Type of Article:  Original Research

Volume 11; Issue 5 (October 2023)

Page No.: 4628-4641

DOI: https://dx.doi.org/10.16965/ijpr.2023.153

A Systematic Review on Comparison between Otago Exercise Program and Balance Exercise in Balance and Fall Risk among elderly with Knee Osteoarthritis

Divya N *1, Praveena Shri P 2, Saipriyaa M 3, Meyammai S 4, Winnie T E 5, Pavithra R 6.

1 Assistant professor, Faculty of Physiotherapy, MAHER, Chennai, Tamilnadu, India. ORCiD: 0000-0002-5620-6820

2,3,4,5,6 Under graduate students, Faculty of Physiotherapy, MAHER, Chennai, Tamilnadu, India.

Corresponding Author: Divya N, 12, Vembuliamman koil street, West KK nagar, Tamilnadu, Chennai 600078. Contact number: +91 9543441934 E-Mail:  divyananda3897@gmail.com


Background: Patients with knee osteoarthritis have balance issues and an increased fall risk; nevertheless, it is unclear whether the Otago exercise programme (OEP) or balance exercise will improve balance and reduce fall risk among individuals with knee osteoarthritis. Therefore, there is a need to compare the effectiveness of these exercises in treating knee osteoarthritis. This review aims to investigate the effects of an OEP and balance exercise programme to improve balance and reduce fall risk among the elderly population with knee osteoarthritis (OA).

Methodology: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were used to conduct this systematic review. Four databases (PubMed, Cochrane central register of controlled trails (CENTRAL), Physiotherapy Evidence Database (PEDro), and Science Direct) were searched until September 2022 using predefined terms by two independent reviewers. The methodological quality of the studies was assessed using PEDro. All literature published from each source was selected according to the inclusion and exclusion criteria, and data extraction was performed independently with the outcomes of the Berg balance scale (BBS), time up and go test (TUG), chair stand test (CST), and short falls efficacy scale (SFES I).

RESULT: The literature review studied seven full-text articles that met the selection criteria and PRISMA guidelines. Those articles were reviewed by grouping them into five different sub-groups based on the interventions. The quality of studies ranged from good (5 studies) to fair (2 studies). The improvement in balance and fall risk prevention following OEP and balance training showed mixed results, and the findings from this review may form the basis for a future systematic research program.

CONCLUSION:  It is difficult to conclude clear evidence-based recommendations for Otago exercise programmes and balance exercises in improving balance and reducing fall risk among the elderly population with knee OA due to limited availability and weak evidence.

KEYWORDS: Fall risk, community dwelling older adults, elderly population, knee osteoarthritis.


[1]. Manlapaz DG, Sole G, Jayakaran P, Chapple CM. Risk Factors for Falls in Adults with Knee Osteoarthritis: A Systematic Review. Vol. 11, PM and R. John Wiley and Sons Inc.; 2019. p. 745–57. https://doi.org/10.1002/pmrj.12066.
[2]. Vennu V, Bindawas SM. Relationship between falls, knee osteoarthritis, and health-related quality of life: Data from the osteoarthritis initiative study. Clin Interv Aging. 2014;9:793–800. https://doi.org/10.2147/cia.s62207.
[3]. Affiliations MM, Higson – E, Pearson – M, Mansfield M, Development Physiotherapist E, Thomas S. International Journal of Rheumatic Diseases Title Page Informative Title: Is there an increased risk of falls and fractures in people with early diagnosed hip and knee osteoarthritis? Data from the Osteoarthritis Initiative. Concise Title: Falls and fractures in early osteoarthritis. https://doi.org/10.1111/1756-185X.12871.
[4]. Taglietti M, dela Bela LF, Dias JM, Pelegrinelli ARM, Nogueira JF, Batista Júnior JP, et al. Postural Sway, Balance Confidence, and Fear of Falling in Women With Knee Osteoarthritis in Comparison to Matched Controls. PM and R. 2017;9(8):774–80. https://doi.org/10.1016/j.pmrj.2016.11.003.
[5]. Sánchez-Herán Á, Agudo-Carmona D, Ferrer-Peña R, López-de-Uralde-Villanueva I, Gil-Martínez A, Paris-Alemany A, et al. Postural Stability in Osteoarthritis of the Knee and Hip: Analysis of Association With Pain Catastrophizing and Fear-Avoidance Beliefs. PM and R. 2016;8(7):618–28. https://doi.org/10.1016/j.pmrj.2015.11.002.
[6]. 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;29–30. https://doi.org/10.1016%2Fj.eclinm.2020.100587.
[7]. Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, et al. The global burden of hip and knee osteoarthritis: Estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(7):1323–30. https://doi.org/10.1136/annrheumdis-2013-204763.
[8]. Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian J Orthop. 2016;50(5):518–22. https://doi.org/10.4103%2F0019-5413.189608.
[9]. Diracoglu D, Aydin R, Baskent A, Celik A. Effects of kinesthesia and balance exercises in knee osteoarthritis. J Clin Rheumatol. 2005;11(6):303–10. https://doi.org/10.1097/01.rhu.0000191213.37853.3d.
[10]. Dadgari A, Hamid TA, Hakim MN, Chaman R, Mousavi SA, Hin LP, et al. Randomized control trials on Otago Exercise Program (OEP) to reduce falls among elderly community dwellers in Shahroud, Iran. Iran Red Crescent Med J. 2016;18(5). https://doi.org/10.5812%2Fircmj.26340
[11]. El-Khoury F, Cassou B, Charles MA, Dargent-Molina P. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: Systematic review and meta-analysis of randomised controlled trials. BMJ (Online). 2013;347. https://doi.org/10.1136/bmj.f6234.
[12]. Levinger P, Dunn J, Bifera N, Butson M, Elias G, Hill KD. High-speed resistance training and balance training for people with knee osteoarthritis to reduce falls risk: Study protocol for a pilot randomized controlled trial. Trials.;18(1). https://doi.org/10.1186/s13063-017-2129-7.
[13]. Davis JC, Liang Hsu C, Cheung W, Brasher PMA, Li LC, Khan KM, et al. Can the Otago falls prevention program be delivered by video? A feasibility study. Available from: http://dx.doi.org/10.1136/bmjsem-2015-000059.
[14]. Martins AC, Santos C, Silva C, Baltazar D, Moreira J, Tavares N. Does modified Otago Exercise Program improves balance in older people? A systematic review. Vol. 11, Preventive Medicine Reports. Elsevier Inc.; 2018. p. 231–9. https://doi.org/10.1016/j.pmedr.2018.06.015.
[15]. Thomas S, Mackintosh S, Halbert J. Does the “Otago exercise programme” reduce mortality and falls in older adults?: A systematic review and meta-analysis. Vol. 39, Age and Ageing. 2010. p. 681–7. https://doi.org/10.1093/ageing/afq102.
[16]. Ory MG, Obradovic B, Gardasevic J, Zhang Jiong Luo T, Copyright fpubh, Yang Y, et al. OPEN ACCESS EDITED BY The impact of Otago exercise programme on the prevention of falls in older adult: A systematic review. https://doi.org/10.3389/fpubh.2022.953593.
[17]. Liu-Ambrose T, Donaldson MG, Ahamed Y, Graf P, Cook WL, Close J, et al. Otago home-based strength and balance retraining improves executive functioning in older fallers: A randomized controlled trial. J Am Geriatr Soc. 2008;56(10):1821–30. https://doi.org/10.1111/j.1532-5415.2008.01931.x.
[18]. Rogers MW, Tamulevicius N, Semple SJ, Krkeljas Z. Efficacy of home-based kinesthesia, balance & agility exercise training among persons with symptomatic knee osteoarthritis [Internet]. Available from: http://www.jssm.org.
[19]. Kennedy DM, Stratford PW, Wessel J, Gollish JD, Penney D. Assessing stability and change of four performance measures: A longitudinal study evaluating outcome following total hip and knee arthroplasty. BMC Musculoskelet Disord. 2005;6. https://doi.org/10.1186/1471-2474-6-3.
[20]. Zasadzka E, Borowicz AM, Roszak M, Pawlaczyk M. Assessment of the risk of falling with the use of timed up and go test in the elderly with lower extremity osteoarthritis. Clin Interv Aging. 2015;10:1289–98. https://doi.org/10.2147/cia.s86001.
[21]. Khalaj N, Osman NAA, Mokhtar AH, Mehdikhani M, Abas WABW. Balance and risk of fall in individuals with bilateral mild and moderate knee osteoarthritis. PLoS One. 2014;9(3). https://doi.org/10.1371%2Fjournal.pone.0092270.
[22]. Sabirli F, Paker N, Bugdayci D. The relationship between Knee Injury and Osteoarthritis Outcome Score (KOOS) and Timed Up and Go test in patients with symptomatic knee osteoarthritis. Rheumatol Int. 2013;33(10):2691–4. https://doi.org/10.1007/s00296-012-2512-3.
[23]. Hatfield G, Hammond C, Hunt MA. Clinical tests of balance in the knee osteoarthritis population: A systematic review. Osteoarthritis Cartilage. 2015;23:A374. https://doi.org/10.2522/ptj.20150025.
[24]. Segal NA, Boyer ER, Wallace R, Torner JC, Yack HJ. Association between chair stand strategy and mobility limitations in older adults with symptomatic knee osteoarthritis. Arch Phys Med Rehabil. 2013;94(2):375–83. https://doi.org/10.1016/j.apmr.2012.09.026.
[25]. Kempen GIJM, Yardley L, van Haastregt JCM, Zijlstra GAR, Beyer N, Hauer K, et al. The Short FES-I: A shortened version of the falls efficacy scale-international to assess fear of falling. Age Ageing. 2008;37(1):45–50. https://doi.org/10.1093/ageing/afm157.
[26]. Zahran DAE, Bahr WM, Abd Elazim FH. Systematic review: exercise training for equinus deformity in children with cerebral palsy. BFPT .2022;27(1). https://doi.org/10.1186/s43161-022-00093-9.
[27]. De Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust. J. Physiother. 2009;55(2):129-33. https://doi.org/10.1016/s0004-9514(09)70043-1
[28]. Mat S, Ng CT, Tan PJ, Ramli N, Fadzli F, Rozalli FI, et al. Effect of Modified Otago Exercises on Postural Balance, Fear of Falling, and Fall Risk in Older Fallers With Knee Osteoarthritis and Impaired Gait and Balance: A Secondary Analysis. PM and R. 2018;10(3):254–62. https://doi.org/10.1016/j.pmrj.2017.08.405.
[29]. Mohan Ra RD o, Methe AD, Patil H. Effect of Otago Exercise versus Dual Task Net Step Exercise on Balance and Functional Mobility in Community Dwelling Elderly Person with Knee Osteoarthritis – A Randomised Control Trial. Int J Health Sci Res. 2021;11(7):179–87. https://doi.org/10.52403/ijhsr.20210726.
[30]. Katre KA, Pushparaj V, Paul J. EFFECT OF OTAGO EXERCISE PROGRAM (OEP) AND STRENGTH TRAINING PROGRAM (STP) ON LEG STRENGTH AND RISK OF FALL AMONG BILATERAL KNEE OSTEOARTHRITIS PATIENTS. International Journal of Medical and Exercise Science [Internet]. 2019;5(1):536–51. Available from: www.ijmaes.org. https://doi.org/10.36678/ijmaes.2019.v05i01.004.
[31]. Elsheikh MMA, El-Hawa MAA, El-saadany HM, Elsergany MAES. The Effect of Balance Training in Knee Osteoarthritis. J Adv Med Med Res. 2020;246–55. https://doi.org/10.9734/jammr/2020/v32i2430775.
[32]. Jahanjoo F, Eftekharsadat B, Bihamta A, Babaei-Ghazani A. Efficacy of balance training in combination with physical therapy in rehabilitation of knee osteoarthritis: A randomized clinical trial. Crescent J Med Biol Sci. 2019;6:225-334.
[33]. Pazit L, Jeremy D, Nancy B, Michael B, George E, Hill KD. Safety and feasibility of high speed resistance training with and without balance exercises for knee osteoarthritis: A pilot randomised controlled trial. Phys Ther Sport. 2018;34:154–63. https://doi.org/10.1016/j.ptsp.2018.10.001.
[34]. Uzunkulaoğlu A, Kerim D, Ay S, Ergin S. Effects of single-task versus dual-task training on balance performance in elderly patients with knee osteoarthritis. Arch Rheumatol. 2020;35(1):35–40. https://doi.org/10.5606%2FArchRheumatol.2020.7174.
[35]. Ng CT, Tan MP. Osteoarthritis and falls in the older person. Vol. 42, Age and Ageing. 2013. p. 561–6. https://doi.org/10.1093/ageing/aft070.
[36]. Tsonga T, Michalopoulou M, Malliou P, Godolias G, Kapetanakis S, Gkasdaris G, et al. Analyzing the history of falls in patients with severe knee osteoarthritis. CiOS Clinics in Orthopedic Surgery. 2015;7(4):449–56. https://doi.org/10.4055/cios.2015.7.4.449.
[37]. Smith TO, Higson E, Pearson M, Mansfield M. Is there an increased risk of falls and fractures in people with early diagnosed hip and knee osteoarthritis? Data from the Osteoarthritis Initiative [Internet]. 2016. Available from: www.oai.ucsf.edu/. https://doi.org/10.1111/1756-185x.12871.
[38]. Deng Z han, Xu J, Long L jue, Chen F, Chen K, Lu W, et al. Association between hip and knee osteoarthritis with falls: A systematic review and meta-analysis. Int J Clin Pract. 2021;75(10). https://doi.org/10.1111/ijcp.14537.
[39]. Park SK, Kobsar D, Ferber R. Relationship between lower limb muscle strength, self-reported pain and function, and frontal plane gait kinematics in knee osteoarthritis. Clinical Biomechanics. 2016;38:68–74. https://doi.org/10.1016/j.clinbiomech.2016.08.009.
[40]. de Zwart AH, van der Esch M, Pijnappels MAGM, Hoozemans MJM, van der Leeden M, Roorda LD, et al. Falls associated with muscle strength in patients with knee osteoarthritis and self-reported knee instability. Journal of Rheumatology. 2015;42(7):1218–23. https://doi.org/10.3899/jrheum.140517.
[41]. Pirayeh N, Kazemi K, Rahimi F, Mostafaee N, Shaterzadeh-Yazdi MJ. The Effect of Balance Training on Functional Outcomes in Patients with Knee Osteoarthritis: A Systematic Review. Med J Islam Repub Iran. 2022;36(1). https://doi.org/10.47176%2Fmjiri.36.107.
[42]. Hatfield GL, Morrison A, Wenman M, Hammond CA, Hunt MA. Clinical Tests of Standing Balance in the Knee Osteoarthritis Population: Systematic Review and Meta-analysis [Internet]. 2016. Available from: https://academic.oup.com/ptj/article/96/3/324/2686535.
[43]. Anderson ML, Allen KD, Golightly YM, Arbeeva LS, Goode A, Huffman KM, et al. Fall Risk and Utilization of Balance Training for Adults with Symptomatic Knee Osteoarthritis: Secondary Analysis from a Randomized Clinical Trial. J Geriatr Phys Ther.2019;42(2):E39–44. https://doi.org/10.1519/jpt.0000000000000213.
[44]. Sanchez-Ramirez DC, van der Leeden M, Knol DL, van der Esch M, Roorda LD, Verschueren S, et al. Association of postural control with muscle strength, proprioception, self-reported knee instability and activity limitations in patients with knee osteoarthritis. J Rehabil Med. 2013;45(2):192–7. https://doi.org/10.2340/16501977-1087.
[45]. Ojoawo AO, Olaogun MOB, Hassan MA. Comparative effects of proprioceptive and isometric exercises on pain intensity and difficulty in patients with knee osteoarthritis: A randomised control study. Technology and Health Care. 2016;24(6):853–63. https://doi.org/10.3233/thc-161234.
[46]. Labanca L, Barone G, Zaffagnini S, Bragonzoni L, Benedetti MG. Postural stability and proprioception abnormalities in patients with knee osteoarthritis. Applied Sciences (Switzerland). 2021;11(4):1–12. https://doi.org/10.3390/app11041469.
[47]. Adhama AI, Akindele MO, Ibrahim AA. Effects of variable frequencies of kinesthesia, balance and agility exercise program in adults with knee osteoarthritis: study protocol for a randomized controlled trial. Trials. 2021;22(1). https://doi.org/10.1186/s13063-021-05386-3.
[48]. Chiu HL, Yeh TT, Lo YT, Liang PJ, Lee SC. The effects of the Otago Exercise Programme on actual and perceived balance in older adults: A meta-analysis. PLoS One. 2021;16(8 August). https://doi.org/10.1371/journal.pone.0255780.
[49]. Xie C, Wang W, Pei J, Wang H, Lv H. Effect of otago exercise on falls in patients with osteoarthritis A protocol for systematic review and meta-analysis. 2020; Available from: www.md-journal.com
[50]. Chhabr HK, Sathya P. Effect of conventional exercises with balance training &only conventional exercises in patients with osteoarthritis of knee. Int J Innov Res Sci Eng. 2015;4(7):5048-6. DOI:10.15680/IJIRSET.2015.0407003.

Cite this article: Divya N, Praveena Shri P, Saipriyaa M, Meyammai S, Winnie T E, Pavithra R. A Systematic Review on Comparison between Otago Exercise Program and Balance Exercise in Balance and Fall Risk among elderly with Knee Osteoarthritis. Int J Physiother Res 2023;11(5):4628-4641. DOI: 10.16965/ijpr.2023.153