arthritis: a conceptual framework of current knowledge and future directions. Physiother
Can. 2012;64:302–14.

[16]. Kabiri S, Halabchi F, Angoorani H, Yekaninejad S. Comparison of three modes of

aerobic exercise combined with resistance training on the pain and function of patients
with knee osteoarthritis: a randomized controlled trial. Phys Ther Sport. 2018;32:22–8.