RESEARCH

PROTOCOL
 CORRELATION BETWEEN CORE STRENGTH
AND KNEE STRENGTH IN ADULTS WITH KNEE
OA – AN ANALYTICAL CROSS SECTIONAL
STUDY

DEPARTMENT OF PHYSIOTHERAPY
KMC, MANGALORE
GUIDE- Dr. Charu Eapen, MPT (MUSCULOSKELETAL SCIENCES),
PhD
PRESENTED BY- NAMITA RAO –192102036
JUNAID MOHAMED - 192102038
HAZEL ROSHNI SOANS - 192102042
SERIAL NUMBER CONTENTS SLIDE NO.

1 INTRODUCTION 4
2 KNOWLEDGE GAP 7
3 REVIEW OF LITERATURE 8
4 NEED OF STUDY 14
5 OBJECTIVE 15
6 MATERIALS AND METHODS 16
7 TOOLS FOR DATA 19
COLLECTION
8 STATISTICAL ANALYSIS 23
9 APPENDIX 1- CLIENT 24
INFORMATION SHEET
10 APPENDIX 2- CONSENT 26
FORM
11 APPENDIX 3- PROFORMA 27
12 REFERENCES 29
INTRODUCTION
• Osteoarthritis is also known as degenerative joint disease.
• It’s defined as a chronic degenerative disorder of multifactorial aetiology characterized by loss of
articular cartilage and periarticular bone remodelling. [1]
• The most common form of arthritis strongly associated with aging and is a major cause of pain and
disability in older individuals prevalence increases with age, overall prevalence of knee OA in India
was found to be 28.7%, the associated factor found to be female gender (prevalence of 31.6%),
obesity (prevalence of 0.04), age (prevalence of 0.001) and sedentary work (0.001%).[2]
• Pathologically in a condition of synovial joint characterized by focal loss of hyaline cartilage with
proliferation of new bone and remodelling of joint contour.
• Clinical manifestation of patient with knee OA are morning stiffness in knee, pain following prolonged
standing walking, weight bearing activities, instability of knee joint ( walking, proprioception, balance
may be affected ).
• In individuals with knee OA pathophysiological changes that is seen are characterized by swelling,
softening, fissuring followed by destruction of articular cartilage, hypertrophy of underlying bone,
subchondral sclerosis , osteophyte formation , synovial inflammation synovitis and thickness of joint
capsule may occur.[1]
• Global, regional prevalence, incidence and risk factor of knee OA in
population based study a meta analysis showed 654.1 million
individuals aged 40 year and old with knee OA in 2020 worldwide.[3]
• Both male and female subjects, age >40 years diagnosed with
unilateral or bilateral OA knee by orthopedician according to the
American College of Rheumatology criteria were recruited.
 CORE

• The core is a box structure made up of diaphragm forming the roof, pelvic girdle forming the floor, abdominal
muscles in the front and side, the paraspinal and gluteal muscles at the back.
• The abdominal muscles create rigid cylinder around the spine during movement and provides stability to the
spine. mainly core stability implies stabilizing the spine during static and dynamic movements of limbs.
• Core provides linkage between upper and lower extremities function. Core stability is requisite for optimal
functioning and injury prevention.
• Core stability is instantaneous to maintain the involved anatomy must continually adapt to changing postures and
loading condition to ensure integrity of vertebral column and provide a stable base for movement of extremities.
KNOWLEDGE GAP

• It is noted that most of the studies focus on relating knee strength

with knee OA where as
very limited evidence was found on relationship between core
strength and knee strength in adults with knee OA.
 REVIEW OF LITERATURE
• WHY ARE WE NEGLECTING THE CORE MUSCLES IN PATIENTS WITH KNEE OA? A
NARRATIVE REVIEW OF LITERATURE
• Narrative review of literature published by Daniel W. flowers , Wayn brewer, katy
Mitchels and Jennifer Ellison in the year 2021 with an objective to determine
whether
• 1-Core training has been beneficial for older adults without knee OA and
• 2- Core activation/stabilization have been integrated into treatment
recommendation for patient with knee OA to improve their gait and functional
ability
• Major findings of the review implies although core training has been safe and
beneficial in older adults to address balance, fall risk and mobility the standard of
care approach for treating knee. OA continues to be either joint specific or
generalized to include whole body activity (eg: cardiovascular training).
• Some early evidence has shown a relationship between core strength and
transversus abdominis muscles, integrity however, using core activation/stabilization
or an intervention for person with knee OA has not yet been reported.[5]
 Is there a correlation between core stability measure with hip strength and functional activity level in the knee OA?

• 2) Correlation of core stability, measure with the hip strength and functional activity level in
the knee OA, an article by Tejashree A Dabholkar, Ajith Surendra Dabholkar, Dilshad Saki
Wala. School of PT, D.Y Patil university published in the year 2016
• The work by Dabholkar et al., which explored the relationship between core stability and lower
extremity strength and function, as measured via the Western Ontario and McMaster
Universities Arthritis Index (WOMAC), found there was a significant positive correlation
between core stability and hip abductor/external rotator strength (r ¼-0.51 and 0.44,
respectively); however, since a higher WOMAC score indicates more disability. These findings
indicate a connection exists between the core muscles and both the extremities’ overall
function. Unfortunately, the nature of this relationship is unclear.[3] This data simply shows
that changes in core strength has some bearing on hip strength and functional ability and vice
versa. The correlations between core stability and hip muscle strength were not significant in
healthy controls. The authors also compared those with unilateral and bilateral KOA, with both
groups having a positive correlation between their core stability and the WOMAC.[4]
Is contraction of abdominal muscles associated with movement lower limb ?

• 3. Contraction of the abdominal muscles associated with movement lower limb a case report conducted
by Paul W Hodgen, Carolyn A Richardson states

• Activity of trunk muscles is essential for maintaining stability of the lumbar spine because of the unstable
structures of that portion of the spine. A model involving evaluation of response of lumbar multifidus and
abdominal muscles to leg movement was developed to evaluate these functions. The subjects were
individuals with history of no low back pain was studied. Fine wire and surface electromyography were used
to record the activity of trunk muscles. In conclusion this provides evidence that the CNS initiates
contraction of the abdominal muscles and the multifidus in a feedforward manner in advance of the prime
mover of the lower limb. It was found that transversus abdominis, a muscle largely ignored in the literature
was invariably the first muscle that was active, furthermore the onset of EMG activity of the transversus
abdominis, oblique internus and oblique externus was not influenced by the direction of movement of the
limb and therefore the associated reactive forces. They proposed that the contraction of these muscles is
linked with the control of stability of spine against the perturbation produced by most of the limb. Therapist
should consider the function of deep muscles particularly TrA when attempting to train patients to control
trunk stability.[6]
Core stability and its relationship to lower extremity function and injury
prevention in athletes.

• 4.Leetun et al. investigated whether pre-season tests that

measure core stability serve as predictors for injury in male and
female basketball and track athletes. Back and lower extremity
injuries rates were tracked over two years, with 41 athletes
sustaining a total of 48 injuries. Those injured had significantly less
isometric strength of the hip musculature and core endurance
compared to uninjured athletes, leading the authors to
recommend core stability programs to prevent knee injury.[7]
• 5. An article published by Kibler et al. on the role of core stability in Athletic function states that the
muscles responsible for core stability in turn provide the stability necessary for the extremities to, ‘do
their specific function, providing the proximal stability for the distal mobility and function of the limbs.
In addition, core activity is involved with almost all extremity activities. The author also states that the
examples of core stabilization providing for optimal extremity movement follow two main tracks, either
allowing for ‘maximal force’ in the upper and lower extremities or ‘precision and stability’ to the distal
component of the extremity. In conclusion, core stability is a pivotal component in normal athletic
activities. It is best understood as a highly integrated activation of multiple segments that provides force
generation, proximal stability for distal mobility and generates interactive moments. [11]
• 6.Case report on core muscles training for knee osteoarthritis through core muscles activation and gait analysis
conducted by D. Maryama Ag Daud, Shye Nee Liau and Suhaini Sudi published in the year
• This case study featured a 47-year-old man who was diagnosed with grade IV knee osteoarthritis and never had a
surgery. His walking pattern was impacted by chronic knee discomfort. Thus the gait of this patient was analysed together
with core muscle activation before and after 2 weeks of core resistance exercise intervention. The knee pain score was
assessed using WOMAC. The outcome of this research is that core resistance training can be used as an alternative
treatment for patients with knee OA.
• Patient underwent exercise testing and was cleared to undergo exercise training.
• 6 sessions in 2 weeks- core muscle training was given according to physical ability with limited ROM of knee.
• Training program included static cycling, rowing, leg raise, abs curl, trunk extension.
• 3 sets of exercise were given with 12 to 15 reps with 45s to 60s of rest interval between the sets. The intensity of training
was 40 to 70% of 1 RM.
• After every session WOMAC score was recorded. Total six WOMAC pain subscale was recorded whose mean score
reduced every session.
• Kinetic analysis of gait was assessed through Zebris FDM treadmill. Patient had to walk on flat treadmill for 1min at his
preferred walking speed with the electrodes place on erector spinae and rectus abdominis, vastus lateralis and rectus
femoris.
• Force pressure distribution, length of gait line, anterior posterior position, cadence, stride length and foot rotation were
also assessed.
• After 2weeks of training deviation in gait line was reduced, normal foot rotation angle and COP shifted to over the balls of
foot and not only the great toe.[9]
• 7. Wilson et al. stated, ‘a growing body of literature suggests that core stability is an
important component of nearly every gross motor activity.’ They also hold that ‘the
greatest influence of core stability can be found at the knee’ citing the increased focus
in the literature on the role the core plays in knee injury and mechanics.[10]

• 8. Proximal body segments have also been a target for

research and intervention for patients with
patellofemoral pain syndrome (PFPS). Ferber et al. were
able to improve pain, strength, and functional ability for
those with PFPS who underwent a core, hip, and knee
strengthening program compared to those in a knee
strengthening program. The group that underwent core,
hip, and knee exercises showed reduced pain levels
earlier, lengthening the time of improved pain levels
with intervention.[8]
NEED OF THE STUDY
• Inadequate evidence and unanimity about the impact of core muscle strength
on knee OA.
• Lack of awareness about benefits of core muscle strengthening in individuals
with Knee OA.
• Inspite of many researches done on proximal stability training i.e core stability
and endurance for prevention of lower extremity injuries in Athletic population
and the efficacy of core, hip and knee strengthening program for patients with
patellofemoral pain syndrome, but there are limited studies correlating the
core strength and knee muscle strength in patients with knee OA.[8]
• Therefore the purpose of our study is to find out the correlation between core
strength and knee strength in patients with knee OA.
 AIM
• To find an association between core muscle strength and knee
muscle strength in patients with knee osteoarthritis.

OBJECTIVES
• To evaluate strength of core muscles and knee using standardised
test measures.
• To find association between core strength and knee strength with
patients with knee OA.
• To compare the strength between case and control groups.
MATERIALS AND METHOD
• STUDY SETTING – KMC hospital, Mangalore
• STUDY DESIGN – Analytical cross- sectional study, institutional based
study
• SUBJECTS
Study group – This study will include subjects diagnosed with
knee OA.
Control group – Age and gender matched subjects.
INCLUSION CRITERIA -Participants diagnosed clinically and verified
radiologically (Kellgren Lawrence, grade 1-4) with knee OA aged 40
years and above.
• Control group have to be without pain or knee complaints during
common activities of daily living.
• In case group- Individuals diagnosed with unilateral or bilateral OA
along with unicompartmental, bicompartmental and
tricompartmental involvement will be included.[4]
• VAS score for knee pain should be less than 5.[4]

EXCLUSION CRITERIA –
Subjects having any history of trauma or surgery in lower extremity are
• Sampling method- purposive sampling
• Tester- undergraduate physical therapy interns will be
the primary investigator and will conduct this study
under the guidance of associate professor, Department
of Physiotherapy, KMC Mangalore.
• Sample Size- The sample size of this study was
calculated for correlation. For a medium size and 3
predicting variables considering 1 percent margin of
error and 90 percent statistical power the required
sample size for this study is 70(35 per group) with a
moderate effect of size of 0.3
TOOLS FOR DATA COLLECTION
• Push pull dynamometer- To assess knee strength

• Plank test- To assess core strength

• VAS score- To assess pain
PROCEDURE
• The study protocol will be submitted to the Scientific Committee and Institutional Ethics
Committee of KMC Mangalore, Manipal Academy of Higher Education (MAHE), for approval.
• The subjects will be selected according to the inclusion and exclusion criteria.
• Potential participants will be classified into two groups one clinically diagnosed with knee OA
(kellgren lawrence grade1-4) while the other group being healthy control group that is age and
gender matched.
• The purpose of the study and procedure will be explained to each subject and standard
instructions will be given.
• Subjects will be given a chance to ask any questions regarding the study protocol and/or
procedures.
• Then strength assessment and functional evaluation of the individual will be done.
• Tools that will be used for the assessment are push pull dynamometer for knee muscle strength
and plank test for core muscle strength.
PUSH TYPE HAND HELD DYNAMOMETER
• Hand held dynamometer is used to measure muscle strength with
the help of a belt that is attached to HHD.
• Muscle strength is measured by pushing a part of body against
sensor pad.
• In measurement of isometric knee extensor strength a sensor pad
is attached to the front of distal lower extremity to measure
strength.
• This accurately measures the amount of compression or tension
being applied between 2 objects.
• Step 1- prepare the push pull gauge to take measurement. Select
unit in pounds, kilograms or newtons. Tension or pulling force will
be displayed as positive number. Pushing force or compression will
display as negative number.
• PLANK TEST
• The aim of this test is to hold an elevated position for as
long as possible. Start with the upper body supported
off the ground by the elbows and forearms and the legs
straight with the weight taken by the toes. The hip is
lifted off the floor creating a straight line from head to
toe.
• As soon as the subject is in correct position, the
stopwatch is started.
• The head should be facing towards the ground and not
looking forwards.
• The test is over when the subject is unable to hold the
back straight and the hip is lowered.[15]
STATISTICAL ANALYSIS-
Data will be analysed using SPSS (Statistical Package for
Social Sciences)
SD and mean will be reported of quantitative variables.
Independent T test will be used depending on the
distribution pattern of data.
Karl Pearson’s/ Spearman’s correlation will be used to
check correlation.
Shapiro- Wilk test will be used to assess whether the data
is normally distributed.
P value less than 0.05 will be considered significant.
APPENDIX 1
CLIENT INFORMATION SHEET
TITLE OF STUDY- CORRELATION BETWEEN CORE ST RENGTH AND KNEE STRENGTH IN ADULTS
WITH KNEE OA – AN ANALYTICAL CROSS SECTIONAL STUDY
TESTER- Namita Rao, Junaid Mohamed, Hazel Roshni Soans pursuing Bachelor’s in Physiotherapy in
KMC Mangalore.
PURPOSE OF RESEARCH- This study will help to find the impact of core strength on knee
osteoarthritis.
PROCEDURE OF THE STUDY-
BENEFIT OF THE STUDY- If we find a relationship between core strength and knee osteoarthritis it
will be helpful to plan a better rehabilitation strategies.
RISK AND DISCOMFORT- The entire procedure is safe and without any side effects.
CONFIDENTIALITY- The information produced by this study will be kept confidential. If the data is
used for publication in the medical literature or for teaching purposes, no names will be used
without permission.
REQUEST FOR ADDITIONAL INFORMATION- In case of any query about the study at any time
contact Namita Rao (contact no.- 9019139240, email id- raonamita2001@gmail.com) or Hazel
Roshni Soans (contact no.- 910814819, email id- hazelroshni10@gmail.com) or Junaid (contact no.-
7025015696, email id- junaidp3@gmail.com).
REFUSAL OR WITHDRAWAL OF PARTICIPANT
• The participation is voluntary and the subject may refuse
to participate or may withdraw consent and discontinue
participation in the study at any time.
APPENDIX 2
INFORMED CONSENT FORM
• Study title- CORRELATION BETWEEN CORE STRENGTH AND KNEE STRENGTH IN ADULTS WITH KNEE OA – AN
ANALYTICAL CROSS SECTIONAL STUDY
• Subject code-
• Subject’s name-
• Date of birth-
• Age-
1. I confirm that I’ve read and understood the information sheet dated ____ for the above study and have had the
opportunity to ask questions.
2. I understand that my participation in this study is voluntary and that I am free to withdraw at anytime, without
giving any reason, without my medical care or legal rights being affected.
3. I understand that the sponsor of the trial, other working on the sponsors behalf, the Ethics Committee and the
regulatory authorities will not need my permission to look at my health records both in respect of the current study
and any further research that maybe conducted in relation to it, even if I withdraw from trial, I agree to this access,
however, I understand that my identity will not be revealed in any information released to third parties or
published.
4. I agree not to restrict the use of any data or results that arise from this study provided such a use in only for
scientific purpose(s).
5. I agree to take part in the above study.
Signature ( or thumb impression) of the subject/ legally acceptable representative:
Signatory’s name: _________ Date: ________
Signature of the investigator: _______. Date:_________
Study investigator’s name:___________
Signature of witness:____________ Date:______
Name of the witness: ___________
APPENDIX 3
PROFOMA
Sr. No.______
Age:
Gender:
Occupation:
Address:
Diagnosis:
Date of Assessment:
History:
Medical history and surgical history

Signs and Symptoms:

VAS score:
CORE STRENGTH
TEST- TRIAL1 TRIAL 2
PLANK TEST
 REFERENCE

1)Davidson, S., Bouchier, I. and Edwards, C., 1991. Davidson's principles and practice of medicine. 21st ed.

2) Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian J Orthop.
2016 Sep;50(5):518-522. doi: 10.4103/0019-5413.189608. PMID: 27746495; PMCID: PMC5017174.
3) Cui A, Li H, Wang D, Zhong J, Chen Y, Lu H. Global, regional prevalence, incidence and risk factors of knee osteoarthritis in
population-based studies. EClinicalMedicine. 2020 Nov 26;29-30:100587. doi: 10.1016/j.eclinm.2020.100587. PMID: 34505846;
PMCID: PMC7704420.
4)Dabholkar TA, Dabholkar AS, Sachiwala D. Correlation of the core stability measures with the hip strength and functional activity
level in knee osteoarthritis. IJTRR. 2016;5(5):37–43.

5) Daniel W. Flowers, Wayne Brewer, Katy Mitchell & Jennifer Ellison (2021) Why are we neglecting the core muscles in patients with
knee osteoarthritis? A narrative review of the literature, Physical Therapy Reviews, 26:4, 276-
283, DOI: 10.1080/10833196.2021.1907947

6) Hodges PW. Is there a role for transversus abdominis in lumbo-pelvic stability? Man Ther. 1999;4(2): 74–86.
7) Leetun DT, Ireland ML, Willson JD, et al. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports
Exerc. 2004;36(6): 926–934.
8)Ferber R, Bolgla L, Earl-Boehm JE, et al. Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral
pain: A multicenter randomized controlled trial. J Athl Train. 2015;50(4):366–377.

9) Daud DMA, Liau SN, Sudi S, Noh MM, Khin NY. A Case Report on Core Muscles Training for Knee Osteoarthritis Through Core
Muscles Activations and Gait Analysis. Cureus [Internet]. 2023 Jan 18; Available from: https://doi.org/10.7759/cureus.33918

10) Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. J Am
Acad Orthop Surg. 2005 Sep;13(5):316-25. doi: 10.5435/00124635-200509000-00005. PMID: 16148357
.
11) Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med. 2006;36(3):189-98. doi:
10.2165/00007256-200636030-00001. PMID: 16526831.

12)

13)

14) Mentiplay BF, Perraton L, Bower KJ, Adair B, Pua YH, Williams G, et al. Assessment of Lower Limb Muscle Strength and Power
Using Hand-Held and Fixed Dynamometry: A Reliability and Validity Study. PLOS ONE [Internet]. 2015 Oct 28;10(10):e0140822.
Available from: https://doi.org/10.1371/journal.pone.0140822

15) Tong TK, Wu S, Nie J. Sport-specific endurance plank test for evaluation of global core muscle function. Phys Ther Sport. 2014
Feb;15(1):58-63. doi: 10.1016/j.ptsp.2013.03.003. Epub 2013 Jul 11. PMID: 23850461.