Original Article

Effectiveness of Muscle Energy Technique and Strengthening Exercises by

KOOS in Knee Osteoarthritis Strengthening Exercise in Reducing Pain to
Improve Functional Activity Measured by KOOS in Knee Osteoarthritis

S.Kalidhasan1, K. Kotteeswaran2, Andrew Anbarason J.P3, Iyyappan Manickavasagam4

1Undergraduate, 2Professor, 3Tutor,Saveetha College of Physiotherapy, Saveetha Institute of Medical and

Technical Sciences, Chennai, Tamil Nadu, India, 4Head of Physiotherapist, DPRC Rehabilitation Center,
Dubai, United Arab Emirates.

How to cite this article: [Link], K. Kotteeswaran, Andrew Anbarason J.P et. al. Effectiveness of Muscle
Energy Technique and Strengthening Exercises by KOOS in Knee Osteoarthritis Strengthening Exercise in
Reducing Pain to Improve Functional Activity Measured by KOOS in Knee Osteoarthritis. Indian Journal of
Physiotherapy and Occupational Therapy / Volume 18, Year 2024.

Abstract

Background: According to 2012 data, the prevalence rate of OA in both rural and urban India was ranging from
33% to 46% of the older adult population where females were more affected than men. Participants with knee OA
frequently need to perform strengthening exercises since they have weaker muscles due to decreased physical
activity and pain tolerance.

Purpose: The Purpose of the study is to find out the efficacy of Muscle energy technique and strengthening exercise
in pain management to improve ROM in knee osteoarthritis.

Materials and methods: This study included a sample of 196 between the age group of 45- 60 years were taken
from Shri Shakthi’s centre for pain relief and rehabilitation according to selection criteria for this experimental
study which was divided into two groups, strengthening exercise group (n=98) and muscle energy technique
group (n=98) . Interventions were given as 5 sessions a week and continued for 2 weeks.

Study period: March 2023 to July 2023.

Result: The Pre-test and post-test values were analysed, pain score was decreased and functional outcome was
improved significantly in strengthening exercise groups when compared to muscle energy technique.

Conclusion: The study shows that strengthening exercise for osteoarthritis of the knee in older adults is more
effective than muscle energy technique.

Key Words: Knee Osteoarthritis, Muscle energy technique, Strengthening exercises, Manual therapy.

Introduction the age of 40, women are more prone than men
to get OA, but the prevalence rises sharply with
The most prevalent type of chronic pathology of
advancing years. According to the Global Burden of
synovial joints is osteoarthritis, commonly known
Disease in 2000, Years lived with disability (YLD) are
as osteoarthritis or degenerative joint disease.1 After
most frequently caused by OA, which ranks fourth

Corresponding Author: K Kotteeswaran, Saveetha College of Physiotherapy, Saveetha Institute of Medical & Technical
Sciences, Chennai, Tamil Nadu, India.
E-Mail: [Link]@[Link]
 Indian Journal of Physiotherapy and Occupational Therapy / Volume 18 Special Issue 2024 575

globally.2 The primary clinical symptoms of OA are the extensor and flexor muscles of the knee contract
the slow degradation of articular cartilage and the strongly together. Patients with stronger hamstrings
formation of bone at the joint margin.3 Weakness in and quadriceps walked faster and with less knee joint
the quadriceps muscle is the first sign of osteoarthritis loading. The pathophysiology of osteoarthritis has
in patients compared to healthy individuals.4 Data been linked to increased articular cartilage loading
from 2012 showed that OA affected between 33% and and cartilage’s capacity to withstand loading. Daily
46% of the population of older adults in both rural walking may put strain on the joints, which could
and urban India, with women being more afflicted alter how osteoarthritis manifests and advances.
than men.5 Walking places 70% of the strain on the medial
compartment of the knee. It has been discovered that
Manual therapy known as the Muscular Energy
a high knee adduction moment is a potent indicator
Technique (MET), involves the patient using their
of the presence, severity, and rate of progression of
own muscles from a specific location, in a certain
knee osteoarthritis. Weight distribution between the
way, and in spite of the therapist applying a counter
compartments of the knee is changed by the knee’s
force.6 The Mulligan Techniques recommend moving
moment of adduction.12
in a particular direction or within a range of motion
that is pain-free in order to increase hip flexion and It is common practice to diagnose and classify
knee extension. Osteoarthritis of the knee patients the severity of OA using radiographic evidence of
experience significant physiological changes that abnormalities in the underlying subchondral bone
impact their ability to do daily chores, such as weakness and attrition of the articular cartilage.
and diminished flexibility, in addition to discomfort.7
The intra-articular changes have been the main
There are numerous therapies available that 8th and
focus of OA research, which has shed a lot of light
9th place a greater emphasis on pain.8 Patients with
on the pathophysiologic processes that take place
knee osteoarthritis have not been studied to compare
within the articular environment. The periarticular
the two procedures. The purpose of this study was
skeletal muscles’ alterations, in contrast, have
to compare the efficacy of Mulligan’s bent leg raise
received very little attention from researchers.13
(BLR) method with the muscular energy technique
The neuromuscular skeletal system, which consists
in treating knee OA.9 The strength of your muscles,
of the articulating bones, cartilage, ligaments,
your ability to manage your muscles, your range of
capsule, the muscles that control movement, and the
motion, the stability of your joints, and your fitness
nerves that regulate movement, should be seen as
can all be enhanced by a good training regimen. Since
a whole, with the synovial joint acting as one of its
their decreased physical activity and pain tolerance
functional components. However, because muscles
have left their muscles weaker, patients with knee
are necessary for joint function, the synovial joint
OA frequently need to do strengthening activities.10
should be viewed as a functional component of
As a result, strengthening activities increase the the neuromuscular skeletal system. The efficient
strength of the quadriceps while also improving operation of each part of these units is necessary
clinical outcomes such as pain, physical function, for precise, controlled movement. Joint dysfunction
and quality of life. In order to better the quadriceps results from any malfunctioning component. A rising
muscle and patellar tendon’s capacity to efficiently body of evidence suggests that muscle dysfunction
unload the knee joint, it is believed that strengthening may play a role in the pathophysiology of OA,
the quadriceps will increase their force when moving. despite the fact that very few research studies have
In addition to exerting more force, the quadriceps been conducted in this field. This is because it is now
would be able to absorb more energy (i.e., perform known how the condition affects muscles.14
negative work), which might help to lessen the stress
applied to the knee joint surface. This clarifies why Aim
it makes sense for the muscles’ strength to serve as a To find out the effectiveness of Muscle energy
shock absorber around the knee joint.11 The knee joint technique and strengthening Exercise in pain
is stabilized and has less varus-valgus laxity when management to improve ROM in knee osteoarthritis.
576 Indian Journal of Physiotherapy and Occupational Therapy / Volume 18 Special Issue 2024

Material and Method medical college and hospital. The detailed procedure
for performing the test will be explained to the
• Couch
subjects. The subjects are made to feel comfortable
• Pillow with the procedure after the explanation. 196 subjects
• Foot stool are divided into 2 groups where one set of group A
• Bedsheet (n=98) will be given muscle energy technique which
have 2 types, the post isometric relaxation with
The experimental study conducted on 196
the sets of 3 and 10 repetitions and the reciprocal
subjects with knee osteoarthritis, age between 45-60
inhibition with the set of 3 and 10 repetitions/
years was taken from Shri Shakthi’s centre for pain
per day, 5 days in a week and group B (n=98) will
relief and rehabilitation. Convenience sampling
receive strengthening exercise with the following
method was used in the study.
by quadriceps strengthening exercise, hamstring
Study period: March 2023 to July 2023. strengthening exercise and calf strengthening
exercise with a sets of 3 and 15 repetitions/ per day, 5
Inclusion Criteria
days in week will be given respectively.
• The subjects diagnosed with OA knee
1. Muscle Energy Technique
subjects of age 45 to 60 years with ACR
(American college of Rheumatology) This technique is divided into two types
• Knee pain duration more than 3 months
A) Post Isometric Relaxation
• Both genders included
B) Reciprocal Inhibition
Exclusion Criteria
A) Post Isometric Relaxation (PIR)
• History of past or recent surgery in lower
limb The subject will be supine with their hips 90
• Any deformity in the affected side lower limb degrees flexed. The individual will be instructed to
flex their knee with 20% more force. The quadriceps,
• Any neurological injury in affected lower
the agonist muscle, will experience resistance for 5
limb
seconds during the contraction. With a 5-second rest
• Any malignancy in affected lower limb
interval in between each set, there will be 3 sets of 10
Outcome Measures repetitions each.

• Knee Injury and Osteoarthritis Outcome B) Reciprocal Inhibition

Score (KOOS)
The subject will be positioned in the same
A self-report questionnaire known as the Knee 90-degree supine position. The individual will be
Injury and Osteoarthritis Outcome Score instructed to flex their knee with 20% more force.
(KOOS) evaluates five outcomes: daily activities, While resistance is being given to the quadriceps, the
sport and recreation function, pain, symptoms, and contraction will be sustained for 5 seconds. With a
knee-related quality of life. The KOOS satisfies the 5-second rest interval in between each set, there will
requirements for a basic outcome measure and can be 3 sets of 10 repetitions each.
be used to determine how well a knee injury has
2. Strengthening Exercises
healed. It can be calculated in percentages, with
100 signifying no problems and 0 signifying severe i) Quadriceps Strengthening Exercise
problems.
The subject will perform this exercise while lying
Procedure supine with the affected leg straightened and the
In the comparative study which carried 196 unaffected leg bent. A towel will be put below the
subjects with OA knee chosen in accordance with knee and pressure will be applied for 3 sets and 15
the inclusion and exclusion criteria from Saveetha repetitions over the course of 5 days.
 Indian Journal of Physiotherapy and Occupational Therapy / Volume 18 Special Issue 2024 577

ii) Hamstring Strengthening Exercise Data Analysis

The subject will be in quadripod position, while The mean and standard deviation (SD) were applied
the affected leg will be raised for 15 repetitions with 3 to all parameters. The significant differences
sets/ per day, 5 days in week will be given. between pre-test and post-test measures of the same
group were analysed using a paired t-test and the
iii) Calf Raises
post-test values of both the group were analysed
The subject will be instructed to stand on the foot using the unpaired t-test to examine significant
stool or at the stairs and tell them to do calf raises for changes between two groups.
3 sets and 15 repetitions per day, 5 days in week will
be given.

Graph- 1: Comparison of the Muscle Energy

Technique Group’s Pre- and Post-Test Values

Graph-2: Comparison of the Strengthening Exercise Group’s Pre- and Post-Test Values
578 Indian Journal of Physiotherapy and Occupational Therapy / Volume 18 Special Issue 2024

Graph-3: Comparison between Post-test values of Strengthening exercise group and muscle energy
technique group

Result ADL SD pre-test (1.71) and post-test (2.36), SR mean

pre-test (22.86) and post-test (54.08) and SR SD pre-
Graph.1. Compare the pre-test and post-test
test (5.18) and post-test (6.52), QOL mean pre-test
values of muscle energy technique using KOOS
(21.88) and post-test (62.55) and QOL SD pre-test
scale. The mean value of muscle energy technique
(3.68) and post-test (2.14). As a result, the findings are
in the experimental group using the Koos scale, the
considered statistically significant when the p-value
value of pain pre-test (22.7) and post-test (47.12)
is <0.0001.
and pain SD pre-test (4.13) and the post test (3.01),
symptoms mean pre-test (21.14) and post-test (42.79) Graph.3. Compare the post-test values of
and symptom SD pre-test (2.49) and post-test (7.00), strengthening exercise group and muscle energy
ADL mean pre-test (22.83) and post-test (43.97) and technique group, revealing that strengthening
ADL SD pre-test (2.89) and post-test (3.50), SR mean exercise group mean of pain pre-test (63.96) and post-
pre-test (21.53) and post-test (54.08) and SR SD pre- test (47.12) and pain SD pre-test (2.46) and post-test
test (2.73) and post-test (6.52), QOL mean pre-test (3.01), mean of symptom pre-test (45.85) and post-
(20.10) and post-test (43.02) and QOL SD pre-test test (42.79) and symptom SD pre-test value (6.80)
(3.69) and post-test (2.39). As a result, the findings are and post-test (7.00), mean of ADL pre-test (52.16) and
considered statistically significant when the p-value post-test (44.96) and symptom of ADL pre-test (2.36)
is <0.0001. and post-test (4.83), mean of SR pre-test (54.08) and
post-test (40.66) and SR’s SD value pre-test (6.52) and
Graph.2. Compare the pre-test and post-test
post-test (2.65), QOL mean pre-test (62.55) and post-
values of strengthening exercise using KOOS
test (43.02) and QOL’s SD value pre-test (2.14) and
scale. The mean value of strengthening exercise in
post-test (2.39)
the experimental group using the Koos scale, the
value of pain pre-test (20.29) and post-test (63.96) Discussion
and pain SD pre-test (1.93) and the post-test (2.48),
symptoms mean pre-test (20.49) and post-test (63.96) Based on the inclusion and exclusion criteria from
and symptom SD pre-test (3.80) and post-test (2.46), Saveetha Medical College and Hospital, 196 patients
ADL mean pre-test (20.49) and post-test (52.16) and with OA knee will be chosen for the comparative
 Indian Journal of Physiotherapy and Occupational Therapy / Volume 18 Special Issue 2024 579

study. The subjects will be given a thorough Ethical Clearance: Taken from institutional
explanation of how the exam will be conducted. ethical committee. ISRB Number: 03/ 036/ 2022/
After the explanation, the individuals are guided ISRB/ SCPT
through the procedure in a comfortable manner.
196 subjects are divided into two groups. Group A Funding: Self funding
(n=98) will receive muscle energy technique, which Conflict of Interest: Nil
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