RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. NAME AND ADDRESS OF THE CANDIDATE : / PATEL SNEHAL VIRENDRADEPARTMENT OF PHYSIOTHERAPY
M.S. RAMAIAH MEDICAL COLLEGE
M.S.R.I.T.POST,
BANGALORE -54
2. NAME OF THE INSTITUTE: / Department of Physiotherapy
M.S. Ramaiah Medical college
M.S.R.I.T.Post,
Bangalore -54
3. COURSE OF STUDY AND SUBJECT: / Master of Physiotherapy (Neurological
and Psychosomatic disorders)
4. DATE OF ADMISSION
TO COURSE: / 28th October 2011
5. TITLE OF THE TOPIC: / “Prevalence of knee hyperextension
in individuals with hemiplegia”.
6 BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR THE STUDY:
WHO defined stroke as “Rapidly developing clinical signs of focal disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin”. The effects of stroke are variable and may include impairment in motor and sensory systems, emotions, language, perception and cognitive function.1
Prevalence of stroke in India is, 250-300 per 1,00,000 population.2 There are several complications after stroke. The most common are brain edema, seizures, clinical depression, deep vein thrombosis, bed sores, hemiplegic shoulder pain, shoulder subluxation, adhesive capsulitis, chronic regional pain syndrome, knee hyperextension and limb contracture of elbow flexors, wrist and finger flexors, forearm pronators and ankle plantar flexors.3
Presence of hyperextension of knee is observed commonly in individuals with stroke who are self ambulant. It has been reported that genu recurvatum or hyperextension of the hemiplegic knee is commonly seen. Etiology of knee hyperextension post stroke could be spasticity and hypertonicity of quardiceps and plantar flexors4,5, Weak hamstrings, lack of eccentric control of quadriceps during stance phase may also lead to knee hyperextension.
A continual adaptation of the hyperextended knee leads to various adaptive changes such as anteriorly knee joint goes into abnormal compression and leads to degenerative changes of the cartilaginous joint surfaces and posteriorly there is adaptive lengthening of the posterior capsule and of the posterior cruciate ligament and the length tension relationship of the anterior and posterior muscles also may get altered. In knee hyperextension, Line of gravity is located considerably anterior to the knee joint axis, which facilitates knee hyperextension.6,7
There are many complications that would appear because of the hyperextension as mentioned above. These complications would lead to minimal recovery or hamper the patients recovery. It would be more appropriate to report the prevalence of hyperextension of knee. If the prevalence is high, the awareness of both patient population and medical professionals regarding this complication can be improved.
Some of the individuals with stroke will be undergoing physiotherapy and some may not be undergoing physiotherapy. There is little literature available on the treatment guidelines prescribed to prevent or treat knee hyperextension in this population. The treatment methods adopted by physiotherapist to prevent and treat knee hyperextension may not have addressed all the possible causes of knee hyperextension, so it is necessary to find the prevalence of knee hyperextension in individuals undergoing physiotherapy and compare with those who are not undergoing physiotherapy.
RESEARCH HYPOTHESIS:
1. To find out the prevalence of knee hyperextension in individuals with hemiplegia.
2. There will be a significant difference in the prevalence of knee hyperextension in individuals with hemiplegia undergoing physiotherapy and those who are not undergoing physiotherapy.
NULL HYPOTHESIS:
There will not be a significant difference in the prevalence of knee hyperextension in individuals with hemiplegia undergoing physiotherapy and those who are not undergoing physiotherapy.
6.2 REVIEW OF LITERATURE:
Perry J et al conducted study on gait analysis:normal and pathological function concluded presence of spastic and retracted muscles of ankle plantar flexor and quadriceps causes hyperextension of knee.1
P.M. Farncombe et al conducted study on the Swedish knee cage: Management of the hyperextended hemiplegic knee physiotherapy concluded there is improvement in hyperextension of knee.2
C.Bleyenherift et al conducted study for assessment of the Chignon dynamic ankle-foot orthosis using instrumented gait analysis in hemiparetic adults found improvement in hyperextension of knee.3
J. Chae L. Sheffler et al conducted study on Neuromuscular electrical stimulation for motor restoration in hemiplegia found change in gait pattern using functional electrical stimulation.4
H. Gok A. Kucukdeveci et al conducted study on Effects of ankle-foot orthoses on hemiparetic gait found use of AFO with limited plantarflexion can help the subject to control their knee during the stance phase.5
D. Casey Kemkan et al conducted study on Knee Recurvatum in Gait: A Study of Associated Knee biomechanics concluded that patients with knee recurvatum have variable peak extensor torque values associated with their knee hyperextension, knowledge of knee hyperextension angle and other clinical factors arc only partially useful in predicting a patient’s peak knee extensor torque imparted to the posterior knee structures during walking.6
Paulo Roberto Garcia Lucareli conducted study on Knee joint dysfunctions that influence gait in cerebrovascular injury concluded that the important mechanisms of loading response in the stance, knee hyperextension in single stance, and reduction of the peak flexion and movement amplitude of the knee in the swing phase. These mechanisms should be taken into account when choosing the best treatment.7
6.3 OBJECTIVES OF THE STUDY:
1. To find out the prevalence of the knee hyperextension in self ambulant individuals with hemiplegia.
2. To compare the prevalence of knee hyperextension in individuals with hemiplegia undergoing physiotherapy and those who are not undergoing physiotherapy.
7. MATERIALS AND METHODOLOGY:
7.1 SOURCE OF COLLECTION OF DATA: Patients visiting Out Patient Department of Neuroscience and Department of Physiotherapy, M.S Ramaiah hospitals, Bangalore and other rehabilitation centers located in Bangalore.
7.2 METHOD OF COLLECTION OF DATA:
Method of sampling - Convenience sampling
Type of study - Observational – cross sectional
Sample size - 61 subjects
(sample size was calculated using” N master software”
Version =1, from the cited study.4 Assuming median
proportion of knee hyperextension of stroke patients
as 50% with allowable error of 25% and desired
confidence interval of 95% (alpha error 5%), the
requisite sample size was estimated to be 61.
The above sample size shall be divided into 2 groups
to compare the prevalence of knee hyperextension.
PROCEDURE OF DATA COLLECTION:
Hemiplegic subjects both male and females who meet the inclusion criteria shall be included for the study. Study shall be explained to each subject and an informed consent shall be obtained from the subjects, and the knee hyperextension will be assessed by video gait analysis and the readings shall be recorded for both groups for analysis.
INCLUSION CRITERIA:
® Individuals with hemiplegia walking independently without aids 3 months post stroke.
® Males and females aged 18 years and above.
EXCLUSION CRITERIA:
® Trauma to the lower limbs.
® Any orthopaedic surgery to the affected lower limb.
® Presence of any other neurological disorder affecting the gait.
MATERIALS USED:
® Video camera
® Markers for the joint
® Video gait analysis software.
Statistical analysis:
1. Descriptive statistics will be expressed in Mean and Standard deviation for prevalence of knee hyperextension.
2. Both the groups comparison will be done by “Man Whitney U test”.
7.3 Does the study require any investigation or intervention to be conducted on patients or other human or animals?
NO.
7.4 Has ethical clearance been obtained from the institution?
YES.
8. LIST OF REFERENCES:
1. WHO | Stroke, Cerebrovascular accident [Internet]. [cited 2010 Aug 3]; Available from: http://www.who.int/topics/cerebrovascular accident/en
2. Tapas kumar banerjee et al. Epidemiology of stroke in India. Journal of Neurology Asia.2006;11:1-4.
3. Sharon A, Raymond Marx, editors. Physical rehabilitation. 5th ed. Jaypee brothers publishers;2007.p.725-726.
4. Allison Cooper et al. The Relationship of Lower Limb Muscle Strength and Knee Joint hyperextension during the Stance Phase of Gait in Hemiparetic Stroke Patients. Journal of Physiotherapy research international.2011;(17)1.
5. Lucarli P et al. Alteration of load response mechanism of knee joint during hemiparetic gait following stroke. Journal of clinics.2007;22:813-820.
6. Jennifer Pine, editor. Joint structure and function. 4thed. Margaret Biblis publishers;2006.p.495-496.
7. Sioban Campbell, editor. Gait analysis an introduction. 4th ed. Heidi Harrison publishers;2007.p.114-116.
8. Bleyenheuft et al. Treatment of genu recurvatum in hemiparetic adult patients: A systematic literature review. Journal annals of physical and rehabilitation medicine.2010;53(3):189-199.
9. SIGNATURE OF THE CANDIDATE :
10. REMARKS OF THE GUIDE :
11. NAME AND DESIGNATION OF
11.1 GUIDE : MR. PARTHA SARATHI KOMMINENI
ASSISTANT PROFESSOR
DEPARTMENT OF PHYSIOTHERAPY
M.S.RAMAIAH MEDICAL COLLEGE
11.2 Signature :
11.3 CO-GUIDE : Miss. ADITI HOMBALI
LECTURER
DEPARTMENT OF PHYSIOTHERAPY
M.S.RAMAIAH MEDICAL COLLEGE
11.4 Signature
11.5 Head of department : Prof. SAVITA RAVINDRA
HEAD OF THE DEPARTMENT
DEPARTMENT OF PHYSIOTHERAPY
M.S.RAMAIAH MEDICAL COLLEGE
11.6 Signature :
12
12.1 Remarks of the Chairman and Principal:
12.2 Signature :
ANNEXURE 1
INFORMED CONSENT
I have been informed by Ms. PATEL SNEHAL VIRENDRA that, a study shall be undertaken to find out the “PREVALENCE OF KNEE HYPEREXTENSION IN INDIVIDUALS WITH HEMIPLEGIA”. I have been explained about the need of the study, effect of knowing the incidence of hyperextension of knee in stroke. I have been informed about the benefits of the study and there is no risk involved in the study. I understand that this study is purely for academic / problem solving purpose.
I have been explained about the entire procedure of measuring knee hyperextension using video gait analysis. Any queries that I will be having during the course of study will be explained.
I have been explained that my participation is voluntary and I can withdraw at any time, hence I am satisfied with the same.
I hereby give my consent to be included in the study.
NAME: DATE:
SIGNATURE:
ANNEXURE: 2
NAME:
AGE:
SEX:
DOMINENT SIDE:
STROKE SINCE:
TYPE OF STROKE:
USE OF ANY MOBILITY AIDS :
o YES
o NO
KNEE RANGE OF MOTION MEASUREMENTS:
NO. / KNEE JOINT RANGE OF MOTION / PARETIC KNEE / NON PARETIC KNEE1 / KNEE FLEXION
KNEE EXTENSION