PROFORMA FOR REGISTATION OF SUBJECTS

FOR DISSERTATION

DISSERTATION PROPOSAL

Topic:-

“A STUDY ON EFFECTIVENESS OF INTENSIVE FUNCTIONAL REHABITATION VS STANDARD PHYSIOTHERAPY CARE ON FUNCTIONAL ABILITY AND QUALITY OF LIFE AFTER FIRST TOTAL KNEE ARTHROPLASTY”

-Comparative study

SUBMITTED BY

SANOOP C. K

1 year MPT[2009-10 Batch]

ShrideviCollege of Physiotherapy

Tumkur-572106

RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCE

BANGALORE

ANNEXURE-11

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS / SANOOP.C.K
MPT -1 ST YEAR, SHRIDEVICOLLEGE OF PHYSIOTHERAPY LINGAPURA, SIRA ROAD, TUMKUR -572106
2 / NAME OF THE INSTITUTION / SHRIDEVICOLLEGE OF PHYSIOTHERAPY, TUMKUR
3 / COURSE OF STUDY AND SUBJECT / IST YEAR MPT –[MUSCULOSKELETAL DISORDER AND SPORTS PHYSIOTHERAPY]
4 / DATE OF ADMISSION TO COURSE / 08/06/2009
5 / TITLE OF THE STUDY / “A STUDY ON EFFECTIVENESS OF INTENSIVE FUNCTIONAL REHABITATION VS STANDARD PHYSIOTHERAPY CARE ON FUNCTIONAL ABILITY AND QUALITY OF LIFE AFTER FIRST TOTAL KNEE ARTHROPLASTY”
-Comparative study

6. BRIEF RESUME OF INTENDED WORK

INTRODUCTION

The knee joint is the largest weight bearing joint and consist of the lower end of the thigh bone (Femur) which rotates on the upper end of the shin bone (Tibia) and the knee cap (Patella), which slides in a groove on the end of the thigh bone ,knee joint is commonly known as hinge joint.1

The knee joint's main function is to bendand straighten. The knee more than just a simple hinge, however ,also twist and rotates .In order to perform all of these action and to support the enter body while doing so, the knee relies on a number of structures like bone, ligament , tendon and cartilage.2

Knee pain is the most common musculoskeletal complaint that brings people to their doctor with today's increasingly active society, the number of knee problem is increasing knee pain has a wide variety of specific cause and treatments.3

The most common reason for the knee pain is Osteoarthritis. Osteoarthritisin the knee occurs when the articular cartilage becomes damaged or wastes away through natural wear and tear. The damage to the cartilage in one or more compartments of the knee joint can be caused by various conditions Including Osteoarthritis and Inflammatory Arthritis.4

Total Knee Replacement is the treatment of choice and it is considered when other non-surgical method of treatments like activity modification, weight loss, medication and injection have failed to relieve arthritis associated knee pain. Candidates for Total Knee Replacement should also have x-ray evidenceof advanced arthritic changes to the knee. 5

Total Knee Replacement is an effective surgery, replacing all three of the knee's compartments and replaced by the new artificial joints called prostheses. Both cemented and cement less designs are used to hold the Prostheses in place.6

Total Knee Replacement or Total Knee Arthoplasty is one of the most commonly performed orthopedic procedures, in the world. It is the successful operation for Knee Pain and disability.7

Thefirst Total Knee Replacement was performed in 1968. The Procedure is one of the most important orthopedic surgical advances of the 20th century. Every year in the US alone, more then 300,000 Knee replacements are Performed and the number expected to increase 52.5 % by the year 2030 according to March, 2008.8

The Post Operative Management after the Total Knee Replacement includes controlling pain with Intravenous or Oral medication. Many joint Replacement patients are given “Patient Controlled analgesics’’.Patients are also given an antibiotic.9

Physical therapy is an important Part of the recovery and rehabilitation Process. Patients should work with a Physical Therapist to develop an exercise and rehabilitation program.10

The Rehabilitation Program generally includes Exercises to improve range of motion, Gait training, Quadriceps Strengthening Training in activities of daily life,activities to improve the quality of life and functional of ability of patients .11

The Specific Intensive Functional Rehabilitation Program is fully functional oriented, aimed to improve the Functional Ability and Quality Of Life of Patients after first Total Knee Arthropasty.12

6.1NEED FOR THE STUDY

ntended Workfo coursesiotherapysculoskeletal LORE-411 Tumkur- Shridevi College of Pgysiotherpyed Rehab, Vol 85, ATotal Knee Replacement is one of the most common orthopedic Procedures performed and is a past of great medical success stories of the Second half of the 20th Century. It has matured from less reliable procedure to a established, generally accepted medical intervention with predictable results.13

In 2001, there is 1, 71,335 Primary Knee replacements and 16,895revisions were Performed. Each year more than 3,50,000 adults elect to have Total Knee Replacement Surgery to eliminate Knee Pain and associated disabilities that persist despite ample medical treatment. The prevalence of arthritis is expected to grow substantially as the Population ages. Common problems of people who undergo Total Knee replacement Surgery include Osteoarthritis, Rheumatoid Arthritis, and Sudden or Gradual Joint Injury.14

Total Knee Replacement is now a routine operation unlike Hip Replacement, Knee Replacement demands a lot of the patient in terms of effort. The patients have to put up with more pain, and swelling, do far more exercising for far longer.15

But most of the people undergo Total Knee Replacement surgery experience immediate and significant decrease in pain improved joint function and increased physical activity.16

The end result should be a painless and movable knee which the patient can use quite normally in daily life. The treatment of the diseased Knee Joint does not end with surgical treatment. Once the operation has been done, the work has only just begun17

The ultimate goal is ensuring pain free function of the joint to improve thepatient’squality of life. Post operative rehabilitation is of the almost importance.18

Standardized physical therapy exercises to the main muscular groups around the knee are very important both before and after having total knee replacement. Some exercises are for the initial period immediately after theoperation and many more could be appropriate later. The specific Intensive functional rehabilitation program aimed to improve the functional ability of the patient and to improve the quality of life.19

However not all people undergo Total Knee Replacement Surgery report improvement, and there is no one factor that contributes to this variation in functional gain. With the rapid growth in the number of electingto have Total Knee Replacement and in the number of candidate eligible for Total Knee Replacement, optimal surgical results, functional ability and better out come of quantity of life are both a major clinical and public health priority.20

Thus this study is very much needed to find out the efficiency ofIntensive Functional Rehabitation on Functional ability and Quality Of Life alters Total Knee Arthoplasty.”21

6.2 OBJECTIVES OF THE STUDY:

  1. To finds out the efficacy of the Intensive Functional Rehabilitation onimproving functional ability and quality of life after Total Knee Arthroplasty.
  1. To find out the efficacy of the Standard Physical therapy Care on improving functional ability and quality of life after Total Knee Arthroplasty
  1. To Compare the efficacy of the Intensive Functional Rehabilitation vs Standard Physical therapy care on improving Functional ability and Quality of life after Total Knee Arthroplasty.

6.3 HYPOTHESIS

(1). Null Hypothesis:-

There is no Significant difference exists between the efficacy of the Intensive Functional Rehabilitation and Standard Physical Therapy Care on improving functional ability and quality of life after Total Knee Arthroplasty.

(2). Alternate Hypothesis:-

There is Significant difference exists between the efficacy of the Intensive Functional Rehabilitation and Standard Physical Therapy Care on improving functional ability and quality of life after Total Knee Arthroplasty.

6.4 REVIEW OF LITERATURE :-

(1). Skinner. B et. al

The Total Knee Replacement Surgery replaces the diseased Knee joint and eliminates the damaged bearing Surfaces that are Causing Pain. Overall there are three benefits from the Knee replacement. are elimination of Pain, improved motion and Minimum wear and tear.20

(2). Walsh. Met. al

Total JointReplacement or Arthroplasty represents a significant advance in the treatment of Painful and disabling joint Pathologies. Total Joint Replacements can be performed on any joints of the body. But the Knee replacement is the most Common one. In 2004, 4, 78,000 Total Knee replacements were Performed in the U.S.21

(3). Petty Netal

Total Knee Replacement Surgery is a method to replace a damaged or worn Knee joint with an artificial joint (Prosthesis). The medical term for this type of Surgery is “Arthroplasty”.22

(4). Tierney NM etal

Osteoarthritis resulting from “wear and tear” is most Common reason individuals need to undergo Knee Replacement Surgery. Generally a Person would be considered for a total Knee replacement.If the individual experience daily pain, restricting not only work and recreation, but also the ordinary activities of daily living.23

(5) Katz’s D.S etal

The Knee absorbs joint reactive load over a thick cartilage. In degenerative Arthritis,which is the condition most commonly necessitating Total Knee Replacement.24

(6) Linton’s etal

Total Knee Replacement (TKR) is orthopedic procedures for the treatment of severe Arthritis. A successful Total Knee Replacement outcome depends on severe factors; correct alignment of the lower limb during loading stress, proper medical care and most importantly the effective the Functional Rehabitation Program.25

(7) Coyote P etal

The 6-Minute Walk Test (6MWT) is an adequate measure of physical function and Locomotor ability by subjects with disability. It was chosen as the primary outcome measure because ofits sound measurement properties and especially because of its excellentresponsiveness, which is known to increase over time in persons with Total Knee Arthoplasty.26

(8). Hageman B etal :-

The WOMACOsteoarthritis Index is a disease Specific Questionnaire developed Specifically for People with Osteoarthritis of the Hip and Knee. The WOMAC questionnaire is reliability and responsiveness.27

(9). Rebecca Boardman etal

Exercisingthe Knee and Leg muscles following Surgery is extremely important to the success of the Total Knee Replacement. Exercisesaim to quickly regain increasing motion in the Knee following Surgery, Prevent muscle loss, which is inevitable after Surgery, rebuild the muscle strength and prevent Stiffness of the new Knee joint. 28

(10). Roddy E etal

After any major Surgery such as Total knee Replacement, one of the Patient’s Prime concerns is regaining function and mobility.Exercises have been found to be beneficial for wound healing and also for more Complete and quickes recovery of mobility and function.29

(11). Freund DA. etal

The study results show that the exercise healed fasts after the TKR Surgery than the non-exercisers group. They reasoned that exercises increase circulation, and that fact alone would improve the flow of nutrients to the wound site and the flow of wastes away from it.30

(12)Moffat B etal

In a study to evaluate the effectiveness of new Intensive Functional Rehabitation (IFR) Program in persons who underwent a first TKA, 77 People with O.A were selected randomly and assigned to either a group with IFR (N=38) who received 12 sessions combined with exercises at home between 2-4 months after TKA or a control group(N=39) who received standard care. The result shows, subjects in the IFR group walked longer distance in 6 minutes than the Control group. So the Intensive Functional Rehabilitation was effective in improving the functional ability after uncomplicated Primary Total Knee Arthoplasty.

7. MATERIALS AND METHODOLOGY

7.1 Sources of Data

  • ShrideviHospital, Tumkur.
  • Govt.Dist.Hospital, Tumkur.

7.2 Method of Collection of Data

7.2.1 Sample design

  • The samples are selected by using purposive Random Sampling technique.

7.2.2 Study design

  • This study is a comparative study with pre test and post test

design.

7.2.3 Sample Size

The Sample size consists of 30 Osteoarthritis samples that underwent Primary Total Knee Arthroplasty were selected and were assigned into two groups with 15 subjects each.

  • Experimental group 1:- Consist of 15 subjects who underwent Primary Total Knee Replacement Surgery, to be treated with Intensive Functional Rehabilitation.
  • Experimental group-2:- Consist of 15 subjects who underwent primary Total Knee Replacement Surgery to be treated with Standard Physiotherapy care.

7.3 Selection Criteria

(A). Inclusion Criteria

  • Subjects with x-ray evidence of advanced O.A changes to the Knee
  • Both genders
  • Age group of between 40-60 yrs
  • Primary Total Knee Replacement subjects
  • Subject with stable Knee joint.
  • Subjects with <100 kg body weight.

(B) Exclusion Criteria

  • Subjects with fractured knee
  • Subjects with uncontrolled diabetes,lung,kidney or other systemic disease.
  • Subjects with severe paralysis of muscles around knee.
  • Subjects with dementia or cognitive impairment as unable to provide informed content..
  • Subjects with severe circulatation problem in the extremity.
  • Badly motivated subjects.
  • Subjects with Revision Total Knee Replacement

7.4 Duration of the study.

  • 2 months duration for each subject.

7.5 Measurement Tools

  • 6 Minute Walk Test (6MWT)
  • WOMAC-Osteoarthritis Index.

7.6 PROCEDURE

A. TREATMENT PROCEDURE FOR EXPERIMENTAL GROUP-I

Intensive functional rehabitation program

Warm-upand stretching exercises (5-10min)

1.Global flexion-extension of the lower limb. 2. Alternated dorsal plantar flexion of the ankles. 3. Stretching of the hamstrings. 4. Mobility exs of the neck, upper limbs and back.

Specific strengthening exercises (15min)

1.ISOM knee extensors; flex 0 2.ISOM knee extensors;flex 60 3.ISOM hamstrings flex 60 4.CONC-ECC hipabductors

Functional task-oriented exercises (15-20min)

1. Get up and sit down. 2. Knee extensor strengthening in standing with Headband. 3. Controlled bilateral knee flexions-extension in standing. 4. Unilateral knee flexion to 90 in standing. 5. Climbing on a platform or a flight of stair case. 6.Walking backward, on a slope and/or laterally crossing lower

limbs. 7. Walking implace,with large amplitude of hip and knee flexion

and upper-limb movements.

D) Endurance exercises (5-20min)

1.Walking 2.Stationary cycling

E)Cool down(10min)

1.Slow walking 2.Stretching exs 3.Ice

B. TREATMENT PROCEDURE FOR EXPERIMENTAL GROUP. II

Standard physiotherapy exercises

Standard exercises that are used for early postoperative knee

Replacement include -

A) Quadriceps setting B) Terminal knee extension C) Heels slides D) Straight leg raising E) Pillow squeezes.

1) ‘Q’Setting

  • Tighten the 2 – muscle while pushing the back of the knee downward into the bed.
  • Hold this muscle contraction for 4-5 sec, relax for a short period of time and repeat 10-20 times, for each leg.

2) Terminal Knee Extension.

  • Tighten the ‘Q’-muscle and straighten the knee by lifting the heel off the bed.
  • Hold this muscle contraction for 5-10sec, then to slowly lower the heel to the bed.

3) Heel Slides(knee flex)

  • Slide the front of the surgical limb toward the buttock to a point where a mild stretch is felt.
  • Hold this position to a consist of ten then slowly return to the starting position.

(4) SLR

  • Bend the uninvolved leg by raising the knee and keeping the foot flat on the bed.
  • While keeping the involved leg straight, raise the straightened leg about 10inches off the bed.
  • Hold this position for 5-10 seconds then lower the lower the leg slowly to the bed and repeat 10-20 sec.

5) Pillow squeeze

  • Place a pillow between knees.
  • Next sequence the pillow and hold for a count of ten.
  • Relax for a short period time and repeat this exercise 10-20 times.

Statistical Test

Statistical tests are used to compare the efficiency of experimental group-1 and experimental group 2. The statistical test to be used in this study are

  • Mean, Standard Deviation
  • Paired and Unpaired t.- test
  • Man-whitney Test
  • Wilcoxon’s Test

7.7 Does the study require any investigation or Intervention to be conducted on patient or other human or animals? If so, please describe briefly.

Yes. This study requires intervention like Intensive Functional Rehabitation and standard Physiotherapy exercise, to be given in subjects who underwent Total knee Arthroplasty.

7.8 Ethical clearance

The study will be conducted after the approval of research committee of the college .Permission will be obtained from the head of the institution The purpose and details of the study will be explained to the study subjects and assurance will be given regarding confidentiality of the data collected.

8.8 List of Reference

1) Saunas Tarasevicius, Otto Robertson;. “Introduction of Total Knee Arthoplasty,”Dep. Of orthopedics, kuakas medical university , kuakas, Sweden; val-so,Issue1 February 2009.page 51-54.

2)Rand JA;Trousadate RT;IlstonpDM;Patient information J.Bone Joint surg Am 2003,feb ; 85-A(20):259-65

3) Gs;Joshi AB; “Long term results of commentedTotal Knee Arthoplasty in Osteoarthritis”; An J knee surg 2001 fall :14(4):209-14

4) Kirwan JR; currey HL ; Freeman MA; “overall long term impact of total knee joint replacement surgeryon patients with Osteoarthritis”Br J Rheumatol 1994 Apr;33(4):357-60

5) Cockerel John R;James L Guyton “Arthroplasty of Knee”; 11th ed Philadelphia; Mosey Elsevier,2008

6) Palmer,Simon H and Mervyn J cross “Total Knee Arthroplasty”. eMedicineEds30Jan2004.Medscape.

7) Ranawat.c.s.A.S. Ranawat and A. Mehta “Total Knee Arthoplasty Rehabitation Protocol. What makes the Difference?”. Journal of Arthoplasty 18-3.suppl 1 (2003):27-30.

8) Dr.Charles clark; Dr.Cecil;Primary Knee Replacement:Management and Alternatives;(1) 1994-2009 by medscape; medscape orthopedic and sports medicine e.jousn.2004:4(2).

9) Robert .V.I;A fifteen year follow-up study of 4606 primary Total Knee Replacement. Jon of Bone and Joint Surgery-British; vol 89-B’Issue-11,1452-1456.

10)Kane Rt’wilt TJ;Total Knee Replacement. Evidence Report/ Technology Assessment. No-86.AHRQ publication No:04-E 006-1.

11). Asim Baykan . MD ; Curbside Consulation in Knee Arthroplasty : 49 clinical question ; J. Sports Science and medicine (2008) 7, 566.

12). Leopold SS. Minimally Invasive Total Knee Arthroplasty for

Osteoarthritis ; N Engl J. Med. 2009 Apr 23;36o (17) ; 1749-58.

13). M.D. Daniel ; J. Brugioni ; Total Knee Replacement and