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Osteoarthritis(OA) is a pathological disorder of synovial joints (Ageberg and Roos, 2015). Itis regarded as the most prevalent type of arthritis among older adultsworldwide, more commonly affecting the knee than the hip. Based on SingHealthstatistics (2014), OA affects approximately 40% of the older adult populationin Singapore.Individualswith lower limb arthritis commonly experience symptoms such as increased pain,reduced physical function, muscle weakness and impaired balance, which are allpotential risk factors for falls. Studies have found that lower limb arthritisand musculoskeletal pain can contribute to falls (Arden et al. 2006, Deandrea et al.

2010). Individuals with knee OA notablyhave a 54%greater chance of experiencing a fall than that of a healthy individual (Smithet al. 2016).

Impairedbalance has been identified as one of the more important risk factors of fallsin patients with arthritis (Sturnieks et al. 2004, Williams et al.2010, Levinger et al. 2012). Balance is a crucial function that allowsindividuals to maintain posture and respond to perturbations (Takacs et al.2017).

With increasing age, the age-related changes of the neuromuscular systemcan lead to slower muscle response, reduced muscle strength and power, henceaffecting the ability to maintain postural control (Levinger et al. 2017). Inindividuals 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 populationare warranted. Exercise programs focusing on balanceexercises 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 improvingbalance are also well established.

However, few studies have assessed theeffectiveness of balance exercises in reducing fall risk in the knee OApopulation. In clinical practice, the common managementof knee osteoarthritis involves strengthening and flexibility targeting painand symptoms (Williamset al. 2010).

In the Cochrane review by Fransen and McConnell in 2008,most exercise interventions for knee arthritis are targeted lower limbstrengthening, aerobic and walking programs. Balance assessment and balanceexercises are less commonly incorporated as part of the routine management ofknee osteoarthritis. In cognisance of these factors, the presentreview aimed to systematically evaluate studies which have trialled balance training as a form of conservative treatment inindividuals with knee OA. The review sought to investigate the effectiveness ofbalance training in the management of knee OA and its effects on falls risk inindividuals with knee OA. 1.2 Overview1.

2.1 Criteria for considering studies for this systematic review Studies werescreened using the PICOS(participants, interventions, comparisons, outcomes and study design)framework. Randomised controlled trials (RCTs) and systematic reviews publishedin the English language were included. All studies that involved subjects withknee OA, with a mean age of 50 years and above were considered.

Studies which includedsubjects with other forms of osteoarthritis (hip and spine) were excluded, asthe main interest were in the effects of balance training on knee OA alone. Only studies that examined balance training or compared balancetraining with other forms of therapy such as resistance, flexibility or aerobictraining 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 followingkeywords: Falls OR falls risk, Kneeosteoarthritis, balance, physiotherapy. OnlyEnglish language journal articles were selected. To yield further pertinentstudies, the reference lists of articles were inspected and abstracts ofrelevant studies were reviewed. From the above search, allstudies found were screened for this review. Non-randomised studies, reviews and journalarticles that were not relevant were excluded.

Finally, seven studies that investigated theeffect of balance training on individuals with knee osteoarthritis wereselected for this systematic review. 

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