Aim: To evaluate the immediate effects of various activity levels on knee joint position sense.
Methodology: Sixty males aged between 19 and 24 years, without any complains of discomfort or pain in the knee joint were selected from Bakhtawar Amin Hospital, Multan using convenience sampling, between April 2nd, 2019 to July 28th, 2019. Group A participants walked on the treadmill at a speed of 4 km/h for 5 min (n = 20). Group B participants ran on a treadmill at 6.4 km per hour for five minutes (n = 20). Group C participants sprinted on a treadmill at 8.5 km per hour for five minutes (n = 20).
Results: Mean age of the subjects was 21.18±1.77. In the moderate physical activity group, the difference in the means in passive reproduction of the knee flexion angle of 20o observed was 1.40±2.39, (p-value 0.013), and similarly in intense physical activity was 1.75±3.58 (p-value 0.020). For the knee flexion angle of 40o, the difference in the means for moderate was 1.35±1.84 (p=0.002), and for the intense activity was 2.35±2.27 (p=0.012). However, in the group with mild physical activity, the difference in the means was statistically insignificant.
Conclusion: The study indicated that physical activities of moderate level and intense level decrease the joint position sense appreciation at the knee joint in less active healthy individuals.
The physical well-being of healthy young adults is important not only for themselves but also to the community1. Routine physical exercise is important for the mental and physical health of individuals. Because of its well established benefits, physical activity is expected to be an integral part of one’s life2.The ability to recognize the body positions and its movements is collectively known as Kinesthesia3.
Proprioception is an integral part of kinesthesia. It is important not only in preventing trauma but also in enhancing the performance of highly complex movements. The power and strength in muscles is of slightest value if the muscles fail to activate on time, as this timely activation is important in protecting the muscles themselves, joints and even other muscle groups4.
A large number of studies have shown that the performance of sensory organs can be influenced depending on the kind of activity undertaken, joint laxity, vibration of tendons, swelling in and around the joints, gender, any disease affecting joints, muscles or tendons, neuromuscular insufficiency and muscle fatigue5,9.
A study10 was conducted to analyze the influence of specific proprioceptive training on knee proprioception among professional female handball players. It was concluded that specific proprioceptive training enhances the knee joint proprioception among such players. Another reseach concluded that the swelling and effusion around knee joint causes a decline in proprioception and recognition of passive and active joint position sense in osteoarthritic joints11.
Muscle fatigue is generally followed by the failure of a muscular tendon to sustain the contraction. Similarly, fatigue may also be described as the powerlessness of a muscle to sustain a certain load and incapability of controlling the activity at a particular level11. Recent research has concluded that a decline in proprioceptive sensations in response to decreased joint12 and muscle’s receptors function might appear with the occurrence of fatigue. It is suggested that this decline in joint position sense might result in increased joint and musculotendinous injuries13,14. In comparison of the recommendations, suggesting that proprioception is affected by fatigue, another study concluded that there was not any significant decline in knee joint proprioception after performing 20 maximal isokinetic contractions of quadriceps in sedentary females15. Alternatively, other studies have concluded that isokinetic exercise till fatigue affects joint position sense considerably16,18. Furthermore, it was determined that sub-maximal intensity physical work to fatigue diminishes the awareness of proprioception, that in turn can cause altered motor coordination and joint position sense. Therefore, the objective of current study is to evaluate the effects of different levels of activities on the reproduction of proprioception sensing on the knee joint.
A quasi-experimental study was conducted from April 2nd, 2019 to July 28th, 2019. Sixty participants (N = 20*3 groups) were included in the study. The study setting was Bakhtawar Amin Memorial Trust Hospital, Multan. A convenience sampling technique was used for collection of data. Healthy males were included in the study, aged between 19 and 24 years with Body Mass Index between 18.5 and 25. The subjects without pain and discomfort in knee joint were enrolled in the study. Those having no active participation in regular sports for the last six months and those with no underlying neuromuscular and musculoskeletal pathologies were enrolled. Whereas the individuals with previous knee surgery, gross knee instability, red flags suggesting knee pathologies, cardiopulmonary conditions, tumor, infections, fracture and subjects with a history of soft connective tissue trauma were excluded from the study.
Informed consent was taken from the subjects and consequences were also explained and were made to understand. The confidentiality of the data was fully ensured. The willing subjects were interviewed by the professional clinical therapists of Bakhtawar Amin Memorial Trust Hospital, Multan. The subjects were assigned to one of the 3 intervention groups. Group A subjects walked on a treadmill at a speed of 4 km per hour (2.5 miles/h) for five minutes (n = 20). Group B subjects ran on a treadmill at a speed of 6.4 km per hour (4 miles/h) for five minutes (n = 20). Group C subjects ran on a treadmill at a speed of 8.5 km per hour (5.5 miles/h) for five minutes. The joint position sense score was calculated before starting the physical activity, and immediately after ending physical activity by the assistance of Continuous Passive Motion Machine (CPM). The rig of CPM and the seating chair was accurately placed to make the center of rotation of rig becomes equal to the central point of knee joint complex. CPM rotated its arm at the speed of 2 degrees/sec. This speed was used as it was in accordance with the speed used in the prior researches19. The basic objective of using the low speed of 2 degrees/sec was to activate the mechanoreceptors located at the joint20. Slow and progressive positioning has maximally targeted the stimulation of ligament receptors and the capsules. Unnecessary movements were minimized by the use of straps attached to the chair at the level of the thigh, pelvic area and torso. All the subjects were blind folded while seated and their ear were also closed with cotton gauges.
The subjects were asked to move their lower legs from the starting position to the target angle with the use of CPM with the knee flexed to 20 degrees to 40 degrees. The knee joint complex was passively encouraged to move at 2 degrees per second at predetermined target position, and then again reaching the start position. Three familiarizing trails were given beforehand the data were collected. The remote of the CPM machine was handed to the subject, so that he could passively move his knee joint from the starting position to the target position at his own will. The subjects were asked to press the stop button when the target degree movement is achieved. After recording the data, subjects in each of the three groups performed their respective physical activities. The knee joint position sense was again assessed immediately after the prescribed physical activity. The same protocol was followed for measuring joint position sense as was done before the physical activity.
Data was analyzed using SPSS 21. The normality of data was checked by Kolmogorov Smirnov test, and the data did not lie normally. So, a non-parametric test was used to compare the means of the data. P value less than 0.05 was taken significant. Comparison of means at different angles of flexion before and after physical activity was depicted through bar charts.
In the moderate physical activity group, the difference of the means in passive reproduction of the knee flexion angle of 40o observed before and after the physical activity was1.35±1.84, it was statistically significantly different (p-value 0.002), and similarly the difference in the means in Intense physical activity was 2.35±2.27 and it was also statistically significantly different (p-value 0.012). In the mild activity group, the difference was not statistically significant (p=0.061).
In the moderate physical activity group, the difference in the means in passive reproduction of the knee flexion angle of 20O observed before and after the physical activity was 1.40±2.39, it was statistically significantly different (p-value 0.013) and similarly the difference in the means in Intense physical activity was 1.75±3.58, it was also statistically significantly different (p-value 0.020). In the mild activity group, the difference was not statistically significant (p=0.136) as mentioned in Table 1.
Table 1: The Wilcoxon Signed Rank Test
Graph 1: Comparison of Means at 40 degrees of Knee Flexion before & after Physical Activity
Graph 2: Comparison of Means at 20 degrees of Knee Flexion before & after Physical Activity
This study evaluated the effects of different levels of activities on the reproduction of proprioception sense on the knee joint. The findings of the current study showed that there has been a significant effect on kinesthetic sense due to increased physical activities. The intense physical activity can target the kinesthetic sensation to decrease. The proprioceptive and kinesthetic sensations on the knee joint are markedly decreased as the intense or moderate levels of activities cause fatigue.
A study compared the effectiveness of acupuncture moxibustion versus conventional physical therapy treatment in enhancing the proprioceptive ability among athletes having injured lateral side collateral of the ankle joint. It was deducted about the therapeutic effects of acupuncture-moxibustion that they were superior to the traditional physical therapy treatment in enhancing the proprioceptive ability of the damaged lateral collateral ligament of the ankle9. The results of the study were in line with the results of current study.
Earlier studies have targeted young and sedentary adults for participation in the study, the subjects have never been involved in any type of sports activity for last years. The neuromuscular coordination of lower extremity is compromised and the stability of the knee joint is also not well established targeting the proprioceptive awareness negative. Fatigue is the main reason for reducing the athlete capabilities and making them prone to injuries21. These previous findings have been in accordance with the current study. Previous literature has also quoted decreased joint position sense decreases proprioception and all this is initiated with the onset of fatigue22, 23. The methodology section of some previous literature in the terms of instruments and interventional techniques was in accordance with the current study. However, this study investigated the effects of various physical activities classified according to the Metabolic Equivalent Task. The previous literature has not compared these different activity levels in a single study.
A study was conducted to evaluate the effects of warm up exercise and fatigue influence on the joint position sense of soccer sports players. The values were assessed at rest, after warm up and finally after a full competition match on the perceived exertion scale. The results of the study showed that joint position sense was markedly improved by warm-up exercise immediately before the competition whereas fatigue component after the match decreased the joint position sense. The harmful effects of high intensity activity related fatigue also contribute to the knee instability, trauma and injury24. These results agreed with the results of our study, which reported that with the moderate and intense physical activity, joint position appreciation is significantly decreased.
Another study evaluated the aging and physical activity effects on knee joint position sense. The study showed that regular physical activity improves the positioning sense in knee joint. However, the aging factor was negatively correlated with the proprioceptive ability of knee25. The current study results are dissimilar to the mentioned study, as the current study has targeted the different levels of physical activity on joint position sense. According to our results intense physical activity targets negatively on the joint position sense. Another study evaluated the effects of fatigue on knee joint positioning in sprinters26. The results of the study agreed with the current study that showed that high intensity activity causing fatigue effects proprioception of knee joint negatively.
It is recommended for future researches to get their focus on an exercise related protocol which produces increasing levels of exertion that most likely replicate sporting activities and athletic actions. Further studies can also compare the physically active individuals with sedentary adults to investigate the relationship between the variables.
The findings of the study concluded that moderate level and intense physical activity decreased joint position sense appreciation (proprioception) at the knee joint in sedentary otherwise healthy young adults.
- Teyhen DS, Rhon DI, Butler RJ, Shaffer SW, Goffar SL, McMillian DJ, et al. Association of physical inactivity, weight, smoking, and prior injury on physical performance in a military setting. Journal of athletic training. 2016;51(11):866-75.
- Loprinzi PD, Kane CJ, editors. Exercise and cognitive function: a randomized controlled trial examining acute exercise and free-living physical activity and sedentary effects. Mayo Clinic Proceedings; 2015: Elsevier.
- Fox AJ, Wanivenhaus F, Burge AJ, Warren RF, Rodeo SA. The human meniscus: a review of anatomy, function, injury, and advances in treatment. Clinical Anatomy. 2015;28(2):269-87.
- Han J, Anson J, Waddington G, Adams R, Liu Y. The role of ankle proprioception for balance control in relation to sports performance and injury. BioMed research international. 2015;2015.
- Hewett TE, Myer GD, Kiefer AW, Ford KR. Longitudinal increases in knee abduction moments in females during adolescent growth. Medicine and science in sports and exercise. 2015;47(12):2579.
- Gong C, Liu W. Acupuncture in Orthopedics. International Journal of Clinical Acupuncture. 2015;24(1).
- Alhajaya M. Effects of proprioception training on knee joint position sense in male soccer athletes. J Sociol Res. 2015;6.
- Soligard T, Schwellnus M, Alonso J-M, Bahr R, Clarsen B, Dijkstra HP, et al. How much is too much?(Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. British journal of sports medicine. 2016;50(17):1030-41.
- Huang D, He X-Z, Yang X-H, Peng S-M, Wu Y-X. Stratification of injuries to the lateral collateral ligament of the ankle using ultrasound: protocol of a prospective, open-label, diagnostic trial and preliminary results. Clinical Trials in Orthopedic Disorders. 2018;3(2):53.
- BALBA AE-DA, ALAA IE-K, AHMED H, MOHAMMED MM. Effect of Core Stability Training on Knee Proprioception after Anterior Cruciate Ligament Reconstruction. The Medical Journal of Cairo University. 2018;86(March):231-40.
- Kavita K, Hassan NC. Work stress among teachers: A comparison between primary and secondary school teachers. International Journal of Academic Research in Progressive Education and Development. 2018;7(4):60-6.
- Han J, Waddington G, Adams R, Anson J, Liu Y. Assessing proprioception: a critical review of methods. Journal of Sport and Health Science. 2016;5(1):80-90.
- Robinson M, Siddall A, Bilzon J, Thompson D, Greeves J, Izard R, et al. Low fitness, low body mass and prior injury predict injury risk during military recruit training: a prospective cohort study in the British Army. BMJ open sport & exercise medicine. 2016;2(1):e000100.
- Tricco AC, Antony J, Zarin W, Strifler L, Ghassemi M, Ivory J, et al. A scoping review of rapid review methods. BMC medicine. 2015;13(1):224.
- Kollock R, Van Lunen BL, Ringleb SI, Oñate JA. Measures of functional performance and their association with hip and thigh strength. Journal of athletic training. 2015;50(1):14-22.
- Barber-Westin SD, Noyes FR. Effect of fatigue protocols on lower limb neuromuscular function and implications for anterior cruciate ligament injury prevention training: a systematic review. The American journal of sports medicine. 2017;45(14):3388-96.
- Shultz SJ, Schmitz RJ, Benjaminse A, Collins M, Ford K, Kulas AS. ACL Research Retreat VII: an update on anterior cruciate ligament injury risk factor identification, screening, and prevention: March 19–21, 2015; Greensboro, NC. Journal of athletic training. 2015;50(10):1076-93.
- O’Connor KM, Johnson C, Benson LC. The effect of isolated hamstrings fatigue on landing and cutting mechanics. Journal of applied biomechanics. 2015;31(4):211-20.
- Jo Y-J, Kim Y-K. Different types of shoulder injuries of throwing and resistance training groups. The Official Journal of the Korean Academy of Kinesiology. 2016;18(3):73-83.
- Wilson LM, Greig M. The efficacy of functional supports in mediating the effects of exercise on shoulder joint position sense. Isokinetics and Exercise Science. 2017;25(2):127-34.
- Bossuyt FM, García-Pinillos F, Azidin RR, Vanrenterghem J, Robinson MA. The utility of a high-intensity exercise protocol to prospectively assess acl injury risk. International journal of sports medicine. 2016;37(02):125-33.
- Daly AC, Critchley SE, Rencsok EM, Kelly DJ. A comparison of different bioinks for 3D bioprinting of fibrocartilage and hyaline cartilage. Biofabrication. 2016;8(4):045002.
- Alhajaya M. Effects of proprioception training on knee joint position sense in male soccer athletes. J Sociol Res. 2015;6.
- Salgado E, Ribeiro F, Oliveira J. Joint-position sense is altered by football pre-participation warm-up exercise and match induced fatigue. The Knee. 2015;22(3):243-8.
- Relph N, Herrington L. The effects of knee direction, physical activity and age on knee joint position sense. The Knee. 2016;23(3):393-8.
- Romero-Franco N, Jiménez-Reyes P. Effects of warm-up and fatigue on knee joint position sense and jump performance. Journal of motor behavior. 2017;49(2):117.
The Ziauddin University is on the list of I4OA (https://i4oa.org/) & I4OC (https://i4oc.org/).
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0). https://creativecommons.org/licenses/by/4.0/
Conflict of Interest: The author (s) have no conflict.
[i] Assistant Professor/Consultant Physical Therapist, College Of Rehabilitation Sciences BAMDC, Multan
[ii] Assistant Professor College Of Rehabilitation Sciences BAMDC, Multan (0000-0002-2450-7186)
[iii] Professor/Dean Lahore College Of Physical Therapy LM&DC, Lahore (0000-0002-2039-7119)
[iv] Associate Professor/Principal College Of Rehabilitation Sciences BAMDC, Multan (0000-0003-1192-4842)