The Effect of a Period of Kinesiotherapy and Reflexology on Pain Intensity and Range of Motion in Elderly Women With Knee Osteoarthritis

* Corresponding Author: Fatemeh Kiani Dooghabadi, MD. Address: Department of Sports Pathology and Corrective Movements, Faculty of Human Sciences, Imam Reza International University, Mashhad, Iran. Tel: +98 (915) 0464252 E-mail: kiyani.fatemeh20@gmail.com 1. Department of Sports Pathology and Corrective Movements, Faculty of Human Sciences, Imam Reza International University, Mashhad, Iran. 2. Department of Corrective Exercise and Sport Pathology, Faculty of Sport Sciences, Ferdowsi University of Mashhad, Mashhad, Iran. 3. Department of Sports Science, Kashmar Higher Education Institute, Kashmar, Iran. *Fatemeh Kiani Dooghabadi1 , Nahid Khoshraftar Yazdi2 , Hossein Farzaneh3


Introduction
steoarthritis (a degenerative disease of the knee joint) is one of the most common musculoskeletal disorders, which significantly causes motor disabilities and pain in the knee joint [1,2]. According to reports, the prevalence of osteoarthritis is between 30%-40% among the elderly and 72.6% among women, which is O higher than other age groups [3]. Heavy expenses are spent annually to diagnose, treat, and rehabilitate this disease [8]. The primary treatment for arthritis is pharmacotherapy [7,9]. However, other non-pharmacological and complementary methods have been considered conservative treatments for these diseases [10,11].
Kinesiotherapy, as an essential method and with the function of improving muscle strength, increasing the depth perception, and strengthening the reflex response, has been introduced to control and prevent this disease's progression [11]. Since the patients with knee osteoarthritis are less likely to exercise due to old age, pain, and disability and they find these activities painful and sometimes risky, complementary and alternative methods (hand and foot reflexology) that do not require actions have been identified as more popular and suitable with these patients [10,12,13]. The study aimed to investigate the effect of a course of kinesiotherapy and reflexology on pain intensity; it introduced a range of motion in older women with knee osteoarthritis.

Methods
In this quasi-experimental study, 45 elderly women with knee osteoarthritis were purposively selected and randomly divided into three groups of 15 named "kinesiotherapy", "reflexology", and "control". The "kinesiotherapy" and "reflexology" groups practiced exercise therapy and reflexology for 4 weeks and 5 sessions per week [9,19,20]. The control group performed their daily activities. To assess the severity of pain and the range of motion of the subject's knee, the Visual Analogue Scale (VAS) of pain and goniometer was used in pre-test and post-test, respectively [8]. Data were analyzed by one-way ANOVA and Tukey's Post-Hoc tests.

Results
The results showed that both kinesiotherapy and reflexology protocols positively and significantly reduce pain intensity and increase the range of motion of the subjects' knee joint (P≤0.05). The kinesiotherapy protocol had more significant effects on the increase in activity range than the reflexology protocol (P=0.001, P=0.001, respectively). The dependent t-test results regarding the comparison of the "amount of pain" and "range of motion" of the subjects' knees are presented separately in Tables 1 and 2.
As shown in Tables 1 and 2, there is a significant difference between the values of pain and range of motion of both "kinesiotherapy" and "reflexology" groups (P≤0.05). However, these differences are not seen in the control group.

Discussion and Conclusion
This study aimed to investigate the effect of a course of kinesiotherapy and reflexology on pain intensity and range of motion in elderly women with knee osteoarthritis. In general, this study's results revealed that both the implementation of exercise therapy protocol and reflexology movements had positive and significant effects on reducing Although no specific and purposive study has been conducted to examine a course of kinesiotherapy and reflexology of severe pain and range of motion in elderly women with knee osteoarthritis, in this regard, numerous studies have investigated the effects of such exercises, especially the impact of reflexology movements on the severity of pain in various abnormalities such as low back pain and thigh osteoarthritis, most of which are consistent with the results of the present study [14,15].
In this regard, for example, a study by Khadiga et al.
(2019) on 50 women with knee osteoarthritis revealed that 3 weeks of plantar reflexology had significant effects on pain intensity, functional disability, and range of active and inactive knee movement [14]. In their study, Kielar et al. (2017) investigated the effects of plantar reflexology movements on joint pain and disability in patients with hip osteoarthritis. They confirmed that performing 8 reflexology sessions (45 minutes each session) significantly reduced the subjects' pain intensity.
Because any pain, including back pain and knee pain, acts on specific nerve terminals and activates C-Delte-A fibers, the presence of this pain leads to increased secretion of stress hormones, stimulation of the adrenal gland. Stimulation of the sympathetic nervous system, which these factors, in turn, cause high blood pressure, irregular breathing, shortness of breath, increased respiration rate, and increased heart rate [13]. As a result, these cases' improvement can be mentioned in justifying the positive effects of reflexology.
Another factor affecting pain and range of motion in people with osteoarthritis is inflammation and decreased activity and neuromuscular inhibition, which play an essential role in reducing muscle function to determine depth perception, reducing sensory system integrity accurately (including muscle spindles and decreased visual and vestibular system), and changing the sensitivity of cutaneous and articular receptors [17]. According to the researchers in this study, the effectiveness of the therapeutic exercises used is probably due to the direct use of stretching exercises and open kinetic chain exercises of the thighs and knees in the protocol of therapeutic movements, which through neuromuscular inhibition causes atrophy of muscles around the knee and decreased patient mobility [1].
In general, it can be said that based on the results of this study, the use of both protocols of kinesiotherapy and reflexology to reduce pain and increase range of motion in elderly women with knee osteoarthritis is recommended, and simul-taneous use of these two protocols for treatment and greater effectiveness in this group of patients is recommended.

Compliance with ethical guidelines
All ethical principles are considered in this article. The participants were informed of the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information. They were free to leave the study whenever they wished, and if desired, the research results would be available to them. This study was conducted to implement research projects at Imam Reza (AS) Non-Profit University.

Funding
This article was extracted from MA. thesis of first author at the Department of Sports Pathology and Corrective Movements, Faculty of Human Sciences, Imam Reza International University, Mashhad.

Authors' contributions
All authors were equally contributed in preparing this article.

Conflicts of interest
The authors declared no conflict of interest.