DISSERTATION SYNOPSIS

SUBMITTED TO

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

TOWARD PARTIAL FULFILMENT OF

MASTER OF PHYSIOTHERAPY DEGREE COURSE

By

PRAVEEN MIKKILI PAUL

UNDER THE GUIDANCE OF

B A BOOMADEVI

VIKAS COLLEGE OF PHYSIOTHERAPY

MARYHILL, KONCHADY, MANGALORE-575006

2009-11

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the Candidate
and Address / PRAVEEN MIKKILI PAUL
VIKAS COLLEGE OF PHYSIOTHERAPY
AIRPORT ROAD
MARYHILL, KONCHADY
MANGALORE – 575008
2. / Name of the Institution / VIKAS COLLEGE OF PHYSIOTHERAPY
Mangalore.
3. / Course of study and subject / Master of Physiotherapy (MPT)
Physiotherapy in Musculoskeletal Disorders and Sports Physiotherapy
4. / Date of admission to Course / 06-05-2009
5. / Title of the Topic
“EFFECTIVENESS OF OPEN KINEMATIC CHAIN EXERCISES OVER CLOSED KINEMATIC CHAIN EXERCISES IN IMPROVING THE KNEE RANGE & FUNCTIONAL STATUS OF PATIENTS AFTER RECONSTRUCTION SURGERY OF GRADE-II & -III ANTERIOR CRUCIATELIGAMENTINJURY- A COMPARITIVE STUDY
6 / BRIEF RESUME OF THE INTENDED WORK
6.1) Need for the study
The Anterior Cruciate Ligament (ACL) is the primary restraint to anterior translation of the tibia and a secondary restraint to tibia rotation and to varus and valgus stress. An intact ACL resists forces up to 2500N and strain of about 20% before falling. ACL is mainly responsible for anterior medial stability of knee joint.1 ACL is one of the more common injured knee ligaments. An estimated 1 out of 3000 people will suffer an ACL injury in any given year. Non-contact mechanism may accursed for up to 78% of all ACL injuries.2
Rehabilitation in the ACL injury in 1st phases of the postoperative program play an important emphasis on regaining full passive extension, progressive weight bearing, control of postoperative effusion and quadriceps and hamstring re-education, prevention of extension loss is the most important goal following surgery.2
In closed kinematic chain (CKC) activities recruitment of muscle contraction are predominantly eccentric, with dynamic muscular stabilization in the form of co-contraction. In open kinematic chain (OKC) activities muscle contractions are predominately concentric.3
Hence the need arises to find out the effective means of treating reconstruction surgery after Grade-II &-III ACL injury. This study is devised to find out the best method of addressing the problem of functional activities post operatively in patients with ACL injury.
6.2) Review of Literature
Sofi Tagesson RPT & Birgitta Oberg (2008) did study on 45 patients with ACL injury and found that rehabilitation with open kinematic chain quadriceps exercise led to significantly greater quadriceps strength compared with rehabilitation with close kinematic chain quadriceps exercises. Forty-two patients were tested a mean of 43 days (range, 20–96 days) after an ACL injury. Patients were randomized to rehabilitation with CKC quadriceps strengthening (11 men and 9 women) or OKC quadriceps strengthening (13 men and 9 women). Aside from these quadriceps exercises, the 2 rehabilitation programs were identical. Patients were assessed after 4 months of rehabilitation. Functional outcome was evaluated by determining the Lysholm score and the Knee Injury and Osteoarthritis Outcome Score.4
Fleming BC et al (2005) has found that open kinematic chain exercises and closed kinematic chain exercises may not differ in their effect in graft healing, postoperative knee function, and patient satisfaction. Recent biomechanical studies have shown that peak strain produce on graft is similar. Studies suggest that both play a beneficial role in early rehabilitation of reconstructed knee.5
Mininder S Kocher (2004) stated that the Lysholm scale is a condition-specific outcome measure that was originally designed to assess ligament injuries of the knee. They had done study on 1657 patients with chondral disorder for assessing the reliability, validity, and responsiveness of the Lysholm knee scale. The Lysholm knee scale demonstrate overall acceptable psychometric performance for assessment of various chondral disorder of the knee.6
Robert L Barrack (2001) the done a randomized study of open and close kinetic chain exercises during accelerated rehabilitation after ACL reconstruction. The CKC group used a length of tubing, the sport cord, to perform weight bearing exercises and the OKC group used conventional physical therapy equipments. And concluded that close kinetic chain exercises are safe and effective and offer some important advantage over open kinetic chain exercises in rehabilitation after ACL reconstruction.7
Genelin F (1993) did a study on 49 patients with anterior cruciate ligament injury and evaluated with the Lysholm scale and The Orthopadische Arpeitsgruppe Knie (OAK) knee evaluation form. On Lysholm scale 81% scored between 85 and 100 where only 52% scored over 90 points on the OAK form.8
Mollinger LA and Steffan TM (1993) collected intra-tested reliability data on measurement of knee extension made by two testers using a universal goniometer. IIC’s (Intraclass Correction Coefficient) for knee extension repeated measurements were high with difference between repeated measurements averaging 1 degree.9
Watkins MA et al (1991) compared passive ROM measurement of the knee of 43 patients made by 14 therapists who used a universal goniometer and visual estimates. They found that intra-tested reliability with the universal goniometer was high for both knee flexion and knee extension. Inter-tested reliability for goniometric measurements were also high for knee flexion but only good for knee extension.10
Gogia PP et al (1987) measured knee joint angle between 0 to 120 degrees of flexion. These measurements were immediately followed by radiographs. Inter-tester reliability was high. The intra-class correction coefficient (IIC) for validity also was high, 0.99. He concluded that the knee angle measurement taken with a universal goniometer were both reliable and valid.11
6.3) Objectives of the study
The objectives of the study are:
1. To find the effect of Open Kinematic Chain exercises in improving the active range of knee and functional outcome in patients following Reconstruction surgery of Grade-II & Grade-III ACL injury.
2. To find the effect of Closed Kinematic Chain exercises in improving the active range of knee and functional outcome in patients following Reconstruction surgery of Grade-II & Grade-III ACL injury.
3. To find the effectiveness of Open Kinematic Chain exercises versus Closed Kinematic Chain exercises in improving the active range of knee and functional outcome in patients following reconstruction surgery of Grade-II & Grade-III ACL injury.
7 / 7.1 Source of Data :
This study will be conducted at HOSMAT Hospital, Bangalore.
7.2 Methods of Collection of Data:
Primary data will be collected from the samples and 30 samples will be included for the study on the basis of Convenient (Non-Probability) sampling method.
Study design:
This study is an Experimental study design involving comparative analysis of two groups with pre & post test measures.
Materials used:
· Towel.
· Weight cuffs.
· Leg press.
· Universal Goniometer.
· Recording Sheets.
· Stationary Bicycle.
Inclusion Criteria:
· Clinically diagnosed patients with Unilateral ACL injury of Grade-II & -III following Reconstruction surgery.
· Patients who underwent Arthroscopy surgery using Patellar tendon graft.
· Patients of both genders.
· Patients with an age group of 18-40 years.
Exclusion criteria:
· Clinically diagnosed patients other than Unilateral ACL injury of Grade-II & -III following Reconstruction surgery.
· Patients who had Arthroscopy surgery with Hamstring tendon graft and also Open surgery.
· Patients with any other musculo-skeletal problems.
· Patients with Cardiovascular & Neurological problems.
· Patients with Congenital Deformities.
Parameters of the Study:
The following will be used as the parameters of the study
· Active Range of motion of knee joint (Both Knee Flexion & Extension) will be measured using Universal Goniometer.
· Functional Ability will be assessed by Lysholm’s Scale.12
7.3 Intervention to be conducted on participants (Methodology):
Subjects will be included for the study based on selection criteria and they will be informed about the treatment program. 30 subjects will be equally divided into two groups consisting of 15 subjects each; namely, Group-I and Group-II.
Range of motion of knee flexion and extension and Lysholm’s scale evaluation will be taken pre-rehabilitation and post-rehabilitation (after 6weeks) for all the subjects. The Wilk protocol1 will be followed in both groups of patients for 6 Weeks.
Group-I: All the subjects of this group will be given a transitional hinged brace locked in full extension for ambulation on the Day-1 of Rehabilitation, followed by weight bearing with two crutches. The patients were then asked to perform the set of Open Kinematic Chain exercises which included the following:-
· Ankle pumps in supine position
· Active and passive knee flexion
· SLR (Flexion, Abduction, Adduction)
· Over pressure into full passive knee extension in supine position
· Quadriceps isometric setting
The frequency and duration for isometric exercises will be 20 contractions with 6 seconds hold time and for isotonic exercises will be 6 to 12 repetitions.
Day 2-7:
Patients will be asked to continue the above exercises which is then followed by the below mentioned exercises:-
· Multi-angle isometrics of quadriceps in 90 degrees and 60 degrees
· Knee extension – 90 to 40 degrees (from 90 degree flexion to 40 degree extension).
· Standing hamstring curls
Week-II:
Weight bearing will be given according to the patient tolerance level and the crutch will be discontinued after 10 days. The self stretching exercises for quadriceps and hamstring will be given four to five times daily, additionally Patellar mobilization will be done by the therapist in supine position - superior, inferior, medial and lateral glides will be given.
· Prone hamstring curls
Week-III:
The brace will be discontinued, and the patients will be asked to continue the same set of exercises of Week-II, to which the following exercises will also be added:-
· Passive ROM of 0-115 degrees, i.e., extension to flexion given by therapist.
· Front step up done with a stool
· Stair climbing; patients will be asked to climb the stairs one by one.
Week-IV&V:
The patients will be asked to wear knee sleeves and continue all the exercises of Week-III to which the following exercises will also be added:-
· Hip adduction and abduction in lying position
· Hip flexion and extension in standing position
Week-VI:
In this week, patient continued all the exercises of Week-IV and along with that poor running (forward) agility drill will be started i.e., the patients will be asked to walk in the figure of eight.
Group-II: All the subjects of this group will be treated with the same exercise program given in Group-I in closed kinematic chain pattern.1 The day-1 will have the same set of exercises. The changes in the protocol are given below for this group.
Day 2-7:
· Mini squats (30 degrees) with weight shifts in standing position
· Heel sliding in lying position; patients will be asked to bend the knee and then slide on the bed to extend it.
Week-II:
· Half squats (0-40 degrees) & Wall slides (Place one foot on a towel against the wall and slowly lower with gravity to flex the knee while other leg is supported.
· Leg presses; patients were sitting on the machine and extending the leg.
Week-III:
· Bicycling for ROM stimulus and endurance.
· Lateral lunges in standing position
Week-IV&V:
· Leg presses, Wall squats (Wall squats will be performed with the back against the wall).
· Bicycling & Lateral lunges.
· Vertical squats & Toe calf raises will be done by standing on toes and then coming to neutral position.
· Stair stepper machine.
Week-VI:
In this week patient will continue all the exercises and along with that balancing on tilt board also will be started.
The pre test and post test scores of active knee range and Lysholm’s Scale will be statistically analysed for significance.
Statistical Analysis:
The effectiveness of treatment given within the groups will be analyzed statistically using Dependent ‘t’ Test and the significant difference between the groups will be analyzed using Independent ‘t’ Test for both the parameters.
Ethical clearance:
Ethical permission for the study will be obtained from the institution where the subject belongs to & a written consent will be taken from each subject who participates in the study.
8 / References
1.Brent Brotzman S & Kevin E Wilk. Clinical Rehabilitation. Mosby. 2nd ed. 1996; p.286-290.
2.JeMe Ciaoppa Mosca and John Cavanaugh. Post rehabilitation guideline for the orthopedic clinician. p. 426.
3.Carri M Hall, Lori Thein Brody. Therapeutic exercises moving towards function. Lippincott Williams and Wilkins. 1999; p.252-273.
4.Sofi Tagesson RPT, Birgitta Oberg. A Comprehensive rehabilitation program with quadriceps strengthening in CKC exercises in patients with ACL. The American journal of sports medicine. 2008; 36:298-307.
5.Fleming BC, Oksendahl H, Beynnon BD. OKC and CKC exercises after ACL reconstruction. Exercises sport sic rev. 2005; 33(3):134-409.
6.Mininder S Kocher. Reliability, validity and responsiveness of the Lysholm Knee scale for various chondral disorder of knee joint. The J bone and joint surgery. 2004; 86:1139-1145.
7.Robert L Barrack. Open verses close kinetic exercises after ACL reconstruction. The American journal of sports medicine. 2001; 29:167-174.
8.F Genelin. Lysholm scale and OAK knee evaluation form in evaluating ACL. Journal of knee surgery, Sports Traumatology, Arthroscopy. 1993; 1:17-19.
9.Mollinger LA and Steffan TM. Knee flexion contracture in institutionalized elderly: prevalence, severity, stability and related variables. Phys ther. 1993; 73:437.
10.Watkins MA. Reliability of goniometric measurements and visual estimates of knee range of motion obtained in a clinical setting. Phys Ther. 1991; 71:90.
11.Gogia PP. Reliability and validity of goniometric measurements at the knee. Phys Ther. 1987; 67:192.
12.David J Magee. Orthopedic physical Assessment. Saunders. 4th ed. 2002; 689.
9. / Signature of the candidate :
10. / Remarks of the Guide
11. / Name and Designation of
11.1  Guide : B A BOOMADEVI M.P.T.
Professor
11.2  Signature :
11.3  Co-Guide : -
11.4  Signature : -
11.5  Head of the Department : Prof. S. NATARAJAN M.P.T.
11.6  Signature :
12. / 12.1 Remarks of the Chairman and Principal
12.2 Signature :