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Table of Contents
Year : 2019  |  Volume : 1  |  Issue : 2  |  Page : 93-99

Effect of retro-walking on treadmill on hamstring flexibility, gait, kinesiophobia, and psychometry in individuals with chronic knee osteoarthritis

Department of Orthopedic Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission22-Apr-2019
Date of Decision28-May-2019
Date of Acceptance17-Aug-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Dr. Peeyoosha Gurudut
Department of Orthopedic Physiotherapy, KAHER Institute of Physiotherapy, Nehru Nagar, Belagavi - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_29_19

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Background and Objective: The purpose of the study was to evaluate and compare the immediate- and short-term (five sessions) effects of retro-walking (RW) on treadmill along with conventional treatment and conventional treatment alone on hamstring flexibility, gait velocity, cadence, kinesiophobia, and psychometry in individuals with chronic knee osteoarthritis (OA).
Materials and Methods: The present study was a randomized controlled trial. Twenty-eight individuals clinically diagnosed with Grade 2 or 3 knee OA between the age group of 40 and 70 years participated in the study. The individuals were randomly allocated to two study groups. Control group received conventional treatment of transcutaneous electrical nerve stimulation (TENS) and exercises, whereas experimental group received RW on treadmill along with TENS and exercises for five sessions. Outcome measures were assessed using popliteal angle measurement, walking velocity, cadence, Tampa Scale for Kinesiophobia 11, and Self-efficacy for Managing Chronic Disease 6-item scale.
Results: Between-group analysis showed that RW was superior to control group (P < 0.005) in terms of improvement in walking velocity, cadence, and reduction in kinesiophobia in individuals with chronic knee OA. However, immediate effect was statistically significantly better in RW group only in terms of walking velocity (P < 0.005).
Conclusion: The RW group demonstrated to be more effective than conventional physiotherapy group on walking velocity, cadence, and kinesiophobia. Hence, RW may be considered as part of the treatment protocol of OA knee patients with mild-to-moderate degenerative changes.

Keywords: Backward walking, Degenerative joint diseases, Gait, Kinesiophobia, Knee, Muscle imbalance

How to cite this article:
Gurudut P, Patel R, Mukkannavar P, Vira P. Effect of retro-walking on treadmill on hamstring flexibility, gait, kinesiophobia, and psychometry in individuals with chronic knee osteoarthritis. Indian J Phys Ther Res 2019;1:93-9

How to cite this URL:
Gurudut P, Patel R, Mukkannavar P, Vira P. Effect of retro-walking on treadmill on hamstring flexibility, gait, kinesiophobia, and psychometry in individuals with chronic knee osteoarthritis. Indian J Phys Ther Res [serial online] 2019 [cited 2023 Oct 1];1:93-9. Available from: https://www.ijptr.org/text.asp?2019/1/2/93/273719

  Introduction Top

Osteoarthritis (OA) is a chronic degenerative joint condition with symptoms such as pain, stiffness, decreased range of motion, and muscle weakness associated with wear and tear of articular cartilage as the age progresses. This disease in knee joint can limit activities such as stair ascend or descend, rising from sitting, and walking, leading to dependency in activities of daily living.[1],[2]

OA has a prevalence of 22%–39% in India, with estimated incidence to be around 18/1000, and is projected as the 10th leading cause of nonfatal burden in the society. One-third of the total population who are older than 65 years have some kind of knee pathology. Studies show it as a major mobility impairment affecting women more in comparison to men.[3],[4] Epidemiological studies have highlighted several reasons that predispose knee to arthritic changes that include hypovitaminosis,[5] higher body mass index levels, genetic predisposition, and overuse of knee, which may further alter the biomechanics of knee joint.[6]

Disuse atrophy of quadriceps muscle leads to muscle imbalance around the knee joint, which often causes hamstring muscle tightness in the bargain to compensate for weaker antagonist muscle, eventually contributing to knee extension lag, thus affecting full range of motion of knee and altered gait mechanics.[7],[8] Further, greater adduction moment increases load on the medial compartment of knee joint and aggravates pain. The gradual limitation of activity progresses the degeneration to a stage of deformity.[9] The associated stress on the degenerated knee joint increases pain and psychological disability. This psychological disability further limits joint motion and leads to pain-related fear of movement i.e., kinesiophobia in patients with OA of knee.[10]

The conventional method of treating OA knee includes application of physical agents such as transcutaneous electrical nerve stimulation (TENS) and short wave diathermy. A randomized controlled trial reported increase in volitional activation of weak musculatures through TENS.[11] The exercises administered in closed kinematic chain improve proprioception and aid in gaining strength to carry out movements. On the other hand, nonweight-bearing exercises have exhibited to improve altered gait mechanisms. Investigators of previous studies have concluded that both weight-bearing exercises and nonweight-bearing exercises increase strength and decrease kinesiophobia in participants with knee OA.[12]

Literature suggests improved oxygen consumption and heart rate with 10% inclination,[13] improved lower-limb strength and athletic performance,[14] increased hamstring flexibility [15] and faster walking velocity, and increased cadence [13] with retro-walking (RW) in normal healthy individuals or athletic population. Past experimental studies have concluded that RW has an advantage over forward walking (FW) as it requires limited range of motion and reduced hip flexion moment, thereby reducing abnormal loading at the knee joint.[16],[17]

In a previous study, RW was given for 3 weeks along with conventional physiotherapy and was compared with conventional physiotherapy alone in terms of subjective measures such as pain and disability in OA knee patients. The authors concluded that RW was better than only conventional physiotherapy.[16] Another study showed that RW was better than the conventional treatment only in decreasing disability.[18] The contradictory results of the two studies indicated a controversy as to whether RW is more beneficial than conventional therapy alone. Further, there remains a gap in literature to evaluate the immediate- and short-term effects of RW in terms of objective measures such as hamstring flexibility and gait velocity in chronic OA of knee. The effect of RW has also not been studied for kinesiophobia and self-efficacy in individuals with chronic knee OA.

Hence, the present study aimed to evaluate and compare the immediate- and short-term effects of RW on treadmill along with conventional treatment and conventional treatment alone on hamstring flexibility, gait velocity, cadence, kinesiophobia, and psychometric affection in individuals with chronic knee OA.

  Materials and Methods Top

Study design and setting

It was a double-blinded randomized controlled trial, wherein both the assessor and the treating physiotherapist were blinded to the patient allocation. The study was conducted at the physiotherapy outpatient department of a tertiary care center and an old-age home, India. Ethical approval was obtained from the institutional ethical committee (KIPT/No: 239/29.10.2018), and written informed consents were obtained from all the study participants. The physical fitness of the participants was assessed by the physician before participation to exclude any comorbid conditions. In addition, the vital parameters such as respiratory rate, pulse rate, and blood pressure of the participants were assessed before and after the RW.


Individuals who were clinically and radiologically diagnosed with OA knee were recruited and further assessed for eligibility for inclusion and exclusion criteria. The individuals were included if they met the following criteria: individuals fulfilling the following clinical criteria listed by the American College of Rheumatology: knee pain and any three out of the following six criteria (age >50 years; morning stiffness lasting <30 min; crepitus on active motion; bony tenderness; bony enlargement; and no warmth on touch [19]); individuals on Grade 2 and 3 as per Kellgren and Lawrence scale;[20] individuals with knee pain for >6 weeks; individuals not doing exercises such as jogging, walking, and running for >1 month; and individuals willing to participate and take treatment for five sessions. Individuals were excluded from the study if they were having any underlying pathology, recent surgeries, trauma or fractures of the lower limb; with other medical condition that does not allow them to participate in the study; known cases of severe osteoporosis; with any neurological disorder including balance issues and motor and sensory loss; taking intra-articular injection for knee for the last 6 months; and those having visual dysfunction or refractory errors not corrected with glasses or contact lenses.

The sample size was calculated as per the prevalence with the anticipated mean ± standard deviation of knee pain score between conventional treatment and RW group.[18] At 5% significance level, 90% power of the study, and considering 5% dropout rate, the sample size was calculated as 28 (14 per group).


The random allocation of participants was done using chit method by a researcher who was not involved with assessment or treatment. The participants picked up any one chit labeled as Group 1 (control) or Group 2 (experimental). Following this, they were assigned to either control or experimental groups. Participants were divided into two study groups: control group was given conventional treatment (TENS + exercises) and the experimental group was given RW with conventional treatment (RW + TENS + exercises) [Figure 1].
Figure 1: CONSORT chart

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Outcome measure assessment

Popliteal angle measurement

The participants were positioned in supine lying with hip flexed to 90° and then actively extended the knee. The pivot of goniometer was placed over the lateral condyle of the knee joint and the popliteal angle was measured in terms of degrees. This test aids as an objective and reliable tool for measuring hamstring muscle tightness.[21]

Walking velocity

The walking velocity was calculated using the following formula: total distance per unit of time in meters per second. The participants were asked to walk a 10-m path, and the time taken to complete the path was recorded.[22],[23]


The number of steps walked by the participant in 1 min was noted.[22],[23]

Tampa Scale for Kinesiophobia 11

It is a subjective measure which has 11 items, and each item is coded on a 4-point Likert scale, ranging from 1 indicating strongly disagree and 4 indicating strongly agree. The total score varied between 11 and 44, with the highest score indicating higher level of fear of movement. This was recorded pre- and postintervention.[24]

Self-efficacy for Managing Chronic Disease: A 6-item scale

This scale is a subjective measure that consists of six items with a 10-step Likert scale which ranges from 1 indicating not at all confident to 10 indicating totally confident. Significant ranges from 1 to 10 with higher values signified high self-efficacy.[25]


Control group (n = 14)

Conventional/low TENS (Technomed electronics, Chennai, Tamil Nadu, India) was applied for the duration of 20 min with the frequency of 80–120 Hz and pulse duration of 150 μs.[26] The participants were positioned in supine lying. Four electrodes with two channels were applied over the painful knee region. Two electrodes from channel 1 were placed inferiorly and superiorly on the medial aspect of the knee. Two electrodes from channel 2 were placed inferiorly and superiorly on the lateral aspect of the affected knee with the intensity as tolerated by the participant. Exercises such as static quads, dynamic quads, knee bending, hip extension, and hip abduction were administered following TENS.[18] Each exercise was given for three sets with ten repetitions. Each treatment session was administered for 45 min for five sessions.

Experimental group (n = 14)

Participants in the experimental group received RW on treadmill along with conventional treatment of TENS and exercises as described above for the control group.

Retro-walking protocol

Day 0: One practice session was given to adapt skill as well as to choose a preferred walking speed for 5 min.

Days 1–5:

  • Backward walking on treadmill with 0% inclination for initial 3 min
  • Increase the speed to accepted level and continue with the same speed at 0% inclination for 5 min
  • For the next 5 min, continue walking with the same speed, but add 10% inclination
  • For the last 2 min, decrease the inclination to 0% while gradually decreasing the speed till the treadmill stops [Figure 2].
Figure 2: Study participants performing retrowalking on treadmill

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Statistical analysis

Statistical analysis of the present study was done using SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY: USA). so as to verify the results obtained. Comparison of within-group changes, i.e., preintervention changes and postintervention changes on day 1 and day 5, was made using Wilcoxon signed-rank test or paired t-test for all the outcome measures. The between-group comparison for all the outcome measures was done using unpaired t-test or Mann–Whitney U-test on the basis of normal distribution.

  Results Top

[Table 1] summarizes the general characteristics of all the study participants.
Table 1: Analysis of demographic data

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Both control and experimental groups showed statistically significant improvement (P < 0.05) on hamstring flexibility, cadence, kinesiophobia, and self-efficacy measure when preinterventional scores were compared to the scores of immediate postintervention on day 1 and on day 5 postintervention except for walking velocity which improved only at day 5 postintervention [Table 2] and [Table 3].
Table 2: Pre - post comparison of variables for control group#

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Table 3: Pre - post comparison of variables for retro-walking group#

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RW group showed statistically significant improvement for walking velocity (P = 0.023), cadence (P = 0.04), and kinesiophobia (P = 0.019) as compared to control group, indicating that participants in RW group were able to walk faster and cover more steps in a minute and have reduced fear of movement than those in the control group. Further, no statistically significant difference was noted in hamstring flexibility (P = 0.637) and self-efficacy measure (P = 0.571) on day 5 postintervention [Table 4].
Table 4: Comparison between the study groups for outcome variables#

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The results indicate that RW group is more effective in treating patients with chronic knee OA in terms of improvement in walking velocity, cadence, and kinesiophobia, although no difference was noted in hamstring flexibility and self-efficacy measure.

  Discussion Top

The present controlled trial was conducted to compare the effect of RW on treadmill on hamstring flexibility, gait, kinesiophobia, and psychometric affection in participants with chronic knee OA. RW group demonstrated to be better effective than conventional physiotherapy group on walking velocity, cadence, and kinesiophobia.

RW or backward walking is a relatively new concept in physiotherapy and rehabilitation. A systematic review concluded that RW improves cardiorespiratory fitness in injured athletes by decreasing joint compressive forces and increasing muscle strength. RW has shown positive results in patient population with patellofemoral pain and anterior cruciate ligament injury rehabilitation. It has also shown to increase balance and improve gait in patients with stroke, cerebral palsy, and  Parkinsonism More Details.[13] RW has been useful in treating knee OA by decreasing pain and functional disabilities.[16]

The improvement in walking velocity and cadence with RW achieved in the present study may be explained highlighting the biomechanical factors. RW differs from FW by the fact that during RW, there is concentric contraction of quadriceps and eccentric contraction of hamstrings.[27] Further, in the early stance phase of gait cycle during RW, there is activation of knee extensors and ankle plantar flexors.[28],[29] This reduces hip and knee flexion in the initial contact of the stance phase of the gait cycle, thereby nullifying the ground reaction forces acting on the knee joint, causing reduced load on the patellofemoral joint. Backward walking also reduces added adductor moment at knee joint, thereby decreasing the impact of compressive forces on the medial part of knee joint.[18]

Similar results were noted in a study conducted on normal healthy individuals where RW on an increased slope was compared with FW. The author concluded that RW was associated with increased gait speed and increased stride length.[30] RW along with conventional physiotherapy was better than only conventional physiotherapy for pain and disability in OA knee patients.[31] Contrary to the present findings, RW along with conventional physiotherapy only reduced disability. Further, the authors mentioned that pain was reduced due to the application of superficial heating modality.[18]

Improvement in kinesiophobia in the present study may be associated with improvement noted in walking velocity and cadence.[32] This can also be explained by reduced pain which may have an effect on reduced level of anxiety and fear-avoidance beliefs.[31],[33] RW has demonstrated to be one of the safe and effective closed chain exercises which reduces symptoms, improves muscle strength, improves functional mobility, and overcomes physical dysfunction.[34]

Further, the results of the present study demonstrated both RW with conventional physiotherapy and only conventional physiotherapy study groups to be equally effective in improving hamstring flexibility and self-efficacy measure. Findings of the present study on hamstring flexibility show contradicting results to that of previous studies. Literature search suggests that hamstring flexibility improves with RW among normal individuals.[15],[35] However, previous study which assessed effect of RW on hamstring flexibility among healthy individuals had no control or comparative group. Findings of one comparative study between static hamstring stretching and RW revealed that static stretching was better than RW in improving hamstring flexibility.[36] This indifference between the two study groups in the present study can be attributed to the fact that both the groups were given certain exercises. During exercises such as static and dynamic quadriceps sets, according to the rule of reciprocal inhibition, when agonist (quadriceps) contracts, the antagonist (hamstring) must lengthen or relax.

Self-efficacy is a subjective measure that assesses the confidence a person has in the ability to perform a specific task. Previous studies that have administered RW as intervention have shown improvement in the knee functional measure.[16],[18] However, their intervention lasted for 6 weeks and more. The present study included only five sessions of intervention, with both study groups being equally effective.

The present study had a few limitations. Gait parameters other than walking velocity and cadence were not measured due to unavailability of sophisticated equipment. The improvement of strength was not assessed due to the short duration of intervention. The participants were not followed up prospectively to understand the carryover effects of retro-walking training.

Future scope of the study may include studies with longer duration of treatment with prospective follow-up of patients to understand carryover effects. A control group with no exercise prescription may be considered. Comparative studies between FW and backward walking on various kinetic and kinematic gait parameters in different patient population may also be considered.

  Conclusion Top

It can be concluded that five sessions of RW intervention with conventional physiotherapy demonstrated to be superior and beneficial over conventional physiotherapy alone on walking velocity, cadence, and kinesiophobia. RW is a simple closed chain exercise that should be included in the rehabilitation of chronic knee OA of initial stage. It significantly improves gait parameters and reduces kinesiophobia in addition to reducing symptoms and improving functions.


We are grateful to the study participants for consenting to participate in the study. We are also thankful to our institute for allowing us to use the infrastructure and resources to carry out the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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