Rajiv Gandhi University of Health Sciences, Karnataka
Bangalore
ANNEXURE II
1. / Name of the Candidate and Address (in block letters) / MOHAMMAD SUHAILDR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY
VIDYANAGAR
KULOOR, MANGALORE-575013
2. / Name of the Institution / DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY
3. / Course of Study and Subject / MASTER OF PHYSIOTHERAPY (MPT)
MUSCULO SKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY
4. / Date of Admission to Course / 26th JUNE 2008
5. / Title of the Topic / EFFECTS OF MANUAL THERAPY ON REDUCING PAIN AND IMPROVING FUNCTIONS IN YOUNG ADULTS WITH PATELLOFEMORAL PAIN SYNDROME (PFPS).
6.
7.
8. / Brief Resume of the Intended Work
6.1) Introduction and Need of the Study:
Knee pain is one of the most commonly reported musculoskeletal disorders with estimates that it will effects 30-40% of population by age 651. Anterior knee pain is the most prevalent disorder involving the knee, with its prevalence being as high as 7% at any one time in active young adults2.
Among all the causes of anterior knee pain, Patellofemoral pain syndrome (PFPS) is the most common diagnosis in outpatients presenting with knee pain. Studies have shown PFPS to be the most common single diagnosis among runners and in sports medicine centers3. Eleven percent of musculoskeletal complaints in the office setting are caused by anterior knee pain (which most commonly results from PFPS), and PFPS constitutes 16 to 25 percent of all injuries in runners1. Patellofemoral pain is common, particularly in active, young patient with patellofemoral malalignment4.
The term “PFPS” is often used interchangeably with “anterior knee pain” or “runner’s knee.”PFPS can be defined as anterior knee pain involving the patella and retinaculum that excludes other intraarticular and peripatellar pathology5. In patellofemoral joint the patella acts as a lever and also increases the moment arm of the patellofemoral joint, the quadriceps and patellar tendons6. Many theories have been proposed to explain the etiology of patellofemoral pain. These include biomechanical, muscular and overuse theories. In general, the literature and clinical experience suggest that the etiology of patellofemoral pain syndrome is multifactorial7. Overuse, trauma, and anatomic factors appear to be the main contributors.
Patellofemoral pain syndrome (PFPS) remains one of the most common and challenging musculoskeletal entities encountered by physiotherapists and sports medicine practitioners8.The lack of understanding of the etiology and pathology associated with patellofemoral pain and dysfunction is reflected in the vast number of treatment options for PFPS. Nonoperative treatments are usually used (especially in the first instance), and physiotherapy is a commonly used conservative physical intervention.
Physiotherapy treatments often include vastus medialis obliqus (VMO) strengthening to promote active medial stabilization of the patella within the femoral trochlea and/or patellar realignment procedures (taping, bracing, stretching) 10,11.While these treatments appear to be based on sound theoretical rationale, the evidence for the efficacy of these interventions is not well established12.
Need of the study:
It has been demonstrated that physiotherapy intervention is effective in reducing pain and improving activity in people with anterior knee pain13-14. These studies have included combinations of patellofemoral taping, muscle stretching, strengthening and co-ordination exercises, along with techniques aimed at decreasing tightness of the lateral structures such as patellofemoral mobilisation and deep friction massage to the lateral soft tissues of the knee. It is not yet known; however, which components may be individually responsible for the improvement. Manual therapy techniques including mobilisation, stretching, and soft tissue massage are used in the treatment of anterior knee pain with the aim of decreasing tightness of the lateral structures15, results in significantly greater improvement in active knee flexion and the ability to step up/down a step in people with anterior knee pain16, but the participants in these trials were relatively old and it may be possible that there would be a better response to this intervention in younger patients, so there is a need to assess the efficacy of manual therapy for Patellofemoral pain syndrome (PFPS) in younger patient.
Research Question:
Is manual therapy is efficient in reducing pain, increasing knee flexion and enhancing activity in young patient of Patellofemoral pain syndrome (PFPS) ?
Hypothesis:
Null Hypothesis:
Six session of manual therapy shows no significant improvement in pain, knee flexion and activity in young patient of Patellofemoral pain syndrome (PFPS)?
Alternate Hypothesis:
Six session of manual therapy result in significant improvement in pain, knee flexion and activity in young patient of Patellofemoral pain syndrome (PFPS)?
6.2) REVIEW OF LITERATURE :
Van Saase JL et al. (1989)1 did a study on Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other populations and according to their findings knee pain is one of the most commonly reported musculoskeletal disorders in all the populations.
Witvrouw E, et al. (2000)2 in their study on Intrinsic risk factors for the development of anterior knee pain in an athletic population found that anterior knee pain is the most prevalent disorder involving the knee, with its prevalence being as high as 7%.
Smillie, I.S (1980)4 in his book “Diseases of the knee joint” wrote that patellofemoral pain is common, particularly in active, young patient with patellofemoral malalignment and it is reported to be seen in young adults having poor quadriceps flexibility.
A literature Review on Patellofemoral Pain Syndrome treatment was done by Mark S. Juhn, (1999).7 According to him the etiology of patellofemoral pain include biomechanical, muscular and overuse theories but in general, the etiology of patellofemoral pain syndrome is multifactorial.
Palumbo PM. (1981)10 did a study to find the effectiveness of Dynamic patellar brace in the management of patellofemoral pain and he concluded that this orthosis can be used with other conservative intervention like taping, stretching to treat the patellofemoral pain syndrome.
A Systematic Review of Physical Interventions for Patellofemoral Pain Syndrome by Crossley, Kay et al. (April 2001)12 concluded that the evidence to support the use of physical interventions in the management of PFPS is limited. There appears to be a consistent improvement in short-term pain and function due to physiotherapy treatment but further trials are warranted for the other interventions.
Paul A van den Dolder et al. (2006)16 did a study on older adults with anterior knee pain to check whether manual therapy is effective in increase knee flexion and improve activity and he concluded that manual therapy is effective in improving knee flexion and stair climbing in patients with anterior knee pain. He also advocates doing the similar study in young adults for better results.
Brukner P et al. (2002)18 in his book “Clinical Sports Medicine.” 2nd ed. 464-93 give a complete examination of the knee, including a careful assessment of the patellofemoral joint in all the aspect (inspection, palpation and range of motion).
A self-administered pain severity scale for patellofemoral pain syndrome was developed by Laprade J et al. (2002)20 which make the patient to do ten common activities that often provoke anterior knee pain. These range from sedentary activities such as sitting and resting to vigorous activities including running/sprinting and participating in sport. It has been shown to have excellent test-retest reliability (rs = 0.95) and a high degree of concurrent validity when compared with the Western Ontario MacMaster and Hughston scales.
Norkin C et al (1995)21 in his book “Measurement of Joint Motion: A Guide to Goniometry.” Told about testing of knee flexion and extension in prone position, this alternative testing position which allows for more stability than the supine position.
Gogia et al (1987)22 studied the reliability and validity of joint angle measurement using a goniometer. Intertester reliability was high, with average correlation coefficients of 0.98(r) and 0.99(ICC). The correlation coefficients for validity also were high, ranging from 0.97 to 0.98(r) and from0.98 to 0.99(ICC).The author concluded that goniometric measurements were both reliable and valid.
A study done by Paul A van den Dolder et al (2006)16 on anterior pain syndrome patients use 1 minute step test for measuring the activity level of the patient on the basis of number of times a patient performance with affected leg on 15 cm step.
Cyriax J (1984)17 in his book “Textbook of Orthopaedic Medicine: Treatment by Manipulation, Massage and Injection” tells about the effectiveness of transverse massage on the lateral aspect of the knee in the case of anterior knee pain.
“Clinical Sports Medicine” (2nd ed.) a book by Brukner P et al. (2001)19 describe about the tilt patellofemoral stretches use in case of anterior knee pain.
6.3) OBJECTIVES OF STUDY :
The aim of this trial is to assess the efficacy of manual therapy on Pain, Knee Flexion and Activity in young adults for Patellofemoral Pain Syndrome.
MATERIALS AND METHODS :
7.1) STUDY DESIGN :
Experimental Study. Pre and post test design.
7.2) SOURCE OF DATA :
7.2(I) Definition of Study Subjects:
Participants were recruited from patients referred to the Physiotherapy Departments from the various hospital in an around the Mangalore for management of anterior knee pain.
7.2(II) Inclusion and Exclusion Criteria:
INCLUSION CRITERIA :
1. Patients were included in the trial if they were between the ages of 18 and 35years.
2. Complains of anterior knee pain.
EXCLUSION CRITERIA :
1. Knee pain was caused by trauma in the preceding four weeks was reproduced with combined extension/rotation and side flexion of the lumbar spine to the ipsilateral side or on hip quadrant with overpressure.
2. Knee pain due to infection
3. Neoplastic disorder
4. Knee pain of acute inflammatory nature
5. If they had undergone knee surgery within the past six weeks
6. No palpable tenderness over the lateral patellofemoral joint17
7.2(III) Study Sampling Design, Method and Size:
SAMPLE – DESIGN:
Purposive Sampling Technique
METHOD OF COLLECTING DATA:
50 subjects will be collected from the various hospitals in and around Mangalore
SAMPLE – SIZE:
More then 50
7.2(IV) Follow Up:
One time study, no follow up required.
7.2(V) Parameters used for comparison and statistical analysis used:
Scores on PF pain Questionaire, Knee flexion ROM and Step test-before and after treatment, paired ‘t’ test will be used to compare the mean scores. P value<0.05 will be kept for Statistical Significance.
7.2(VI) Duration of study:
The study will be conducted over duration of 12 months.
7.2(VII) Methodology:
Once the inclusion criterion is achieved, upon initial interview, patients were screened for Patellofemoral Pain Syndrome to determine their eligibility for the study18. If eligible, written consent will be taken and baseline measures of pain, range of motion, and activity limitations will be taken. Each patient will receive six sessions of manual therapy consisting of transverse frictions to the lateral retinaculum as described by Cyriax (1984)17 conducted both in the fully extended and fully flexed position, tilt patellofemoral stretches as described by Brukner et al (2001)19, and the application of a sustained medial glide during repeated flexion and extension of the knee. Each session lasted for 15–20 minutes.The technique of application and position of the patient and therapist varies according to the affect requireds. No other intervention (such as advice or exercise) will be given during the trial.Participants were shown their baseline responses to questionnaires immediately prior to filling them out again to improve the reliability of responses.23 Finally, participants were asked to fill out their satisfaction with treatment using the words ‘very satisfied’, ‘somewhat satisfied’, ‘somewhat dissatisfied’ or ‘very dissatisfied‘.
7.3) Does the study require any investigations to be conducted on patients or other human or animal? If so, please describe briefly.
Patellofemoral Pain Severity Questionnaire31- For pain measurement.
Goniometer32, 33- For accessing active knee flexion.
Step test34- Activity was measured using a step test
7.4) Has ethical clearance been obtained from your institution in case of 7.3.
Yes.
LIST OF REFERENCES :
1. Van Saase JL, Van Romunde LK, Cats A, Vandenbroucke JP, Valkenburg HA (1989) Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other populations. Annals of the Rheumatic Diseases 48: 271–280.
2. Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G (2000) Intrinsic risk factors for the development of anterior knee pain in an athletic population. A two-year prospective study. American Journal of Sports Medicine 28: 480–489.
3. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36:95-101.
4. Smillie, I.S.: Diseases of the knee joint. Edinburgh, Churchill-Livingston, 1980.
5. Reid DC. The myth, mystic and frustration of anterior knee pain [Editorial]. Clin J Sport Med 1993; 3:139-43.
6. Beynnon BD, Johnson RJ, Coughlin KM. Relevant biomechanics of the knee. In: DeLee JC, Drez D, Miller MD, eds. Orthopaedic Sports Medicine:Principles and Practice. 2nd ed. Philadelphia, Pa.: Saunders, 2003:1590.
7. Mark S. Juhn. Patellofemoral Pain Syndrome: A Review and Guidelines for Treatment American Family Physician Vol. 60/No. 7 (November 1, 1999).
8. Baquie P, Brukner P. Injuries presenting to an Australian sports medicine centre: a 12 month study. Clin J Sports Med 1997; 7:28–31.
9. Devereaux M, Lachmann S. Patellofemoral arthralgia in athletes attending a sports injury clinic. Br J Sports Med 1984; 18:18–21.
10. Palumbo PM. Dynamic patellar brace: a new orthosis in the management of patellofemoral pain. Am J Sports Med 1981; 9:45–49.
11. McConnell J. The management of chondromalacia patellae: a long term solution. Aust J Physiother 1986; 32:215–223.
12. Crossley, Kay; Bennell, Kim; Green, Sally; McConnell, Jenny. A Systematic Review of Physical Interventions for Patellofemoral Pain Syndrome Volume 11(2),April 2001,pp 103-110.
13.Crossley K, Bennell K, Green S, Cowan S, McConnell J (2002) Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. American Journal of Sports Medicine 30: 857–86.
14. Harrison E, Sheppard M, McQuarrie A (1999) A randomized controlled trial of physical therapy treatment programs in patellofemoral pain syndrome. Physiotherapy Canada 51:
93–100
15. Cyriax J (1977) Textbook of Orthopaedic Medicine. London: Bailliere Tindall.
16. Paul A van den Dolder and David L Roberts. Six sessions of manual therapy increase knee flexion and improve activity in people with anterior knee pain: a randomised controlled trial. Australian Journal of Physiotherapy 2006 Vol. 52 261–264.
17. Cyriax J (1984) Textbook of Orthopaedic Medicine: Treatment by Manipulation, Massage and Injection. London: Bailliere Tindal.
18. Brukner P, Khan K, McConnell J, Cook J. Anterior knee pain. In: Brukner P, Khan K. Clinical Sports Medicine. 2nd ed. New York, N.Y.: McGraw Hill, 2002:464-93
19. Brukner P, Khan K, McConnell J, Cook J (2001): Anterior knee pain. In Brukner P, Kahn K (Eds): Clinical Sports Medicine (2nd ed.) Sydney: McGraw Hill, Ch 24.
20. Laprade J, Culham E (2002) A self-administered pain severity scale for patellofemoral pain syndrome. Clinical Rehabilitation 16: 780–788.
21. Norkin C, D.Joyce White (1995) Measurement of Joint Motion: A Guide to Goniometry. Philadelphia: FA Davis.
22.Gogia,PP,et al: Reliability of goniometric measurements at the knee.Phys Ther 67:192,1987
23. Guyatt G, Berman L, Townsend M, Taylor D (1985) Should study subjects see their previous responses? Journal of Chronic Diseases 38: 1003–1007.