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Comparison of effectiveness of forward and backward walking on pain,

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Article  in  International Journal of Health & Allied Sciences · January 2016

DOI: 10.4103/2278-344X.194085

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 ISSN
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S
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International Journal of
H

Health & Allied Sciences

J
International Journal of Health & Allied Sciences • Volume 5 • Issue 3 • July-September 2016 • Pages ***-****

www.ijhas.in
I

Volume 5 / Issue 4 / October-December 2016

Official Publication of JSS University, Mysore
 Original Article

Comparison of effectiveness of forward and

backward walking on pain, physical function, and
quality of life in subjects with osteoarthritis of knee
Priya Singh Rangey, Megha Sandeep Sheth, Neeta J Vyas
Department of Physiotherapy, S. B. B. College of Physiotherapy, V. S. Hospital Campus, Ellisbridge, Ahmedabad, Gujarat, India

ABSTRACT 5%. Results: The results showed improvement in all the

outcome measures within all the three groups. However,
Context: Walking, both forward and backward, is
there was no statistically significant difference between
found to be effective for reducing pain in subjects with
the groups except Western Ontario and McMaster
osteoarthritis (OA) of the knee and improving physical
Universities Arthritis Index (WOMAC). Visual analog
function and quality of life (QOL). Aims: This study aims to
scale (VAS) at rest on the right side in all three groups
determine and compare the effects of forward walking (FW)
and on the left side in Group A as well as in scores
and backward walking (BW) on pain, physical function,
of VAS at activity on both the sides (P < 0.05) and no
and QOL in subjects with OA knee. Settings and Design:
improvement in VAS at rest on the left side in Groups B
Quasi‑experimental study set up at general hospital,
and C (P > 0.05). Improvement in WOMAC scores within
Ahmedabad, India. Subjects and Methods: Thirty
all the 3 groups (P < 0.05) and SF‑36 (P < 0.05). No
subjects >40 years diagnosed as having bilateral OA
statistically significant difference between the groups for
knee according to American College of Rheumatology
VAS at rest (left P = 0.919, right P = 0.823) or activity (left
criteria having indoor and outdoor walking ability without
P = 0.706, right P = 0.052) on both the sides and SF‑36
aids were included in this study. Group A and B subjects
scores (P > 0.05). Statistically significant difference
received FW and BW respectively for 10 min in addition to
between the groups for WOMAC (P = 0.043), Group A was
conventional treatment thrice daily for 2 weeks. Group C
better than Group C (P = 0.043). Conclusions: FW and
received conventional treatment in the form of hot
BW along with conventional therapy are equally effective
water fomentation and exercises. Exercises comprised
and not better than conventional treatment alone in
of static quadriceps, short arc terminal extension of
reducing pain and improving physical function and QOL.
the knee, ankle toe movements, straight leg raises,
knee flexion and extension, proprioceptive exercises Key words: Backward walking, forward walking, knee,
in the form of lunges, weight shifts, partial squats and osteoarthritis, pain, physical function, quality of life
balance training on the balance board and stretching of
hamstrings, tendo‑Achilles and rectus femoris muscles.
Statistical Analysis Used: SPSS 16.0 (IBM Corporation). INTRODUCTION
Parametric tests were used. The level of significance was
Osteoarthritis (OA) of the knee is a major cause of mobility
Address for correspondence: Priya Singh Rangey, (Lecturer) impairment, particularly among females.[1] The prevalence
Department of Physiotherapy, S. B. B. College of Physiotherapy, V. S.
Hospital Campus, Ellisbridge, Ahmedabad, Gujarat, India.
E‑mail: priya_singh9192@yahoo.in
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Access this article online others to remix, tweak, and build upon the work non‑commercially, as long as the
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www.ijhas.in For reprints contact: reprints@medknow.com

How to cite this article: Rangey PS, Sheth MS, Vyas NJ. Comparison
DOI: of effectiveness of forward and backward walking on pain, physical
10.4103/2278-344X.194085 function, and quality of life in subjects with osteoarthritis of knee. Int J
Health Allied Sci 2016;5:220-6.

220 © 2016 International Journal of Health & Allied Sciences | Published by Wolters Kluwer - Medknow
 Rangey, et al.: Comparison of effect of forward and backward walking in OA of knee
of OA knee in rural and urban India is 3.9% and 5.5%,
respectively.[2‑4]
Knee OA is associated with symptoms of pain and
functional disability. Physical disability arising from pain
and loss of functional capacity reduces the quality of
life (QOL) and increases the risk of further morbidity and
mortality.[5]
Osteoarthritis Research Society International (OARSI)
guidelines recommend that patients with OA knee should
be encouraged to undertake regular aerobic walking
exercises.[6] Walking is the most common form of exercise
employed by older adults, and walking‑based exercise
programs improve pain and functional limitation in people
with symptomatic knee OA.[7] Graded walking provides a
functional exercise that improves muscular activity around
the affected joints, employs an appropriate range of motion,
and provides a controlled environment which minimizes
the possibility of further damage.[8]
Shankar et  al. in 2013 found that retro‑walking is highly
effective in reducing pain and extension lag and improving
physical function and dynamic balance in knee OA
patients. [9] Gondhalekar and Deo in 2013 concluded
that retro‑walking is an effective adjunct to conventional
treatment in decreasing disability in patients with knee
OA.[10]
Recently, the investigation of backward locomotion has
received particular attention from researchers. From a
physical therapist perspective, backward walking (BW) on a
treadmill is a common tool employed for injury prevention
and lower extremity rehabilitation in the clinical setting
since it has been demonstrated that BW is associated with
less biomechanical strain on the knee joint rather than
forward walking (FW).
The previous studies have examined the differences between
FW and BW terms of several biomechanical parameters.[11]
Comparison of FW and BW has also been done more in
normal subjects.[11] However, FW and BW have not been
compared clinically to see their effectiveness in a particular
population. Furthermore, there are a limited number of
studies comparing the effect of FW and BW in OA of the
knee. Hence, this study aims to determine and compare the
effectiveness of FW and BW on pain, physical function,
and QOL in subjects with OA of the knee.
The alternative hypotheses were that there is statistically
significant difference between FW and BW for pain,
physical function, and quality life for the same.
International Journal of Health & Allied Sciences • Vol. 5 • Issue 4 • Oct‑Dec 2016
SUBJECTS AND METHODS
A quasi‑experimental study was conducted among the
general population of Ahmedabad, India. The study was
set in the Physiotherapy Department of V. S. General
Hospital, Ahmedabad. Ethics approval was taken from
the hospital’s review board. All the subjects were referred
from the orthopedic out‑patient department of the General
Hospital. The study was conducted from May 2014 to
October 2014. The total duration of the study was 2 weeks.
The subjects were treated in the physiotherapy department
for 2 weeks except Sunday and public holidays. Informed
written consent was taken from each subject.
Males and females aged >40 years with a diagnosis of
bilateral OA of the knee according to American College
of Rheumatology Criteria and referred by the orthopedic
out‑patient department and ability to walk indoor and
outdoor without assistive aid were included in this study.
Those having a history of any lower extremity injury or
underlying pathology, any inflammatory joint disease, any
cardiac or neurological disorder, soft tissue injury of the
knee, or previous history of knee surgery were excluded
from this study.
The pain was measured using visual analog scale (VAS),
Physical Function using Western Ontario and McMaster
Universities Arthritis Index (WOMAC) of OA and QOL
using SF36.
Group A subjects received FW along with conventional
treatment. Each patient was asked to perform FW on level
ground for 10 min at their comfortable speed up to a rate
of perceived exertion (RPE) of 11–13 in the department.
The subjects were asked to walk at a similar speed at home
in two sessions of 10 min each.
Group B subjects received BW and conventional treatment.
Each patient was asked to perform BW on level ground
for 10 min at their comfortable speed up to RPE of 11–13.
Since BW is not a part of our routine lives and the subjects
were not accustomed to walking backward, they were
given training on day 1 before the actual intervention in
the parallel bars. Only when they had gained confidence
in walking backward, were they allowed to walk backward
without support. The subjects were asked to walk at a
similar speed at home in one or two sessions for 20 min
but since BW is an unaccustomed activity they were asked
to do so with supervision.
Group C subjects received conventional treatment alone
consisting of exercises and hot water fomentation for
221
 Rangey, et al.: Comparison of effect of forward and backward walking in OA of knee

10 min. Exercises in the form of static quadriceps exercises, Table 1: Demographic details of subjects
short arc terminal extension, ankle and toe movements, Characteristics Group A Group B Group C
straight leg raise, knee extension in a high sitting, prone Mean age (Mean±SD) years 53.3±9.8 53.4±8.9 49.0±7.2
knee bending, lunges, weight shifts, and partial squatting. Males (%) 2 (20) 4 (40) 1 (10)
Along with this stretching of the hamstrings, tendo‑Achilles Females (%) 8 (80) 6 (60) 9 (90)

and rectus femoris was also done.

Table 2: Baseline data in each group
The patients were assessed again at the end of 2 weeks and Outcome Group A Group B Group C P
then the data were collected. measure
VAS at rest on 0.79±1.1 0.61±1.7 0.55±1.2 0.919
RESULTS left side
VAS at activity 3.17±2.1 3.3±1.7 5.4±0.96 0.008
on left side
Data were analyzed using SPSS 16.0 (IBM Corporation).
VAS at rest on 1.81±2.2 1.74±2.4 1.25±1.9 0.825
Level of significance was kept at 5%. right side
VAS at activity 5.02±1.97 4.1±2.9 3.67±2 0.428
All the outcome measures along with age and gender were on right side
tested for normal distribution using Kolmogorov–Smirnov WOMAC‑Total 54.3±18.4 46.2±15.9 50.6±9.0 0.490
test. The data for all tested measures were found to be SF 36‑Physical 56.5±30.3 56±18.1 47±21.4 0.609
Functioning
normally distributed, and hence parametric tests were SF 36‑Role 35±35.7 17.5±28.9 42.5±39.2 0.276
applied. Paired t‑test was applied for within group analyses, physical
and one‑way ANOVA was used for between‑group analyses. SF 36‑Role 66.6±44.5 26.7±43.9 40±46.6 0.149
Tukey’s test was applied for post‑hoc analysis. emotional
SF 36‑Vitality 39.5±28.8 45±21.3 45.5±25.8 0.844
SF 36‑Mental 68±27.5 60.4±29.2 53.6±27.9 0.530
Table 1 shows demographic details of the subjects. Health
SF 36‑Social 62.5±41.2 80±25.1 73.75±27.9 0.478
There was no statistically significant difference between the functioning
three groups (F = 0.827, P = 0.448) with respect to age and SF 36‑Body pain 38.4±28.7 35.4±16.2 39.3±26.6 0.933
gender (χ2 = 2.522, P = 0.283). SF 36‑General 49.2±27.8 57.8±24.2 50.7±24.6 0.727
Health
There was no statistically significant difference between
the groups for all the measures at baseline except VAS on There was statistically significant difference between
activity on the left side as shown in the Table 2. the groups WOMAC score (0.043). Group A was found
to be statistically better than Group C (P = 0.043).
There was statistically significant difference for VAS at There was no statistically significant difference between
rest within Group A on both sides (left P = 0.046, right Groups A and B (P = 0.822) and Groups B and
P = 0.044), Group B on right side (P = 0.041) and Group C C (P = 0.145) [Tables 8 and 9].
on right side (P = 0.042). There was no statistically significant
difference within Group B on the left side (P = 0.293) and SF‑36 scores were analyzed according to the different
Group C on the left side (P = 0.170) [Table 3]. components: Physical functioning, role physical, role
emotional, vitality, mental health, social functioning, bodily
There was statistically significant difference for VAS at pain, and general health. There was statistically significant
activity on both the sides within Group A (left P = 0.005, difference within all the 3 groups for all the components of
right P = 0.002), Group B (left P = 0.005, right P = 0.005), SF‑36 [Tables 10.1 and 10.2].
and Group C (left P = 0.008, right P = 0.005) [Table 4].
There was no statistically significant difference between the
There was no statistically significant difference between the groups for any of the SF‑36 component scores as shown
groups for VAS at rest (left P = 0.919, right P = 0.823) as in Table 11.
well as on activity (left P = 0.706, right P = 0.052) on both
the sides. Results are presented in Tables 5 and 6. DISCUSSION

Statistically significant difference within all the three groups The purpose of this study was to evaluate and compare
was observed for WOMAC (Group A P < 0.01, Group B the effects of FW and BW on pain, physical function
P < 0.01, Group C P = 0.005) [Table 7]. and QOL.

222 International Journal of Health & Allied Sciences • Vol. 5 • Issue 4 • Oct‑Dec 2016
 Rangey, et al.: Comparison of effect of forward and backward walking in OA of knee

Table 3: Mean differences within the groups for vas scores at rest
Group A Group B Group C
Left Right Left Right Left Right
Pre VAS 0.79±1.1 1.81±2.2 0.61±1.7 1.74±2.4 0.55±1.2 1.25±1.9
Post VAS 0 0.55±1.1 0 0.13±0.3 0 0.13±0.41
t value 2.319 2.338 1.116 2.377 1.494 2.368
P value 0.046 0.044 0.293 0.041 0.170 0.042

Table 4: Mean differences within the groups for vas scores at activity
Group A Group B Group C
Left Right Left Right Left Right
Pre VAS 3.17±2.1 5.02±1.97 3.28±1.7 4.1±2.9 5.41±0.96 3.67±2
Post VAS 1.23±1.3 1.77±1.3 0.99±0.8 1.88±1.5 3.66±1.5 2.6±2.2
t value 3.709 4.249 3.745 3.713 3.404 3.653
P value 0.005 0.002 0.005 0.005 0.008 0.005

Table 5: Mean differences between the groups for vas at rest on the left side in Groups B and C. However, in these
rest groups, the post VAS at rest was 0. Hence, there was an
Group VAS score F value P value improvement compared to the pre VAS, but the difference
Left A 0.79±1.1 0.085 0.919 could not be statistically significant.
B 0.61±1.7
C 0.55±1.2 The results of this study are consistent with the findings of
Right A 1.26±1.7 0.196 0.823
Evcik and Sonel[12] who evaluated the effects of home‑based
B 1.61±2.1
exercise program and walking program on pain, physical
C 1.12±1.5
function, and QOL in subjects with OA of the knee. They
concluded that walking reduces pain in subjects with OA
Table 6: Mean differences between the groups for vas at of the knee but it is not better in comparison to home‑based
activity
exercise program. The pain relief in the FW group may be
Group VAS score F value P value
attributed to the aerobic effects that they cause. Aerobic
Left A 1.94±1.6 0.353 0.706
B 2.29±1.9 walking programs are effective with individuals diagnosed
C 1.65±1.5 with OA of the knee because they help relieve pain and
Right A 3.25±2.4 3.316 0.052 promote nutrition and remodeling without increasing
B 2.22±1.9 stress in the affected joint. Aerobic exercise can increase
C 1.11±0.97 endorphin production, generating an analgesic effect, which
gradually induces a decrease in pain.[13]
Table 7: Mean differences within the groups for WOMAC
score The findings in Group B are similar to the findings of Flynn
Group A Group B Group C and Soutas‑Little[14] who concluded that BW may provide a
Pre WOMAC 54.3±18.4 46.2±15.9 50.6±9 greater benefit for certain conditions such as overuse injuries in
Post WOMAC 24.5±15.6 21.3±13.2 36.7±16.3 the lower extremities and patellofemoral dysfunctions. Shankar
t value 6.141 7.550 3.656 et al.[9] and Kedia and Sharma[15] also concluded a similar
P value <0.01 <0.01 0.005
findings in chronic OA and patellofemoral pain syndrome,
respectively. The pain relief occurs because, during backward
Table 8: Mean differences between the groups for WOMAC locomotion, patellofemoral joint reaction forces, and eccentric
Group WOMAC score F value P value loading of the patellar tendon are both reduced. Specifically,
A 28.8±16.3 3.544 0.043 peak patellofemoral joint compressive forces are significantly
B 25.3±10.2 lower and occur significantly later in the stance phase in
C 13.9±12
backward locomotion in comparison to forward locomotion.
Furthermore, pain relief may be seen due to a reduction in
There was a significant improvement in the VAS scores both excess adductor moment at knee joint which decreases the
at rest and at activity in all the three groups except VAS at compressive forces on medial compartment of knee joint.[10]

International Journal of Health & Allied Sciences • Vol. 5 • Issue 4 • Oct‑Dec 2016 223
 Rangey, et al.: Comparison of effect of forward and backward walking in OA of knee

Pain relief after conventional treatment could be attributed
to the thermal effects associated with heating modality,
strengthening exercises for hip and knee helping to steady
the knee and giving additional joint protection from shock
and stress.[16]
There was a statistically significant difference within all
the three groups for the WOMAC scores. Martin et al.[17]
suggested that a 6‑month weight loss and walking program
improved measures of physical functioning as determined
by WOMAC, up and go test and 6 min walk test and
pain measured by WOMAC in overweight and obese
postmenopausal women with knee OA. The intervention
included weekly nutrition classes and an exercise walking
program.
Gondhalekar and Deo[10] postulated that as advantages of
retro‑walking include improvement in muscle activation
pattern, reduction in adductor moment at the knee
during stance phase of gait and augmented stretch of
hamstring muscle groups during the stride; all of these
may have helped in reducing disability thus leading to
improved function. Furthermore, there is a possibility that
proprioceptive and balance training may have occurred
during retro‑walking adding to its benefits. They also found
improvement in physical function following conventional
treatment comprising deep heating modality (Short Wave
Diathermy) for 20 min for pain relief and free exercises. For
the conventional treatment, the improvement in function
may be attributed to the reduction of pain, reduction in
abnormal joint kinetics and kinematics during functional
movements and improved muscle activation pattern.
All the groups showed a statistically significant difference
for all the SF‑36 scores, but there was no difference between
the groups. Evcik and Sonel[12] too found a statistically
significant improvement in the QOL scores in the walking
group when compared to the control group in the subjects
with OA knee. Dias et al.[18] concluded that walking program
had a positive effect on QOL of elderly individuals with
knee OA. Aerobic walking programs improve joint stability.
This stability of the affected joint assists persons with OA to
be more functional in everyday living, which progressively
improves their QOL. The significant improvements in QOL
may be in relation with physical activity, by helping patients
reduce fatigue, anxiety, and recover their self‑esteem,
motivation, and mental health.[13]

Table 9: Post‑hoc multiple comparison of mean difference

According to Skevington[19] who investigated the relationship
in womac score between the groups between pain and discomfort and QOL, when QOL is
Comparison Mean±SE 95% CI P value Significance assessed, negative feelings are most closely associated
A vs B 3.5±5.8 −11.01-18.01 0.822 No with reports of pain and discomfort than any other facet.
B vs C 11.4±5.8 −3.11-25.9 0.145 No Those who are pain‑free have significantly better QOL
C vs A −14.9±5.8 −29.4-−0.39 0.043 Yes
than those in pain. A longer duration of pain is associated

Table 10.1: Mean differences within groups for sf‑36

Component Group A Group B Group C
Physical Functioning Pre Score 56.5±30.3 56±18.1 47±21.4
Post Score 75.5±22.4 72.5±23.8 63.5±19.4
t value −3.073 −2.881 −3.298
P value 0.013 0.018 0.009
Role‑Physical Pre Score 35±35.7 17.5±28.99 42.5±39.2
Post Score 75±42.5 70±40.5 70±36.9
t value −3.073 −3.992 −3.498
P value 0.013 0.003 0.007
Role‑Emotional Pre Score 66.63±44.5 26.67±43.9 40±46.6
Post Score 100±0 76.67±41.7 76.7±35.3
t value −2.373 −3.00 −3.16
P value 0.042 0.015 0.012
Vitality Pre Score 39.5±28.8 45±21.3 45.5±25.8
Post Score 62±18.7 73±17.8 70.5±24.8
t value −3.48 ‑4.00 −6.024
P value 0.007 0.003 <0.001
Mental Health Pre Score 68±27.5 60.4±29.2 53.6±27.98
Post Score 91.6±15.9 82.8±20.6 82±18.5
t value −3.891 −3.173 −4.472
P value 0.004 0.011 0.002

224 International Journal of Health & Allied Sciences • Vol. 5 • Issue 4 • Oct‑Dec 2016
 Rangey, et al.: Comparison of effect of forward and backward walking in OA of knee

Table 10.2: Mean differences within groups for sf‑36 the authors’ knowledge, no study till date has compared the
Social Pre Score 62.5±41.2 80±25.1 73.75±29.9 effects of FW and BW on pain, physical function, and QOL.
Functioning Post Score 100±0 95±10.5 90±17.5 The present study shows that all the three interventions: FW,
t VALUE −2.875 −2.571 −2.327 BW, and Conventional treatment are equally effective in the
P VALUE 0.018 0.03 0.045 short term. However, studies researching the effects of these
Bodily pain Pre Score 38.4±28.7 35.4±16.2 39.3±26.6
interventions in the long‑term need to be done. Most of the
Post Score 71.3±24.8 63.8±12.5 74.6±23.3
studies regarding the effectiveness of aerobic exercises in OA
t value −5.41 −10.548 −12.804
P value <0.001 <0.001 <0.001
of knee have continued the intervention for 8 weeks or more.
General health Pre Score 49.2±27.8 57.8±24.2 50.7±24.6 Also, for BW most of the studies that have been done have
Post Score 78.7±13.99 84.5±13.2 76.4±16.8 been performed on the treadmill. There might be a possibility
t value −5.182 −5.627 −6.359 that the subject learns the activity better over treadmill than
P value 0.001 0.00 <0.001 on the ground. In addition, the speed that was used in the
present study was limited by the pain of the subject. Due
Table 11: Mean differences between the groups for
to pain and altered gait pattern, there would have been the
Short Form‑36 possibility that the subject did not walk up to a speed required
Component Group SF‑36 score F value P value to gain the therapeutic effects of BW. In general, higher
Physical functioning A 19±19.5 0.065 0.937 intensity training programs lead to greater improvements;
B 16.5±18.1 however, higher‑intensity exercise programs also result in
C 16.5±15.8 increased rates of injury and lower compliance.[20]
Role‑Physical A 40±41.2 1.160 0.329
B 52.5±41.6
There was statistically significant difference between
C 27.5±24.9
the groups for WOMAC scores. FW group was found
Role‑emotional A 33.37±44.5 0.379 0.688
B 50±52.7
to be better than control in improving physical function
C 36.8±36.8 as measured by WOMAC. These results are consistent
Vitality A 22.5±20.4 0.211 0.811 with the findings of  Kovar et al.[20] who also found that a
B 28±22.1 program of supervised fitness walking and patient education
C 25±13.1 can improve functional status without worsening pain or
Mental health A 24±18.8 0.230 0.796 exacerbating arthritis‑related symptoms in patients with
B 22.4±22.3 OA of the knee.
C 28.4±20.1
Social functioning A 37.5±41.2 1.896 0.170
Clinical implication
B 15±18.4
OA of the knee is a condition that leads to a lot of disability
C 16.25±22.1
Bodily pain A 32.9±19.2 0.685 0.513
and reduction of physical activity. The incidence of OA is
B 28.5±8.6 quite large in the Indian population, and the pain it causes
C 35.3±8.7 leads to further disability. Walking is an activity that can
General health A 29.5±18.0 0.163 0.850 be performed at any time and even at home without the
B 26.7±15 need of any specialist.
C 25.7±12.8
This study proves that both forward and backward lead to
with increasingly poorer QOL. Intense affective pain a reduction of pain and improvement of physical function
is particularly detrimental to a good QOL. Hence, the and QOL. This may eventually lead to a lessened burden
improvement in the QOL scores might be attributed to of life and the individual can perform his ADLs without
the reduction in pain and improved physical function and any complaints. Also, as the individual gets better he is able
disability in all the three groups. to fulfill his role in the society being an active participant.

There was no statistically significant difference between the
groups for VAS at rest as well as on activity and any of the
SF‑36 component scores on both the sides.
No difference between the groups might be due to the
duration of the walking. It could be possible that the duration
was not sufficient to get additional effects of walking. To
Thus, FW and BW can be used to increase the functional
independence of the individual with OA of the knee.
Limitations
• The speed of walking was not monitored for both FW
and BW groups
• Long‑term follow‑up was not taken

International Journal of Health & Allied Sciences • Vol. 5 • Issue 4 • Oct‑Dec 2016 225
 Rangey, et al.: Comparison of effect of forward and backward walking in OA of knee
• Assessor blinding was not done
• T h e c o m p a r t m e n t o f i nvo l ve m e n t wa s n o t
noted– whether it was tibiofemoral or patellofemoral
• Footwear was not taken into consideration.
Future recommendations
• Future studies with long‑term follow‑up can be
undertaken
• Studies monitoring the intensity of walking can be done
• Studies with longer duration of walking can be done.
CONCLUSION
FW and BW along with conventional treatment and
conventional treatment alone lead to a reduction of pain and
improvement of physical function and QOL after 2 weeks
of intervention.
There is no difference between FW and BW along with
conventional treatment and conventional treatment alone
for pain and QOL.
FW along with conventional treatment is more effective
in improving physical function compared to conventional
treatment alone.
There is no difference between FW and BW along with
conventional treatment for pain, physical function, or QOL.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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