Curriculum Development Cell
Registration No. / :
Name of the Candidate / : Ms. Khushbu V Fadadu
Address / : SDM College of Physiotherapy,
Manjushree nagar, sattur. Dharwad
Name of the Institution / : SDM College of Physiotherapy, Dharwad
Course of Study and Subject / : MPT (Masters In Musculoskeletal Disorders
And Sports)
Date of Admission to Course / : 29/05/2012.
Title of the Topic / : TO COMPARE THE EFFECT OF MULLIGAN’S MOBILIZATION WITH MOVEMENT VERSUS LATERAL WEDGE INSOLE WITH SUB TALAR STRAPPING IN MEDIAL COMPARTMENT OSTEOARTHRITIS KNEE.
Brief resume of the intended work / : Attached
Signature of the Student / :
Guide Name / : Dr. Poornima P Sankanagoudar
Remarks of Guide
Signature of the Guide / : Recommended for registration
:
Co-Guide Name / :
Signature of the Co-Guide / :
HOD Name / : Mr. Ravi Savadatti
Signature of the HOD / :
Principal Name / : Mr. Ravi Savadatti
Principal Mobile No. / : 09845051209
Principal E-mail ID
Remarks of Principle
Signature of Principal / :
: Recommended for registration
:
A) / BRIEF RESUME OF THE STUDY :
Introduction:
Osteoarthritis (OA) is a chronic degenerative disorder of multi factorial etiology characterized by loss of articular cartilage, hypertrophy of bone at the margins, subchondral sclerosis and range of biochemical and morphological alterations of the synovial membrane and joint capsule. Typical clinical symptoms are pain, particularly after prolonged activity and weight bearing; whereas stiffness is experienced after inactivity.1Primary osteoarthritis is mostly related to aging. It can present as localized, generalized or as erosive osteoarthritis. Secondary osteoarthritis is caused by another disease or condition.1 Osteoarthritis is the second most common diagnosis made in older people, and the commonest cause of disability at older ages.2 Knee OA is more common among women than men.3
The Chingford study documented a 12% prevalence of radiologic knee OA and a 6% prevalence of symptomatic knee OA in women aged 45–64 years.1 Above the age of 55, radiographic knee osteoarthritis is an increasingly common cause of knee pain.2
Osteoarthritis of the knee affects approximately 6% of adults 30 years of age and older and 11% of adults 65 years of age and older, and it accounts for more disability in the elderly than any other disease.3 In India, the prevalence of knee osteoarthritis is 10.20%.4
The most common associated risk factors for development of osteoarthritis of the knee are obesity, menopause in women, history of OA, and previous knee injury. Several studies have found that increasing age and Body Mass Index (BMI) have positive correlation with the development of knee osteoarthritis.4
More recently it has become apparent that OA is a disease process that affects the entire joint structure, including cartilage, synovial membrane, subchondral bone, ligaments and periarticular muscles. This ultimately results into inflammation, pain and structural damage leading to loss of function.1
Clinical classification criteria for knee osteoarthritis:
Knee Pain, Joint Stiffness <30 minutes ,Crepitus, Bony enlargement, Bony tenderness,
No palpable warmth.18
OA is graded on the basis of X ray findings. Kellgren and Lawrence also defined a widely utilized grading system for radiographic evidence of knee OA.
• Grade 1: doubtful narrowing of joint space and possible osteophytic lipping
• Grade 2: definite osteophytes, definite narrowing of joint space
• Grade 3: moderate multiple osteophytes, definite narrowing of joint space, some
sclerosis and possible deformity of bone contour
• Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosis and
definite deformity of bone contour.4,5
Patients with knee OA usually show major involvement in only 1 compartment, with the medial compartment involved nearly 10 times more often than the lateral compartment. One of the first conservative treatments for patients with medial compartment knee OA is an inserted lateral wedged insole.3
Anatomically, the medial compartment has thinner articular cartilage than the lateral compartment and receives less protection from the medial meniscus. Mechanically, functional activities such as gait and stair climbing oblige the medial compartment to bear greater loads than the lateral compartment. The relatively high medial compartment load is due to the fact that the line of force acting at the foot passes medial to the knee joint center during gait.6
During walking, the normal forces acting on the leg produce a varus torque (i.e. a torque tending to adduct the knee into varus). This varus torque is directly associated with the compressive force across the medial aspect of the knee, which is nearly 2.5 times the force through the lateral aspect of the knee.6
Along with mechanical factors, one important contributory cause of medial compartment knee OA is a pre-existing varus deformity of the ipsilateral lower leg, which can produce abnormal force concentrations across the knee. The aim of wedged insoles in medial knee OA is to reduce the load on the medial joint surface (as opposed to forcing the lateral joint surface to receive the load).7
Many treatment programs have been developed, including medication with non steroidal anti-inflammatory drugs, physical modalities, and therapeutic exercises. Common physiotherapy treatments are exercise, taping, bracing, insoles and shoes and manual therapy.8
If conservative therapy, such as use of an insole, can provide a low-cost, effective complement or alternative to surgical treatment, it will be useful for patients and the health care economy.3
The majority of the studies incorporated other forms of physiotherapy treatment in combination with Mulligan’s mobilization with movement (MWMs). MWM is feasible and efficacious in individuals with knee osteoarthritis.(9) Mulligan's concept of mobilization with movement (MWM) is a contemporary form of joint mobilization, consisting of a therapist-applied pain-free accessory gliding force combined with active movement.10
Strengthening exercise is commonly recommended .Patients with knee OA tend to have reduced muscle strength as a consequence of reductions in physical activity and pain inhibition.8
NEED FOR THE STUDY:
O.A is a leading cause of pain and disability in elderly population worldwide. Knee osteoarthritis is most common type of arthritis. Conservative treatment aims to reduce pain and limit functional impairment. Inexpensive interventions with minimal side effects are desirable. A conservative therapy such as use of an insole which is a low-cost would be a very useful adjunct to the care of patients with knee OA.Mulligan mobilization with movement and Isometric quadriceps exercises is believed to reduce pain by improving alignment of tibio femoral joint. Isometric exercise has proven to improve quadriceps muscle strength that is effective in treating OA of the knee joint and thereby it reduces disability of the patients.
Considering OA being a progressive disease, we aim at slowing the progression of symptoms. To improve the adherence of any treatment regime, an easy to perform and cost effective therapies such as use of lateral wedge with subtalar strapping and MWM with exercises can be used.
With the existence of various electrotherapeutic modalities to manage the symptoms of OA, we aim to have a simple yet cost effective way of managing the condition in the therapy set up as well as after discharge from therapy. Hence a comparison of the above mentioned two treatment strategies is being done to determine the most effective treatment.
Lack of published literature in this regard gives us the need to study the efficacy of lateral wedged insole with subtalar strapping v/s MWM in medial compartment OA knee.
RESEARCH HYPOTHESIS:
Null hypothesis (H0): There will not be any significant difference between mulligan’s mobilization with movement and lateral wedge insole with subtalar strapping in OA knee.
Alternative Hypothesis (H1): There will be significant difference between mulligan’s mobilization with movement and lateral wedge insole with subtalar strapping in OA knee.
REVIEW OF LITERATURE:
A literature search identified studies of incidence and prevalence of knee pain, disability, and radiographic osteoarthritis in the general population, and data related to primary care consultations. During a one year period 25% of people over 55 years have a persistent episode of knee pain, of whom about one in six in the UK and the Netherlands consult their general practitioner about it in the same time period. The prevalence of painful disabling knee osteoarthritis in people over 55 years is 10%, of whom one quarter are severely disabled.2
A study compared the radiographic effect on femorotibial alignment, with the goal being the ability to assess pain improvement by using a clinical index in patients treated with elevations of 8-mm, 12-mm, and 16-mm laterally wedged insoles with subtalar strapping. In this study the 16-mm group (n=21) showed a significantly greater valgus correction of the femorotibial angle than the 8-mm group (n=20). The remission score was significantly improved in the 12-mm group (n=21) compared with the 16-mm group. Adverse effects were more common in the 16-mm group (9/21, 42.8%) than in the 12-mm (3/21, 14.3%) or 8-mm (2/20, 10%) groups.3
A study reported that 61 patients who completed the 6-month study were evaluated. At baseline, there was no significant difference in the femorotibial angle (P = 0.66) and the VAS score (P = 0.75) between the 2 groups. At the 6-month assessment, the 29 subjects wearing the subtalar-strapped insole demonstrated a significantly decreased femorotibial angle (P < 0.0001) and significantly improved VAS scores (P =0.001) and Lequesne index scores (P = 0.033) compared with their baseline assessments. These significant differences were not observed in the 32 subjects assigned to the traditional shoe-inserted wedged insole.11
A study in which 30 subjects (21 men and 9 women) aged 29 to 77 years (mean ± SD, 58.1 ± 11.6 years) with radio graphically confirmed medial compartment knee osteoarthritis were issued custom-molded foot orthoses with a 5° lateral heel wedge. Pain levels were recorded using a 100-mm visual analogue pain scale on the date of issue of the orthosis (baseline) and again 3 and 6 weeks later. Mean ± SD pain levels were significantly reduced at 3 weeks (34 ± 22 mm) and 6 weeks (23 ± 22 mm) versus baseline (69 ± 19 mm) (F2 = 39.57). The degree of pain reduction was greater in patients with less severe osteoarthritis. At 6 weeks, all subjects had achieved at least some reduction in pain, and 28 reported that their orthosis were comfortable. This preliminary study indicates that laterally wedged foot orthosis may be beneficial in the treatment of mild-to-moderate osteoarthritis of the medial compartment of the knee.23
Researchers demonstrated that Reductions in the adduction moment occurred with insoles accompanied by a reduction in walking pain. Insoles had no mean effect on static alignment. Mean improvement in WOMAC pain and physical functioning was observed at 3 months, with 25 (69%) and 26 (72%) of 36 individuals reporting global improvement in pain and functioning, respectively. Regression analyses demonstrated that disease severity, baseline functioning, and magnitude of immediate change in walking pain and the first peak adduction moment with insoles were predictive of clinical outcome at 3 months.12
A study assessed the optimal tilt of the lateral wedge insole with subtalar strapping. Patients with knee OA treated with a lateral wedge with elevations of 8mm, 12mm, and 16mm with subtalar strapping.The remission score was significantly improved in the 12-mm group (n=21) compared with the 16-mm group (P=.029). Adverse effects were more common in the 16-mm group (9/21, 42.8%) than in the 12-mm (3/21, 14.3%) or 8-mm (2/20, 10%) groups Researchers concluded from the result that the 12mm wedge is best suited for routine and regular use.3
A pilot study investigated whether lateral-wedge insoles inserted into shock-absorbing walking shoes altered joint pain, stiffness, and physical function in patients with symptomatic medial compartment knee osteoarthritis (OA). Twenty-eight subjects wore full-length lateral-wedge insoles with an incline of 4° in their walking shoes for 4 weeks. Pain, stiffness, and functional status were measured with the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index at baseline and 4 weeks post intervention. Significant improvements were observed in all three WOMAC subscales (pain, stiffness, and function). Pain scores were significantly reduced for the most challenging activity—stair climbing. Subjects wore insoles daily and tolerated them well. The results of this study indicated that lateral-wedge insoles inserted into shock-absorbing walking shoes are an effective treatment for medial compartment knee OA).20
A study to provide evidence based recommendations for prescription of mobilization with movement. This study demonstrated that strengthening of knee musculature was more effective after the MWM and was associated with significant improvement in quadriceps strength and function, when compared with controls is effective in reducing pain and improving function in individuals diagnosed with knee osteoarthritis.19
Twenty-one studies, which have investigated MWM’s at peripheral joints, were included for analysis. This review highlights that specific parameters identified for MWM prescription (tenets, technical and response parameters), are variable and in general inconsistently implemented and explained. The efficacy of MWM’s at peripheral joints is well established for various joints and pathologies with 20 out of 21 studies (95%) demonstrating positive effects overall.13
Manual therapy has proven to be a benefit in the management of knee osteoarthritis (OA), but the effects of the method of Mulligan's mobilization with movement (MWM) have yet to be explored in knee OA. As a first step, this case series investigated MWM's immediate and short-term benefits over three occasions of treatment in 19 patients with knee OA. Patients received individually prescribed MWM and performed self-MWM. Outcome measures included: 1) pain intensity (visual analogue scales) during walking, ascending and descending stairs, and sit-to-stand; 2) passive flexion and extension range of motion (ROM); and 3) Activities of Daily Living Scale of the Knee Outcome Survey (KOS-ADLS). Pain and ROM were assessed at baseline, after the initial treatment, before the second treatment and at exit following the fourth. Consultation .Significant improvements from baseline were detected in flexion ROM and pain scores in all tasks following the initial treatment.22
A clinical study has shown consistent improvement in knee extension strength after exercise training, as well as reductions in pain and physical disability in people with knee OA.8
There are 600 (76.3%) participants completed the study. At 24 months, highly significant reductions in knee pain were apparent for the pooled exercise groups compared with the no exercise groups (mean difference –0.82, 95% confidence interval –1.3 to –0.3). Similar improvements were observed at 6, 12, and 18 months. The reduction in pain was greater the closer patients adhered to the exercise plan. A simple home based exercise programme can significantly reduce knee pain.24