Pro Forma for Registration of Subjects for Dissertation

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE II

Pro forma for registration of subjects for dissertation

6. BRIEF RESUME OF THE INTENDED WORK

Patellofemoral pain is one of the most common reasons for a person to seek help from a physical therapist.Patellofemoral pain syndrome very commonly known as PFPS is a condition sustained by the general and sporting populations1.Patellofemoral pain is generally described as anterior knee or retropatellar pain that is aggravated by such activities as stair ascent or descent, squatting, kneeling, jumping or prolonged factors like sitting and standing. 1Patellofemoral pain syndrome or PFPS is diagnosed in one patient out of four (24% in men and 30% in women) with running injuries.3 The occurrence of patellofemoral pain in females is two to three times as common as in males, and once present it frequently causes people to cease aggravating activities (Christau,2004)2.Several factors that are believed to contribute to patellofemoral pain are decreased joint flexibility, a large Q angle (Quadriceps angle),impaired activation or timing of the vastus medialis obliques (VMO), patella alta, genu recurvatum, increased subtalar joint pronation, tight hamstrings or gastrocnemius muscles, tightness at the iliotibial tract and trauma (Larsen, Andreasen, Urfer, Mickelson, and Newhouse, 1995)4.

Conservative treatment for PFPS often consists of a variety of components designed to improve patellar alignment including quadriceps retraining (especially VMO), stretching lower limb muscles, patella mobilizing, correcting foot biomechanics with orthoses and patellar taping or bracing1.There is some evidence to support the associationbetween plantar flexors tightness and PFPS4.In an effort to relieve some of the stress and pain at the patellofemoral joint with aggravating activities, many clinicians have begun to use taping to allow patients to perform exercises under supervision that would usually cause pain. The theory behind taping is that it passively corrects patellar tilt, lateral glide and rotation to keep the patella within the trochlear groove during activity (Kowall, Kolk, Cassisi, Nuber, and Stern 1993)5.

It has been theorized that patients with PFPS exhibit altered movement patterns in the lower extremities that may result in alterations of the load distribution across the patellofemoral joint.

This study aims in determining the effectiveness of McConnell taping, quadriceps strengthening exercise and plantar flexor stretching comparedto quadricepsstrengthening exercise and plantar flexor stretching in the treatment of pain and impairment in patellofemoral pain syndrome.

6.1. NEED FOR STUDY

Conservative treatment for PFPS often consists of a variety of components designed to improve patellar alignment including quadriceps retraining (especially VMO), stretching lower limb muscles, patellar mobilization, correcting foot biomechanics with orthoses and patellar taping or bracing.1The use of tape became popular following McConnell’s original publication , which proposed that pulling the patella medially with tape (medial glide) will correct the patella position, stretch the tight lateral structures, increase the activity of the VMO muscle, decrease pain and thus allow the patient to begin strengthening exercises of the quadriceps.

So the need of the study is to detect the effectiveness of Mc Connell taping and quadriceps strengthening exercise, plantar flexor stretching compared to quadriceps strengthening exercise and plantar flexor stretching in the treatment of PFPS.

6.2. OBJECTIVES OF STUDY

1. To find the effect of McConnell taping, quadriceps strengthening exercise and plantar flexor stretching in reducing pain and impairment in patellofemoral pain syndrome.
2. To find the effect of quadriceps strengthening and plantar flexor stretching in reducing pain on patellofemoral pain syndrome.
3. To compare the effect of McConnell taping, quadriceps strengthening exercise and plantar flexor stretching versus quadriceps strengthening and plantar flexor stretching in reducing pain and impairment in patellofemoral pain syndrome.

HYPOTHESIS

Null hypothesis

H01- McConnell taping along with quadriceps strengthening exercise and plantar flexor stretching

are not significantly effective in reducing pain and impairment in patellofemoral pain

syndrome.

H02-Quadriceps strengthening and plantar flexor stretching are not significantly effective in

reducing pain and impairment in patellofemoral pain syndrome

H03- McConnell taping, quadriceps strengthening exercise and plantar flexor stretching is not more

effective than quadriceps strengthening and plantar flexor stretching in reducing pain and

impairment in patellofemoral pain syndrome

Experimental hypothesis

H1-McConnell taping along with quadriceps strengthening exercise and plantar flexor stretching

are significantly effective in reducing pain and impairment in patellofemoral pain syndrome

H2-Quadriceps strengthening and plantar flexor stretching are significantly effective in reducing

pain and impairment in patellofemoral pain syndrome

H3- McConnell taping, quadriceps strengthening exercise and plantar flexor stretching is more

effective than quadriceps strengthening and plantar flexor stretching in reducing pain and

impairment in patellofemoral pain syndrome.

6.3. REVIEW OF LITERATURE

Derasari A. et al (2010)proposed a study titled as McConnell Taping Shifts the Patella Inferiorly in Patients with Patellofemoral Pain: A Dynamic Magnetic Resonance Imaging study. Here 14 individuals with PFPS were randomly assigned in untapped and taped groups and MRI were taken while performing knee flexion and extension and they found that there was inferior shift of patella in taped group and pain reduced due to inferior shift in knee. So they concluded that the inferior shift in patellar displacement with tapingpartially explains the previously documented decrease in pain due to increase in contact area.

Aminaka N. et al (2008)conducted repeated measure design with 2 within-subjects factors and 1 between-subjects factor on Patellar Taping, Patellofemoral Pain Syndrome, Lower Extremity Kinematics, and Dynamic Postural Control. Here 20 participants with PFPS and 20 healthy participants between the ages of 18 and 29 years performed 3 reaches of the star excursion balance test (SEBT) in the anterior direction under tape and no-tape conditions on both legs. The participants with PFPS had a reduction in pain level with patellar tape application compared with the no-tape condition (P = .005).So they concluded that patellar taping seemed to reduce pain and improve SEBT performance of participants with PFPS.

Collins N. et al (2008) performed a randomized clinical trial onFoot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome. 179 participants , with a clinical diagnosis of patellofemoral pain syndrome of greater than six weeks’ duration got six weeks of physiotherapy intervention with off the shelf foot orthoses, flat inserts, multimodal physiotherapy (patellofemoral joint mobilization, patellar taping, quadriceps muscle retraining, and education), or foot orthoses plus physiotherapy. All groups showed clinically meaningful improvements. They concluded that While foot orthoses are superior to flat inserts according to participants’ overall perception, they are similar to physiotherapy and do not improve outcomes when added to physiotherapy in the short term management of patellofemoral pain.

Finch E. et al (2008) in their book Physical rehabilitation Outcome Measures commented that Visual Analogue Scale (VAS) directly measures the intensity of pain and therefore has high content validity and has high test-retest reliability.

Mohammad-Jafar Emami et al(2007), this study was undertaken to evaluate the relationship between the anterior knee pain and Q-angle. This prospective study was performed on two groups; the case group consisted of 100 outpatients,the control group consisted of 100 outpatients aged between 15 and 35 years. The Q-angle of each knee was measured in all participants, using a universal goniometer. All measurements were taken while the participants were in a standing position, the knees exposed in full extension, the patella directed forward in the sagittal plane, and the foot in the neutral position. The Q-angle of both knees of all participants were measured using a universal goniometer. Their results substantiate the fact that patients with anterior knee pain have larger Q-angles than healthy individuals

Keet J.H.L et al (2007) conducted placebo-controlled clinical trial with randomized interventions on the effect of medial patellar taping on pain, strength and neuromuscular recruitment in subjects with and without patellofemoral pain. Here 15 individuals with PFPS and 20 individuals without patellofemoral pain were tested during three different knee taping conditions: (1) no tape; (2) placebo tape; and (3) medial tape and found out that Medial patellar tape did not result in a significant reduction in pain during the step testing. They concluded that although taping did not reduce pain in the patellofemoral pain group, it did enhance the efficiency of the vastus medialis oblique.

Carolyn Kisner and Lynn Allen Colby et al (2007) in their book Therapeutic exercise foundation and technique; 5th edition, mini-squats is effective in causing a greater VMO ratio than a maximum voluntary isometric quadriceps contraction. But there are higher patellar compressive loads when the knee is flexed beyond 600 during weight bearing, exercises and activities with the knee flexed beyond this angle may provoke symptoms in PFPS.

Cristina Maria Nunes Cabra(2007)l et al studied consisted of 10 female patients with diagnosis of PFS, who performed quadriceps femoris muscle strengthening exercises in Closed kinematic chain five series of 10 repetitions and progressive increase in resistance, based on a modified pain monitoring system. They concluded that progressive resistance increases according to the pain level should be used in patients with muscle skeletal disorders, to protect the joints. quadriceps femoris strengthening exercises with ROM control should be prescribed for PFS patients since they improve the knee functional level.

Sara R Piva et al (2006), they carried a study in which the purpose was to determine the inter-tester reliability and measurement error of measures of impairments associated with PFPS in patients with PFPS. Thirty patients with PFPS participated in this study Inter-testerreliability coefficients were substantial for measures of hamstrings, quadriceps, “plantarflexors”, andITB/TFL complex length, hip abductors strength, and foot pronation (ICCs from .85 to .97); moderate for measures of“Q-angle”, tibial torsion, hip external rotation strength, lateral retinaculartightness, and quality of movement during a step down task (ICCs from .67 to .79); and poor forfemoral anteversion (ICC of .45). Standard error of measurement (SEM) for measures of musclelength ranged from 1.6 degrees to 4.3 degrees. They concluded that several of the impairments associated with PFPS had sufficient reliability and lowmeasurement error.

Carol A Oatis (2004) in their book Kinesiology; The mechanics and pathomechanics of human movement mentioned that since gastrocnemius is a two joint muscle, its tightness may lead to flexion of knee and the patient may walk on forefoot which may alter the patellar position( lateral maltracking) and causes the compression of the patella on femoral sulcus. Gastrocnemius is also a flexor of knee which has a significant in moment arm for flexion of the knee.

Whittingham M, et al(2004) conducted a randomized controlled trial on effect of taping on pain and function in patellofemoral pain syndrome. 30 patients randomly assigned in 3 groups. Separate mixed-model ANOVAs, with repeated measures on time, indicated statistically significant improvements in pain and function over time for all groups (P<.01) and also significant differences between groups for all measures (P<.01) Separate independent samples t- tests showed that the group receiving taping and exercises had better pain and function scores. There were no significant differences between the placebo taping, exercise group and group with exercise alone at any point of time. They concluded that combination of daily patellar taping and exercises was successful in improving pain and function in individuals with patellofemoral pain syndrome.

Herrington and Nester(2004) reported that any method that improved the reliability and applicability of Q angle measurement could be useful in investigating the etiology and outcome of patellofemoral pain syndrome treatment.

Heintjes E et al (2003),thisreview 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. Only trials focusing on exercise therapy in patients with PFPS were considered. Trials in patients with other diagnoses such as tendinitis, Osgood Schlatter syndrome, bursitis, traumatic injuries, osteoarthritis, plicasyndrome, Sinding-Larssen-Johansson syndrome and patellarsubluxation were excluded. 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

Wilson T. et al (2003) performed A multicenter, single-masked study of medial, neutral, and lateral patellar taping in individuals with patellofemoral pain syndrome.71 patients with PFPS were taken to performed 4 single step-downs with the patella untapped and then with the patella taped in a medial, neutral, and lateral direction. All the methods of taping significantly decreased pain when compared to the untapped condition (P<.0001). Neutral and lateral glide techniques produced a significantly greater degree of pain relief (P<.0001) than the medial-glide technique. They concluded that patellar taping produced an immediate decrease in pain in patients with PFPS.

Crossley et al (2002) according to their study they concluded that 3 repetitions 30-60 second stretch duration and intensity can produce lengthening changes in tightened calf muscles

. Cynthia c Norkin and D. Joice White et al (1998) in ‘Measurement of joint motion: a guide to goniometry, second edition. Universal goniometer is the reliable and versatile and reliable equipment used to measure range of motion. The normal dorsiflexion range of motion for ankle is 200.

Kowall MG (1996) performed a study on randomized controlled trial on Patellar taping in the groups treatment of patellofemoral pain.25 patients with patellofemoral pain were randomized into two group underwent a standard physical therapy program while the other group underwent the same physical therapy program with patellar taping. No difference in improvement of patellofemoral pain was noted between the groups. The results of this study suggest no beneficial effect of adding a patellar taping program to a standard physical therapy program in the conservative treatment of patellofemoral pain.

Youdas JW et al (1993) examined intratester and intertester reliability for goniometric measurements of ankle dorsiflexion (ADF) and ankle plantar flexion (APF) active range of motion (AROM). Parallel-forms intratester reliability for ankle AROM measurements obtained by the universal goniometer (UG) and by visual estimation (VE) and intertester reliability for VE of ADF and APF were examined. Repeated measurements were obtained on 38 patients with orthopedic problems by 10 physical therapists in a clinical setting. For intratester reliability of measurements obtained with UG, intraclass correlation coefficients (ICC) for all physical therapists were 0.64 to 0.92 (median, 0.825) for ADF and 0.47 to 0.96 (median, 0.865) for APF. Intertester reliability was quantified with use of ICC. ICCs for measurements obtained by UG were 0.28 for ADF and 0.25 for APF; ICC of VE for ADF was 0.34 and was 0.48 for APF. ICC for parallel-forms intratester reliability obtained with UG and VE ranged from 0 to 0.94 (median, 0.58) for ADF and 0 to 0.86 (median, 0.625) for APF. Thus,they concluded that a physical therapist should use a goniometer when making repeated measurements of ankle joint AROM.

Clapper and Wolf (1988) ina study involving 10 female and 10 males with mean age of 30 yrs and 28.3 yrs respectively found that ICC for measurement of ankle dorsiflexion for universal goniometer is 0.92.

Huberti et al(1984) and Sara R et al (2006) the technique they used to measure Q-Anglewas measured with the knee in full extension with the subject supine. The angle formed by the intersection of the line of application of the quadriceps force (line from the anterior superior iliac spine to the center of patella) with the center line of the patellar tendon (line from the center of the patella to the tibial tubercle) was measured in degrees with a universal goniometer. The center of the patella and the tibial tubercle were marked with a demographic pencil, which waswiped out after the measurement. Before the measurement, the tester palpated the anterior superior iliac spineand asked the subject to keep his second finger pointing down over this landmark during the measurement. Subject was also asked not to contract the quadriceps muscles during the measurement.The technique used to measure plantar flexors length was determined by measuring the amount of ankle joint dorsiflexion with the knee extended, and again with the knee flexed at 90°. Ankle dorsiflexion measured with the knee extended was used to account for the influence of gastrocnemius tightness. Measurement of ankle dorsiflexion with the knee bent was used to detect tightness of joint capsule or soleus muscle. The subject was positioned in the prone position with the foot hanging off the table and the subtalar joint was maintained in the neutral position. Dorsiflexion was measured with a standard goniometer as the angle formed by the lateral midline of the leg on a line from the head of the fibula to the tip of the lateral malleolus and the lateral midline of the foot in line with the border of the rearfoot/calcaneus The average measurement of two trials was taken.

7. METHODOLOGY AND MATERIALS

7.1 SOURCE OF DATA

• Alva’s PhysiotherapyOPD, Moodbidri.
• Alva’s Physiotherapy clinic (Extension unit), Karkala.

7.2 METHODS OF COLLECTION OF DATA