RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 Name of the Candidate and Address

R.SUDHANRAM.SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER.PANDESHWARA, MANGALORE-575001.

2 Name of the Institute SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER, MANGALORE.

3 Course of Study and Subject

Master of Physiotherapy (MPT)2 years Degree Course. “Musculoskeletal Disorders & Sports ”

4 Date of AdmissionTo Course 07.06.2009

5 Title of the Topic “A study to Compare the Effects of Two Home Based Rehabilitation Methods in Patellofemoral Pain Syndrome.”

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6 Brief resume of the intended work:

6.1 Need for the study:

Patellofemoral pain syndrome is the term used to describe pain in and around the patella which results in reduction of functional ability1. Patellofemoral pain syndrome (PFPS) is the most common cause of knee pain in the outpatient setting2. It accounts for 25% to 40% of all knee problems seen in sports medicine centers2 and 6-30% in the general population suffers from PFPS2.

Patellofemoral pain syndrome is most commonly due to

malalignment of the PF joint, an increased Q angle, hyper- mobility of patella; an imbalance in the activity of the vastus medialis obliquis (VMO) compared with the vastus lateralis (VL), tightness of the gastrocnemius which affects the knee extensor mechanism results in increased patellofemoral joint stress2.

Rehabilitation of the PFPS includes taping of the patella, mobilization of the patella, ultrasound therapy, phonophoresis, low-level laser treatment, ice therapy3 and by training the vastus medialis obliquis there will be improvement in the loading of the lower extremity so that the forces can spread evenly through the Patellofemoral joint which results in reduction of pain, improves functional ability and maintain normal patellofemoral joint alignment1,3.

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Conservative treatment of PFPS consists of exercises that are designed to decrease patellofemoral joint irritation and pressure, caused by excessive patellofemoral pressure. Exercises such as straight-leg raises are designed to improve patellar tracking by recruiting the VMO, there by counteracting the lateral pull of the vastus lateralis (VL) and resulting in an increased VMO ratio and rehabilitation of patellofemoral pain syndrome is done by training VMO strengthening as a home exercise programme.4

Many researchers are actively looking for a rehabilitation exercise to selectively strengthen the VMO5.Performing a straight leg raise exercise with external hip rotation was the most effective techniques for specific strengthening of vastus medialis oblique for people with weak vastus medialis oblique muscle, such as those with patello-femoral pain syndrome3,6. VMO can be specifically trained by Muncie method which may result in greater VMO muscle activity, and possibly improved quadriceps muscle balance than the traditional T straight leg raise. Patients with PFPS will benefit from using the Muncie method in a home therapy program5.

There are many studies3,7,8, documented about the conventional treatment7,8 in clinical settings but there are only very few evidences documented mentioning about the home based rehabilitation8 in patients with patella femoral pain. But still there is disagreement as to which technique is best for strengthening the VMO5.

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So this study intends to compare the effects of two home based rehabilitation methods in Patellofemoral Pain Syndrome.

6.2 Review of Literature:

1. G. Syme et al. (2009) conducted a randomized controlled trial study to compare the effects of rehabilitation with emphasis on retraining the vastus medialis (VMO) component of the quadriceps femoris muscle and rehabilitation with emphasis on general strengthening of the quadriceps femoris muscles on pain, function and Quality of Life in patients with patellofemoral pain syndrome (PFPS) and concluded that selective VMO training results in improving pain and function in PFPS10.

2. Sinead P O'Sullivan et al. (2005) determined the

various positions of the lower extremity affect the muscle activity of the vastus medialis obliquus (VMO) differently during open kinetic chain exercise among the individuals with patellofemoral pain syndrome and concluded that maximum VMO activity was achieved with terminal knee extension with medial tibial rotation 9.

3. Crossley et al. (2004) conducted a study to examine the test-retest reliability, validity, and responsiveness of VAS

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on several outcome measures in the treatment of patellofemoral pain and found that VAS is reliable(icc-0.83),valid ,responsive and can be used for usual or worst

pain. They also concluded that VAS can be recommended for future clinical trials or clinical practice in assessing treatment outcome in persons with patellofemoral pain12.

4. Erik Witvrouw et al.(2004) conducted a study to find effectiveness of Open Versus Closed Kinetic Chain Exercises in Patellofemoral Pain and concluded that both open kinetic chain and closed kinetic chain programs lead to an equal long-term good functional outcome13.

5. Kevin Sykes et al.(2003) conducted a study to find the Electrical Activity of Vastus Medialis Oblique Muscle in Straight Leg Raise Exercise with Different Angles of Hip Rotation and concluded that straight leg raise exercise with external hip rotation was the most effective as a specific strengthening exercise for vastus medialis oblique6.

6. Witvrouw et al.(2000) conducted a study to find the efficacy of open versus closed kinetic chain exercises in the conservative management of patello-femoral pain and concluded both open and closed kinetic chain programmes showed a statistically significant decrease in pain and increase in functional performance in PFPS 14.

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7. Matthew B. Roush et al.(2000) compared the different types of rehabilitation for anterior knee pain and concluded that Muncie method results in improved clinical outcome

at at a lower cost than traditional home and physical therapy and possibly improved VMO/ quadriceps muscle balance5.

8. Kim Bennell et al. (2000) conducted a study to find out the test retest reliability and inter-relationship of Kujala Scale questionnaire indices used in PFPS to measure functional limitation in general and during specific aggravating activities for PFPS. And concluded that Test retest reliability was Good (ICC=0.96) for Kujala Scale in PFPS17.

6.3 Objective of the study

The objective of this study is to compare the effect of Muncie Method Exercise with Vastus Medialis Obliquis Exercise in relation to pain and Physical function in patients with Patello femoral pain syndrome.

6.4 Hypothesis:

Experimental hypothesis: There will be significant difference between Muncie Method Exercise and Vastus Medialis Obliquis Exercise.

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Null hypothesis: There will be no significant difference between Muncie Method Exercise and Vastus Medialis Obliquis Exercise.

Material and Methods: 7.1 Source of data: The subjects with diagnosed PFPS will be taken from

o Srinivas college of Physiotherapy and Research Center, Mangalore.

o Kurinji Multispeciality Hospital, Salem.o Gopi Multispeciality Hospital, Salem.o Vijaya Multispeciality Hospital, Chennai.

Sample Size: 40 Sampling: Purposive Sampling.

7.2 Method of collection of data:

A total of 40 subjects of both sexes between the age range of 20-50 years/equally divided into two groups 20 subjects in each group. Subjects will be clearly explained about the study. Basic demographic details will be collected from the subjects (containing Name, Age, Sex, side of pain ,Site of pain, Duration of pain, Aggravating factors, Reliving factors, quantity of pain by using a scale from 0 to 10, history of any lower limb surgeries / injuries) to fulfill the inclusion criteria.

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Group 1 = Muncie method exercise + Conventional treatmentGroup 2 = VMO exercise + Conventional treatment

Treatment procedure :

Patient will be clearly explained about the treatment procedure. Before the treatment Pain will be measured with 11 point numeric pain scale( VAS scale)12 and Functional disability with Kujala scale17, It is a self administered questionnaire which consist 13 questions to which the patient has to answer that measures the amount of pain while performing everyday activities.

Exercise protocol for both Group 1 & Group 2:Conventional Treatment:

Exercise protocols will be clearly explained and demonstrated to each subjects. Self stretch of the following muscle groups (Hamstring ,Quadriceps , Iliotibial [IT] band ,Gastrocnemius )will be taught to the patients of both groups , Holding 20 -30 seconds ,two to three times daily before and after performing the exercises, ice7 will be applied for 5 to 10 minutes .Treatment program will be carried out for 6 weeks and at the end of every week, level of pain and functional disability of knee joint will be measured5.

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Group -1(MUNCIE METHOD EXERCISE)5

The patient unaffected knee is bent up with the heel of the foot at 2 inches proximal to the joint line of the injured

knee , patient sits forward and hugs the bent knee then externally rotates the affected leg and maintains the big toe at the 10 o’clock position (if left leg affected) or the 2 o’clock position (if right leg affected).

Then foot on the affected leg should be dorsiflexed as much as possible. The quadriceps of the straight leg contracted until the heel lifts off the ground.

The patient then lifts the entire straight leg 2.5cm off the ground .Holds the leg off the table for up to 5 sec and lowers the straight leg slowly by relaxing the knee and then the heel.

Two sets of ten repetitions twice a day, holding for 5 seconds each repetition. After one week it is progressed by three sets of 10 repetitions twice a day holding for 5 seconds each repetition5.

Group 2 (VMO EXERCISE)3,6.

The patient should be in a supine position with affected side hip externally rotated and knee extended in the exercise limb and the non exercise limb hip and knee flexion,

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Then patient is asked to lift the lower limb with extended knee until 45° hip flexion and hold it for 3–4 seconds, and then let it down for a 3–4 seconds of rest. The number of exercises are increased by 5 every 2 days, so by the end of the programme the subject was performing 70 repetitions twice a day 3,6, .

Materials to be used:1.Pen and Paper2.Inch tape3.Ice pack4.VAS scale5.Kujala scale

Inclusion Criteria:o Males & females Subjects with Unilateral

Patellofemoral paino Pain on patellar grind testo Anterior or retro patellar knee pain aggravated by

at least two activities that load patello femoral joint (stair ambulation, squatting or raising from sitting)

o Pain severity between 4 and 7 in 11 point numerical pain scale during aggravating activities

Exclusion Criteria:o History of internal knee derangement or pathologic

damageo Obesityo History of rheumatalogic disorders o Any neurological condition affecting the lower

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extremitieso Any lower limb surgery/ traumao Inflammatory joint pathology of lower limbo Any severe knee deformities

Statistical analysis:Study design: Experimental study design.

TEST: Paired t -test, Unpaired t- test. 7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly.

YES. This study tends to give home based rehabilitation protocol for patients with Patello femoral Pain Syndrome.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?YES. The consent has been taken from the institute ethical clearance committee.

List of references.

1. Peter burkner , Karim Khan. Clinical Sports Medicine. Third edition. Tata McGraw – Hill Edition 2008; 506-535.

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2. Mario Bizzini,Capt. John D. Childs, Systematic Review of the Quality of Randomized Controlled Trials for Patellofemoral Pain Syndrome. .Journal of Orthopaedic & Sports Physical Therapy .2003; 33: 1-20.

3. A H Bakhtiary, E Fatemi. Open versus closed kinetic chain exercises for patellar chondromalacia British Journal Sports Medicine 2008;42:99–102.

4. John P. Miller,Daniel Sedory. Leg Rotation and Vastus Medialis Oblique/ Vastus Latera is Electromyogram Activity Ratio During Closed Chain Kinetic Exercises Prescribed for Patellofemoral Pain. Journal of Athletic Training.1997;32: 216-219.

5. Matthew B. Roush, Thomas L. Sevier,Julie K. Wilson, Jenkinson. Anterior Knee Pain: A Clinical Comparison of Rehabilitation Methods. Clinical Journal of Sport Medicine .2000;10:22–28.

6. Kevin Syke and Yiu Ming Wong; Electrical Activity of Vastus Medialis Oblique Muscle in Straight Leg Raise Exercise with Different Angles of Hip Rotation. Physiotherapy. 2003; 89: 423-430.

7. Guy.Shelton. Kay Thigpen, Rehabilitation of Patellofemoral Dysfunction: A Review of Literature. Journal of orthopeadics and sports physiotherapy. 1991;14: 243-249.

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8. Kay Crossley,Kim Bennell, Green. A Systematic Review of Physical Interventions for Patellofemoral Pain Syndrome. Clinical Journal of Sport Medicine. 2001;11:103-110.

9. Sinéad P O'Sullivan, Celeste A Popelas. Activation of vastus medialis obliquus among individuals with patellofemoral pain syndrome .Journal of Strength and Conditioning Research.2005; 19:301 -304.

10. G. Syme, , P. Rowe, D. Martin and G. Daly, Disability in patients with chronic patellofemoral pain syndrome.A randomised controlled trial of VMO selective training versus general quadriceps strengthening. Manual therapy .2009;14:252-263.

11. Cynthia LaBella. Patellofemoral pain syndrome: evaluation and treatment. Primary Care Clinical Office Practice .2004;30: 977-1003

12. Crossley, KM, KL Bennell, SM Cowan, and S Green. Analysis of outcome measures for persons with patellofemoral pain: Which are reliable and valid? Archives Physical Medicine Rehabilitation .2004; 85: 815–822. 13. Erik Witvrouw, E, L Danneels, D Van Tiggelen, TMWillems, and D Cambier. Open versus closed kinetic chain exercises in patellofemoral pain: A 5-year prospective

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randomized study. Americian Journal Sports Medicine. 2004;32:1122–1130.

14.Witvrouw E, Lysens R, Bellemans J, Peers K, Vanderstraeten G. Open versus closed kinetic chain exercises

for patellofemoral pain. A prospective, randomized study. American journal of Sports Medicine 2000;28:687–694.

15. Gilmar Moraes Santos, Karina Gramani. Integrated electromyographic ratio of the vastus medialis oblique and vastus lateralis longus muscles in gait in subjects with and without patellofemoral pain syndrome. Rev Bras Med Esporte.2007;17:14-17.

16. Kelly Rafael Ribeiro Coqueiro a, De´bora Bevilaqua-Grossi b, Fausto Be´rzin c, Alcimar Barbosa Soares. Analysis on the activation of the VMO and VLL muscles during semisquat exercises with and without hip adduction in individuals with patellofemoral pain syndrome. Journal of Electromyography and Kinesiology . 2005;15: 596–603.

17.Kim Bennell, Steven Bartam, Kay Crossley and Sally Green. Outcome measures in patellofemoral pain syndrome:Test retest reliability and inter-relationships. Physical Therapy in Sport .2000; 1: 32-41.

18. Arnold. The effects of patellar taping on pain and 14

neuromuscular performance in subjects with patellofemoral pain syndrome clinical rehabilitation . 2002; 16 :812-827.

19. Mario Bizzini, John D. Childs. Systematic Review of the Quality of Randomized Controlled Trials for Patellofemoral Pain Syndrome. Journal of Orthopaedic & Sports Physical

Therapy .2003; 33: 1-20.

20. Monteiro-pedro, vitti m,berzin, bevilaqua-gross .The effect of free isotonic and maximal isometric contraction exercises of the hip adduction on vastus medialis oblique muscle : an electromyographic study. Electromyography and Clinical Neurophysiology. 1999 ;39:435-440.

21.Ludi Laprade, Elsie Culham, BrendaBrouwer. Comparison of Five Isometric Exercises in the Recruitment of the Vastus Medialis Oblique in Persons With and Without Patellofemoral Pain Syndrome .Journal of Orthopeadic and Sports Physical Therapy. 1998 ;27:197-204.

22. Schenck Rc , Anterior knee pain and patellofemoral pain problems.Athelitic training and sports medicine .1999;16: 1-10.

23. Souza DR, Gross MT. Comparison of vastus medialis obliqus: vastus lateralis muscle integrated electromyographic ratio between healthy subjects and patients with patellofemoral pain. Physical Therapy. 1991;71:310-330.

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9 Signature of the Candidate

10 Remarks of the Guide

11 Name & Designation of:

11.1 Guide

11.2 Signature

DR. PURUSOTHAM CHIPPALA. Assistant Professor in Physiotherapy.

11.3 Co-Guide (If Any)

11.4 Signature

DR.RAMAPRABHU.K.R. Associate Professor in Physiotherapy.

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11.5 Head of the Department

11.6 Signature

DR. T.JOSELEY SUNDERRAJ PANDIAN.Associate Professor in Physiotherapy and P.G Coordinator.

1212.1 Remarks of Chairman and Principal

12.2 Signature

DR. RAMPRASAD M.Associate Professor and Principal in Physiotherapy.

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