6.brief resume of the intended work:
6.1 Need Of Study:
The 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 2500 N 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. The majority of these injuries occur during sport activities, which involve rapid change of direction and jumping (basketball, soccer, football, skiing). 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. 1
Neuromuscular electrical stimulation (NMES) can be used to minimize weakness associated with disuse by facility passive exercises in the presence of pain. Electrical stimulation enhances the contraction and possibly initiates the concept of contraction long before the patient can initiate voluntary contraction. 6
In close kinetic chain (CKC) activities recruitment of muscle contraction are predominantly eccentric, with dynamic muscular stabilization in the form of co contraction. In open kinetic chain (OKC) activities muscle contraction are predominately concentric. 7
Hence the need arises to find out the effective means of treating reconstruction surgery after grade II ACL injury. This study is devised to find out the best method of addressing the problem of functional activities in ACL injury.
Hypothesis:
Null Hypothesis
There is no significant difference between the effectiveness of open kinetic chain exercises with muscle stimulation and close kinetics chain exercises with muscle stimulation in strength gain, range of motion and return to sport for quadriceps and hamstring following reconstruction surgery of grade II ACL injury.
Alternative Hypothesis
There is a significant difference between the effectiveness of open kinetic chain exercises with muscle stimulation and close kinetic chain exercises with muscle stimulation in strength gain, range of motion and return to sport for quadriceps and hamstring following reconstruction surgery of grade II ACL injury.
6.2 REVIEW OF LITERATURE
John Cavanaugh stated that CKC exercises are used predominantly for strengthening in the early phases of the program as these activities have been shown to minimize stress to the ACL. 2
Carrie Hall emphasizes parameters for initiating NMES program for patient with minimal atrophy with frequency 30-50 Hz, on time 10-15 sec, off time 10-30 sec. session length 15min, session per day 1-2. 5
Yack & collegues 1993 has found increase in anterior displacement during OKC exercises (knee extension) compared with CKC exercises (parallel squats) through a flexion range of 0-64 degree. 6
Beynnon & associates 1997 used implanted transducer to measure the strain in the intact ACL during various exercises and found not consistent distinction between CKC and OKC activities. 7
Kvist & Gillqust 1999 demonstrated that displacement occur with even low level of muscular activity generation of 1st 10 % of peak quadriceps torque produce 80% of total tibia translation with maximal quadriceps torque. 8
William & Street in a study of 20 patients with quadriceps femoris atrophy used 20 min of NMES per session for 30 sessions and found recovery of normal quadriceps function in majority of cases. 9
Eriksson & Haggmark in their study of healthy subjects seated earlier, use the identical regime to compare the NMES and isometric exercises that had undergone knee ligament surgery. They reported less observable atrophy of the thigh, marked functional improvement and an increase in oxidative activities in NMES group as compared to isometric exercises group. 10
Siks & coworkers investigated the effect of NMES + Isometrics VS Isometric exercises alone on the quadriceps femoris strength on the group of 22 patients immobilized after ACL reconstruction the stimulator produced a 300 micro seconds PD, balanced, symmetrical, biphasic pulsed current at 40 pps and training cycle of 10 sec on is to 30 sec off training was at MTIC, 8 hr per day, 7 day per week, for 6 week .no difference in MVIT was noted between the groups. 11
Pumberges B, Van Usen, C. has found moderate evident to recommend CKC exercises or a combination of CKC and OKC exercises rather then OKC exercises alone for ACL rehabilitation: when considering force on ACL. 12
Mikkclsen C, Werners, Erikssone Addition of quadriceps training after ACL reconstruction results in a significantly better improvement in quadriceps torque without reducing knee joint stability at 6 month and also leads to a significantly
higher number of athlete returning to there previous activity early and at the same level as before injury 13
.
Fleming B C; Oksendahl H; Beynnon B D OKC and CKC exercises may not differ in their effect in heeling response of ACL reconstruction knee. Resent biomechanical studies have shown that peak strain produce on graft is similar. Studies suggest that both play a beneficial role in early rehabilitation of reconstruction knee. 14
Bynum E B, Barrack RL, Alexander AH.concluded that CKC exercises are safe and effective and of an important advantage over OKC exercises. As a result of study we know use CKC exercises protocol exclusively after ACL reconstruction.15
6.3 Objective Of Study : To evaluate if muscle stimulation and open kinematics chain exercises OR muscle stimulation and close kinematics chain exercises are more effective in regaining the strength of quadriceps and hamstrings muscle following a reconstruction surgery of grade II ACL injury.
MATERIALS AND METHODS:
7.1 Source Of Data Collection :
· KTG hospital.
· HOSMAT hospital.
7.2 Method Of Collection Of Data :
Research Design: Experimental study with control group.
Sample size: 30 subjects
Sample Technique: Sample random technique.
Materials Used:
· Weight cuff
· Muscle stimulator
· Quadriceps table
· Goniometer
Evaluation tools:
· One RM
· Range of motion
· Knee OA out come scale (KOOS)16
Inclusion:
· Grade II
· Arthroscopy surgery.
· Unilateral.
· Both gender
· Age 18-40.
· Sport person.
Exclusion:
· Grade III
· Open surgery.
· Bilateral
· Any other musculoskeletal problem.
· Associated fractures around knee.
· Associated fracture of lower limb.
· Cardiovascular problem.
Methodology:
30 subjects of grade II ACL injury who admitted to hospital and received ACL reconstruction were taken.
Subjects are randomly assigned in-group A, B and C.
ROM of knee flexion and extension, RM for Quadriceps and KOOS for functional evaluation were take pre rehabilitation and post rehabilitation for all the subjects. Purpose of study was explained to all the subjects and the consent for study were obtained as an ethical procedure.
7.3 Intervention To Be Conducted On The Participants:
Group A, B and C were assessed using 1 RM, ROM and KOOS scale before and after treatment of 4 weeks. The exercises taught to each group are as follows:
Treatment Procedure:
GROUP A
1. Muscle stimulator
For 15 min with Amplitude 100 ma, phase duration 0.3 ms, frequency 30pps and duty cycle 1:3 is given.
2. Isometric and stretching exercises quadriceps, hamstring, and calf.
3. Open kinematics chain exercises
· All plane straight leg raise (SLR)
· Quads table exercises.
· Prone extension hangs.
· Supine leg hangs.
· Prone hamstring curls.
GROUP B
1. Muscle stimulator
For 15 min with Amplitude 100 ma, phase duration 0.3 ms, frequency 30pps and duty cycle 1:3 is given.
2. Isometric and stretching exercises quadriceps, hamstring, and calf.
3. Close kinematics chain exercises
· Short arc quads
· Wall slides.
· Mini squats.
· Wall squats
· Forward lunges.
GROUP C
1. Isometric and stretching exercises quadriceps, hamstring, and calf.
2. Open kinematics chain exercises:
· All plan straight leg raise. (SLR)
· Flexion and extension.
· Prone extension hangs.
· Supine leg hangs.
· Prone hamstring curls.
3. Close kinematics chain exercises:
· Short arc quads.
· Wall slides.
· Mini squats.
· Wall squats
· Forward lunges
Statistical Analysis:
A two way repeated measure analysis of variance will be used to test the effectiveness of the treatment protocols.
7.4 Ethical clearance:
As my study includes human subjects ethical clearance is obtained from research and ethical commits of the institution.
REFFRERNCES:
1. Michael D Amato, MD and Bernard, Jr MD: knee injury .Ed Clinical orthopedic Rehabilitation2003, 267-293.
2. John Cavanaugh PT .ACL reconstruction Ed Post surgical Rehabilitation for the Orthopedic Clinician 426.
3. Richard B Johnson. Surgery of the knee: Rehabilitation Ed. Orthopedic Physical Therapy 2000.471
4. De. Valhi J.NMES in Rehabilitation Ed Electrotherapy in Rehabilitation Philadelphia FA Davis 2004.218-268.
5. Carri Hall. Ed Therapeutic exercises moving towards function 1999.252-273.
6. Yack HJ, Collins CE, Whieldon TJ: Comparison of CKC and OKC in ACL deficient knee. Am J sport med 21:29-54, 1993.
7. Beynnon BD, Johnson RJ: ACL injury rehabilitation in athletes. Biomechanics consideration, sport med 22:54-64, 1996.
8. Kvits J, Gillquist J, Anterior tibial translation during eccentric, isokinetic quadriceps work in healthy subjects. Am J Med Sci Sports 9:189-194, 1999.
9. William JCP, Street M. Sequential fradism in quadriceps rehabilitation physiotherapy 1976; 62: 252-254
10. Erikson E, Haggmark T.Comparision of isometric muscle training and electrical stimulation supplementing isometric muscle training in the recovery after major knee ligament surgery. Am J Sports Medicine 1979; 7:169-171
11. Sisk TD, Stralk SW, Deering MB, Griffim JW. Effects of electrical stimulation of quadriceps strengthening after reconstructive surgery of ACL. Am J Sports Medicine.1987: 15:215-219.
12. Pumberger B, Van Usen, C. evaluation of the effect of two exercises regime in producing force on ACL ligament a systemic review. The IJAHS vol 5. No. 2. ISSN 1540-580Napril 2007.http://ijahsp.nova.edu.
13. Mikkclsen C, Werner S, Eriksson, CKC alone compared to combined OKC and CKC exercises of quadriceps strengthening after ACL reconstruction with respect to sports; a prospective matched follow-up study. Knee surgery sport Traumatol Arthosc.2000;8(6): 337-42.
14. Fleming B C; Oksendahl H; Beynnon B DOKC and CKC exercise after ACL ligament reconstruction? Exercises sport sic rev.2005: 33(3): 134-409(ISSN:0091-6331)
15. Bynum E B, Barrack RL, Alexander AH. OKC exercises after ACL ligament reconstruction a prospective randomized study. Am J sport med 1995 Jul-Aug; 23 (4): 401-6.
16. Roos EM,Roos HP,Lohmander LS,Ekdahl C,Beynnon BD.Knnee injury and Osteoarthritis outcome scale (KOOS)-development of a self administrated outcome measure.JOSPT 1998;78:88-96