Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore.
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / Name of the Candidate& Address / PRADEEP KUMAR YADAV
Kharukyahi-9,
Siraha,Nepal
2 /
Name of the Institution and address
/ KTG COLLEGE OF PHYSIOTHERAPYHegganahalli Cross,Peenya 2nd Stage,
Sunkadakatte Main Road,V.N Post
Bangalore-560091
3 /
Course of study and subject
/ MASTER OF PHYSIOTHERAPY(Musculoskeletal disorders and Sports physiotherapy)
4 /
Date of admission to course
/ 28th May 20125 /
Title Of The Topic:
“COMPARISON OF EFFECT OF KNEE STRENGTHENING VERSUS HIP POSTEROLATERAL MUSCULATURE STRENGTHENING IN PATELLOFEMORAL PAIN SYNDROME”6 / Brief Resume of the intended work:
6.1 Need of the study
Patellofemoral pain syndrome is a common clinical entity used to describe a variety of pathologic conditions associated with the articulation between the under surface of the patella and the femoral condyles.
Patellofemoral pain syndrome can be caused by a variety of factors, including quadriceps weakness, increased Q angle, faulty lower extremity mechanics, overuse, and lateral retinaculum tightness. The major complaints of patients with Patellofemoral pain syndrome diffuse knee pain, patellar crepitus and locking, knee joint stiffness, and decreased activity levels. Onset of symptoms is usually insidious and may occur bilaterally. Activities such as prolonged sitting, stair descent, and squatting often exacerbate the pain.1
The clinical diagnosis of Patellofemoral pain syndrome typically encompasses retro patellar or peri patellar knee pain that is aggravated by prolonged sitting or activities that load the patellofemoral joint, such as stairs ascending or descending, squatting, running, jumping, or kneeling. 2
Various authors have suggested that hip weakness may be an impairment associated with PFPS, because poor hip control may lead to abnormal lower extremity or patellofemoral motions. Theoretically, weakness of the hip abductors and external rotators may be associated with poor control of eccentric femoral adduction and internal rotation during weight-bearing activities, leading to misalignment of the patellofemoral joint as the femur medially rotates underneath the patella. Consequently, to reduce excessive lateral patellar deviations during weight-bearing activities and potentially reduce anterior knee pain, physical therapy intervention may need to address hip muscle performance to facilitate greater control of weight-bearing femoral adduction and internal rotation.3
Specific activities targeting performance of the lateral hip musculature have been incorporated into physical therapy intervention programs for improving pain, disability, and function in patients with PFPS.4
A study found that 15 female subjects with PFPS demonstrated 26% less hip abduction strength and 36% less hip external rotation strength when compared to 15 age-matched control subjects. In contrast, reported that there were no statistically significant differences in hip abduction or external rotation strength when 30 subjects with PFPS (17 females and 13 males) were compared with 30 age- and gender-matched control subjects.5
Weak hip extensors and quadriceps of the injured leg could lead to reduced hip extension and therefore a reduced hip displacement angle (HDA), step length and velocity. The primary contributors to hip extension in single limb stance are the vasti, hamstrings, and gluteus maximus.7,8 The hip and knee accelerations induced by four muscles during stance. They showed that the gluteus maximums and vasti accelerated the joints toward extension in early to mid stance, and that the soleus accelerated the joints toward extension in mid- to late stance.25 The hip extensors, knee extensors, and ankle plantar flexors all help to control hip and knee extension during the stance phase of normal gait.9,10
Hip external rotation and abduction musculature contribute to pelvic stability and leg alignment by eccentrically controlling femoral internal rotation and influencing hip adduction during weight-bearing activities,weakness of these muscles may increase medial femoral rotation, valgus knee moments, or cause a gluteus medius gait. These deviations may alter the abduction/adduction moments at the hip or lead to an increased Q-angle, which may subsequently alter tracking of the patella, increase compressive forces on the patellofemoral joint, and ultimately lead to knee pain.11Tightness of soft tissues, such as the gastrocnemius, quadriceps, and hamstring muscles and ITB/TFL, has also been suggested to influence distal fibers of the ITB/TFL complex attach to the lateral aspect of the patella via the ITB, it has been theorized that tightness of ITB/TFL may pull the patella laterally and increase the stress over the patellofemoral joint.12
The ultimate goal of rehabilitation for patients with Patellofemoral pain syndrome is to return to the highest functional level in the most efficient manner2
There has been no studies comparing the effectiveness of strengthening the different group of musculature around the hip joint and hence this study is trying to find out the effect of strengthening of hip extensor and hip lateral musculature supplemented by knee strengthening, which can be included in the treatment programs for patients with patellofemoral pain syndrome.
RESEARCH QUESTION:
Is there any difference in the effectiveness of Knee strengthening and hip Posterolateral musculature strengthening in the treatment of patellofemoral pain syndrome?
Null hypothesis:
There will no significant difference between knee strengthening and strengthening of posterolateral muscles of hip in the subject with patellofemoral pain syndrome.
Experimental hypothesis:
There will be significant difference between knee strengthening and strengthening of posterolateral muscles of hip in the subject with patellofemoral pain syndrome.
6.2 Review of Literature:
Review on patellofemoral pain syndrome:
Thiago Yukio Fukuda, William Pagotti Melo et al(2012) Posterolateral Musculature Strengthening in Sedentary Women With Patellofemoral Pain Syndrome: A Randomized Controlled Clinical Trial With 1-Year Follow-up. Knee-stretching and -strengthening exercises supplemented by hip posterolater-al musculature–strengthening exercises were more effective than knee exercises alone in improving long-term function and reducing pain in sedentary women with PFPS.13
Defne Kaya, Michael James Callaghan et al (2011) The Effect of an Exercise Program in Conjunction With Short-Period Patellar Taping on Pain, Electromyogram Activity,and Muscle Strength in Patellofemoral Pain Syndrome .Twelve patients and 16 healthy people participated. Patients underwent short-period patellar taping plus an exercise program for 3 months. Numeric pain rating, muscle strength of the knee extensors, and electromyogram activity of the vastus lateralis and VMO were evaluated. And they concluded that Short-period patellar taping plus an exercise program improves VMO and vastus lateralis activation. A shorter period of taping for the exercise program may be as beneficial as a prolonged taping application.1
Edith M Heintjes, Marjolein Berger et al (2009) conducted a study Exercise therapy for patellofemoral pain syndrome This review aims to summarise the evidence of effectiveness of exercise therapy in reducing anterior knee pain and improving knee function in patients with PFPS. From 750 publications 12 trials were selected. All included trials studied quadriceps strengthening exercises. Outcome assessments for knee pain and knee function in daily life were used in a best evidence synthesis to summarise evidence for effectiveness. The evidence that exercise therapy is more effective in treating PFPS than no exercise was limited with respect to pain reduction, and conflicting with respect to functional improvement. There is strong evidence that open and closed kinetic chain exercise are equally effective. Further research to substantiate the efficacy of exercise treatment compared to a non-exercising control group is needed, and thorough consideration should be given to methodological aspects of study design and reporting.2
Michael P. Reiman, Lori A. Bolgla et al (2009)The purpose of this commentary is to describe the multifactorial relationships between the hip-joint strength, range of motion, kinetics,kinematics, and various knee pathologies, specifically as they relate across an individual’s life span. A growing body of evidence suggests that hip weakness, as well as altered lower extremity mechanics, might contribute to many knee injuries across the life span. Furthermore, authors from more recent studies have inferred that interventions at the hip can improve knee function. Screening for hip weakness and lack of rotation mobility also seems warranted to prevent potential knee injury.17
Michelle C. Boling, PhD, ATC; Darin A. Padua et al (2009) To compare concentric and eccentric torque of the hip musculature in individuals with and without patellofemoral pain. Twenty participants with patellofemoral pain Concentric and eccentric torque of the hip musculature was measured on an isokinetic dynamometer. All volunteers performed 5 repetitions of each strength test. Average and peak concentricand eccentric torque of the hip extensors, abductors, and external rotators. Torque measures were normalized to the participant’s body weight multiplied by height. The patellofemoral pain group displayed weakness in eccentric hip abduction and hip external rotation, which may allow for increased hip adduction and internal rotation during functional movements16
Lori A. Bolgla, Terry R. Malone et al (2006) conducted a study to find out Hip Strength and Hip and Knee Kinematics During Stair Descent in Females With and Without Patellofemoral Pain Syndrome. Eighteen females diagnosed with PFPS and 18 matched controls participated. Strength measures were taken for the hip external rotators and hip abductors. Hip and knee kinematics were collected as subjects completed a standardized stair-stepping task. Independent “t” tests were used to determine between-group differences in strength and kinematics during stair descent. Subjects with PFPS had significant hip weakness but did not demonstrate altered hip and knee kinematics as previously theorized. Additional investigations are needed to better understand the association between hip weakness and PFPS etiology.3
Sara R. Piva, Edward A. Goodnite et al(2006) conducted a study to find out Strength Around the Hip and Flexibility of Soft Tissues in Individuals With and Without Patellofemoral Pain Syndrome. Thirty patients with PFPS and 30 age- and gender-matched controls without PFPS (17 females and 13 males in each group) participated in the study. Data were collected during 1 testing session by an examiner not blinded to group assignment. Demographic, health history, physical activity levels, and pain and function were assessed using patientcompleted measures. Physical examination measures included assessment of hip external rotation strength, hip abduction strength, length of the iliotibial band/tensor fascia lata complex, gastrocnemius length, soleus length, and quadriceps and hamstrings muscles length. Patients with PFPS demonstrated significantly less flexibility of the gastrocnemius, soleus, quadriceps, and hamstrings compared to healthy control subjects. No differences existed in flexibility of the iliotibial band/tensor fascia lata complex and strength of the hip external rotators and abductors.
Review on hip and knee muscle strengthening in PFPS
Fukuda TY, Rossetto FM et al (2010) Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: a randomized controlled clinical trial. The author concluded that ,in the short term, both treatment approaches were more effective that no treatment for improving function and reducing pain. However, improvements were greater in the group that performed a combination of hip and knee strengthening exercises.14
Theresa Helissa Nakagawa, Thiago Batista Muniz et al (2008)conducted a study to find out the effect of additional strengthening of hip abductor and lateral rotator muscles in a strengthening quadriceps exercise rehabilitation programme for patients with the patellofemoral pain syndrome. Fourteen patients with patellofemoral pain syndrome. The subjects were randomly assigned to the intervention group (strengthening of quadriceps plus strengthening of hip abductor and lateral rotator muscles) or to the control group (strengthening of quadriceps). Both groups participated in a six-week home exercise protocol. The perceived pain symptoms, isokinetic eccentric knee extensor, hip abductor and lateral rotator torques and the gluteus medius electromyographic activity were assessed before and after treatment. Supplementation of strengthening of hip abductor and lateral rotator muscles in a strengthening quadriceps exercise programme provided additional benefits with respect to the perceived pain symptoms during functional activities in patients with patellofemoral pain syndrome after six weeks of treatment.5
Timothy F. Tyler, Stephen J. Nicholas et al (2006) The Role of Hip Muscle Function in the Treatment of Patellofemoral Pain Syndrome Thirty-five patients with patellofemoral pain syndrome, were evaluated and placed on a 6-week treatment program. Hip flexion, abduction, and adduction strength, Thomas and Ober test results, and visual analog scale scores for pain with activities of daily living as well as with exercise were documented on initial evaluation and again 6 weeks later. Treatment consisted of strength and flexibility exercises primarily focusing on the hip improvements in hip flexion strength combined with increased iliotibial band and iliopsoas flexibility were associated with excellent results in patients with patellofemoral pain syndrome18
Review on outcome measures:
Kujala patellofemoral pain syndrome questionnaire:
Tugba Kuru, Elif Elcin Dereli et al [2010] Patellofemoral pain syndrome is one of the most common knee problems, with major effects on quality of life and function. The Kujala patellofemoral score is a functional evaluation instrument to evaluate knee problems related to the patellofemoral system. The aim of this study was to evaluate the validity of the Turkish version of the Kujala patellofemoral score in patients with patellofemoral pain syndrome. The study concluded that the internal consistency of the Turkish version of the Kujala patellofemoral score showed good reliability and test-retest results showed high reliability, suggesting that it is an appropriate functional instrument for Turkish patients with patellofemoral pain syndrome15.
Visual Analogue Scale:
Bert M. Chesworth, Elsie G. Culham et al [1989] The purpose of this study was to determine the reliability and validity of the following outcome measures in a group of 18 patients with patellofemoral pain syndrome: the visual analogue pain scale (VAS), a functional index questionnaire (FIQ), selected temporal components of gait on level walking and ascending stairs, knee joint angle on downhill walking, and electromyography activity of the quadriceps during stair climbing. The VAS was found to be valid outcome measures when assessing patients with PFPS19.
6.3 Objectives of the Study:
To compare the effects of knee strengthening and strengthening of hip posterolateral musculature in the subject with patellofemoral pain syndrome.
7
8. / Materials and Methods:
7.1 Study Design:
Experimental study with pre-post study design.
7.2 Methodology:
Sample size:
The study will be carried out on 30 subjects.
Study population:
Subjects with patellofemoral pain syndrome.
Source of data
· KTG Hospital outpatient department.
· ESI Hospital,Rajajinagar,Bangalore.
· K C General Hospital,Malleshwaram,Bangalore.
Sampling Method: