Rheumatol Int (2012) 32:3339–3351
DOI 10.1007/s00296-012-2480-7
REVIEW ARTICLE
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
Received: 7 February 2012 / Accepted: 7 July 2012 / Published online: 22 July 2012
Ó Springer-Verlag 2012
Abstract 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, Pub-
Med, PEDro) and unpublished/trial registry (OpenGrey, the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 exer-
cise regime, against a non-proprioceptive exercise pro-
gramme 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
This study was undertaken at the University of East Anglia, Norwich,
UK.
T. O. Smith (&)
Faculty of Medicine and Health Sciences, Queen’s Building,
University of East Anglia, Norwich Research Park, Norwich
NR4 7TJ, UK
e-mail: toby.smith@uea.ac.uk
J. J. King
Physiotherapy Department, Norfolk and Norwich University
Hospital, Norwich, UK
C. B. Hing
Department of Orthopaedics and Trauma, St George’s Hospital,
London, UK
eligible. The methodological quality of the evidence base
was moderate. Compared to a non-treatment control, pro-
prioceptive 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 demon-
strated 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.
Keywords Joint position sense
Tibiofemoral

Patellofemoral
Degenerative changes
Rehabilitation

Conservative management
Introduction
Proprioception is composed of several different biome-
chanical components including joint position sense (JPS),
velocity, movement detection and force [1]. Principally
proprioceptive sensation is derived from mechanoreceptors
in muscle, joint capsule, tendon, ligaments and skin [2].
Motion stimulates mechanoreceptors to provide proprio-
ceptive sensation essential for undertaking co-ordinated
normal activities of daily living and more physically
demanding tasks [3]. However, trauma and pathological
processes can impact on this feedback system. This may
increase subsequent susceptibility to injury with reduced
motor control [4–6].
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OA is the most common form of arthritis, with osteo- Table 1 Example of the MEDLINE search strategy adopted in this
arthritis of the knee being a leading cause of functional study
impairment in the elderly [7]. OA is predicted to be the 1. Knee/
fourth largest cause of disability by 2020 [8]. Previous 2. Exp knee joint/
literature has shown that proprioceptive defects may be 3. Patellofemoral
associated with the onset and progression of OA of the 4. Tibiofemoral
knee [9–11] leading to pain and disability [12, 13]. Fur- 5. OR/1–4
thermore, proprioceptive acuity has been demonstrated to 6. Exp osteoarthritis/
be reduced in those with knee OA when compared to age-, 7. Degenerative disease.tw
gender- and body mass-matched controls [14–16]. 8. Osteoarthr$.tw
Knoop et al.’s [17] recent narrative review identified 9. (Degenerative adj2 arthritis).tw
four key factors that may cause impairment to proprio- 10. OR/6–9
ceptive accuracy in knee OA. These were impaired artic- 11. Joint position sense.tw
ular mechanoreceptors, muscle weakness through reduced
12. Proprioception.tw
c-motoneurone activation with decreased muscle spindle
13. Kinesthesi$.tw
sensitivity, OA-related inflammation and effusion, and
14. Postural stability.tw
concomitant injuries to the anterior cruciate ligament
15. Postural orientation.tw
(ACL) or meniscus [17, 18]. However, the authors
16. Exp balance/
acknowledged that the evidence base was limited in its
17. Stabilomet$.tw
consensus of these factors [17]. Nonetheless, it has been
18. OR/11–17
hypothesised that exercises can improve knee propriocep-
19. Exp exercise/
tion [19] by the facilitation of dynamic joint stabilisation to
20. Exp rehabilitation/
retrain altered afferent pathways, thus enhancing proprio-
21. Re-train$.tw
ception and improving patient function [20, 21].
22. Training.tw
Whilst previous authors have examined the effects of
exercise on knee OA, none have specifically examined the 23. Activity.tw
effectiveness of proprioceptive-type training for this pop- 24. OR/19–23
ulation using a meta-analysis statistical process [22–24]. 25. Randomized controlled trial.pt
Therefore, the purpose of this study was to compare the 26. Controlled clinical trial.pt
clinical outcomes of people who receive an exercise pro- 27. Randomized.ab
gramme incorporating proprioceptive training compared to 28. OR/25–27
rehabilitation without proprioceptive training or a non- 29. AND/5, 10, 18, 24, 28
treatment control for those with OA of the knee. 30. Remove duplicates/30

Methods were searched, and the corresponding authors of each eli-

gible study were contacted to identify any previously
Search strategy omitted studies.

The primary search strategy was conducted using the
electronic databases: Cochrane Library, MEDLINE via
Ovid, EMBASE via Ovid, CINAHL, AMED, PubMed and
the PEDro database from their inceptions to December
2011. The MEDLINE MeSH, keyword search terms and
Boolean operators used for this strategy are presented in
Table 1. The format of these was modified for each data-
base reviewed.
A secondary search was conducted of the unpublished
and trial registry databases: OpenGrey, the WHO Interna-
tional Clinical Trials Registry Platform, Current Controlled
Trials and the UK National Research Register Archive. In
addition, the reference lists of all full-text retrieved articles
Eligibility criteria
Studies were included if they were full publications of
randomised or non-randomised controlled trials (RCT)
comparing the inclusion of a proprioceptive re-education
or exercise training regime, against a non-proprioceptive
re-education or exercise training regime or no-treatment
control in the non-operative management of OA of the
knee in adults (18 years and over). Studies required at least
10 participants allocated to each treatment group for
inclusion. Studies were excluded if they were not full-text
publications, trials where neither or both intervention arms
included a proprioceptive re-training element, or studies

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Rheumatol Int (2012) 32:3339–3351
using healthy volunteers or those with other knee
pathologies.
Studies were required to demonstrate the establishment of
OA and to categories this. Studies that included patients with
other concomitant musculoskeletal pathologies such as hip
OA were included. Where possible, those with solely knee
OA were analysed separately. Studies assessing the effects of
the intervention with those following total knee arthroplasty
(TKA) were excluded. However, study data were eligible
when interventions were provided prior to arthroplasty sur-
gery, and the pre-surgical outcomes were collected.
There was no control regarding the proprioceptive
training regime; however, heterogeneity between different
regimes was analysed. Studies that assessed the effects of
whole body vibration training were excluded from this
review. No language restrictions were applied to the
potentially eligible studies.
The eligibility of each study was decided by two reviewers
(JK, TS) who independently assessed the titles and abstracts
for each search result. The full-text of each potentially eli-
gible paper was ordered and then re-reviewed by the two
reviewers independently. Any disagreements were resolved
by consensus or referral to a third reviewer (CH).
Primary outcome measures
The primary outcome measure was functional outcome at
1-year post-randomisation. This was assessed with vali-
dated outcome measures such as the Western Ontario and
McMaster Universities Arthritis Index (WOMAC) [25] or
Knee injury and osteoarthritis outcome score (KOOS) [26].
Alternatively function was assessed with tests such as the
timed get-up-and-go, timed stair ascent, or the sixty-metre
walk test.
Secondary outcome measures
These included pain, general or quality of life health
measures, JPS capability, knee range of motion, exercise
compliance and acceptability, and quadriceps and ham-
string muscle strength.
Data extraction and critical appraisal
Data extraction from each eligible paper was independently
conducted by one reviewer (JK) and verified by a second
(TS). The data collected included characteristics of par-
ticipants, stage of knee OA, study interventions, outcome
measurements, follow-up period, results, in addition to the
critical appraisal of each study. All data were recorded on a
standard data extraction form.
Each included study was assessed for its methodological
merit using the PEDro critical appraisal tool. This was
3341
deemed appropriate since it has been demonstrated as a
reliable and valid appraisal tool for the assessment of
physiotherapy-based RCTs [27–29]. Each paper was
appraised using this tool by two reviewers independently
(JK, TS). Any inconsistency in appraisal score was dis-
cussed until a consensus was met.
Data AnalysisData homogeneity was initially assessed
visually using the data extraction table. Where methodo-
logical heterogeneity was exhibited, that is, interventions,
populations, assessment methods differed, this data were
analysed narratively. When data appeared broadly homo-
geneous, statistical heterogeneity was assessed using the I2
and chi2 statistical tests. If chi2 was greater than p = 0.10
and the I2 greater than 20 %, higher levels of statistical
heterogeneity were denoted and a random effects model
was adopted. When chi2 was less than 0.10 and I2 less than
20 %, a fixed-effects model was adopted.
When meta-analysis was appropriate, continuous data
outcome measurement was assessed by mean difference
(MD) or standardised mean difference (std MD) between
the groups, that is rehabilitation with or without the addi-
tion of proprioceptive-type exercises. For dichotomous
outcomes, a risk difference (RD) ratio to compare the risk
of an event occurs. All statistically significant analyses
were interpreted using p values where p \ 0.05 was con-
sidered a statistically significant difference, in addition to
the presentation of 95 % confidence intervals (CI).
A sensitivity analysis was planned to compare the
analyses finding’s of RCT data only. Since all identified
studies were RCTs, this was not performed.
All statistical analyses were conducted by one reviewers
(TS) using the Review Manager 5.0 for Windows (The
Nordic Cochrane Centre, Copenhagen, The Cochrane
Collaboration, 2008).
Results
Search results
The results of the search strategy are presented in Fig. 1.
In total, eight studies were considered eligible after review.
After further consideration, one study [30] was excluded,
as this did not compare the use of a proprioceptive inter-
vention compared to different interventions. Therefore,
seven studies were included in the review. All seven
studies were RCTs.
Methodological quality assessment
The results of the methodological appraisal are summarised
in Table 2. This indicated that the methodological quality of
the current evidence base was moderate. All seven studies
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Records identified through database Additional records identified
searching through other sources
(n =294)
Records after duplicates removed
(n=179)
Records screened
(n=179)
Full-text articles assessed
for eligibility (n=25)
Studies included in
qualitative synthesis
(n=7)
Studies included in
quantitative synthesis
(meta-analysis)
(n=7)
Fig. 1 PRISMA flow-chart depicting study search results
were RCT designs, clearly stating their eligibility criteria, and
using appropriate randomisation procedures. Nonetheless,
only Chaipinyo and Karoonsupcharoen [31], Fitzgerald et al.
[32] and Lin et al. [33] clearly stated that their randomisation
procedures were concealed to minimise allocation bias. All
but Chaipinyo and Karoonsupcharoen [31] assessed and
ensured baseline comparability between their groups. All
studies analysed their results based on an intention-to-treat
principle, assessing both between groups difference appro-
priately with descriptive and inferential statistical tests.
However, only four studies ensured that their assessors were
blinded to group allocation. Due to the interventions under
assessment, that is, exercise regimes, it was logistically
impractical to attempt to blind clinicians or participants to the
interventions they received. Nonetheless, the two major
limitations that the studies recurrently presented were that all
but three studies recruited small, underpowered cohorts
where sample size was not based on a power calculation
[31–33], whilst only three studies reported between-group
inferential statistical analyses confidence interval data [32, 33].
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(n =2)
Records excluded
(n=154)
Full-text articles excluded,
with reasons (n=18)
- No intervention/control
(11)
- Whole Body Vibration
intervention (2)
- Not RCT (4)
- Assessed TKR only (1)
Study characteristics
A summary of the study characteristics is presented in
Table 3. In total, 560 participants were reviewed, 203
males and 357 females. The mean age was 63.0 years
(Standard deviation, SD = 1.8). All but Jan et al. [34]
assessed the outcomes of a proprioceptive exercise group
to a non-proprioceptive exercise group. In total, 250 par-
ticipants were randomised to a proprioceptive exercise
group whilst 221 were randomised to a non-proprioceptive
exercise group. Three studies compared the outcomes of a
proprioceptive exercise group to a no-treatment control
group [33–35]. In these studies, 89 participants were ran-
domised to a no-treatment control group compared to 75
randomised to a proprioceptive exercise group.
All but Chaipinyo and Karoonsupcharoen [31] used the
Kellgren and Lawrence [36] radiological assessment scale
to diagnose knee OA. The diagnosis of knee OA was also
made in four studies using the American College of
Rheumatologist’s diagnostic classification [31, 32, 34, 37].
Rheumatol Int (2012) 32:3339–3351 3343

Table 2 PEDro critical appraisal results for methodological assessment

PEDro criteria Study
Chaipinyo and Diracoglu Fitzgerald Jan Lin Lin Tsauo
Karoonsupcharoen [31] et al. [37] et al. [32] et al. [34] et al. [33] et al. [35] et al. [20]

Eligibility criteria 4 4 4 4 4 4 4
Random allocation 4 4 4 4 4 4 4
Concealed allocation 4 8 4 8 4 8 8
Baseline comparability 8 4 4 4 4 4 4
Blind subject 8 8 8 8 8 8 8
Blind clinician 8 8 8 8 8 8 8
Blind assessor 4 8 4 4 4 8 8
Adequate follow-up (C85 %) 8 4 4 4 8 4 4
Intention-to-treat analysis 4 4 4 4 4 4 4
Between-group analysis 4 4 4 4 4 4 4
Point estimates and variability 4 4 4 4 4 4 4
Total score 7 7 9 8 8 7 7
4—Yes, 8—No

Using these, all but Jan et al.’s [34] studies excluded par-
ticipants with evidence of extreme degenerative changes
(i.e. grade IV) [36].
The proprioceptive interventions were all weight bearing
in nature, based on functional activities such as stepping,
standing, walking and balancing. Lin et al. [33, 35] per-
formed these activities using a computer programme, whilst
Tsauo et al. [30] also used an electrogoniometer as an adjunct
to facilitate JPS re-training. Non-proprioceptive exercise
regimes consisted of lower limb exercises with a bias on
strengthening regimes for quadriceps and hamstring muscle
groups. Exercise programmes were conducted from between
4 and 8 weeks in duration (Table 3). Follow-up periods
ranged from 4 weeks [31] to 52 weeks [32]. The median
follow-up period was 8 weeks following commencing the
exercise programmes.
Proprioceptive intervention versus no-treatment control
Primary outcome
No studies were identified, which reported the functional
outcomes of those taught proprioceptive exercises com-
pared to those provided with no treatment at 1 year.
Secondary outcomes
The majority of functional outcome measurements indi-
cated superior outcomes for those provided with the
proprioceptive exercise interventions compared to the
no-treatment control at less than 12 months (Table 4).
Meta-analysis was appropriate to assess WOMAC phys-
ical function 8 weeks following commencement of
interventions. Meta-analysis demonstrated that those who
received the proprioceptive intervention presented with
statistically significantly better functional scores
(MD = 12.19; 95 % CI: -15.67, -8.71) compared to
the non-treatment group. Similarly, there were statisti-
cally significantly greater functional outcomes for the
proprioceptive group when assessed for timed walk over
spongy ground (MD = 4.83 s; 95 % CI: -6.09, -3.56;
p \ 0.01), timed figure-of-eight task (MD = 9.71 s;
95 % CI: -11.40, -8.02; p \ 0.01), and timed stair
ascent and descent (MD = 4.01 s; 95 % CI: 6.27, 1.76;
p \ 0.01).
Whilst there was no statistically significant difference
between the groups at 8 weeks with respect to walking
speed (p [ 0.05) [33], Jan et al. [34] reported signifi-
cantly slower timed stair ascent (p \ 0.01) and greater
Functional Incapacity Score (p \ 0.01) indicating greater
disability in the non-treatment control group compared to
proprioceptive exercise group (p \ 0.01) at 6 weeks.
Joint position angulation error was used to assess JPS at
8 weeks in two studies [33, 35]. On meta-analysis, the
proprioceptive intervention group presented with better JPS
at 8 weeks compared to those who did not receive an
exercise intervention (MD = 2.32°; 95 % CI: -2.91,
-1.74; p \ 0.01). Pain was only reported by Lin et al. [33],
indicating statistically significantly less pain in the pro-
prioception group compared to the non-treatment control
group at 8 weeks after commencing the interventions
(p \ 0.01).
Muscle strength and specifically torque were investi-
gated by Lin et al. [33, 35]. They reported statistically
greater knee flexion torque measurements in the proprio-
ceptive group at 8 weeks at 60°/s (MD = 13.16; 95 % CI:

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Table 3 Summary of included study’s characteristics

Study N Gender Age Diagnosis/grade OA Intervention Follow-
(m/f) (years) up
periods
(weeks)

Chaipinyo and 42 11/37 66 ACR criteria for knee OA Proprioceptive intervention: 930 steps; 4
Karoonsupcharoen forwards/backwards alternate; 930 mini
[31] squats; 930 side stepping. Control
exercises: 930 static quadriceps exercises
(5 s hold; 10 9 3 sets). Both programme
carried out 95 weekly for 4 weeks
Diracoglu et al. [37] 66 0/66 35–65 ACR criteria for knee OA. Proprioceptive intervention: progressive 8
Radiologically grade I and II kinaesthesia, balance and strengthening
bilateral knee OA (Kellgren and exercises including modified Rhomberg
Lawrence scale) exercise, retrowalking, walking on heels/toes,
rocker board, one leg standing. Control
exercises: only strengthening exercises: static
exercise bike, isometric hamstrings, quadriceps
and abductor (6 s hold 98), through range
isotonic resisted quadriceps and hamstring
exercises 910 reps of maximal weight 91 set
In addition all patients received informed about
knee OA and joint protection. Both
programmes performed 3 days a week in
groups of 5 people under the supervision of a
physiotherapist for 8 weeks
Fitzgerald et al. [32] 183 51/122 64 Met the ACRs criteria for knee OA. Proprioceptive intervention: received same 8, 26 and
Radiologically grade II or greater standard exercise programme in addition of 52
knee OA (Kellgren and Lawrence agility and perturbation exercises: side
scale) stepping, braiding (lateral stepping combined
with forward and backward crossover steps),
front crossover steps during forward
ambulation, back crossover steps during
backward ambulation, shuttle walking, walking
with changes, tilt boards and roller boards.
Control exercises: lower limb muscle stretching
(quadriceps, hamstring and calf muscle
stretching) and strengthening (quadriceps sets,
supine straight leg raises, prone hip extensions,
seated isometric knee extensions, single-leg leg
presses, standing hamstring curls and standing
heel raises), long-sitting knee flexion and
extension range of motion and treadmill
walking. All performed bilaterally
Jan et al. [34] 43 12/31 63 ACR criteria for knee OA. Proprioceptive intervention: a virtual foot 6
Radiologically grade III or greater stepping exercise which is a target matching
knee OA (Kellgren and Lawrence task. For each patient, each lower extremity
scale) was trained for 20 min, with a 10-minute break
between lower extremities to prevent fatigue.
The patients underwent 3 training sessions per
week for 6 supervised by an experienced
therapist. No-treatment control: no specific
intervention and were not visited between
assessments. All patients received health
education regarding knee pain and knee OA
Lin et al. [33] 108 33/75 62 Radiologically grade III or lower knee Proprioceptive intervention: computer foot 8
OA (Kellgren and Lawrence scale) stepping games mainly involving knee
movement in a sitting position (stepping on
targets in multiple directions). Control
exercises: open-chain knee extension exercises
4 9 6 sets (50 % of 1 rep maximum). No-
treatment control: no specific intervention.
Both exercise groups were performed 3 days
per week for 8 weeks

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Table 3 continued
Study N Gender Age Diagnosis/grade OA Intervention Follow-
(m/f) (years) up
periods
(weeks)

Lin et al. [35] 89 62/19 61 Radiologically grade III or lower knee Proprioceptive intervention: computer foot 8
OA (Kellgren and Lawrence scale) stepping games mainly involving knee
movement in a sitting position (stepping on
targets in multiple directions). Control
exercises: closed chain knee extension
exercises leg press (10 9 10 sets). No-
treatment control: no specific intervention.
Both exercise groups were performed 3 days
per week for 8 weeks
Tsauo et al. [20] 29 24/5 62 Radiologically grade II or III knee OA Proprioceptive intervention: in addition to 8
(Kellgren and Lawrence scale) receiving the control exercise intervention, a
sensorimotor training programme was used to
facilitate joint position sense and dynamic joint
stabilization using rhythmic active motion,
angle repositioning and standing on an air
cushion with support to stimulate muscular co
activation. The equipment included: two sets of
sling suspension systems, a metronome and an
electrogoniometer
The programmes progressed from supine to a
sitting position to a standing position to
increase knee WB. A sensory challenge was
given by doing the exercises with eyes open or
eyes closed in each position. Control exercises:
the routine physical therapy programme
included thermotherapy, interferential therapy
and instructions for exercise at home. Straight
leg raising, short arc extension exercise, and
walking or 30 min (within a tolerable time
interval) were suggested as the home
programme

ARC American College of rheumatologists, F females, M males, N number in sample, OA osteoarthritis, WB weight bearing

6.62, 19.71; p \ 0.01), but no statistically significant dif- Secondary outcomes

ference at 120 or 180°/s (p [ 0.05; Table 4). Similarly,
there was statistically greater knee extension torque mea-
surements in the proprioceptive group at 8 weeks at 60°/s
(MD = 10.04; 95 % CI: 1.83, 18.25; p = 0.02), but no
statistically significant difference at 120 or 180°/s
(p [ 0.05; Table 4).
Proprioceptive intervention versus strengthening
exercise control
Primary outcome
One study presented their 12-month functional outcomes
between a proprioceptive intervention group and a non-
proprioceptive exercise group [32]. These authors
reported no statistically significant difference between the
intervention arms at 12 months when assessed using the
WOMAC-total score, WOMAC functional assessment
score, or timed get-up-and-go measurement (p = 0.62–
0.74).
Only one functional outcome measure was shown to be
statistically significant between those who were prescribed
a proprioceptive exercise intervention compared to a gen-
eral non-proprioceptive exercise regime (Table 5). Timed
walk over spongy ground was demonstrated to be statisti-
cally faster by the proprioceptive group with a mean dif-
ference of 4 s over 12 m (95 % CI: -7.08, -0.41;
p = 0.03; Fig. 2).
One study assessed function using the KOOS outcome.
Chaipinyo and Karoonsupcharoen [31] reported no signif-
icant difference between the proprioceptive group and
general exercise group for each of the KOOS domains
(p [ 0.05) with the exception of knee-related quality of life
where the proprioceptive group reported greater quality of
life compared to the general exercise group (MD: 17
points; p \ 0.05). However, there was a 25 point difference
at baseline with superior outcomes for the proprioceptive
group prior to commencing their interventions indicating a
substantial baseline imbalance.

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There was no statistically significant difference for a
number of objective functional measurements between the
intervention groups on meta-analysis (Table 5). This
included the assessment of walking speed over 60 m at
8 weeks (MD = 0.86 s; 95 % CI: -3.36, 1.63; p = 0.50),
timed figure-of-eight at 6–8 weeks (MD = 5.44 s; 95 %
CI: -12.79, 1.91; p = 0.15) or timed stair ascent/descent
at 8 weeks (MD = 0.92 s; -2.81, 0.98; p = 0.34). Simi-
larly, there was no statistically significant difference
between the proprioceptive compared to general exercise
groups at 8 weeks in WOMAC physical function
(MD = 0.59, 95 % CI: -2.12, 3.29; p = 0.67). One study
reported WOMAC-total score [32]. These authors reported
no statistically significant difference between the groups at
2- or 6-month follow-ups (p [ 0.05).
It was not possible to analyse a number of functional
outcome measurements due to insufficient data. Nonethe-
less, when assessed individually, Chaipinyo and Karoon-
supcharoen [31] reported no significant difference in
walking speed over 10–15 m at 4 weeks (p [ 0.05), whilst
Diracoglu et al. [37] reported a significant difference in this
outcome at 6 weeks where the proprioception group was
significantly faster (p = 0.04). However, this was not a
clinically meaningful difference being only 0.68 s between
the groups at this final follow-up. Total mobility was
assessed by Chaipinyo and Karoonsupcharoen [31]. They
reported no statistically significant difference between their
interventions for this outcome at 4 weeks (p [ 0.05).
Finally, timed get-up-and-go was reported by Fitzgerald
et al. [32] and Chaipinyo and Karoonsupcharoen [31]. Both
reported no statistically significant difference between their
proprioceptive exercise groups to their general exercise
interventions (p [ 0.05).
One study reported the findings of SF-36 general health
perception between the two study interventions. Diracoglu
et al. [37] reported statistically significantly better general
perceived health scores using SF-36 in each subsection
examined (physical function, p \ 0.01; role limitation,
p = 0.05; vitality, energy or fatigue, p = 0.05) at 8 weeks.
However, Fitzgerald et al. [32] examined global rating
score of perceived knee function [38]. Over the initial
12 months, they reported no statistically significant dif-
ference between the groups at any follow-up period
(p [ 0.05).
Exercise compliance was examined in all studies. This
indicated a statistically significantly greater compliance to
exercises in the proprioceptive compared to the general
exercise group (RD = 0.08, 95 % CI: 0.04, 0.14, p \ 0.01;
Fig. 3). Furthermore, joint position angulation measure-
ment to assess JPS was statistically significantly better in
the proprioceptive exercise group compared to the general
exercise group (MD = 2.18; 95 % CI: 2.70, 1.66;
p \ 0.01; Fig. 4).
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Rheumatol Int (2012) 32:3339–3351
There was no difference between pain on meta-analysis of
the groups at 4-to-8-week post-commencement of inter-
ventions (MD = 0.11; 95 % CI: -0.22, 0.44; p = 0.51;
Table 5), or at 6 or 12 months as presented in Fitzgerald
et al.’s [32] study (p [ 0.05).
Knee flexion and extension torque were examined. Two
studies assessed knee flexion torque at 60°/s, reporting
statistically significantly higher torque measurements in the
general exercise group compared to the proprioceptive
exercise group (MD = 23.99 Nm; 95 % CI: 40.05, 7.93;
p \ 0.01). There was no statistically significant difference
between the groups in knee flexion torque at 120 or 180°/s
(p [ 0.05; Table 5). However, when knee extension torque
was assessed at 60°/s, there was statistically significantly
greater torque values in those prescribed the proprioceptive
exercise programme compared to the general exercise
programme, although not a clinically meaningful differ-
ence (MD = 0.44Nm; 95 % CI: 0.03, 0.84; p = 0.03). As
in flexion, there was no statistically significant difference
between the groups in knee extension torque at 120 or
180°/s on meta-analysis (Table 5), or at 240°/s, as in
Diracoglu et al.’s [37] study (p [ 0.05).
Discussion
The findings of this study indicate that compared to a non-
treatment control, proprioceptive exercises improve func-
tional outcomes in people with knee OA during the first
8 weeks following commencement of their exercises.
When compared against a general non-proprioceptive
exercise programme, proprioceptive exercises demon-
strated similar outcomes, only providing superior results
with respect to JPS-related measurements such as timed
walk over uneven ground (p = 0.03) and joint position
angulation error (p \ 0.01). Whilst the evidence base was
moderate in its methodological quality, only three studies
based their sample size on a power calculation. Accord-
ingly, there was a risk that the numerous non-statistically
significant findings reported in Table 4 may be attributed to
a type II statistical error [39].
The studies included in this review predominantly
recruited younger people who presented early in their
disease-stage. The cohort’s mean age was 63 years, with
the majority of participants presenting with either grade II
or III Kellgren-Lawrence radiological signs of knee OA
[36]. Given this, the findings of this study can only be
generalised to this OA population. It therefore remains
unclear whether the same clinical findings would be
obtained if older people or those with more advanced OA
were prescribed proprioceptive exercises. This is of note
given that age, trauma and pathological processes are
associated with greater joint instability, pain and
Rheumatol Int (2012) 32:3339–3351 3347

Table 4 Results of the meta-analysis of outcomes comparing proprioceptive exercises to a no-treatment control for people with knee
osteoarthritis
Outcome Proprioceptive Exercise MD (95 % CI) P value I2 (%)
sample size sample size

WOMAC—physical function at 8 weeks 66 66 12.19 (-15.67, -8.71) \0.01 8

Timed walk over spongy ground (12 m) at 8 weeks 66 66 4.83 (-6.09, -3.56) \0.01 0
Timed figure-of-eight task at 6–8 weeks 50 53 9.71 (-11.40, -8.02) \0.01 7
Timed stair ascent/descent at 8 weeks 66 66 4.01 (6.27, 1.76) \0.01 70
Joint position angulation error at 8 weeks 66 66 2.32 (-2.91, -1.74) \0.01 0
Knee flexion torque at 8 weeks (60°/s) 66 66 13.16 (6.62, 19.71) \0.01 0
Knee flexion torque at 8 weeks (120°/s) 66 66 5.30 (-0.46, 11.06) 0.07 0
Knee flexion torque at 8 weeks (180°/s) 66 66 2.53 (-2.81, 7.87) 0.35 0
Knee extension torque at 4–8 weeks (60°/s) 66 66 10.04 (1.83, 18.25) 0.02 0
Knee extension torque at 8 weeks (120°/s) 66 66 4.47 (-2.61, 11.55) 0.22 0
Knee extension torque at 8 weeks (180°/s) 66 66 6.11 (-0.29, 12.51) 0.06 0
CI confidence interval, MD mean difference, WOMAC Western Ontario and McMaster Universities Arthritis Index

Table 5 Results of the meta-analysis of outcomes comparing proprioceptive exercises to non-proprioceptive exercise regimes for people with
knee osteoarthritis
Outcome Proprioceptive Exercise MD (95 % CI) P value I2 (%)
sample size sample size

WOMAC—physical function at 8 weeks 205 204 0.59 (-2.12, 3.29) 0.67 54

Walking speed (60 m) at 8 weeks 51 50 0.86 (-3.36, 1.63) 0.50 0
Timed walk over spongy ground (12 m) at 8 weeks 66 66 3.75 (-7.08, -0.41) 0.03 87
Timed figure-of-eight task at 8 weeks 45 44 5.44 (-12.79, 1.91) 0.15 88
Timed stair ascent/descent at 4–8 weeks 105 98 0.92 (-2.81, 0.98) 0.34 73
Exercise compliance at 4–8 weeks 218 197 0.06 (0.01, 0.11)* 0.03 23
Joint position angulation error at 8 weeks 81 80 2.18 (2.70, 1.66) \0.01 0
Pain at 4–8 weeks 75 68 0.11 (-0.22, 0.44) 0.51 0
Knee flexion torque at 8 weeks (60°/s) 65 62 23.99 (40.05, 7.93) \0.01 81
Knee flexion torque at 8 weeks (120°/s) 65 62 3.32 (-9.50, 2.86) 0.29 0
Knee flexion torque at 8 weeks (180°/s) 65 62 5.28 (-10.79, 0.23 0.06 0
Knee extension torque at 4–8 weeks (60°/s) 120 114 0.44 (0.03, 0.84) 0.03 57
Knee extension torque at 8 weeks (120°/s) 65 62 4.36 (-11.13, 2.43) 0.21 0
Knee extension torque at 8 weeks (180°/s) 95 92 0.06 (-0.35, 0.22) 0.66 0
CI confidence interval, MD mean difference, WOMAC Western Ontario and McMaster Universities Arthritis Index

* Risk difference, standardised mean difference

inflammation that have a detrimental effect on JPS. Fur-
thermore, it remains unclear what the acceptability of
proprioceptive exercises would be based on those with
greater severity of knee OA and associated pain, and older
people with greater co-morbidities. Further study to assess
this may be warranted given that knee OA is a chronic
longer-term condition that therefore affects predominantly
older individuals [7].
The meta-analysis indicated that those participants
allocated to the proprioceptive exercise regime were more
compliant to their allocated treatment compared to the non-
proprioceptive exercise regime (p = 0.03). It remains
unclear how generalisable this is to clinical practice since
people who participate in research studies may behave
differently whilst they are under investigation (Hawthorne
effect) compared to people who normally attend clinics or
hospital departments [39]. The adherence to exercise
regimes has been previously noted as a general limitation
[40]. The high compliance to the exercise programme,
although only over the initial 2 months, indicated a degree

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3348 Rheumatol Int (2012) 32:3339–3351

Fig. 2 Forest-plot depicting the statistically significant difference between in timed walk over spongy ground at 8 weeks between people with
knee osteoarthritis who were allocated to a proprioceptive exercise compared to non-proprioceptive exercise regime

Fig. 3 Forest-plot depicting the

statistically significant
difference between in exercise
compliance between people
with knee osteoarthritis who
were allocated to a
proprioceptive exercise
compared to non-proprioceptive
exercise regime

Fig. 4 Forest-plot depicting the

statistically significant
difference between in joint
position sense between people
with knee osteoarthritis who
were allocated to a
proprioceptive exercise
compared to non-proprioceptive
exercise regime

of acceptable with the proprioceptive intervention studied
here. This is important since, as Lin et al. [33] acknowl-
edged, lower extremity exercises performed in weight
bearing, as the majority of the proprioceptive interventions
were in these studies, have a potential to aggravate
symptoms in people with knee OA.
The meta-analysis included the assessment of two out-
come measurements that specifically assessed propriocep-
tion: the evaluation of JPS and walking speed over spongy
surfaces. Both outcomes reported superior results for those
who were allocated to the proprioceptive exercise regime
compared to the general exercise regime (Table 5) or the
non-treatment control group (Table 4). This provided fur-
ther evidence that the proprioceptive interventions exam-
ined specifically improved knee joint proprioception in this
population, thus indicating efficacy for this intervention.
The results of the muscle strength/torque outcomes were
not consistent (Table 5). Previous authors have suggested
that improvements in proprioception can promote muscle
strength gains [30, 41, 42]. This may account for the fact
that non-proprioceptive exercise regimes may also provide
a therapeutic benefit to the proprioceptive system since Lin
et al. [35] hypothesised that 10–25 % of body weight as
exercise resistance can facilitate knee proprioception. This
has been attributed to isometric strengthening programme’s
ability to decrease pain that may enhance proprioception
[30]. Secondly, the addition of strengthening exercises can
optimise joint function and biomechanical stability.
Through both means, proprioception is facilitated with
greater impulses in the medulla spinalis that can be
inhibited by pain and abnormal joint position [43]. Previ-
ous authors have suggested that pain or inflammation can
cause a sensitisation of a large proportion of nerve endings
through chemical inflammatory substances. As a result, the
abnormal discharge of small-diameter groups III and IV
(pain) and large-diameter group II (proprioceptive) afferent
nerve signals may combine to provide abnormal JPS and
abnormal muscle spindles activity [43–47]. Therefore, by
addressing the pain and inflammatory processes through
general exercises, these interventions may inadvertently
improve JPS as well. This would account for the minimal
difference between the proprioceptive exercises to the non-
proprioceptive exercise groups examined in this meta-
analysis.
The objective of this systematic review was to determine
whether there was a difference in clinical outcomes

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Rheumatol Int (2012) 32:3339–3351
between the proprioceptive exercises and not providing
proprioceptive exercises to people with knee OA. By
ensuring the limited differences in population characteris-
tics and outcome measurement methods between the
studies, it was deemed appropriate to perform a meta-
analysis. As Table 4 demonstrates, all proprioceptive
exercise interventions were largely the same, that is,
closed-kinetic chain exercises with functional elements. It
is assumed that these were used on a premise that these
activities can provide further tactile sensation from the sole
of the foot to contribute to greater sensorimotor input to
optimise joint reposition during training. Through this, the
exercises, through repeated motions, can lead to cortical
reorganisation in attrition to re-enforcing the assessment of
proprioceptive receptor accuracy at the muscle spindle [35,
48]. The only exception to these was Tsauo et al.’s [20] that
also included the use of a sling suspension exercise system.
They justified this open-chain regime on the premise that
this would train joints at a targeted angle position and
would therefore specifically improve JPS for specific joints
in addition to improving co-contraction and balance
training. There is currently insufficient literature to deter-
mine the superiority of different proprioceptive exercise
regimes in this population. Given that there may be a
therapeutic value in this type of exercise, further evaluation
of the optimal type of proprioceptive exercises is therefore
warranted.
The current evidence base has not examined a number
of key outcomes. These include the progression of OA,
return to work or sporting participation for those with early
stage OA, and, for the elderly population, the impact of
introducing a proprioceptive regime on general mobility
and the incidence of falls. Furthermore, only one study
assessed outcomes longer than 8 weeks [32]. Accordingly,
further, longer-term studies are required to determine the
appropriateness of proprioceptive exercises on these unin-
vestigated outcomes. Finally, all the studies investigated in
this review, with the exception of Chaipinyo and Karoon-
supcharoen [31], delivered their proprioceptive exercise
regime in a departmental setting. This was partly attributed
in Jan et al. [34], Lin et al. [33, 35] and Tsauo et al. [20]
studies due to a need for technical equipment as part of
their proprioceptive intervention. However, this may have
a cost and service-provision implication. Given that knee
OA is a long-term chronic condition, allowing people to
self-manage and perform their exercise programmes within
their own home may be advantageous [49]. Previous
studies have demonstrated that home-exercise programmes
can be successfully delivered providing favourable clinical
outcomes in this population [50, 51]. However, only hos-
pital-delivery exercises were shown to improve JPS com-
pared to home-based interventions in Tunay et al.’s [52]
study. Therefore, further assessment of the feasibility and
3349
effectiveness of home-based proprioceptive exercise pro-
grammes should be examined.
Conclusions
The findings of this review indicate that proprioceptive
exercises are efficacious in the treatment of people with
knee OA. There is some evidence to indicate the effec-
tiveness of proprioceptive exercises compared to general
strengthening exercises in functional outcomes. However,
the current evidence base is small, with limited literature
over longer-term outcomes or cost-effectiveness. Further
study is therefore warranted to determine the clinical
applicability of these exercises regimes for different pop-
ulations with knee OA.
Conflict of interest The authors declare that they have no conflict
of interest.
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