The effect of adding virtual reality-based rehabilitation to conventional physiotherapy on pain, functional ability and static balance control in patients with total knee arthroplasty

The effect of adding virtual reality-based rehabilitation to conventional physiotherapy on pain, functional ability and static balance control in patients with total knee arthroplasty | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effect of adding virtual reality-based rehabilitation to conventional physiotherapy on pain, functional ability and static balance control in patients with total knee arthroplasty Ghazal hashemi Zenooz, Afshin taheriazam, Tahere Rezaeian, Hamidreza Mokhtarinia, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5806312/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Physiotherapy in patients with total knee arthroplasty (TKA) is necessary to reduce pain, return to daily activities, and maintain balance. Today, virtual reality (VR) is being used to provide real-time visual feedbacks during the exercise. Hence, aim of the present study was to evaluate the effect of adding virtual reality-based therapy in comparison to conventional physiotherapy on the pain, functional ability, and static balance in the acute phase after TKA. Methods Fifty-two patients who underwent TKA (11male, 41 female, mean age 61.92 ± 6.91 years) were randomly assigned into two groups: a control group (n = 24) and an intervention group (n = 28). The control group received conventional physiotherapy, whereas the intervention group participated in a combination of VR-based therapy and conventional physiotherapy. The primary outcome was functional ability, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes included pain, measured using the Numeric Rating Scale (NRS), and static balance, assessed with the Wii Balance Board. Static balance control was evaluated using center of pressure (COP) parameters, including COP area and mean velocity, under two conditions: open eyes and closed eyes. Pain and functional ability were evaluated at baseline, post-treatment, and at the one-month follow-up. Static balance measurements were taken at baseline and post-treatment. Results The intervention group demonstrated significant improvements compared to the control group. The WOMAC scores and pain levels showed greater reductions at both the post-treatment and follow-up phases (effect size [ES] = 36%, P < 0.001). The static balance parameters improved in both groups; however, the intervention group exhibited significantly greater reductions in COP ellipse area in the standing position (P < 0.001) and mean velocity in the mediolateral direction (P < 0.001, ES = 23%). Additionally, anteroposterior mean velocity with open eyes decreased significantly only in the intervention group (P < 0.001). No significant changes were observed in static balance parameters under the eyes-closed condition. Conclusions This study demonstrated that VR-based exercise therapy significantly improved knee function, static balance, and pain management in TKA patients during early rehabilitation. The intervention group exhibited superior improvements compared to the control group, highlighting the effectiveness of integrating VR-based therapy with conventional physiotherapy. These findings suggest that this combined approach can optimize recovery and improve rehabilitation outcomes in the early phase following TKA. Trial registration: The study was retrospectively registered in the Iranian Clinical Trials Registry with the number IRCT20230524058283N1. Virtual Reality Total Knee Arthroplasty Postural Control Pain Intensity Figures Figure 1 Introduction Osteoarthritis (OA) is the most prevalent degenerative joint disease in the elderly population, leading to significant impairments, including functional impairments, pain, joint stiffness, and cartilage degeneration [ 1 , 2 ]. Beyond physical challenges, OA adversely affects individuals' social, psychological, and emotional well-being and imposes a substantial economic burden on healthcare systems worldwide [ 3 ]. Globally, approximately 53% of individuals aged 65 and older experience OA, with the knee joint being the most commonly affected site, accounting for 82.6% of cases [ 4 ]. The knee joint plays a critical dual role in providing both stability and mobility, making it particularly vulnerable to degenerative changes [ 5 ]. Knee OA is associated with symptoms such as joint pain, restricted mobility, impaired balance control, proprioceptive deficits, and overall functional limitations [ 6 ]. When conservative treatments fail to alleviate these dysfunctions, total knee arthroplasty (TKA) emerges as a highly effective therapeutic intervention [ 7 ]. Early physiotherapy is essential following TKA, as it plays a pivotal role in restoring normal function, range of motion (ROM), balance control, and pain reduction [ 8 ]. Furthermore, enhancing proprioceptive function in the knee joint is vital for improving both static and dynamic balance [ 9 ]. While drug therapies and conventional treatments such as physiotherapy remain standard approaches, the long-term use of medications is often limited by side effects [ 10 ]. Conversely, physiotherapy offers a safer and highly effective means to improve function and balance in these TKA patients [ 11 ]. In recent years, virtual reality (VR)-based rehabilitation has emerged as a novel approach that integrates biofeedback and visual inputs to evaluate and correct patient performance in real time during exercises [ 12 – 14 ]. The VR therapy engages patients through interactive environments, enhancing their exercise experience with visual, auditory, and tactile feedback [ 15 , 16 ]. Studies have shown that combining VR with conventional physiotherapy can improve outcomes in the TKA patients, particularly in reducing pain and enhancing function [ 17 , 18 ]. Despite the growing body of research on the VR therapy in the TKA rehabilitation [ 14 , 19 – 20 ], findings remain inconsistent. For instance, José Blasco et al. (2018) reported that the VR therapy was superior to conventional physiotherapy for balance improvements, while other studies suggested that the VR-based physiotherapy did not significantly outperform conventional methods in improving function and reducing pain after the TKA [ 21 ]. Furthermore, Linbo Peng et al. (2022) concluded that although VR-based therapy improved knee function and reduced pain, it failed to demonstrate significant benefits in balance control compared to conventional rehabilitation [ 22 ]. Notably, while global studies on the VR therapy for TKA rehabilitation have expanded, no research has yet explored its application in Iran. To our knowledge, this study is the first to investigate the effects of VR-based rehabilitation on functional ability, pain, and balance control in TKA patients in the Iranian population. Therefore, this study aimed to evaluate the effectiveness of integrating VR-based therapy with conventional physiotherapy in improving pain, functional ability, and static balance control during the acute rehabilitation phase following TKA. Materials and Methods Participants This randomized controlled trial included 52 patients who underwent TKA (11 male, 41 female; mean age: 61.92 ± 6.91 years). The study was conducted between October 2023 and May 2024 at the Physical Therapy Research Center, University of Social Welfare and Rehabilitation Sciences (USWR), Tehran, Iran. The sample size was determined based on the minimal clinically important difference (MCID) of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire (5 points), with a 30% allowance for potential dropout. Participants were eligible inclusion if they met the following criteria: aged between 45–65 years, had undergone unilateral TKA surgery within the past 14 days, and had no post-operative complications. Exclusion criteria included a history of prior surgery or orthopedic disorders in the operated limb, inadequate physical fitness for the intervention, or the presence of neurological or cognitive impairments [ 19 ]. Ethical approval for this study was obtained from the USWR Ethics Committee (IR.USWR.REC.1402.024), and the trial was registered in the Iranian Clinical Trials Registry [clinical trial number IRCT20230524058283N1 (10/08/2023)]. This study matched to all the Consolidated Standards of Reporting Trials (CONSORT) guidelines and reported the required information accordingly [ 23 ]. A flow diagram of the study methods was demonstrated in Fig. 1 . Insert Fig. 1 here Study Protocol Study Protocol All participants provided written informed consent prior to the intervention. Following consent, patients were randomly assigned into either the control or intervention group using block randomization. The control group received 10 sessions of conventional physiotherapy, conducted five times per week over a two-week period, with each session lasting 60 minutes. The intervention group followed the same protocol but with the addition of VR-based therapeutic exercises using Kinect technology [ 24 ]. Both interventions began 2 to 7 days after hospital discharge and were supervised by an experienced physiotherapist specializing in TKA rehabilitation. Control Group The control group participated in a conventional physiotherapy program, aligned with the standard TKA rehabilitation protocol. This program included pain and inflammation management modalities, ROM exercises, and strengthening exercises targeting the quadriceps and associated muscle groups. Electrotherapy Modalities Each physiotherapy session began with transcutaneous electrical nerve stimulation (TENS) applied at a frequency of 100 Hz and a pulse duration of 100 ms for 10 minutes to alleviate pain around the suture site. This was followed by functional electrical stimulation (FES) at 50 Hz, targeting specific muscles during the initial phase of therapeutic exercises [ 25 ]. To address lower limb edema, a lymph drainage device was applied for 12 minutes, complemented by active ankle pumping exercises performed by the patient [ 26 ]. Exercises During the first five sessions, the exercises program focused on basic movements to promote joint mobility and muscle activation. These exercises included ankle pumping, knee extension (performed in supine and sitting positions), knee flexion (in the supine position), and heel raises with walker support. Each exercise was performed under therapist supervision in three sets of 12 repetitions. In the subsequent sessions, the program was progressively advanced to include knee flexion-extension (in the supine position), hamstring curls, step-ups, forward lunges, and modified squats. Patients were instructed to perform all exercises during therapy sessions and to repeat them twice daily at home [ 27 ]. For the intervention group, in addition to the conventional physiotherapy program provided to the control group, VR-based exercises were introduced during the fifth to tenth physiotherapy sessions. The VR-based program utilized the Microsoft Kinect V2 system, a motion sensing platform capable of capturing three-dimensional movements of 25 body joints along the X, Y, and Z axes through its depth sensor [ 28 ]. Patients performed VR-based exercises while standing in front of a monitor displaying their real-time avatar. This interactive setup provided visual feedback, enabling patients to correct errors, such as pelvic tilts or involuntary body bending, under the guidance of the physiotherapist. The VR-based exercises protocol included squats, modified lunges, weight-shifting in standing, step-ups and step-downs adjusted to patient capability, one-leg standing with walker support, and sit-to-stand transitions using a walker [ 24 ]. Outcome measurements The primary outcome of the study was functional ability, assessed using the WOMAC questionnaire. Measurements were conducted at baseline, post-treatment, and at the one-month follow-up. Secondary outcomes included pain intensity and static balance parameters. Pain intensity was evaluated at the same three time points as functional ability, while static balance parameters—center of pressure (COP) area and mean velocity—were assessed before and after the treatment. Functional ability Functional ability, the primary outcome of this study, was assessed using the WOMAC. This standardized questionnaire is specifically designed to evaluate treatment outcomes in patients with OA. The WOMAC index consists of 24 items divided into three subscales: pain (20 points), stiffness (8 points), and physical function (68 points). Patients rate each item on a scale from 0 (none) to 4 (very severe), resulting in a total score ranging from 0 to 100. A score of 0 indicates an asymptomatic individual, while 100 represents maximum severity of symptom [ 29 ]. The Persian version of the WOMAC questionnaire, validated for Persian-speaking patients with knee OA, has demonstrated high reliability and validity [ 30 ]. Pain intensity Pain intensity was assessed using the Numeric Rating Scale (NRS), a widely used and reliable tool for assessing treatment effectiveness. The reliability of this scale has been established in previous studies [ 31 ]. In this study, a 10 cm horizontal NRS was employed to measure pain levels. Patients indicated their pain by marking a point along the 10 cm line, where 0 represented "no pain “and 10 denoted "the worst possible pain" [ 32 ]. Balance control assessment Balance control was evaluated using the Nintendo Wii Balance Board (WBB), a validated tool for measuring static balance. The WBB system was wirelessly connected to a laptop via Bluetooth, with raw data processed using Brain Blox software developed by the University of Colorado Boulder [ 33 ]. Key COP parameters, including ellipse area and mean velocity, were calculated. Participants performed a double-leg standing test under two conditions: open eyes and closed eyes. During the test, they stood barefoot with their arms at their sides, focusing on a fixed point located 2 meters away [ 34 ]. Each task lasted 30 seconds, and three trials were conducted with a 60-second rest interval between trials. This protocol has been validated in previous studies [ 35 , 36 ]. Statistical analysis Data normality was assessed using the Shapiro-Wilk test (P > 0.05), and homogeneity of variances was evaluated with Levene's test. Descriptive statistics were used to summarize the characteristics of the variables. For normally distributed data, parametric tests, including analysis of covariance (ANCOVA), independent t-tests, and paired t-tests, were performed. For non-normally distributed data, the Mann-Whitney U test and Wilcoxon signed-rank test were applied. Bonferroni corrections were used for multiple pairwise comparisons to control for type I error. All analyses were conducted at a significance level of α = 0.05, and data were processed using SPSS version 23. Results A total of 60 patients were initially enrolled in this study. Of these, 30 patients were randomly assigned to the intervention group (the VR-based therapy combined with conventional physiotherapy) and 30 patients to the control group (conventional physiotherapy only). Eight patients were excluded from the study: two from the intervention group and six from the control group, as they declined to start treatment due to their inability to perform the interventions (Fig. 1 ). The average age in the intervention group was 61.60 ± 6.93 years, while in the control group it was 62.29 ± 7.01 years. No significant differences were observed between the two groups in terms of age or Body Mass Index (BMI) (Table 1 ). Table 1 Demographic data of the subjects (Mean SD) Variables Control group (n = 24) Intervention group (n = 28) 2 P-value Age(years) 62.29 ± 7.01 61.60 ± 6.93 0.72 BMI 1 28.39 ± 4.20 30.37 ± 4.44 0.10 Sex 5males, 19 females 6 males, 22 females - 1 Body Mass Index, 2 Independent t-test Insert Table 1 here A repeated measures ANOVA/ANCOVA was performed to analyze the WOMAC scores. The results revealed significant main effects for time (F = 219.954, P < 0.001), group (F = 18.393, P < 0.001), and a significant interaction between time and group (F = 26.919, P < 0.001). As the primary outcome, the mean WOMAC index showed a significant reduction in both groups following the interventions (F = 3.94, P < 0.001). Moreover, the intervention group demonstrated significantly lower WOMAC scores compared to the control group (t = 21.54, P < 0.001; Tables 2 – 4 ). In the post-intervention stage, the intervention group demonstrated an average WOMAC score that was 17 points lower than the control group, indicating a significant difference between the groups (effect size = 36%). During the follow-up phase, the average WOMAC score in the intervention group remained 14 points lower than the control group, with a significant difference observed (effect size = 41%). Table 2 Results of statistical models fitted for pain, functional score, and mediolateral mean velocity responses Variable Model Type Source of Variation F/Wald Statistic* P-Value Functional score Repeated Measures ANOVA Time 219.954 < 0.001 Time × Group Interaction 26.919 < 0.001 Group 18.393 < 0.001 Pain intensity Generalized Estimating Equations Time 192.070* < 0.001 Time × Group Interaction 31.282* < 0.001 Group 12.777* < 0.001 Mediolateral mean velocity (standing) with open eyes ANCOVA Group 15.007 < 0.001 Baseline Score 150.873 < 0.001 Mediolateral mean velocity (standing) with closed eyes ANCOVA Group 0.133 0.89 Baseline Score 3.348 0.002 Anterio-posterior mean velocity (standing) with closed eyes ANCOVA Group 2.030 0.16 Baseline Score 27.696 < 0.001 COP area with closed eyes ANCOVA Group 0.550 0.46 Baseline Score 1.791 0.18 Table 3 Comparison of pain threshold and functional score between subjects of the two groups in different phases Variable Control group (n = 24) Intervention group (n = 28) P-value 1 (Mean difference) P-value 2 Effect size After follow Control Intervention After Follow Pain threshold Before 3 6.75 ± 1.39 7.50 ± 1.79 (1.87 ± 0.47) 0.001 (3.96 ± 0.32) < 0.001 t = 3.25 0.002 t = 7.18 < 0.001 0.16 0.51 After 4 4.87 ± 1.84 3.53 ± 1.07 Follow up 4.70 ± 1.12 2.64 ± 0.95 (2.04 ± 0.37) < 0.001 (4.85 ± 0.34) < 0.001 Functional Score Before 64.50 ± 8.83 67.53 ± 10.84 (10.98 ± 2.75) 0.002 (31.28 ± 1.45) < 0.001 t= -5.32 < 0.001 t=-5.39 < 0.001 0.36 0.41 After 54.87 ± 14.32 36.25 ± 8.82 Follow up 42.57 ± 10.84 27.50 ± 7.08 (22.12 ± 2.43) < 0.001 (40.03 ± 1.83) < 0.001 1 P-value for paired t-test; 2 P-value for independent t-test, 3 Before the intervention, 4 After the intervention Table 4 Pairwise comparison of means for pain and WOMAC using Bonferroni test Response Variable Comparison Groups Compared Mean difference Standard error P-value Functional Score Control Before vs. After 10.98 2.75 0.002 Before vs. Follow up 22.12 2.43 < 0.001 After vs. Follow up 11.16 3.04 0.004 Intervention Before vs. After 31.28 1.45 < 0.001 Before vs. Follow up 40.03 1.83 < 0.001 After vs. Follow up 8.75 1.23 < 0.001 Baseline Control vs. Intervention 3.03 2.77 0.27 Post-Intervention Control vs. Intervention 17.29 3.25 < 0.001 Follow up Control vs. Intervention 14.87 2.50 < 0.001 Pain threshold Control Before vs. After 1.87 0.46 0.001 Before vs. Follow up 2.04 0.37 < 0.001 After vs. Follow up 0.89 0.17 < 0.001 Intervention Before vs. After 3.96 0.32 < 0.001 Before vs. Follow up 4.85 0.34 < 0.001 After vs. Follow up 0.89 0.17 < 0.001 Baseline Control vs. Intervention 0.75 0.43 1.00 Post-Intervention Control vs. Intervention 1.33 0.41 0.02 Follow up Control vs. Intervention -2.06 0.28 < 0.001 Insert Tables 2 – 4 here A Generalized Estimating Equations (GEE) model was used to analyze repeated measures of pain scores, with the Wald test was applied to assess the significance of fixed effects. The analysis revealed significant main effects for time (Wald χ² = 192.070, P < 0.001), group (Wald χ² = 12.777, P < 0.001), and a significant interaction between time and group (Wald χ² = 31.282, P < 0.001). The mean NRS scores decreased significantly in both groups following the intervention. In the intervention group, a substantial reduction in NRS scores was observed (t = 12.11, P < 0.001; Tables 2 – 4 ), while the control group also showed a significant, albeit smaller, reduction (t = 3.94, P = 0.001). Post-intervention, NRS scores were significantly lower in the intervention group compared to the control group, with a notable between-group difference (F = 2.46, P = 0.002). The ANCOVA was performed to evaluate the COP parameters, including area, mediolateral velocity, and anteroposterior velocity, during standing tasks with open and closed eyes. The results indicated significant effects for mediolateral mean velocity in the intervention group (F = 15.007, P < 0.001) and baseline scores (F = 150.873, P < 0.001). The COP area and mediolateral mean velocity with open eyes significantly decreased in both groups, however, the reduction was significantly greater in the intervention group compared to baseline (t = -3.98, P < 0.001; Table 5 ). Additionally, mean velocity in the anteroposterior direction with open eyes significantly decreased only in the intervention group relative to baseline (P < 0.05). No significant changes were observed in static balance parameters under the eyes-closed condition. Table 5 Comparison of COP area, mean velocity in mediolateral and anterio-posterior direction during double leg stance with open and closed eyes between subjects of the two groups in different phases. Variable Variable Control group (n = 24) Intervention group (n = 28) P-value Mann-Whitney Test Statistic P-value Wilcoxon*/Paired t-test Eyes open Control Intervention COP 1 area Baseline Post-Intervention 2.11 ± 0.93 1.46 ± 0.55 2.61 ± 0.61 1.11 ± 0.39 t=-1.84 P = 0.07 -1.98 P = 0.53 4.28 P = < 0.001 -4.37 P = < 0.001 Mean difference (Before- after) (-0.65 ± 0.51) (-1.49 ± 0.54) t = 4.13 P = < 0.001 Mediolateral mean velocity Baseline Post-Intervention 0.99 ± 0.31 0.87 ± 0.23 0.80 ± 0.31 0.65 ± 0.14 t = 2.57 P = 0.17 t = 3.98 P = < 0.001 3.31 P = < 0.001 3.92 P = < 0.001 Anterio-posterior mean velocity Baseline Post-Intervention 1.23 ± 0.36 1.05 ± 0.27 0.96 ± 0.29 0.69 ± 0.11 t= -2.75 P = 0.39 t= -4.89 P = < 0.001 -2.51 0.13 -4.00 P = < 0.001 Mean difference (Before- after) (-0.18 ± 0.32) (-0.26 ± 0.31) t=-0.86 P = 0.38 Eyes closed COP 3 area Baseline Post-Intervention 0.61 ± 0.20 0.61 ± 0.19 0.68 ± 0.22 0.66 ± 0.17 t = -1.11 P = 0.27 t = -0.95 P = 0.34 -0.07 P = 0.94 0.29 P = 0.76 Mediolateral mean velocity Baseline Post-Intervention 1.97 ± 0.71 1.90 ± 0.56 1.95 ± 0.62 1.91 ± 0.56 t = 0.08 P = 0.93 t=-0.08 P = 0.93 0.016 P = 0.60 0.013 P = 0.77 Anterio-posterior mean velocity Baseline Post-Intervention 1.35 ± 0.37 1.28 ± 0.30 1.45 ± 0.37 1.48 ± 0.50 t = -0.84 P = 0.40 t = -1.66 P = 0.10 0.025 P = 0.756 -0.026 P = 0.721 Note: 1 Center Of Pressure, The Mann-Whitney U test and Wilcoxon test were used for non-parametric variables. Insert Table 5 here Discussion As the primary outcome of this study, functional ability, assessed through the WOMAC index, demonstrated significant improvements with the addition of VR-based therapy. In the intervention group, the WOMAC score decreased by 28.31 points post-treatment (effect size: 0.36) and by an additional 8.75 points during the follow-up period (effect size: 0.41). In comparison, the control group showed reductions of 9.63 points post-treatment and 12.3 points during follow-up. According to Maredupaka et al. (2020), a minimal clinically important difference (MCID) of 5 points on the WOMAC questionnaire indicates clinical significance for knee replacement patients [ 37 ]. In our study, the observed changes exceeded these thresholds, confirming that the VR therapy not only achieved statistical significance but also demonstrated clinical relevance. Despite these promising results, the effects of VR interventions on pain and functional ability in TKA patients remain a subject of debate due to variations in study designs and assessment procedures. While some studies have demonstrated significant benefits of VR therapy [ 24 , 38 ], others have reported no considerable improvements [ 14 , 39 ]. Similar to our findings, a study investigating the impact of the VR interventions on WOMAC scores in knee OA patients reported that the VR therapy was superior to conventional physiotherapy in improving functional outcomes [ 40 ]. Overall, these findings confirm the efficacy of VR-based therapy in significantly enhancing functional ability in TKA patients compared to conventional physiotherapy. The results also showed that pain intensity in the intervention group decreased by 39.7 cm post-treatment and by an additional 0.89 cm during the follow-up phase. In the control group, pain intensity reduced by 1.88 cm after treatment and 0.7 cm at follow-up. Although both groups experienced pain reduction, the decrease was significantly greater in the intervention group. Previous research has established the MCID for pain outcomes in knee joint lesions as 1.61 cm [ 41 ]. The pain reduction observed in this study exceeded this threshold, confirming both statistical and clinical significance. The mechanisms underlying pain reduction and improved functional ability with VR-based therapy may include increased motivation, enhanced adherence to prescribed exercises, and real-time error correction facilitated by therapist supervision and visual feedback [ 39 ]. Unlike conventional physiotherapy, VR-based therapy incorporates active visual feedback in a safe controlled treatment environment that accounts for both physiological and psychological factors. This approach fosters greater patient engagement and cooperation, ultimately leading to improved treatment outcomes [ 42 , 43 ]. The therapeutic benefits of VR are largely attributed to its ability to enhance adherence to exercise regimens. Recent findings suggest an adherence rate of approximately 24% among patients consistently following prescribed exercises [ 44 ]. In contrast, virtual-based exercises have been shown to significantly improve adherence rates by offering a more engaging and interactive rehabilitation experience. A systematic review of 54 studies reported an adherence rate of approximately 89% for exercise therapy involving virtual games, emphasizing VR as a promising tool to enhance patient compliance [ 45 ]. In addition, VR-based rehabilitation may reduce pain by altering pain perception and engaging psychological mechanisms [ 46 ]. By creating an interactive and immersive environment, VR distracts patients from their pain, a mechanism supported by the "gate control theory," which suggests that attention reduces the transmission of pain signals to the brain. Furthermore, VR activities may stimulate endorphin production, acting as natural painkillers to alleviate discomfort [ 47 , 48 ]. Despite its potential, the effects of the VR therapy on pain remain controversial. Some studies have reported no additional benefits of VR-based therapy. For instance, Fung et al. (2012) found that video games using the V-Fit system did not significantly reduce pain compared to conventional physiotherapy in 50 knee replacement patients. The study’s focus on balance control and its tele-VR approach may explain these findings [ 49 ]. Similarly, Fuchs et al. (2022) observed limited efficacy in a VR intervention delivered via a headset with a musical film in 55 knee replacement patients. The headset’s heaviness and lack of interactive features likely contributed to the lack of significant pain reduction, as both intervention and control groups experienced similar outcomes [ 39 ]. Conversely, other studies have demonstrated the effectiveness of VR-based therapy in reducing pain and improving functional ability. Chi Jin et al. (2018) confirmed that VR-based therapy effectively decreased pain and improved functional ability in TKA patients [ 50 ]. Similarly, a cohort study by Chughtai et al. (2018) involving 157 knee replacement patients reported pain reduction in 66% of cases treated with VR-based interventions. However, the tele-VR method used in that study differed from the approach in our research [ 51 ]. In addition, a systematic review highlighted VR-based therapy as an effective intervention for improving pain, functional ability, and balance control following TKA, with sustained benefits observed at 3 and 6 months post-surgery [ 15 ]. Peng et al. (2021) similarly reported that VR was significantly more effective than conventional physiotherapy in reducing pain within the first month after surgery [ 22 ]. For balance assessment, we used the double-leg standing test under two conditions: open and closed eyes. This test is widely recognized as a reliable and valid measure for assessing balance in TKA patients and has consistency demonstrated reproducibility in its application [ 36 , 37 ]. Our findings revealed that VR-based therapy significantly improved static balance in TKA patients. Parameters such as mean velocity in the mediolateral direction and COP area during standing decreased significantly in both groups, with a more pronounced reduction observed in the intervention group. Specifically, for mean velocity in the mediolateral direction with open eyes, the intervention group demonstrated a mean value 0.11 units lower than the control group, with an effect size of approximately 23%. This result highlights the effectiveness of VR-based therapy in addressing static balance impairments commonly observed after TKA. The mean velocity of COP is widely utilized in research for analyzing postural control. According to Quijoux, et al. (2017), COP mean velocity, particularly in the anteroposterior direction, is highly reproducible and one of the most commonly used parameters for evaluating the effects of exercise. This parameter is significantly influenced by the aging and balance-related impairments. Individuals with a higher risk of fall risk exhibit notable increases in COP mean velocity, reflecting the detrimental effects of aging and balance deficits on postural stability [ 52 ]. Therefore, the reduction in COP area observed in our study may reflect an improvement in static balance. Similarly, Wang et al. (2021) reported comparable findings, consistent with ours, showing that in the double-leg standing position, the mean velocity showing that in the double-leg standing position, the mean velocity of COP in the anteroposterior direction decreased in TKA patients undergoing VR-based therapy [ 53 ]. Additionally, Duque et al. (2013) demonstrated significant improvements in balance control using VR-based rehabilitation in elderly populations [ 54 ]. Also, Muhammad Kashif et al. (2022) reported a combination VR and motor imagery resulted in improvements in motor function, balance along with enhancing the balance confidence and all these together resulted in improved ADL performance in patients with Parkinson’s disease [ 55 ]. Clark et al. (2017) evaluated static balance indices in the double-leg standing position among 466 TKA patients using the Wii Balance Board [ 56 ]. The study demonstrated that the velocity of COP movement was faster at four weeks post-surgery compared to twelve weeks, indicating reduced balance ability during this timeframe. Similarly, the reduction in mean COP velocity observed in our study is associated with improved balance in TKA patients. Clark suggested that the underlying cause of this phenomenon remains unclear but may be attributed to patients' inability to transfer weight between legs and increased instability during the acute phase. This instability, characterized by faster COP movements, likely results from an inability to maintain COP control [ 56 ]. Similarly, Stan et al. (2013) examined COP displacement during double-leg standing in TKA patients and found that COP values increased post-surgery, reflecting balance impairments [ 57 ]. Age-related proprioceptive deficits, compounded by mechanoreceptor damage during surgery, exacerbate balance challenges in TKA patients [ 58 , 59 ]. Additional factors such as joint destruction, muscle weakness, and reduced range of motion further contribute to postural instability, underscoring the importance of balance-focused rehabilitation programs [ 60 , 61 ]. VR-based therapy may enhance balance through neuromuscular re-education [ 62 ], a concept supported by prior research demonstrating the effectiveness of VR interventions in improving postural stability and motor control [ 63 ]. Neuromuscular re-education achieved via the VR therapy can enhance balance responses in TKA patients by promoting spatial awareness of the body’s COP, thereby facilitating motor awareness and balance improvement [ 64 ]. In individuals with somatosensory impairments and reduced internal feedback—such as those who have undergone TKA—motor control often relies on compensatory mechanisms. Incorporating activities that provide external feedback is therefore highly recommended for rehabilitation, as these activities stimulate afferent signals from muscles and joints, promoting faster recovery. The VR tools offer a practical and effective way to deliver such interventions by providing real-time external feedback, facilitating motor learning and improving postural stability [ 65 ]. Interestingly, our study found that improvements in static balance were limited to the open-eye condition. This aligns with findings by Chiarovano et al. (2017), who highlighted the dependence of older adults on visual input for balance control [ 66 ], and Taglietti et al. (2017), who observed more pronounced balance deficits in TKA patients under open-eye conditions [ 65 ]. These findings underscore the importance of incorporating VR-based therapy into rehabilitation programs to maximize the benefits of visual feedback and enhance postural stability. Limitation and strength This study has several limitations. First, it focused exclusively on static balance tasks, which may not fully capture the comprehensive potential of VR-based therapy. Future research should incorporate dynamic balance tasks to provide a more holistic evaluation of balance and functional mobility. Second, the short follow-up period limited the assessment of long-term effects. Longer follow-up studies are recommended to determine the ability to assess long-term effects. Studies with longer follow-up durations are recommended to evaluate the sustainability of the observed improvements. Third, the single-center design may limit the generalizability of the results, highlighting the need for multi-center studies to validate the results. Finally, advanced analytical methods, such as nonlinear analysis, were not employed in this study. Future research could benefit from these methods to gain deeper insights into the complex mechanisms underlying balance control. Conclusion This study demonstrated that virtual reality-based exercise therapy, when combined with conventional physiotherapy, significantly enhanced knee function, improved static balance, and reduced pain in TKA patients compared to conventional therapy alone. The intervention group exhibited greater improvements across all measured outcomes, highlighting the potential of VR-based therapy as an effective complement to traditional rehabilitation. These findings underscore the importance of incorporating VR-based exercise therapy into early rehabilitation programs for TKA patients to optimize recovery outcomes. Abbreviations OA Osteoarthritis TKA Total knee arthroplasty ROM Range of motion VR Virtual reality USWR University of Social Welfare and Rehabilitation Sciences MCID Minimal clinically important difference WOMAC Western Ontario and McMaster Universities Osteoarthritis Index CONSORT Consolidated Standards of Reporting Trials TENS Transcutaneous electrical nerve stimulation FES Functional electrical stimulation COP Center of pressure NRS Numeric Rating Scale WBB Wii Balance Board ANCOVA Analysis of covariance Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (IR.USWR.REC.1402.024) and in accordance with the 1964 Declaration of Helsinki [clinical trial registry number IRCT20230524058283N1 (10/08/2023)]. Written informed consent was obtained from all participants. Consent for publication Written informed consent for publication was obtained from individuals. Competing interests The authors declare no competing interests. Author details 1 Neuromusculoskeletal Rehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. Clinical Research Development Center, Rofeideh Rehabilitation Hospital, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. Department of Physical Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. 2 Department of Orthopedics, Faculty of medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran. Farhikhtegan Medical Convergence Sciences Research Center, Farhikhtegan Hospital Tehran Medical Sciences, Islamic Azad University, Tehran, Iran. 3 Department of Physical Therapy, Faculty of Allied Medicine, Kerman University of Medical Sciences, Kerman, Iran. 4 Department of Ergonomics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. 5 Department of Chemical Engineering, Amirkabir University of Technology, Tehran, Iran. 6 Department of Mechanical Engineering, Sharif University of Technology, Tehran, Iran. Department of Musculoskeletal Medicine (DAL), Centre Hospitalier Universitaire Vaudois (CHUV), Swiss BioMotion Lab, Lausanne, Switzerland. 7 Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran. Funding This study did not support by any funding. Author Contribution "G.H. and T.R. wrote the main manuscript text and S.M.S. and A.M.Z. and S.H. prepared tables 1-5. Z.M. and A.T. drafted the work and substantively revised it. All authors reviewed the manuscript." Acknowledgement " This article was extracted from Iranian Register of Clinical Trials number IRCT20230524058283N1 (10/08/2023) and the PhD thesis written by Ghazal Hashemi Zenooz, which was supported by the University of Social Welfare and Rehabilitation Sciences. We gratefully acknowledge the individuals who participated in this study." Data availability All data generated or analyzed during this study are included in this published article [and its supplementary information files]. References Kehlet H. Surgery for the elderly is an urgent multidisciplinary challenge. Ugeskr Laeger. 2013;175(41):2394. Moravek M, Matejova J, Spakova T. Soluble and EV-Associated diagnostic and prognostic biomarkers in knee osteoarthritis pathology and detection. Life. 2023;13(2):342. Tudor-Locke CE, Myers AM. Challenges and opportunities for measuring physical activity in sedentary adults. 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Front Psychiatry. 2016;7:164. Ling Y, Ter Meer LP, Yumak Z, Veltkamp RC. Usability test of exercise games designed for rehabilitation of elderly patients after hip replacement surgery: Pilot study. JMIR serious games. 2017;5(4):e7969. Laver KE et al. Virtual reality for stroke rehabilitation. Cochrane database Syst reviews, 2017(11). Jordan M, Richardson EJ. Effects of Virtual Walking Treatment on Spinal Cord Injury–Related Neuropathic Pain: Pilot Results and Trends Related to Location of Pain and at-level Neuronal Hypersensitivity. Am J Phys Med Rehabil. 2016;95(5):390–6. Hoffman HG, et al. Virtual reality as an adjunctive pain control during burn wound care in adolescent patients. Pain. 2000;85(1–2):305–9. Malloy KM, Milling LS. The effectiveness of virtual reality distraction for pain reduction: a systematic review. Clin Psychol Rev. 2010;30(8):1011–8. Fung V, et al. Use of Nintendo Wii Fit™ in the rehabilitation of outpatients following total knee replacement: a preliminary randomized controlled trial. Physiotherapy. 2012;98(3):183–8. Jin C, Feng Y, Ni Y, Shan Z. Virtual reality intervention in postoperative rehabilitation after total knee arthroplasty: a prospective and randomized controlled clinical trial. Int J Clin Exp Med. 2018;11(6):6119–24. Chughtai M, et al. The Role of Virtual Rehabilitation in Total Knee and Hip Arthroplasty. Surg Technol Int. 2018;32:299–305. Quijoux F, et al. A review of center of pressure (COP) variables to quantify standing balance in elderly people: Algorithms and open-access code. Physiol Rep. 2021;9(22):e15067. Wang J, Severin AC, Mears SC, Stambough JB, Barnes CL, Mannen EM. Changes in mediolateral postural control mechanisms during gait after total knee arthroplasty. J Arthroplast. 2021;36(9):3326–32. Duque G, Boersma D, Loza-Diaz G, Hassan S, Suarez H, Geisinger D, Suriyaarachchi P, Sharma A, Demontiero O. Effects of balance training using a virtual-reality system in older fallers. Clinical interventions in aging. Feb. 2013;28:257–63. Kashif M, Ahmad A, Bandpei MA, Gilani SA, Hanif A, Iram H. Combined effects of virtual reality techniques and motor imagery on balance, motor function and activities of daily living in patients with Parkinson’s disease: a randomized controlled trial. BMC Geriatr. 2022;22(1):381. Clark RA, Seah FT, Chong HC, Poon CL, Tan JM, Mentiplay BF, Pua YH. Standing balance post total knee arthroplasty: sensitivity to change analysis from four to twelve weeks in 466 patients. Osteoarthr Cartil. 2017;25(1):42–5. Stan G, Orban H, Orban C, Petcu D, Gheorghe P. The influence of total knee arthroplasty on postural control. Chirurgia. 2013;108(6):874. Jogi P, Zecevic A, Overend TJ, Spaulding SJ, Kramer JF. Force-plate analyses of balance following a balance exercise program during acute post-operative phase in individuals with total hip and knee arthroplasty: A randomized clinical trial. SAGE open Med. 2016;4:2050312116675097. Chan AC, Pang MY, Ouyang H, Jehu DA. Minimal clinically important difference of four commonly used balance assessment tools in individuals after total knee arthroplasty: a prospective cohort study. PM&R. 2020;12(3):238–45. Hadamus A, Białoszewski D, Błażkiewicz M, Kowalska AJ, Urbaniak E, Wydra KT, Wiaderna K, Boratyński R, Kobza A, Marczyński W. Assessment of the effectiveness of rehabilitation after total knee replacement surgery using sample entropy and classical measures of body balance. Entropy. 2021;23(2):164. DiDomenico A, Strang A, McGorry RW. Changes in Postural Sway Related to Age in Adults 18–65 Years Old. ISB: Brussels, Belgium.; 2011. Bragonzoni L, Rovini E, Barone G, Cavallo F, Zaffagnini S, Benedetti MG. How proprioception changes before and after total knee arthroplasty: a systematic review. Gait Posture. 2019;72:1–1. Juras G, Brachman A, Michalska J, Kamieniarz A, Pawłowski M, Hadamus A, Białoszewski D, Błaszczyk J, Słomka KJ. Standards of virtual reality application in balance training programs in clinical practice: a systematic review. Games Health J. 2019;8(2):101–11. Chen HM, Liu CC, Yang SY, Wang YR, Hsieh PL. Factors related to care competence, workplace stress, and intention to stay among novice nurses during the coronavirus disease (COVID-19) pandemic. Int J Environ Res Public Health. 2021;18(4):2122. Taglietti M, Bela LF, Dias JM, Pelegrinelli AR, Nogueira JF, Júnior JP, da Silva Carvalho RG, McVeigh JG, Facci LM, Moura FA, Cardoso JR. Postural sway, balance confidence, and fear of falling in women with knee osteoarthritis in comparison to matched controls. PM&R. 2017;9(8):774–80. Chiarovano E, Wang W, Rogers SJ, MacDougall HG, Curthoys IS, De Waele C. Balance in virtual reality: effect of age and bilateral vestibular loss. Front Neurol. 2017;8:5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 Feb, 2025 Editor assigned by journal 11 Feb, 2025 Submission checks completed at journal 11 Feb, 2025 First submitted to journal 10 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5806312","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":414221016,"identity":"d5b59d03-a30a-49f3-b338-3b1e0206711b","order_by":0,"name":"Ghazal hashemi Zenooz","email":"","orcid":"","institution":"University of Social Welfare and Rehabilitation Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ghazal","middleName":"hashemi","lastName":"Zenooz","suffix":""},{"id":414221018,"identity":"49b00c72-1fbc-49b8-a300-fcda25e8d6d2","order_by":1,"name":"Afshin taheriazam","email":"","orcid":"","institution":"Tehran Medical 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10:39:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1155963,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5806312/v1/766582d2-aabc-4819-8435-82f793b7760d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect of adding virtual reality-based rehabilitation to conventional physiotherapy on pain, functional ability and static balance control in patients with total knee arthroplasty","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOsteoarthritis (OA) is the most prevalent degenerative joint disease in the elderly population, leading to significant impairments, including functional impairments, pain, joint stiffness, and cartilage degeneration [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Beyond physical challenges, OA adversely affects individuals' social, psychological, and emotional well-being and imposes a substantial economic burden on healthcare systems worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Globally, approximately 53% of individuals aged 65 and older experience OA, with the knee joint being the most commonly affected site, accounting for 82.6% of cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe knee joint plays a critical dual role in providing both stability and mobility, making it particularly vulnerable to degenerative changes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Knee OA is associated with symptoms such as joint pain, restricted mobility, impaired balance control, proprioceptive deficits, and overall functional limitations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. When conservative treatments fail to alleviate these dysfunctions, total knee arthroplasty (TKA) emerges as a highly effective therapeutic intervention [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Early physiotherapy is essential following TKA, as it plays a pivotal role in restoring normal function, range of motion (ROM), balance control, and pain reduction [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, enhancing proprioceptive function in the knee joint is vital for improving both static and dynamic balance [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While drug therapies and conventional treatments such as physiotherapy remain standard approaches, the long-term use of medications is often limited by side effects [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Conversely, physiotherapy offers a safer and highly effective means to improve function and balance in these TKA patients [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, virtual reality (VR)-based rehabilitation has emerged as a novel approach that integrates biofeedback and visual inputs to evaluate and correct patient performance in real time during exercises [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The VR therapy engages patients through interactive environments, enhancing their exercise experience with visual, auditory, and tactile feedback [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Studies have shown that combining VR with conventional physiotherapy can improve outcomes in the TKA patients, particularly in reducing pain and enhancing function [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Despite the growing body of research on the VR therapy in the TKA rehabilitation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], findings remain inconsistent. For instance, Jos\u0026eacute; Blasco et al. (2018) reported that the VR therapy was superior to conventional physiotherapy for balance improvements, while other studies suggested that the VR-based physiotherapy did not significantly outperform conventional methods in improving function and reducing pain after the TKA [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Furthermore, Linbo Peng et al. (2022) concluded that although VR-based therapy improved knee function and reduced pain, it failed to demonstrate significant benefits in balance control compared to conventional rehabilitation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Notably, while global studies on the VR therapy for TKA rehabilitation have expanded, no research has yet explored its application in Iran. To our knowledge, this study is the first to investigate the effects of VR-based rehabilitation on functional ability, pain, and balance control in TKA patients in the Iranian population. Therefore, this study aimed to evaluate the effectiveness of integrating VR-based therapy with conventional physiotherapy in improving pain, functional ability, and static balance control during the acute rehabilitation phase following TKA.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThis randomized controlled trial included 52 patients who underwent TKA (11 male, 41 female; mean age: 61.92\u0026thinsp;\u0026plusmn;\u0026thinsp;6.91 years). The study was conducted between October 2023 and May 2024 at the Physical Therapy Research Center, University of Social Welfare and Rehabilitation Sciences (USWR), Tehran, Iran. The sample size was determined based on the minimal clinically important difference (MCID) of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire (5 points), with a 30% allowance for potential dropout. Participants were eligible inclusion if they met the following criteria: aged between 45\u0026ndash;65 years, had undergone unilateral TKA surgery within the past 14 days, and had no post-operative complications. Exclusion criteria included a history of prior surgery or orthopedic disorders in the operated limb, inadequate physical fitness for the intervention, or the presence of neurological or cognitive impairments [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Ethical approval for this study was obtained from the USWR Ethics Committee (IR.USWR.REC.1402.024), and the trial was registered in the Iranian Clinical Trials Registry [clinical trial number IRCT20230524058283N1 (10/08/2023)]. This study matched to all the Consolidated Standards of Reporting Trials (CONSORT) guidelines and reported the required information accordingly [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. A flow diagram of the study methods was demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eInsert\u003c/em\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cem\u003ehere\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eStudy Protocol\u003c/div\u003e \u003cp\u003e All participants provided written informed consent prior to the intervention. Following consent, patients were randomly assigned into either the control or intervention group using block randomization. The control group received 10 sessions of conventional physiotherapy, conducted five times per week over a two-week period, with each session lasting 60 minutes. The intervention group followed the same protocol but with the addition of VR-based therapeutic exercises using Kinect technology [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Both interventions began 2 to 7 days after hospital discharge and were supervised by an experienced physiotherapist specializing in TKA rehabilitation.\u003c/p\u003e\n\u003ch3\u003eControl Group\u003c/h3\u003e\n\u003cp\u003eThe control group participated in a conventional physiotherapy program, aligned with the standard TKA rehabilitation protocol. This program included pain and inflammation management modalities, ROM exercises, and strengthening exercises targeting the quadriceps and associated muscle groups.\u003c/p\u003e\n\u003ch3\u003eElectrotherapy Modalities\u003c/h3\u003e\n\u003cp\u003eEach physiotherapy session began with transcutaneous electrical nerve stimulation (TENS) applied at a frequency of 100 Hz and a pulse duration of 100 ms for 10 minutes to alleviate pain around the suture site. This was followed by functional electrical stimulation (FES) at 50 Hz, targeting specific muscles during the initial phase of therapeutic exercises [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. To address lower limb edema, a lymph drainage device was applied for 12 minutes, complemented by active ankle pumping exercises performed by the patient [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eExercises\u003c/h3\u003e\n\u003cp\u003eDuring the first five sessions, the exercises program focused on basic movements to promote joint mobility and muscle activation. These exercises included ankle pumping, knee extension (performed in supine and sitting positions), knee flexion (in the supine position), and heel raises with walker support. Each exercise was performed under therapist supervision in three sets of 12 repetitions. In the subsequent sessions, the program was progressively advanced to include knee flexion-extension (in the supine position), hamstring curls, step-ups, forward lunges, and modified squats. Patients were instructed to perform all exercises during therapy sessions and to repeat them twice daily at home [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor the intervention group, in addition to the conventional physiotherapy program provided to the control group, VR-based exercises were introduced during the fifth to tenth physiotherapy sessions. The VR-based program utilized the Microsoft Kinect V2 system, a motion sensing platform capable of capturing three-dimensional movements of 25 body joints along the X, Y, and Z axes through its depth sensor [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Patients performed VR-based exercises while standing in front of a monitor displaying their real-time avatar. This interactive setup provided visual feedback, enabling patients to correct errors, such as pelvic tilts or involuntary body bending, under the guidance of the physiotherapist.\u003c/p\u003e \u003cp\u003eThe VR-based exercises protocol included squats, modified lunges, weight-shifting in standing, step-ups and step-downs adjusted to patient capability, one-leg standing with walker support, and sit-to-stand transitions using a walker [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcome measurements\u003c/h2\u003e \u003cp\u003eThe primary outcome of the study was functional ability, assessed using the WOMAC questionnaire. Measurements were conducted at baseline, post-treatment, and at the one-month follow-up. Secondary outcomes included pain intensity and static balance parameters. Pain intensity was evaluated at the same three time points as functional ability, while static balance parameters\u0026mdash;center of pressure (COP) area and mean velocity\u0026mdash;were assessed before and after the treatment.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFunctional ability\u003c/h3\u003e\n\u003cp\u003eFunctional ability, the primary outcome of this study, was assessed using the WOMAC. This standardized questionnaire is specifically designed to evaluate treatment outcomes in patients with OA. The WOMAC index consists of 24 items divided into three subscales: pain (20 points), stiffness (8 points), and physical function (68 points). Patients rate each item on a scale from 0 (none) to 4 (very severe), resulting in a total score ranging from 0 to 100. A score of 0 indicates an asymptomatic individual, while 100 represents maximum severity of symptom [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The Persian version of the WOMAC questionnaire, validated for Persian-speaking patients with knee OA, has demonstrated high reliability and validity [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003ePain intensity\u003c/h3\u003e\n\u003cp\u003ePain intensity was assessed using the Numeric Rating Scale (NRS), a widely used and reliable tool for assessing treatment effectiveness. The reliability of this scale has been established in previous studies [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In this study, a 10 cm horizontal NRS was employed to measure pain levels. Patients indicated their pain by marking a point along the 10 cm line, where 0 represented \"no pain \u0026ldquo;and 10 denoted \"the worst possible pain\" [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBalance control assessment\u003c/h2\u003e \u003cp\u003eBalance control was evaluated using the Nintendo Wii Balance Board (WBB), a validated tool for measuring static balance. The WBB system was wirelessly connected to a laptop via Bluetooth, with raw data processed using Brain Blox software developed by the University of Colorado Boulder [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Key COP parameters, including ellipse area and mean velocity, were calculated. Participants performed a double-leg standing test under two conditions: open eyes and closed eyes. During the test, they stood barefoot with their arms at their sides, focusing on a fixed point located 2 meters away [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Each task lasted 30 seconds, and three trials were conducted with a 60-second rest interval between trials. This protocol has been validated in previous studies [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData normality was assessed using the Shapiro-Wilk test (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), and homogeneity of variances was evaluated with Levene's test. Descriptive statistics were used to summarize the characteristics of the variables. For normally distributed data, parametric tests, including analysis of covariance (ANCOVA), independent t-tests, and paired t-tests, were performed. For non-normally distributed data, the Mann-Whitney U test and Wilcoxon signed-rank test were applied. Bonferroni corrections were used for multiple pairwise comparisons to control for type I error. All analyses were conducted at a significance level of α\u0026thinsp;=\u0026thinsp;0.05, and data were processed using SPSS version 23.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 60 patients were initially enrolled in this study. Of these, 30 patients were randomly assigned to the intervention group (the VR-based therapy combined with conventional physiotherapy) and 30 patients to the control group (conventional physiotherapy only). Eight patients were excluded from the study: two from the intervention group and six from the control group, as they declined to start treatment due to their inability to perform the interventions (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The average age in the intervention group was 61.60\u0026thinsp;\u0026plusmn;\u0026thinsp;6.93 years, while in the control group it was 62.29\u0026thinsp;\u0026plusmn;\u0026thinsp;7.01 years. No significant differences were observed between the two groups in terms of age or Body Mass Index (BMI) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data of the subjects (Mean SD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003csup\u003e2\u003c/sup\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.29\u0026thinsp;\u0026plusmn;\u0026thinsp;7.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.60\u0026thinsp;\u0026plusmn;\u0026thinsp;6.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.39\u0026thinsp;\u0026plusmn;\u0026thinsp;4.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.37\u0026thinsp;\u0026plusmn;\u0026thinsp;4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5males, 19 females\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 males, 22 females\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e1\u003c/sup\u003eBody Mass Index, \u003csup\u003e2\u003c/sup\u003e Independent t-test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eInsert\u003c/em\u003e Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cem\u003ehere\u003c/em\u003e\u003c/p\u003e \u003cp\u003eA repeated measures ANOVA/ANCOVA was performed to analyze the WOMAC scores. The results revealed significant main effects for time (F\u0026thinsp;=\u0026thinsp;219.954, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), group (F\u0026thinsp;=\u0026thinsp;18.393, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and a significant interaction between time and group (F\u0026thinsp;=\u0026thinsp;26.919, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). As the primary outcome, the mean WOMAC index showed a significant reduction in both groups following the interventions (F\u0026thinsp;=\u0026thinsp;3.94, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Moreover, the intervention group demonstrated significantly lower WOMAC scores compared to the control group (t\u0026thinsp;=\u0026thinsp;21.54, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). In the post-intervention stage, the intervention group demonstrated an average WOMAC score that was 17 points lower than the control group, indicating a significant difference between the groups (effect size\u0026thinsp;=\u0026thinsp;36%). During the follow-up phase, the average WOMAC score in the intervention group remained 14 points lower than the control group, with a significant difference observed (effect size\u0026thinsp;=\u0026thinsp;41%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of statistical models fitted for pain, functional score, and mediolateral mean velocity responses\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSource of Variation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF/Wald Statistic*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFunctional score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eRepeated Measures ANOVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e219.954\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTime \u0026times; Group Interaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.919\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.393\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePain intensity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eGeneralized Estimating Equations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e192.070*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTime \u0026times; Group Interaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.282*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.777*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMediolateral mean velocity (standing) with open eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eANCOVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e150.873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMediolateral mean velocity (standing) with closed eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eANCOVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.348\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnterio-posterior mean velocity (standing) with closed eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eANCOVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.696\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCOP area with closed eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eANCOVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.550\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.791\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of pain threshold and functional score between subjects of the two groups in different phases\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIntervention group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c6\" namest=\"c5\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(Mean difference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c8\" namest=\"c7\" rowspan=\"2\"\u003e \u003cp\u003eP-value \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eEffect size\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003efollow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFollow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePain threshold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(1.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47)\u003c/p\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(3.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32)\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;3.25\u003c/p\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;7.18\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFollow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.70\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37)\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(4.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34)\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFunctional Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.50\u0026thinsp;\u0026plusmn;\u0026thinsp;8.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.53\u0026thinsp;\u0026plusmn;\u0026thinsp;10.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(10.98\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75)\u003c/p\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e(31.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45)\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003et= -5.32\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003et=-5.39\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.87\u0026thinsp;\u0026plusmn;\u0026thinsp;14.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.25\u0026thinsp;\u0026plusmn;\u0026thinsp;8.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFollow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.57\u0026thinsp;\u0026plusmn;\u0026thinsp;10.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.50\u0026thinsp;\u0026plusmn;\u0026thinsp;7.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(22.12\u0026thinsp;\u0026plusmn;\u0026thinsp;2.43)\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(40.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.83)\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003csup\u003e1\u003c/sup\u003eP-value for paired t-test; \u003csup\u003e2\u003c/sup\u003eP-value for independent t-test, \u003csup\u003e3\u003c/sup\u003e Before the intervention, \u003csup\u003e4\u003c/sup\u003eAfter the intervention\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePairwise comparison of means for pain and WOMAC using Bonferroni test\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse Variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroups Compared\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean difference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandard error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003eFunctional Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore vs. After\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore vs. Follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter vs. Follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore vs. After\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore vs. Follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter vs. Follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl vs. Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl vs. Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFollow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl vs. Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003ePain threshold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore vs. After\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore vs. Follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter vs. Follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore vs. After\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore vs. Follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter vs. Follow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl vs. Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl vs. Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFollow up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl vs. Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eInsert Tables \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e here\u003c/h2\u003e \u003cp\u003eA Generalized Estimating Equations (GEE) model was used to analyze repeated measures of pain scores, with the Wald test was applied to assess the significance of fixed effects. The analysis revealed significant main effects for time (Wald χ\u0026sup2; = 192.070, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), group (Wald χ\u0026sup2; = 12.777, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and a significant interaction between time and group (Wald χ\u0026sup2; = 31.282, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean NRS scores decreased significantly in both groups following the intervention. In the intervention group, a substantial reduction in NRS scores was observed (t\u0026thinsp;=\u0026thinsp;12.11, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), while the control group also showed a significant, albeit smaller, reduction (t\u0026thinsp;=\u0026thinsp;3.94, P\u0026thinsp;=\u0026thinsp;0.001). Post-intervention, NRS scores were significantly lower in the intervention group compared to the control group, with a notable between-group difference (F\u0026thinsp;=\u0026thinsp;2.46, P\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e \u003cp\u003eThe ANCOVA was performed to evaluate the COP parameters, including area, mediolateral velocity, and anteroposterior velocity, during standing tasks with open and closed eyes. The results indicated significant effects for mediolateral mean velocity in the intervention group (F\u0026thinsp;=\u0026thinsp;15.007, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and baseline scores (F\u0026thinsp;=\u0026thinsp;150.873, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The COP area and mediolateral mean velocity with open eyes significantly decreased in both groups, however, the reduction was significantly greater in the intervention group compared to baseline (t = -3.98, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Additionally, mean velocity in the anteroposterior direction with open eyes significantly decreased only in the intervention group relative to baseline (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No significant changes were observed in static balance parameters under the eyes-closed condition.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of COP area, mean velocity in mediolateral and anterio-posterior direction during double leg stance with open and closed eyes between subjects of the two groups in different phases.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003cp\u003eMann-Whitney Test Statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003cp\u003eWilcoxon*/Paired t-test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEyes open\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCOP\u003csup\u003e1\u003c/sup\u003e area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e \u003cp\u003e1.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61\u003c/p\u003e \u003cp\u003e1.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003et=-1.84\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.07\u003c/p\u003e \u003cp\u003e-1.98\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.28\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-4.37\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean difference\u003c/p\u003e \u003cp\u003e(Before- after)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-0.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(-1.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;4.13\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMediolateral mean velocity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e \u003cp\u003e0.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e \u003cp\u003e0.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;2.57\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.17\u003c/p\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;3.98\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.31\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.92\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnterio-posterior mean velocity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e \u003cp\u003e1.05\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e \u003cp\u003e0.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003et= -2.75\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.39\u003c/p\u003e \u003cp\u003et= -4.89\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.51\u003c/p\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-4.00\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean difference\u003c/p\u003e \u003cp\u003e(Before- after)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-0.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(-0.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003et=-0.86\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEyes closed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOP\u003csup\u003e3\u003c/sup\u003e area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20\u003c/p\u003e \u003cp\u003e0.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22\u003c/p\u003e \u003cp\u003e0.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003et = -1.11\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.27\u003c/p\u003e \u003cp\u003et = -0.95\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMediolateral mean velocity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e \u003cp\u003e1.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.95\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e \u003cp\u003e1.91\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;0.08\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.93\u003c/p\u003e \u003cp\u003et=-0.08\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterio-posterior mean velocity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.35\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e \u003cp\u003e1.28\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e \u003cp\u003e1.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003et = -0.84\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.40\u003c/p\u003e \u003cp\u003et = -1.66\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.026\u003c/p\u003e \u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.721\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: \u003csup\u003e1\u003c/sup\u003eCenter Of Pressure, The Mann-Whitney U test and Wilcoxon test were used for non-parametric variables.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eInsert\u003c/em\u003e Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e \u003cem\u003ehere\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs the primary outcome of this study, functional ability, assessed through the WOMAC index, demonstrated significant improvements with the addition of VR-based therapy. In the intervention group, the WOMAC score decreased by 28.31 points post-treatment (effect size: 0.36) and by an additional 8.75 points during the follow-up period (effect size: 0.41). In comparison, the control group showed reductions of 9.63 points post-treatment and 12.3 points during follow-up. According to Maredupaka et al. (2020), a minimal clinically important difference (MCID) of 5 points on the WOMAC questionnaire indicates clinical significance for knee replacement patients [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In our study, the observed changes exceeded these thresholds, confirming that the VR therapy not only achieved statistical significance but also demonstrated clinical relevance.\u003c/p\u003e \u003cp\u003eDespite these promising results, the effects of VR interventions on pain and functional ability in TKA patients remain a subject of debate due to variations in study designs and assessment procedures. While some studies have demonstrated significant benefits of VR therapy [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], others have reported no considerable improvements [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Similar to our findings, a study investigating the impact of the VR interventions on WOMAC scores in knee OA patients reported that the VR therapy was superior to conventional physiotherapy in improving functional outcomes [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Overall, these findings confirm the efficacy of VR-based therapy in significantly enhancing functional ability in TKA patients compared to conventional physiotherapy.\u003c/p\u003e \u003cp\u003eThe results also showed that pain intensity in the intervention group decreased by 39.7 cm post-treatment and by an additional 0.89 cm during the follow-up phase. In the control group, pain intensity reduced by 1.88 cm after treatment and 0.7 cm at follow-up. Although both groups experienced pain reduction, the decrease was significantly greater in the intervention group. Previous research has established the MCID for pain outcomes in knee joint lesions as 1.61 cm [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The pain reduction observed in this study exceeded this threshold, confirming both statistical and clinical significance. The mechanisms underlying pain reduction and improved functional ability with VR-based therapy may include increased motivation, enhanced adherence to prescribed exercises, and real-time error correction facilitated by therapist supervision and visual feedback [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Unlike conventional physiotherapy, VR-based therapy incorporates active visual feedback in a safe controlled treatment environment that accounts for both physiological and psychological factors. This approach fosters greater patient engagement and cooperation, ultimately leading to improved treatment outcomes [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The therapeutic benefits of VR are largely attributed to its ability to enhance adherence to exercise regimens. Recent findings suggest an adherence rate of approximately 24% among patients consistently following prescribed exercises [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In contrast, virtual-based exercises have been shown to significantly improve adherence rates by offering a more engaging and interactive rehabilitation experience.\u003c/p\u003e \u003cp\u003eA systematic review of 54 studies reported an adherence rate of approximately 89% for exercise therapy involving virtual games, emphasizing VR as a promising tool to enhance patient compliance [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In addition, VR-based rehabilitation may reduce pain by altering pain perception and engaging psychological mechanisms [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. By creating an interactive and immersive environment, VR distracts patients from their pain, a mechanism supported by the \"gate control theory,\" which suggests that attention reduces the transmission of pain signals to the brain. Furthermore, VR activities may stimulate endorphin production, acting as natural painkillers to alleviate discomfort [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Despite its potential, the effects of the VR therapy on pain remain controversial. Some studies have reported no additional benefits of VR-based therapy. For instance, Fung et al. (2012) found that video games using the V-Fit system did not significantly reduce pain compared to conventional physiotherapy in 50 knee replacement patients. The study\u0026rsquo;s focus on balance control and its tele-VR approach may explain these findings [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Similarly, Fuchs et al. (2022) observed limited efficacy in a VR intervention delivered via a headset with a musical film in 55 knee replacement patients. The headset\u0026rsquo;s heaviness and lack of interactive features likely contributed to the lack of significant pain reduction, as both intervention and control groups experienced similar outcomes [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Conversely, other studies have demonstrated the effectiveness of VR-based therapy in reducing pain and improving functional ability. Chi Jin et al. (2018) confirmed that VR-based therapy effectively decreased pain and improved functional ability in TKA patients [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Similarly, a cohort study by Chughtai et al. (2018) involving 157 knee replacement patients reported pain reduction in 66% of cases treated with VR-based interventions. However, the tele-VR method used in that study differed from the approach in our research [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. In addition, a systematic review highlighted VR-based therapy as an effective intervention for improving pain, functional ability, and balance control following TKA, with sustained benefits observed at 3 and 6 months post-surgery [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Peng et al. (2021) similarly reported that VR was significantly more effective than conventional physiotherapy in reducing pain within the first month after surgery [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor balance assessment, we used the double-leg standing test under two conditions: open and closed eyes. This test is widely recognized as a reliable and valid measure for assessing balance in TKA patients and has consistency demonstrated reproducibility in its application [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Our findings revealed that VR-based therapy significantly improved static balance in TKA patients. Parameters such as mean velocity in the mediolateral direction and COP area during standing decreased significantly in both groups, with a more pronounced reduction observed in the intervention group. Specifically, for mean velocity in the mediolateral direction with open eyes, the intervention group demonstrated a mean value 0.11 units lower than the control group, with an effect size of approximately 23%. This result highlights the effectiveness of VR-based therapy in addressing static balance impairments commonly observed after TKA. The mean velocity of COP is widely utilized in research for analyzing postural control. According to Quijoux, et al. (2017), COP mean velocity, particularly in the anteroposterior direction, is highly reproducible and one of the most commonly used parameters for evaluating the effects of exercise. This parameter is significantly influenced by the aging and balance-related impairments. Individuals with a higher risk of fall risk exhibit notable increases in COP mean velocity, reflecting the detrimental effects of aging and balance deficits on postural stability [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Therefore, the reduction in COP area observed in our study may reflect an improvement in static balance. Similarly, Wang et al. (2021) reported comparable findings, consistent with ours, showing that in the double-leg standing position, the mean velocity showing that in the double-leg standing position, the mean velocity of COP in the anteroposterior direction decreased in TKA patients undergoing VR-based therapy [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Additionally, Duque et al. (2013) demonstrated significant improvements in balance control using VR-based rehabilitation in elderly populations [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Also, Muhammad Kashif et al. (2022) reported a combination VR and motor imagery resulted in improvements in motor function, balance along with enhancing the balance confidence and all these together resulted in improved ADL performance in patients with Parkinson\u0026rsquo;s disease [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClark et al. (2017) evaluated static balance indices in the double-leg standing position among 466 TKA patients using the Wii Balance Board [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. The study demonstrated that the velocity of COP movement was faster at four weeks post-surgery compared to twelve weeks, indicating reduced balance ability during this timeframe. Similarly, the reduction in mean COP velocity observed in our study is associated with improved balance in TKA patients. Clark suggested that the underlying cause of this phenomenon remains unclear but may be attributed to patients' inability to transfer weight between legs and increased instability during the acute phase. This instability, characterized by faster COP movements, likely results from an inability to maintain COP control [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Similarly, Stan et al. (2013) examined COP displacement during double-leg standing in TKA patients and found that COP values increased post-surgery, reflecting balance impairments [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Age-related proprioceptive deficits, compounded by mechanoreceptor damage during surgery, exacerbate balance challenges in TKA patients [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Additional factors such as joint destruction, muscle weakness, and reduced range of motion further contribute to postural instability, underscoring the importance of balance-focused rehabilitation programs [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVR-based therapy may enhance balance through neuromuscular re-education [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e], a concept supported by prior research demonstrating the effectiveness of VR interventions in improving postural stability and motor control [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Neuromuscular re-education achieved via the VR therapy can enhance balance responses in TKA patients by promoting spatial awareness of the body\u0026rsquo;s COP, thereby facilitating motor awareness and balance improvement [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. In individuals with somatosensory impairments and reduced internal feedback\u0026mdash;such as those who have undergone TKA\u0026mdash;motor control often relies on compensatory mechanisms. Incorporating activities that provide external feedback is therefore highly recommended for rehabilitation, as these activities stimulate afferent signals from muscles and joints, promoting faster recovery. The VR tools offer a practical and effective way to deliver such interventions by providing real-time external feedback, facilitating motor learning and improving postural stability [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterestingly, our study found that improvements in static balance were limited to the open-eye condition. This aligns with findings by Chiarovano et al. (2017), who highlighted the dependence of older adults on visual input for balance control [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e], and Taglietti et al. (2017), who observed more pronounced balance deficits in TKA patients under open-eye conditions [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. These findings underscore the importance of incorporating VR-based therapy into rehabilitation programs to maximize the benefits of visual feedback and enhance postural stability.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitation and strength\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, it focused exclusively on static balance tasks, which may not fully capture the comprehensive potential of VR-based therapy. Future research should incorporate dynamic balance tasks to provide a more holistic evaluation of balance and functional mobility. Second, the short follow-up period limited the assessment of long-term effects. Longer follow-up studies are recommended to determine the ability to assess long-term effects. Studies with longer follow-up durations are recommended to evaluate the sustainability of the observed improvements. Third, the single-center design may limit the generalizability of the results, highlighting the need for multi-center studies to validate the results. Finally, advanced analytical methods, such as nonlinear analysis, were not employed in this study. Future research could benefit from these methods to gain deeper insights into the complex mechanisms underlying balance control.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrated that virtual reality-based exercise therapy, when combined with conventional physiotherapy, significantly enhanced knee function, improved static balance, and reduced pain in TKA patients compared to conventional therapy alone. The intervention group exhibited greater improvements across all measured outcomes, highlighting the potential of VR-based therapy as an effective complement to traditional rehabilitation. These findings underscore the importance of incorporating VR-based exercise therapy into early rehabilitation programs for TKA patients to optimize recovery outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOsteoarthritis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTKA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTotal knee arthroplasty\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eROM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRange of motion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVirtual reality\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSWR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversity of Social Welfare and Rehabilitation Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMCID\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinimal clinically important difference\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWOMAC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWestern Ontario and McMaster Universities Osteoarthritis Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCONSORT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConsolidated Standards of Reporting Trials\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTENS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTranscutaneous electrical nerve stimulation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFunctional electrical stimulation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCenter of pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNumeric Rating Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWBB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWii Balance Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANCOVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnalysis of covariance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (IR.USWR.REC.1402.024) and in accordance with the 1964 Declaration of Helsinki [clinical trial registry number IRCT20230524058283N1 (10/08/2023)]. Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from individuals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eAuthor details\u003c/h2\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eNeuromusculoskeletal Rehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. Clinical Research Development Center, Rofeideh Rehabilitation Hospital, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. Department of Physical Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. \u003csup\u003e2\u003c/sup\u003eDepartment of Orthopedics, Faculty of medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran. Farhikhtegan Medical Convergence Sciences Research Center, Farhikhtegan Hospital Tehran Medical Sciences, Islamic Azad University, Tehran, Iran. \u003csup\u003e3\u003c/sup\u003eDepartment of Physical Therapy, Faculty of Allied Medicine, Kerman University of Medical Sciences, Kerman, Iran. \u003csup\u003e4\u003c/sup\u003eDepartment of Ergonomics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. \u003csup\u003e5\u003c/sup\u003eDepartment of Chemical Engineering, Amirkabir University of Technology, Tehran, Iran. \u003csup\u003e6\u003c/sup\u003eDepartment of Mechanical Engineering, Sharif University of Technology, Tehran, Iran. Department of Musculoskeletal Medicine (DAL), Centre Hospitalier Universitaire Vaudois (CHUV), Swiss BioMotion Lab, Lausanne, Switzerland. \u003csup\u003e7\u003c/sup\u003eDepartment of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study did not support by any funding.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003e\u0026quot;G.H. and T.R. wrote the main manuscript text and S.M.S. and A.M.Z. and S.H. prepared tables 1-5. Z.M. and A.T. drafted the work and substantively revised it. All authors reviewed the manuscript.\u0026quot;\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003e\u0026quot; This article was extracted from Iranian Register of Clinical Trials number IRCT20230524058283N1 (10/08/2023) and the PhD thesis written by Ghazal Hashemi Zenooz, which was supported by the University of Social Welfare and Rehabilitation Sciences. We gratefully acknowledge the individuals who participated in this study.\u0026quot;\u003c/p\u003e\n\u003ch2\u003eData availability\u003c/h2\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKehlet H. Surgery for the elderly is an urgent multidisciplinary challenge. Ugeskr Laeger. 2013;175(41):2394.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoravek M, Matejova J, Spakova T. 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Front Neurol. 2017;8:5.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Virtual Reality, Total Knee Arthroplasty, Postural Control, Pain Intensity","lastPublishedDoi":"10.21203/rs.3.rs-5806312/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5806312/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePhysiotherapy in patients with total knee arthroplasty (TKA) is necessary to reduce pain, return to daily activities, and maintain balance. Today, virtual reality (VR) is being used to provide real-time visual feedbacks during the exercise. Hence, aim of the present study was to evaluate the effect of adding virtual reality-based therapy in comparison to conventional physiotherapy on the pain, functional ability, and static balance in the acute phase after TKA.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFifty-two patients who underwent TKA (11male, 41 female, mean age 61.92\u0026thinsp;\u0026plusmn;\u0026thinsp;6.91 years) were randomly assigned into two groups: a control group (n\u0026thinsp;=\u0026thinsp;24) and an intervention group (n\u0026thinsp;=\u0026thinsp;28). The control group received conventional physiotherapy, whereas the intervention group participated in a combination of VR-based therapy and conventional physiotherapy. The primary outcome was functional ability, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes included pain, measured using the Numeric Rating Scale (NRS), and static balance, assessed with the Wii Balance Board. Static balance control was evaluated using center of pressure (COP) parameters, including COP area and mean velocity, under two conditions: open eyes and closed eyes. Pain and functional ability were evaluated at baseline, post-treatment, and at the one-month follow-up. Static balance measurements were taken at baseline and post-treatment.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe intervention group demonstrated significant improvements compared to the control group. The WOMAC scores and pain levels showed greater reductions at both the post-treatment and follow-up phases (effect size [ES]\u0026thinsp;=\u0026thinsp;36%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The static balance parameters improved in both groups; however, the intervention group exhibited significantly greater reductions in COP ellipse area in the standing position (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and mean velocity in the mediolateral direction (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, ES\u0026thinsp;=\u0026thinsp;23%). Additionally, anteroposterior mean velocity with open eyes decreased significantly only in the intervention group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant changes were observed in static balance parameters under the eyes-closed condition.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study demonstrated that VR-based exercise therapy significantly improved knee function, static balance, and pain management in TKA patients during early rehabilitation. The intervention group exhibited superior improvements compared to the control group, highlighting the effectiveness of integrating VR-based therapy with conventional physiotherapy. These findings suggest that this combined approach can optimize recovery and improve rehabilitation outcomes in the early phase following TKA.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eThe study was retrospectively registered in the Iranian Clinical Trials Registry with the number IRCT20230524058283N1.\u003c/p\u003e","manuscriptTitle":"The effect of adding virtual reality-based rehabilitation to conventional physiotherapy on pain, functional ability and static balance control in patients with total knee arthroplasty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-20 10:07:02","doi":"10.21203/rs.3.rs-5806312/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-11T12:29:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-11T10:53:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-02-11T05:52:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-01-10T21:11:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2e7ce84b-9ad5-4024-926f-74c637ca42db","owner":[],"postedDate":"February 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T13:23:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-20 10:07:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5806312","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5806312","identity":"rs-5806312","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}