Authors:

Bo Young Hong, MD, PhD

Seong Hoon Lim, MD Osteoarthritis
Soo Ah Im, MD
Jong In Lee, MD, PhD

Affiliations:
From the Department of Rehabilitation
Medicine, St. Vincent’s Hospital,
College of Medicine (BYH, SHL),
the Department of Radiology,
Seoul St. Mary’s Hospital, College
of Medicine (SAI), and the Department
of Rehabilitation Medicine, Seoul St.
Mary’s Hospital, College of Medicine
(JIL), The Catholic University of Korea,
Seoul, Korea.
Correspondence:
All correspondence and requests for
reprints should be addressed to:
Jong In Lee, MD, PhD, Department of
Rehabilitation Medicine, Seoul St.
Mary’s Hospital, College of Medicine,
The Catholic University of Korea,
505 Banpo-dong, Seocho-ku, Seoul,
Korea 137-040.
Disclosures:
Financial disclosure statements have
been obtained, and no conflicts of
interest have been reported by the
authors or by any individuals in
control of the content of this article.
Supported by the Catholic Medical
Center Research Foundation in 2009.
0894-9115/13/9201-0045/0
American Journal of Physical
Medicine & Rehabilitation
Copyright * 2012 by Lippincott
Williams & Wilkins
DOI: 10.1097/PHM.0b013e318269d78f
ORIGINAL RESEARCH ARTICLE
Effects of Acute Joint Effusion on
Balance in Patients with
Knee Osteoarthritis
ABSTRACT
Hong BY, Lim SH, Im SA, Lee JI: Effects of acute joint effusion on balance in
patients with knee osteoarthritis. Am J Phys Med Rehabil 2013;92:45Y52.
Objectives: The purpose of this study was to assess the effects of acute joint
effusion on balance in patients with knee osteoarthritis.
Design: Forty-four female subjects with painful knee osteoarthritis participated
in this single-blind, randomized, controlled clinical trial. All subjects were randomly
assigned to either the injection or the control group. A volume of 20 ml of normal
saline was injected into the knee joint cavity of the test subjects, who performed
static and dynamic balance tests twice before and after joint infusion. The subjects
in the control group performed the same tests without joint infusion. The outcome
variables for static measurement were the mean speeds (millimeter per second) of
the movement of the center of pressure in the mediolateral and anteroposterior
directions and the mean velocity moment (square millimeter per second) with
both eyes opened and eyes closed conditions. For dynamic measurement, time
(second) and distance (millimeter) of the center of pressure were used.
Results: Significant interaction of the balance-test variables (mean speeds,
velocity moment, time, and distance) between the groups and time (P 9 0.05) was
not found. There were no significant differences between the groups in any of
the balance-test variables (P 9 0.05).
Conclusions: This study showed that acute joint effusion has no effect on
static or dynamic postural sway in patients with knee osteoarthritis.
Key Words: Knee, Osteoarthritis, Balance, Effusion

www.ajpmr.com Effects of Acute Joint Effusion on Balance 45

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 K nee osteoarthritis (OA) is a common musculo-
skeletal disease, affecting more than 20% of elderly
subjects in Western and Asian countries.1Y3 Elderly
patients with knee OA often experience pain, phys-
ical and functional impairment, and, consequently,
a poorer quality-of-life.4,5 Furthermore, the disease
causes a significant economic burden,6 and as life
expectancy increases in the coming years, its prev-
alence is expected to increase.
Balance function has been reported to decline
with age, as evidenced by increased postural sway.7,8
Balance is controlled by multiple sensory inputs,
central processing, and neuromuscular responses.9
The sensory input systems are the visual, vestibular,
and proprioceptive systems. The deterioration of
balance may be accompanied by reduced function
in any sensory system, declined neuromuscular re-
sponses, or problems in central processing. Indi-
viduals with knee OA demonstrate a significantly
higher postural sway than do age-matched control
subjects,9Y12 although the mechanisms are not well
understood. Changes in the intracapsular tissue and
the periarticular tissues including the ligaments,
joint capsule, tendons, and muscles in patients with
knee OA are known to exist.13 Altered hamstring-
quadriceps muscle activity,14,15 weaker quadriceps
strength,16,17 and a greater decline in propriocep-
tion18 have been identified in patients with knee
OA. All of these factors, in combination with the
aging process, could contribute to attenuated bal-
ance function in patients with knee OA.
Previous studies have investigated the nu-
merous signs and symptoms that accompany knee
OA to explore the cause of impaired postural sta-
bility.12,19,20 Although the severity of radiographic
abnormalities is known to be correlated with pos-
tural instability,13,21 it has little clinical implication
because it cannot be modified. Pain, varus mal-
alignment, and quadriceps weakness are modifi-
able factors that are associated with poor single-leg
standing balance.21
Knee effusion is a common symptom asso-
ciated with chronic degenerative joint conditions
such as OA. Palmieri et al.22 revealed that the in-
hibition of quadriceps function was induced by an
experimental knee joint fluid.23 A case study24 re-
vealed significant improvement of proprioceptive
ability in a subject’s passive ability to reposition
after aspiration of chronic knee effusion. In addi-
tion, the authors’ previous study found that acute
joint effusion (20 ml) impaired the proprioceptive
function in osteoarthritic knee joints.25 The authors
hypothesized that knee effusion may accentuate
46 Hong et al.
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
postural instability, considering that joint effusion
may induce arthrogenic inhibition or impairment
of proprioception. Knowledge of the correctable
factors that affect balance function, such as effu-
sion, is important because this knowledge can be
clinically applied in therapeutic strategies to main-
tain or improve postural stability. In the present
study, the authors conducted a prospective study
to investigate the influence of acute knee effusion
on postural balance through recording body sway
under static and dynamic conditions.
METHODS
Study Design and Subjects
This study was designed as a single-blind,
randomized, controlled clinical trial. Female sub-
jects with knee OA were recruited from the De-
partment of Rehabilitation Medicine at Seoul St.
Mary’s Hospital in South Korea. All subjects were
50 yrs or older and displayed knee pain without
joint effusion, which was confirmed by ultraso-
nography. They also fulfilled the inclusion criteria
suggested by the American College of Rheumatol-
ogy for the diagnosis of OA.26 The authors checked
the knee x-rays (anteroposterior [AP] and lateral
views) in a standing position with the knee fully
extended. The Kellgren and Lawrence grading was
performed by one author. Subjects were excluded
if they had any previous lower limb surgery, re-
ported symptomatic disease of other weight-bearing
joints (hip, ankle, or foot), reported any neurologic
or systemic pathology that would influence balance,
had received a knee injection within 3 mos, or were
currently prescribed with anticoagulants.
The subjects were randomly assigned to the
injection or control groups (Fig. 1). In the cases of
bilateral knee OA, the more symptomatic leg was
selected. Numerical pain ratings were evaluated by
asking about current pain levels before the balance
test. Normal saline (20 ml) was injected into the
knee joint cavity of the subjects in the injection
group. While the patient was lying supine with the
knees in an extended and neutral rotation position,
the authors inserted a needle horizontally into the
middle lateral aspect of the knee joint, targeting the
center of the patella.27 The transducer was placed
parallel to the long axis of the leg, along the lateral
aspect of the superior border of the patella, and
the presence of fluid in the joint was confirmed by
ultrasonography.27 The subjects in the injection
group were tested for balance before and after the
joint infusion, with a 30-min interval between the
trials, and the time from the injection of fluid to
Am. J. Phys. Med. Rehabil. & Vol. 92, No. 1, January 2013
FIGURE 1 Flow diagram of patients’ progress through the design of the study.
the test was 10 mins or less. For the control group,
a needle was inserted into the joint cavity of the
subjects, but no saline was infused. The control
group also performed the two tests without infu-
sion, with a 30-min rest interval between the trials.
The patient was not blinded with respect to the
infusion; however, the examiner who performed the
balance measurement procedure was blinded with
respect to the injection. Sterilization using povidone-
iodine and application of a small adhesive plastic
bandage at the site of injection were performed in
both the control and injection groups. Failure to vi-
sualize an effusion by ultrasonography with a 20-ml
infusion or severe pain that precluded an infusion
to 20 ml was regarded as an injection failure.
This study was approved by the ethics com-
mittee of The Catholic University of Korea, and
written consent was obtained from all subjects
according to the Declaration of Helsinki.
Balance Measurements
Postural stability was assessed using the Good
Balance system (Metitur Ltd, Jyväskylä, Finland;
www.Metitur.com), a force platform test that con-
sists of a triangular force platform, a three-channel
amplifier with an eight-channel 12-byte analog-to-
digital converter (sampling frequency, 50 Hz), and
a computer program. This system calculates the
x (mediolateral [ML]) and y (AP) coordinates of the
center of pressure (COP) affecting the platform
when the person is standing on the platform. The
force platforms performed a self-test for the basic
levels every time the computer was opened.8 The
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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
tests were conducted under quiet conditions to
eliminate abrupt postural sway caused by auditory
stimuli. To avoid the learning effect and to improve
familiarity with the test process, all participants
performed three repeat practice tests before the
actual tests. The outcome variables for static pos-
turography were (1) the mean speed of COP move-
ment in the AP direction (millimiter per second),
(2) the mean speed of COP movement in the ML
direction (millimiter per second), and (3) the mean
velocity moment (square millimeter per second),
which indicates the area of COP movement during
each second of the testing. To reduce errors caused
by height differences, the authors adjusted the COP
measurement data (values of the original AP and
ML speed variables) by dividing the value by the
participant’s height (centimeter) and multiplying
by 180 (constant), as in previous studies.8,28 For
the velocity moment data, the adjustment was per-
formed by dividing the original value by (height in
centimeters)2 and multiplying by (180)2.
Balance was examined in three different con-
ditions in the following order: (1) static standing
with eyes opened for 30 secs, (2) static standing with
eyes closed for 30 secs, and (3) dynamic standing
and weight shifting according to a programmed
protocol. The subjects were asked to move their
COP along a track shown on a computer screen in
the dynamic test (Fig. 2). The performance time
(time used to complete the test in seconds) and the
distance (the extent of the path traveled by the COP
during the test in millimeters) were measured.
These tests had been recommended to be performed
Effects of Acute Joint Effusion on Balance 47
 FIGURE 2 The dynamic balance test: moving to three forward directions.

on a minimum of two occasions to increase reli- groups. For the nonYnormally distributed vari-
ability when applied to older patients.29,30 Thus, ables (age and numeric rating scale for pain), the
the static and dynamic tests were performed in Mann-Whitney U test was used to assess the differ-
triplicate, with a 1-min rest period between each ences. The Kellgren and Lawrence grade was com-
test. The mean values of the three repetitions in pared between the groups using the Fisher’s exact
each test were used for analysis. In the dynamic test. The effects of intervention (joint effusion) be-
test, a performance time exceeding 1 min was re- tween the two groups were assessed by repeated-
garded as an examination failure. During the bal- measures analysis of variance.
ance tests, the subjects looked straight ahead (at
an BX[ marked on the wall) and stood on the force
platform with their feet positioned at shoulder- RESULTS
width apart and their arms comfortably by their Seven right knees (15 left knees) in the control
sides. All participants wore shorts and stood with group and 11 right knees (nine left knees) in the
bare feet to eliminate any contribution of cuta- injection group were assessed (Fig. 1); two patients
neous receptors. in the injection group were unable to complete the
study because of injection failure. Two patients, one
Statistical Analysis from each group, failed to complete the baseline
To the authors’ knowledge, no previous reports dynamic test. The baseline characteristics of the
have investigated the effect of effusion on balance 42 subjects are given in Table 1. No significant
in patients with OA. Thus, using data from the ex-
perimental knee effusion in healthy subjects,31 for a
power of more than 80% to detect differences in the TABLE 1 Baseline characteristics in the injection
and control groups
outcome, the authors calculated from a sample size
of 22 subjects per group, given an anticipated in- Injection Group Control Group
jection failure rate of 10%. Statistical analyses were Variables (n = 20) (n = 22) P
performed using the SPSS, version 11.5. All tests were Age, yrs 57.75 T 5.11 55.68 T 3.60 0.376
two-tailed, and P G 0.05 was deemed statistically sig- Height, cm 154.70 T 5.06 156.63 T 5.05 0.222
nificant. The authors used the Shapiro-Wilcoxon’s Weight, kg 58.30 T 7.15 58.27 T 7.30 0.990
BMI, kg/m2 24.34 T 2.59 23.70 T 2.23 0.394
test to assess the normality of the distributions of Pain, NRS 3.1 T 0.72 3.23 T 0.81 0.522
the variables. To correct the variance of the balance- K/L scale, n 0.503
test variables (mean velocities, velocity moment, 1 2 1
2 12 10
time, and distance), the authors applied a loga- 3 4 9
rithmic transformation. For the normally distrib- 4 2 2
uted variables (height, body weight, body mass Values are presented as mean T standard deviation.
index, and balance test variables), Student’s t tests K/L indicates Kellgren and Lawrence; BMI, body mass
were used to analyze the differences in baseline index; NRS numeric rating scale.
characteristics between the injection and control

48 Hong et al. Am. J. Phys. Med. Rehabil. & Vol. 92, No. 1, January 2013

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 TABLE 2 Baseline results (mean T standard deviation) and group differences in static
posturography variables
Eyes Opened Eyes Closed
Balance Test/COP
Movement Variable Injection Group Control Group P Injection Group Control Group P
ML sway velocity, mm/sec 3.60 T 0.96 3.66 T 1.16 0.958 4.12 T 1.14 4.21 T 1.45 0.999
AP sway velocity, mm/sec 6.92 T 1.26 6.29 T 1.36 0.119 10.85 T 2.54 9.39 T 2.12 0.050
Velocity moment, mm2/sec 12.82 T 4.07 11.58 T 5.79 0.214 19.11 T 7.73 15.75 T 8.73 0.078
COP indicates center of pressure; ML, mediolateral; AP, anteroposterior.

differences in age, height, body weight, body mass
index, pain, or Kellgren and Lawrence grade were
found between the two groups at baseline (P 9 0.05;
Table 1). The intraclass correlation coefficients and
95% confidence intervals for the mean speed of ML
and AP with eyes opened were 0.848 (0.656 and
0.937) and 0.770 (0.506 and 0.902), respectively.
Table 2 represents the results of static posturo-
graphy at baseline with eyes opened and eyes closed.
The mean ML and AP sway velocities and velocity
moment showed no significant difference between
the injection and control groups. The baseline data of
dynamic posturography also showed no significant
difference between the two groups (Table 3).
Significant interaction of the balance-test
variables (mean speeds, velocity moment, time, and
distance) between the groups and time (P 9 0.05)
was not found (Tables 4, 5, and 6). There were
significant differences between the times in the
mean ML sway velocity with eyes closed and the
dynamic-test performance times (P = 0.001 and
P = 0.008, respectively; Tables 5 and 6). However,
there were no significant differences between the
groups in any of the balance-test variables (P 9 0.05;
Tables 4, 5, and 6).
DISCUSSION
Approximately one in three people 65 yrs or
older falls one or more times each year, with ap-
proximately half of the falls resulting in injury. Falls
can result in disability, loss of mobility, poor quality-
of-life, and fear of falling.32,33 Postural instability is
a risk factor for falls.28,34,35 Balance can be assessed
using many different methods. Among these, the
staticYforce platform balance test has been used in
many studies8,20,28,35 and is widely used to assess pos-
tural balance.35 A recent prospective study showed
that indoor fallers had greater COP movement com-
pared with nonfallers and that staticYforce plat-
form balance tests provided valid information on
postural control that could be used to predict fall

TABLE 3 Baseline results (mean T standard deviation) and group differences in dynamic
posturography variables

Variables Injection Group Control Group P

Time, secs 23.18 T 8.62 19.92 T 6.43 0.156
Distance, mm 1243.38 T 364.61 1354.17 T 517.01 0.467

TABLE 4 Changes in static variables with EO

Injection Group Control Group Pa
COP Movement
Variable in EO Baseline Post Baseline Post Group Time
ML sway velocity (mm/sec) 3.60 (0.96) 3.46 (0.85) 3.66 (1.16) 3.23 (0.94) 0.647 0.051
AP sway velocity (mm/sec) 6.92 (1.26) 7.09 (1.33) 6.29 (1.36) 6.85 (1.64) 0.246 0.063
Velocity moment (mm2/sec) 12.82 (4.07) 13.47 (6.21) 11.58 (5.79) 11.41 (5.48) 0.152 0.982
Variables are presented as mean (standard deviation).
a
P values were calculated using repeated-measures analysis of variance for all variables, with logarithmic transformation.
EO indicates eyes opened; COP, center of pressure; ML, mediolateral; AP, anteroposterior.

www.ajpmr.com Effects of Acute Joint Effusion on Balance 49

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 TABLE 5 Changes in static variables with EC
Injection Group Control Group Pa
COP Movement
Variable in EC Baseline Post Baseline Post Group Time
ML sway velocity (mm/sec) 4.12 (1.14) 3.58 (0.86) 4.21 (1.45) 3.70 (1.99) 0.988 0.001
AP sway velocity (mm/sec) 10.85 (2.54) 10.63 (2.61) 9.39 (2.12) 9.76 (2.84) 0.125 0.847
Velocity moment (mm2/sec) 19.11 (7.73) 18.86 (8.15) 15.75 (8.73) 15.79 (11.36) 0.063 0.535
Variables are presented as mean (standard deviation).
a
P values were calculated using repeated-measures analysis of variance for all variables, with logarithmic transformation.
EC indicates eyes closed; COP, center of pressure; ML, mediolateral; AP, anteroposterior.

risk among older individuals, even those without
apparent balance problems or fall history.28
Contrary to the authors’ initial hypothesis, acute
artificial knee effusion had no significant effect on
static and dynamic postural sway. Although propri-
oception and muscle activities were negatively affected
by knee joint effusion,23,25 the results of this study
indicate that acute joint effusion is not a major con-
tributor to poor balance in the population with OA.
This study had some limitations that may
have contributed to the negative test results: the
volume of effusion was low because quadriceps in-
hibition more evidently occurs with high effusion
(60 ml) compared with low effusion (30 ml).36 How-
ever, because of ethical concerns, the authors in-
fused only 20 ml of normal saline, on the basis of
a study in which 20 ml of intra-articular physio-
logic saline and 2 ml of sodium hyaluronate did
not show significant differences in the reduction
of knee pain.37 In addition, the patients in this
study were not healthy young subjects, and all
had knee OA. In studies evaluating the level of ef-
fusion in patients with knee OA, the mean (SD)
levels of synovial fluid were 27.5 (15.5) ml and 17
(9.87) ml.38,39 Torry et al.38 suggested that a vol-
ume of 20 ml represents a mild effusion and con-
stitutes a clinical representation of knee effusions.
Therefore, the authors assumed that this study’s
infusion volume would be clinically relevant and
adequate for joint distension in Korean subjects
because the mean height of this study’s experi-
mental subjects was 155.7 cm, which is smaller
compared with that of the subjects (9180 cm tall)
in other studies of arthrogenic inhibition.36,38 In
addition, the authors’ previous study showed that
acute joint effusion (20 ml) impaired propriocep-
tive function in osteoarthritic knee joints.25 The
second explanation for the negative results is a pos-
sible compensation by another limb (the effusion-
free knee). The authors assessed postural sway with
subjects standing on both legs; thus, reduced pro-
prioception caused by effusion in one joint may
have been overcome by the sensory input from the
other side. An evaluation of standing on one leg
would have potentially assessed the effect of joint
effusion on the affected leg more accurately and
excluded any compensatory mechanism. However,
further study in which a single-leg balance test
could present a greater risk of falling than the
double-leg balance test will be needed. In addition,
balance might have been impaired if a more dy-
namic balance test had been performed. Although
a simple dynamic test to investigate body sway and
performance time with directed weight shifting was
done, apparently, this test did not present sufficient
dynamic motion. More dynamic balance tests that
better predict the risk of falls will be needed before
the authors can address this issue. In addition, be-
cause the authors included only female patients,
this result does not apply to male patients.
Knee effusion in subjects with OA is typically
inflammatory and chronic in nature and could lead

TABLE 6 Changes in dynamic variables

Injection Group Control Group Pa

Baseline Post Baseline Post Group Time

Time, secs 23.18 (8.62) 20.61 (7.26) 19.92 (6.43) 19.69 (13.51) 0.223 0.008
Distance, mm 1243.38 (364.61) 1284.23 (419.20) 1354.17 (517.01) 1380.74 (999.42) 0.784 0.533
Variables are presented as mean (standard deviation).
a
P values were calculated using repeated-measures analysis of variance for all variables, with logarithmic transformation.

50 Hong et al. Am. J. Phys. Med. Rehabil. & Vol. 92, No. 1, January 2013

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
to different effects compared with simple mechan-
ical joint distension. The injection material used
in this experiment was a noninflammatory fluid,
that is, normal saline. Thus, the authors calculated
the effects of joint distension alone, resulting in a
discrepancy between the simulated scenario and
real-life inflammatory knee effusion. For instance,
higher levels of inflammatory mediators including
interleukin-6 have been associated with sarcopenia,
functional decline, and a reduction in muscle en-
durance and balance.40,41 However, the authors
were unable to examine the impact of chronic in-
flammatory joint fluid on balance function.
Post hoc power analysis (the two groups and
repeated-measures analysis of variance) showed low
power (1 j A = 0.27). In the authors’ opinion, more
patients should not be added to increase the prob-
ability of finding differences in the static balance
test. Instead, more dynamic balance tests should be
performed to identify an effect of knee effusion on
balance. However, further studies are required to
evaluate which dynamic balance test is better in
the context of the possible risk of falling.
Pain associated with the injection may have in-
fluenced balance. However, none of the experimental
subjects complained of pain or discomfort during
the measurement tasks. Some studies have shown
that the knee effusion model allowed for mechan-
ical effects of joint injury without the effects of
perceived pain.36,38,42,43 In addition, a previous
study showed that static postural stability did not
improve after pain reduction in subjects with knee
OA.19 Therefore, pain is unlikely to have affected
the results of this study.
To the authors’ knowledge, this study is the
first randomized, controlled clinical trial to assess
the effects of acute joint effusion on postural sway in
patients with degenerative OA. Although balance
change was not observed and there were some lim-
itations to this study, these results may be informa-
tive for future research on balance in patients with
knee OA.
CONCLUSIONS
The results of this study suggest that simulated
noninflammatory acute knee effusion induced by
20 ml of saline does not result in detrimental effects
on postural balance in patients with knee OA. Fur-
ther studies are required to evaluate the effect of
chronic inflammatory knee effusion on postural
stability or the effect of knee effusion on postural
stability in more dynamic movement tests.
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ACKNOWLEDGMENTS
The authors thank all patients who par-
ticipated in this study. The authors would like to
express gratitude for the support.
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