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Osteoarthritis
(OA) is a pathological disorder of synovial joints (Ageberg and Roos, 2015). It
is regarded as the most prevalent type of arthritis among older adults
worldwide, more commonly affecting the knee than the hip. Based on SingHealth
statistics (2014), OA affects approximately 40% of the older adult population
in Singapore.

Individuals
with lower limb arthritis commonly experience symptoms such as increased pain,
reduced physical function, muscle weakness and impaired balance, which are all
potential risk factors for falls. Studies have found that lower limb arthritis
and musculoskeletal pain can contribute to falls (Arden et al. 2006, Deandrea et al. 2010). Individuals with knee OA notably
have a 54%
greater chance of experiencing a fall than that of a healthy individual (Smith
et al. 2016).

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Impaired
balance has been identified as one of the more important risk factors of falls
in patients with arthritis (Sturnieks et al. 2004, Williams et al.

2010, Levinger et al. 2012). Balance is a crucial function that allows
individuals to maintain posture and respond to perturbations (Takacs et al.

2017). With increasing age, the age-related changes of the neuromuscular system
can lead to slower muscle response, reduced muscle strength and power, hence
affecting the ability to maintain postural control (Levinger et al. 2017). In
individuals with knee OA, these neuromuscular deficits can be more apparent,
predisposing them to a greater fall risk (Levinger et al. 2017). Therefore,
programs targeting balance and fall risk specifically for knee OA population
are warranted.

Exercise programs focusing on balance
exercises have been shown to be effective in reducing falls for older people
(Sherrington et al.

2011). For the non-arthritic population, benefits of exercises in improving
balance are also well established. However, few studies have assessed the
effectiveness of balance exercises in reducing fall risk in the knee OA
population. In clinical practice, the common management
of knee osteoarthritis involves strengthening and flexibility targeting pain
and symptoms (Williams
et al. 2010). In the Cochrane review by Fransen and McConnell in 2008,
most exercise interventions for knee arthritis are targeted lower limb
strengthening, aerobic and walking programs. Balance assessment and balance
exercises are less commonly incorporated as part of the routine management of
knee osteoarthritis.

In cognisance of these factors, the present
review aimed to systematically evaluate studies which have trialled balance training as a form of conservative treatment in
individuals with knee OA. The review sought to investigate the effectiveness of
balance training in the management of knee OA and its effects on falls risk in
individuals with knee OA.

1.2 Overview

1.2.1 Criteria for considering studies for this systematic review

Studies were
screened using the PICOS
(participants, interventions, comparisons, outcomes and study design)
framework. Randomised controlled trials (RCTs) and systematic reviews published
in the English language were included. All studies that involved subjects with
knee OA, with a mean age of 50 years and above were considered. Studies which included
subjects with other forms of osteoarthritis (hip and spine) were excluded, as
the main interest were in the effects of balance training on knee OA alone.

Only studies that examined balance training or compared balance
training with other forms of therapy such as resistance, flexibility or aerobic
training were selected. Studies that employed osteoarthritis-related outcomes,
balance-related outcomes and/or falls risk were included.

1.2.2 Search methods for identification of studies

A systematic search of Embase,
Pub Med, and Science Direct databases were conducted using the following
keywords: Falls OR falls risk, Knee
osteoarthritis, balance, physiotherapy. Only
English language journal articles were selected. To yield further pertinent
studies, the reference lists of articles were inspected and abstracts of
relevant studies were reviewed.

From the above search, all
studies found were screened for this review. 
Non-randomised studies, reviews and journal
articles that were not relevant were excluded. Finally, seven studies that investigated the
effect of balance training on individuals with knee osteoarthritis were
selected for this systematic review. 

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