RAJIV GANDHIUNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1 / Name of the Candidate
And Address
(in block letters): / JAICE D JOSEPH
LAXMI MEMORIAL COLLEGE OF PHYSIOTHERPY,
A.J TOWERS, BALMATTA,
MANGALORE - 2
2. / Name of the Institute: / LAXMI MEMORIAL COLLEGE OF PHYSIOTHERPY
3. / Course of study and subject : / MPT, MUSCULOSKELETAL AND SPORTS PHYSIOTHERAPY
4. / Date of Admission to Course : / 06.08.2012
5. / Title of the topic: / “A COMPARATIVE STUDY BETWEEN THE EFFECTS OF TAPING AND BRACING IN PATIENTS WITH PATELLOFEMORAL OSTEOARTHRITIS.”
6 / Brief resume of intended study
6.1 Need for the study
Unicompartmental arthritis is traditionally thought of as acondition affecting the femorotibial compartments, but it canalso be isolated to the patellofemoral articulation. In fact,isolated patellofemoral arthritis may not be so rare.1-3Ina radiographic study of patients over the age of forty yearswho had painful knees, Davies et al. noted that the prevalenceof isolated patellofemoral arthritis was 9%.2McAlindon et al performed a radiographic study of symptomaticknees in patients over the age of fifty-five years and founda prevalence of isolated patellofemoral arthritis of 8% in women.The condition also exists, albeit at a lower frequency, in youngand middle-aged people.4
Wear and damage of articular cartilage can have a biologicalor mechanical cause. Biological causes include inflammatorydiseases and infection, although neither leads to isolated patellofemoralarthritis. Mechanical causes include all conditions associatedwith loads that overwhelm the capacity of cartilage to withstandthem. These conditions include any combination of obesity, repetitivedeep knee flexion, malalignment5,6, dysplasia, and blunt trauma.The prevalence of osteoarthritis of the knee is higher in obeseindividuals, presumably as a result of increased loads placed onall parts of the joint7.
One part or another of the patellar cartilage remains loadedthroughout the entire flexion-extension cycle, with the exceptionof the earliest degrees of flexion12. The distal portion ofthe patella is loaded as the knee flexes, and the contact areaon the patella migrates proximally with progressive flexion.At 90°, the contact area is located proximally, after whichthe contact area moves back toward the central aspect of thepatella. Thus, the central portion of the patella is the partthat is most frequently loaded. It also happens to be the partof the patella that exhibits the thickest cartilage (5 mm),the thickest cartilage in the human body8.
Most activities involving knee flexion take place in a closed-kinetic-chain modewhereby the foot is on the ground. These activities includebending down, rising from a chair, and ascending stairs. Activitiesinvolving repeated bending against resistance (with body weightbeing the most common resistance) also lead to stresses acrossthe patellofemoral joint. In a closed-chain mode, the forcesacross the patellofemoral joint increase as the knee flexesfrom 0° to 90°, as do the contact pressures.9
An improper fit between two mating surfaces leads to an abnormalstress distribution. Rotational malalignment in the axial plane(posterior tilt of the lateral border of the patella) resultsin abnormally high lateral stressesthat can lead to arthritis.10A dysplastic trochlea, whereby the trochlea is flat or evenconvex, can also lead to unusually high loads and the developmentof arthritis in younger patients.
A patient with isolated patellofemoral arthritis typically describes anteriorknee pain when rising from a seated position and/or ascending stairs11.The pain is diminished when the subject walks on level ground.Pain at rest should arouse suspicion of nerve-related pain,such as a neuroma, reflex sympathetic dystrophy/complex regionalpain syndrome, or a radiculopathy. More rarely, pain at restcan be associated with a patellar tumor, an infection, or a stressfracture.
Physical examination in the standing and walking position can reveal asquinting (inward-pointing) patella, foot pronation,and other signs of distant, pain-producing pathological conditions. In sitting or supine, evaluation of hips may showsigns of tightness, synovitis, and joint inflammation, sincepathological conditions of the hip can present as anterior kneepain. A key sign of symptomatic patellofemoral arthritis on the physical examinationis tenderness of the lateral (or occasionally medial) facetof the patella5. Thisis assessed by gently curlingthe fingers under the lateral (or medial) border of the patella.In the setting of clinically meaningful patellofemoral arthritis,this causes pain.
Initially, most patients with patellofemoral arthritis can betreated with a nonoperative approach. Reduction of loading to the patellofemoral joint and surrounding soft tissues is the first step to reduce pain. This includes activitymodification, medications, weight control, physical therapy,taping, bracing and possibly nutritional supplements, and viscosupplementation.12
Activity modification involves an avoidance of squats, wall-slides,and large steps as well as the admonition that, during exercise,pain should not be "worked through" but avoided altogether.12Medications include anti-inflammatory drugs and analgesics,in isolation or in combination. The challenge of physical therapy isto strengthen and stretch the structures about the knee withouteliciting pain. Water exercises can be beneficial in that regard.A knee support used in the setting of patellofemoral arthritisshould feature an anterior cutout to minimize direct pressureon the patellofemoral joint.12
Nutritional supplements have notbeen conclusively found to be helpful in the treatment of arthritis, butsubstances such as glucosamine appear to be safe13,14. Preliminarystudies suggest that viscosupplementation is potentially beneficial.15,16
A well-structured rehabilitation program is the mainstay of treatment. Several studies have shown physical therapy to be effective.17-20 The rehabilitation program should focus on correcting maltracking of the patella by addressing the findings identified on the physical examination. Some patients may require significant strengthening of the quadriceps.21 Others may have excellent quadriceps strength but excessively tight lateral structures or poor quadriceps flexibility. Soft tissue techniques and flexibility exercises can be helpful for these patients.21
Patients with malalignment require a morepatella-specific approach22, since commonly used exercises canaggravate the pain and standard knee protocols fail to specificallyaddress the malalignment. Stretching is the hallmark of a patellarmalalignment rehabilitation protocol, which includes stretchingof the lateral retinaculum, the iliotibial band, the hamstringmuscles, the quadriceps, and the Achilles tendon.23,24
Interventions that alter the load distribution across the patellofemoral joint, such as patella taping, may be helpful in alleviating symptoms. The goal of tapingis to pull the patella away froma painful area, thereby unloading it and providing pain relief.25,26 The extent to which this is possible and the amount of displacementrequired to provide pain relief varies from patient to patient. The taping technique aims to correct the patellar tracking and position which decreases pain allowing for more intensive quadriceps rehabilitation in patellofemoral osteoarthritis.27 Displacement need not be perceptible to effect improvement.10
Patellar taping has shown to be effective in the short-term for treating patellofemoral osteoarthritis.28The American College of Rheumatologist recommends knee taping for patients with osteoarthritis.29But it has not been widely adopted in the clinical setting because it is complicated to administer, difficult to educate the patient about ongoing application, and lacks evidence of long-term efficacy. Also, patients often experience skin irritation from the taping and discomfort when removing the taping.30
An alternative treatment option is the use of a knee brace that realigns the tracking of the patella.Braces are prescribed to modify the position of the patella. Thesedevices range from simple straps across the patellar tendon tocomplex supports. Although they relieve symptoms in a number ofpatients, their mode of action remains speculative and their effectivenessis unpredictable.26,31
Though there are few studies available to assess the effects of taping and bracing in patellofemoral osteoarthritis their results are conflicting. Due to the above factors, further studies are necessary to evaluate the effects of taping and bracing in patellofemoral osteoarthritis to determine the most effective technique in reducing patellar mal alignment and generate evidence to integrate them into clinical practice.
Hypothesis
Null hypothesis
There will be no statistically significant difference between the effects of taping and bracing in reduction of pain and improving health outcomes in patients with patellofemoral osteoarthritis.
Alternate hypothesis
There will be statistically significant difference between the effects of taping and bracing in reduction of pain and improving health outcomes in patients with patellafemoral osteoarthritis.
6.2 Review of Literature
The patellofemoral joint comprises the patella and the femoral trochlea. The patella acts as a lever and also increases the moment arm of the patellofemoral joint, the quadriceps and patellar tendons.32 Contact of the patella with the femur is initiated at 20 degrees of flexion and increases with further knee flexion, reaching a maximum at 90 degrees.33
Stability of the patellofemoral joint involves dynamic and static stabilizers, which control movement of the patella within the trochlea, referred to as “patellar tracking.” Patellar tracking can be altered by imbalances in these stabilizing forces affecting the distribution of forces along the patellofemoral articular surface, the patellar and quadriceps tendons, and the adjacent soft tissues. Forces on the patella range from between one third and one half of a person's body weight during walking to three times body weight during stair climbing and up to seven times body weight during squatting.34
Dynamic stability of the patellofemoral joint is provided by the quadriceps tendon, patellar tendon, vastus medialis obliquus (VMO), vastus lateralis, and iliotibial band. The VMO is the only muscle that provides a medial force and is therefore of particular importance in stabilizing the patella. Static stability is provided via the articular capsule, the femoral trochlea, the medial and lateral retinacula, and the patellofemoral ligaments.21
A variety of braces, sleeves, and straps have been used in the treatment of PFPS. Most braces are designed to preventlateral subluxation and support thepatella without putting direct pressureon it.35The brace should be consideredan alternative to immobilizationbecause it minimizes the load onthe patellofemoral joint and preventsatrophy of the quadriceps muscle.36 Although bracing alone may provide some symptomatic relief, studies found no significant benefit when bracing was used in addition to physical therapy.37-39
Patellar taping has been suggested as a method to treat PFPS by improving alignment and quadriceps function. Knee taping is believed to relievepain by improving alignment of the patellofemoral joint and/orunloading inflamed soft tissues.40Although the results from uncontrolled studies were encouraging, the results of clinical trials have not been consistent: two found no benefit when patellar taping was added to a program of physical therapy.41-42
McAlindon et alconducted a study in two hundred and seventy three subjects who reported knee pain in a postal questionnaire survey and 240 control subjects, who consented to have anteroposterior weightbearing and lateral knee radiographs and complete a Stanford Health Assessment Questionnaire (HAQ). Radiographic knee osteoarthritis was found in 53% of symptomatic and 17% of asymptomatic subjects. They concluded that patellofemoral joint osteoarthritis is common, associated with disability, and occurs in the absence of tibiofemoral disease.4
Kalichman et al conducted a study to examine the association between patellofemoral alignment using MRI and knee pain and function. The association of patellar alignment in sagittal and transverse planes and WOMAC Index pain and function were examined. Results showed increasing trochlear angle was associated with both WOMAC pain and function scale and increasing lateral patellar title angle and increasing lateral subluxation appeared to be associated with increasing WOMAC pain. They concluded that increasing trochlear angle is associated with increased functional impairment while other measures of malalignment were not significantly associated with either knee pain or functional impairment.43
Kalichman et al conducted a cross-sectional observational study to evaluate the association between patellar alignment using MRI images and MRI indices of patellofemoral (PF) osteoarthritis (OA) features. Results showed that all measurements of patellar alignment were statistically significantly associated with cartilage morphology and bone marrow lesion (BML) in the lateral compartment of PF joint. They concluded that patellar alignment is associated with manifestations of PF OA such as cartilage thickness loss and BML.44
Warden et al conducted a systematic review and meta-analysis to evaluate the evidence for patellar taping and bracing in the management of chronic knee pain. Results showed that the methodological quality of the taping studies was significantly higher than the bracing studies. Tape applied to exert a medially-directed force on the patella decreased chronic knee pain compared with no tape and sham tape. For anterior knee pain and OA, medially-directed tape decreased pain compared with no tape. There was disputable evidence from low-quality studies for patellar bracing benefits. They concluded that there was evidence that tape applied to exert a medially-directed force on the patella produces a clinically meaningful change in chronic knee pain and limited evidence to demonstrate the efficacy of patellar bracing.45
Worrell et al conducted a study to determine the effects of patellar taping, bracing, and not taping on patellar position as determined by magnetic resonance imaging (MRI) in twelve subjects with patellofemoral pain. They conclude that patellar bracing and taping influenced patellar position (PFC and LPD) at 10° of knee flexion during a static MRI condition.46
Crossley et al conducted a study aimed to compare patellar alignment in people with and without patellofemoral joint OA and to evaluate immediate effects of patellar taping on patellar alignment and pain in people with patellofemoral joint OA. Results showed that people with patellofemoral joint OA exhibited greater lateral displacement and in the patellofemoral joint OA group, patellar tape resulted in a significant lessening of lateral alignment, with reduced lateral displacement and increased lateral patellar tilt angle. Mean pain during squatting decreased with patellar tape. They concluded that patellar tape may reduce malalignment and pain associated with patellofemoral joint OA.47
Aminaka and Gribble conducted a study to evaluate the effects of patellar taping on sagittal-plane hip and knee kinematics, reach distance, and perceived pain level during the Star Excursion Balance Test (SEBT) in individuals with and without PFPS. Results showed that the participants with PFPS had a reduction in pain level with patellar tape application compared with the no-tape condition. The concluded that patellar taping seemed to reduce pain and improve SEBT performance of participants with PFPS.48
Hinman et al evaluated the effects oftherapeutic tape and neutral tape, on pain and observed disabilityin symptomatic generalized knee osteoarthritis (OA). Results showed that therapeutic tape significantly reduced pain when compared with the neutraland untaped conditions and observed disability in thestep test. They concluded that therapeutic knee tape is a simple, inexpensivestrategy that increases the treatment options for therapistsand patients in the conservative management of knee OA.49
Ng and Cheng conducted a study to examine the immediate effects of patellar tapingon pain and relative activity of vastus medialis obliquus tovastus lateralis inpatellofemoral pain and patellofemoraljoint malalignment.Results showed a significant decrease in anterior knee painand vastus medialis obliquus to vastus lateralisactivity ratio during patellar taping.They concluded that patellar taping can reduce pain in people withpatellofemoral pain syndrome and patellofemoral malalignment.50
Cushnaghanconducted a randomised, single blind, crossover trial in 14 subjects to test the hypothesis that medial taping of thepatella reduces the symptoms of osteoarthritis of the knee whenthe patellofemoral joint is affected.Results showed that medial taping of the patella wassignificantly better than the neutral or lateral taping forpain scores, symptom change, and patient preference. They concluded that patella taping is a simple, safe, cheap way ofproviding short term pain relief in patients with osteoarthritisof the patellofemoral joint.28
Bockrath et al conducted a study to determine the effects of patella taping on patella position and perceived pain in twelve subjects with anterior knee pain syndrome (AKPS) currently using patella taping procedures. Results revealed no significant change in patellofemoral congruency and patella rotation angles and significant reduction pain level. They concluded that Results patella taping significantly reduced the perceived pain levels, however, this reduction in pain was not associated with patella position changes.51
Shellock et alconducted an experimental study to evaluate the effect of patellar realignment on using knee brace in patients with patellofemoral osteoarthritis. The treatment intervention includes the use of brace for a period of 5 weeks. The result of the study revealed that after the application of brace patellar realignment is increased.52
Shellock et alevaluated the effect of a patellar realignment brace in 21 patellofemoral joints with patellar subluxation by using active-movement, loaded kinematic magnetic resonance (MR) imaging. The results indicated that the patellar realignment brace was able to counteract patellar subluxation in the majority of patellofemoral joints studied. This brace appears to be useful for conservative treatment of patients with patellofemoral joint pain secondary to patellar malalignment and maltracking.31
Bohnsack et al conducted a study to analyze the biomechanical consequences of patella bracing in order to evaluate possible mechanisms supporting its clinical application. Physiologic isokinetic knee extension motions were simulated on ten human knee cadaver specimens using a knee kinematic simulator. They concluded that patellar bracing significantly influences patella biomechanics in a reduction of the patellofemoral contact area and contact pressure as well as a decrease in the infrapatellar tissue pressure and suggested the application of infrapatellar straps for the treatment and prevention of anterior knee pain, especially in high level sports.53
Powers et al conducted a study to assess the effectiveness of an elastic patellofemoral sleeve brace in altering patellar tracking in subjects with patellofemoral pain in ten female subjects who demonstrated lateral patellar tracking based on magnetic resonance imaging (MRI) assessment. Imaging was performed with and without a patellofemoral joint brace. Results showed no statistically significant differences in medial/lateral patellar displacement or tilt were found between braced and unbraced trials across all knee flexion angles but a small but statistically significant increase in sulcus angle was found. They concluded that the brace does not correct patellar tracking patterns in subjects with patellofemoral pain but a change in patella position within the trochlea and it is possible that the clinical improvements seen with bracing may be the result of subtle differences in joint mechanics and not gross changes in alignment.54