International Journal of Physical Education, Sorts and Health 2017; 4(5): 11-16 P-ISSN: 2394-1685 E-ISSN: 2394-1693 Imact actor (ISRA): 5.38 IJPESH 2017; 4(5): 11-16 2017 IJPESH www.kheljournal.com Received: 06-07-2017 Acceted: 07-08-2017 Dishant Panchal Shree Devi College of Physiotheray, angalore, India Pavana Assistant Professor Shree Devi College of Physiotheray, angalore, India. A study on efficacy of ultrasound effect of ultrasound with atellar taing and ultrasound with isometric exercises in the atients with atellofemoral ain syndrome-an exerimental study Dishant Panchal and Pavana Abstract Patellofemoral ain syndrome (PPS) is a syndrome characterized by ain or discomfort seemingly originating from the contact of the osterior surface of the atella (back of the knee ca) with the femur (thigh bone). Commonly occurs in the athletes. Several non- oerative interventions with varying success rates, have been described. The aim of this study was to comare the effectiveness of 2 rotocols for the management of atellofemoral ain syndrome: (1) ultrasound with atellar taing (2) ultrasound with isometric exercises. The urose of the study is to determine which treatment is more effective in treating atients with atellofemoral ain syndrome.40 subjects with a case of PPS were chosen for the study. Then the subjects are divided in two grous each grou will have 20 subjects. Subjects were re-tested using Visual analogue scale (VAS) for ain intensity and WOAC scale for functional disability. The first grou was given ultrasound with atellar taing second grou received ultrasound with isometric exercises. Both the grous will be trained for 2 weeks and the assessment arameters will be taken at the end of the 2 weeks. In the resent study, within grou analysis showed ain relief and increased range of motion which was statistically significant in both the grous (<0.001) whereas the between grou analysis revealed that (ultrasound with isometric exercises) was highly significant (<0.001) as comared to. Both grous statistically showed significant resonses to their interventions. Ultrasound with isometric exercises was found to be more effective than the ultrasound with atellar taing to reduce the ain and to decrease functional disability in atients with atellofemoral ain syndrome. Keywords: Patellofemoral ain syndrome, ultrasound, isometric exercises, atellar taing, visual analogue scale (vas), womac scale Corresondence Dishant Panchal Shree Devi College of Physiotheray, angalore, India Introduction Patellofemoral ain syndrome (PPS) is described in the literature as anterior knee ain, caused by aberrant motion of the atella in the trochlear groove, which results from biochemical and/or hysical changes within the atellofemoral joint (PJ). PPS exists without gross abnormality of the articular cartilage. It is a roblem of chronic overload of the muscles of the lower extremity [1]. Patellofemoral ain syndrome (PPS) is a common musculoskeletal comlaint characterized by ain in front of the knee which is rovoked by activities such as walking u and down stairs, sitting with flexed knees for long eriods, running, kneeling and squatting [2] Patellofemoral ain syndrome (PPS) is usually due to weakness of vastus medialis obliqus (VO) resulting in abnormal atellar tracking [3]. Pain at the front of the knee or ''behind the knee ca'' is a common roblem for many sorts eole and can be very debilitating. This condition has a number of names including ''Patello-emoral Pain Syndrome'' & "Runners Knee". The roblem occurs between the atella and the femur. Under normal circumstances, the atella resses against the lower ortion of the femur when the knee is in a bent osition [4, 5]. Patellofemoral syndrome (PPS) is one of the most common joint comlaints and affects athletes and non-athletes alike. PPS atients reort of symtoms of anterior knee ain, aggravated by functional activities. Patellar creitation, swelling and locking are other symtoms [6]. During running or any ste, squat or landing & juming activity, the atella moves u and down or ''tracks'' against the femur and in so doing, acts as a ~ 11 ~
International Journal of Physical Education, Sorts and Health fulcrum, which rovides a mechanical advantage for the quadrices muscle. Decreased soft-tissue flexibility is also evident in adolescents due to the inability of soft tissues to accommodate the raid growth of skeletal structures such as the long bones [7, 8]. There is a commonly acceted concet that conservative rehabilitation induces symtom relief for PPS atients. Different treatments can be tried to reduce the ain and difficulties exerienced during daily activities which includes drugs, electric modalities and massage. Exercise regimens to strengthen the muscles surrounding and suorting the knee are other otions [9]. The atello femoral ain is one of the most common cause of retro atellar or eriatellar ain. It is caused by imbalances in the forces controlling atellar tracking during knee flexion and extension articularly in the knee joint. PPS is a condition of both mal alignment and mal tracking, the most widely acceted cause of atellaofemoral ain is mal tracking of atella which occurs due to weakness of VO [10]. Conservative treatment of atellofemoral ain syndromes is focused on restoring normal atella tracking and its strengthening of quadrices muscle which laces an imortant role in maintaining atella in its normal osition. Patella taing was originally develoed to create a mechanical medial shift to the atella, thus centralizing it and thereby imroving atellar tracking. In the aroriate hands and with the right technique atellar taing has been successful [4]. Patellofemoral ain is associated with atellar mal alignment and quadrices weakness, which are seen more commonly in women. In general oulation females have a higher incidence of atellofemoral ain than males 3:2. There are clear structural, biomechanical, sociological and hormonal differences between women and men that contribute to an increase in incidence of PPS in women. This high incidence in women has been attributed to the gender difference in muscle strength, conditioning and anatomic structure esecially increased Q angle [7]. Studies have shown that strengthening the quadrices secifically the VO can have the imact on mechanics of atellofemoral joint and VO is the only muscle that can move the atella medially and it works tonically throughout the entire range of motion [11]. It is roved that atellar taing is very effective at reducing the level of ain during activities that create large atellofemoral joint reaction forces. However it has been roven that taing can be helful in reducing short term ain with activities [2]. Conservative treatment for PPS often consists of a variety of comonents designed to imrove atellar alignment including quadrices retraining (esecially VO), atellar mobilization, stretching lower limb muscles, correcting foot biomechanics with orthosis, taing, icing, ultrasound for relief of ain and inflammation, squatting exercises [11, 12]. Treatment of PPS in a running individual should focus on the usual methods of the quadrices strengthening [13]. Anterior knee ain is a common resenting comlaint and in many cases no identifiable cause can be found. In these circumstances it is commonly known as anterior knee ain syndrome or atellofemoral ain syndrome. The management for this condition is most commonly nonoerative. Treatment strategies includes hysiotheray, harmacotheray, orthotics and combination of the above. Patellofemoral ain syndrome (PPS) is a term commonly used to describe anterior knee ain and is usually aggravated by walking u/down stairs, dee-squatting, kneeling, rolonged sitting and standing u [11, 1]. PPS esecially affects young adults daily living activities and leads to functional deficiency. Rehabilitation includes secific exercises thought to encourage VO activity, general quadrices exercises and stretching tight lateral structures [3]. Additionally to this atient education, rest, activity modification, electromyograhic biofeedback, neuromuscular electric stimulation, theraeutic ultrasound, thermotheray, atellar taing, bracing, shoe orthotics, knee sleeves and nonsteroidal anti-inflammatory drugs are generally included in the nonoerative treatment of PPS [4, 7]. Patellofemoral ain syndrome (PPS) is a relatively common disorder encountered in the clinical setting affecting an estimated 7% to 40% of adolescents and active young adults [10, 3]. The diagnosis of PPS is tyically made based on the resence of anterior or retroatellar knee ain associated with rolonged sitting or with weight-bearing activities that load the atellofemoral joint such as squatting, kneeling, running and ascending and descending stes [14]. Current evidence-based treatment aroaches include taing, strengthening of the hi musculature and quadrices, manual theray to the lower quarter and fitting of foot orthoses. Treatment interventions for PPS have reviously targeted resumed altered atellofemoral joint biomechanics [15, 16, 17, 18]. One intervention often incororated into the management of atients with PPS is atellar taing [15]. Theraeutic ultrasound has benefits on tissue such as seeding healing rocess, reduction of swelling and edema with decrease in ain intensity micromassage benefits to reduce the adhesion.patellar taing is useful in erson with PPS to imrove stability of atellofemoral joint during range of motion activities.isometric contraction of quadrices muscle hels in increasing the muscle strength and fasten soft tissue healing with imroved ADL activies.this study focuses on functional recovery and imrovement of ADL activities in atient with PPS. aterials and ethods: Source of data obtained from atients referred to the Government Wenlock hosital, angalore. Shree devi college of hysiotheray, angalore. SCS hosital, angalore with confirmed diagnosis of PPS. Research design: Pre and ost- test exerimental study. ethod of collection of data: Subjects were assigned in to two grous by random samling method. 40 Patients diagnosed to have PPS was been recruited for the study after obtaining informed consent. : The subjects received ultrasound with atellar taing. : The subjects received ultrasound with isometric exercises. Subjects fulfill the following inclusion and exclusion criteria randomly assigned in to two grous. INCLUSION CRITERIA: Sub acute symtomatic atients age ranges between 18-45 years of both genders, Sub acute stage, Pain resent during activities such as descending and ascending stairs, squatting and running, Subjects with lateral tilt of atella. (ositive J sign), On radiograh atellar malalignment (atellar tracking). EXCLUSION CRITERIA: Patella dislocation, History of fracture around knee, Knee flexion deformities like genu varum, flexion contracture, genu recurvatum, Ligament/ meniscal injuries, O.A Tibiofemoral, Other neurological abnormalities. ATERIALS: Plinth to osition the subject, Ultrasound machine, Non allergic tae, Cotton, Pillow, Bolster, ackintosh, Aqua sonic gel. ETHODOLOGY: All the subjects randomly assigned into two grous ( and of 20 each.) Both the grous receives conventional treatment. Conventional treatment (ultrasound theray) which was given in suine lying osition illow laced under the knee. chosen was ulsed mode with mark: ulse ratio 1:1 with intensity 0.8-1.0 watts/cm 2. : The subjects were received ultrasound with atellar taing. ~ 12 ~
International Journal of Physical Education, Sorts and Health 2: The subjects were treated with ultrasound and isometric exercises. GROUP 1:- Subjects were given ultrasound and atellar taing by using adhesive tae. The atient ositioned in suine lying osition. The urose of taing was to correct the comonents of lateral tilt, medial glide and rotation. In suine lying osition Glide Comonent- irst of all lateral border of the atella will be alated. Then medial glide of atella is achieved by fixing the tae to the lateral border and ulling the atella medially before attaching tae to the skin. Tilt comonent- Place the tae in the middle of the atella and ull the tae osterior and attach over the tae used for glide correction or over the skin. Rotation comonent- Internal rotation of atella was corrected by anchoring on the lateral asect of the inferior ole of the atella and ulling towards medially. GROUP 2: The subjects given ultrasound and isometric exercises. Ask the atient to lie in suine osition with knee extension by lacing rolled towel or bolster under the knee, and subject is asked to tighten the quadrices muscles as ossible as hold the contraction by ressing the rolled towel or bolster with knee, the contractions held for 6 seconds and the subject should relax the quadrices muscle. The same exercises reeated for 15 times. Treatment duration for both grous continuously 2 weeks. OUT COE EASURES: The following outcome measures were measured at baseline and at the end of 2nd week of treatment. A follow-u measurement was done at 4 weeks from the end of treatment. Visual analog scale (VAS), WOAC SCALE ig no: 3 Isometric Exercise of Quadrices ig No: 1 Patellar Taing ig no: 4 ultile Angle Isometric Exercise of Quadrices ig No: 2 Ultrasound achine ig no: 5 Conventional Theray (ultrasound theray) ~ 13 ~
International Journal of Physical Education, Sorts and Health Results Paired and unaired t tests and chi square test were done for statistical analysis. In resent study intra grou comarison results showed that ain relief and imroved functional activities was statistically significant in both the grous. Whereas inter grou comarison results showed that grou 2 i.e. ultrasound with isometric exercises was statistically significant in reducing ain and imroving functional activities than subjects with PPS. Hence based on results of resent study it can be concluded that both grou showed significant decrease in VAS, imrovement in functional activities whereas grou 2 showed better results as comared to grou 1. This study was focused on ain relief, where ain assessment was done by visual analog scale (VAS) and imrovement in the functional activities of daily living, assessment was done by WOAC score. In this study the age grou was between 18-45 years. of 40 subjects were included in the study after satisfying the inclusion criteria. consists of 20 subjects and consists of 20 subjects. The mean s of data from resent study indicates that grou 1 and grou 2 treated with ultrasound with atellar taing and ultrasound with isometric exercises resectively showed when the intra grou mean s of VAS were analyzed it was found statistically significant in both grous re to ost intervention, but when comarison was done inter grou, statistically grou 2 showed more significance as comared to grou 1 in relieving ain. In the resent study of reduction in ain level, as quantified by the VAS with the alication of both ultrasound with atellar taing and ultrasound with isometric exercises is consistent on ain relief and imroved functional disability on WOAC scale. Also the result of the study shows an overall imrovement in ain score on VAS and imrovement in functional activity on WOAC scale in grou 2 in comarison to grou. Table no. 5.1: age wise distribution of subjects in both the grou X2=.410, =.815, NS years. : In grou 2 20% subjects were in the age grou of 18-25 years, 50% subjects were in the age grou of 26-35 years and 30% subjects were in the age grou of 36-45 years.there was no singnificant difference between age wise distribution in both the grous as 0.815 > 0.05. Table no 5.2: Gender wise distribution of subjects in both the grou X2=.102, =.749, NS SEX 8 9 17 40.0% 45.0% 42.5% 12 11 23 60.0% 55.0% 57.5% 20 20 40 100.0% 100.0% 100.0% igure no 5.2: Gender wise distribution of subjects in both the grou.:in grou 1 there were 40 females and 60 males. : In grou 2 there were 45 females and 55 males.there was no significant difference between two grous with resect to gender as 0.749 > 0.05. Table no 5.3: Side involvmennt wise distribution of subjects in both the grou.x2=.102, =.749, NS SIDE 12 11 23 60.0% 55.0% 57.5% 8 9 17 40.0% 45.0% 42.5% 20 20 40 100.0% 100.0% 100.0% igure no: 5.1 Age wise distribution of subjects in both the grou : In grou 1 25% subjects were in the age grou of 18-25 years, 40% subjects were in the age grou of 26-35 years and 35% subjects were in the age grou of 36-45 igure no.5.3: Side involvmennt wise distribution of subjects in both the grou. : In grou 1 right side involvment was 60% and left side involvment was 40%. : In grou 2 right side involvment was 55% and left side involvment was 45%.There was no significant difference between two grous with resect to side involvment as 0.749 > 0.05. ~ 14 ~
International Journal of Physical Education, Sorts and Health Table no 5.4: Comarison of two grous before the treatment.there is no significant difference between grou 1 and 2 with resect to all the outcome arameters as > 0.05. WOAC SCORE N inimum aximum 20 5 8 6.50 1.051 6.50.81.423 20 5 9 6.80 1.281 7.00 NS 40 5 9 6.65 1.167 7.00 20 65 93 80.50 8.069 79.50.16.874 20 65 95 80.90 7.806 80.00 NS Deviatio 40 65 95 80.70 7.839 80.00 Table no 5.5: Within grou comarison- re to ost comarison in grou 1 and grou 2 : VAS ATER ATER N inimum aximum Deviatio n edian n edian 20 5 8 6.50 1.051 6.50 2.400.681 36.92 15.77.000 20 2 6 4.10 1.021 4.00 HS 20 5 9 6.80 1.281 7.00 3.850 1.424 56.62 12.09.000 20 1 4 2.95.826 3.00 HS S.D of (%) t t ig no. 5.7: Within grou comarison- re to ost comarison in grou 1 and grou 2 In grou 1: unctional level before treatment was 80.50 ± 8.06 and after the treatment 59.00 ± 8.57 resulting in 26.71% imrovement after the treatment. Test shows there is significant imrovement after the treatment as 0.00 < 0.01.In grou 2: unctional level brfore treatment was 80.90 ± 7.80 and after the treatment 44.65 ± 9.63 resulting in 44.81% imrovement after the treatment. Test shows there is significant imrovement after the treatment as 0.00 < 0.01. So both the treatments are effective in imroving functional disabilities. Table no 5.8: Comarison of effect between the grous. : In grou 1 there was 26.71% imrovement. : In grou 2 there was 44.81% imrovement. Test shows that there is significant difference in the effect of two treatment as < 0.01 so grou 2 treatment is better than grou 1 treatment. : WOAC SCORE : WOAC SCORE S.D of t N (%) 20 21.500 6.992 26.71 5.57.000 20 36.250 9.558 44.81 HS igure no.5.5: Within grou comarison- re to ost comarison in grou 1 and grou. In grou1: Pain level before treatment was 6.5 ± 1.05 and after the treatment 4.10 ± 1.02 resulting in 36.92% imrovement after the treatment. Test shows there is significant imrovement after the treatment as 0.00 < 0.01.In grou 2: Pain level brfore treatment was 6.80 ± 1.2 and after the treatment 2.95 ± 0.8 resulting in 54.6% imrovement after the treatment. Test shows there is significant imrovement after the treatment as 0.00 < 0.01. So both the treatments are effective in reducing ain. Table no 5.6: Comarison of effects between the grous. : In grou 1 there was 36.92% imrovement. : In grou 2 there was 56.62% imrovement.test shows that there is significant difference in the effect of two treatment as < 0.01 so grou 2 treatment is better than grou 1 treatment. : VAS Vas N S.D of 20 2.400.681 36.92 4.11.000 (%) 20 3.850 1.424 56.62 HS t Table no 5.7: Within grou comarison- re to ost comarison in grou 1 and grou 2 Table no.5.9: Effect of gender on the treatment.there is no significance difference with resect to gender in both the treatment grous. WOAC SCORE SEX Deviation t 2.25.463.797.436 2.50.798 NS 4.00 1.225.417.682 3.73 1.618 NS 24.25 8.049 1.480.156 19.67 5.836 NS 35.22 11.734.426.676 37.09 7.854 NS Table no 5.10: Effect of side involved on the treatment. There is no significance difference with resect to side involvement in both the treatment grous. WOAC SCORE SIDE Deviation t 2.33.778.526.605 2.50.535 NS 4.09 1.640.829.418 3.56 1.130 NS 20.67 6.972.643.529 22.75 7.305 NS 38.36 10.529 1.099.286 33.67 8.047 NS Table no 5.11: Effect of age on the treatment Correlations : WOAC SCORE Karl earson Deviatio S.D of t N inimum aximum n edian (%) 20 65 93 80.50 8.069 79.50 21.500 6.992 26.71 13.75.000 AGE w ith correlation coeff icient r -.046.848 NS -.395.085 NS ATER 20 40 71 59.00 8.572 60.00 HS WOAC SCORE -.183.440 NS 20 65 95 80.90 7.806 80.00 36.250 9.558 44.81 16.96.000 -.145.541 NS ATER 20 27 60 44.65 9.631 45.00 HS ~ 15 ~
International Journal of Physical Education, Sorts and Health AGE Deviation 32.20 7.777 32.20 7.991 32.20 7.783 There is no significance difference with resect to age in both the treatment grous. Discussion The resent study was conducted to comare the effectiveness of ultrasound with atellar taing versus ultrasound and isometric exercises in subjects with atellofemoral ain syndrome. The results of the study were focused on ain relief, ain assessment was done by visual analog scale (VAS) and imrovement in the functional activities of daily living, assessment was done by WOAC score. In this study the age grou was between 18-45 years consecutively atient referred to hysical theray treatment with PPS. The mean s of data from resent study indicates that grou 1 and grou 2 treated with ultrasound with atellar taing and ultrasound with isometric exercises resectively showed when the intra grou mean s of VAS were analyzed and was found statistically significant in both grous re to ost intervention, but when comarison was done inter grou, statistically grou 2 showed more significance as comared to grou 1 in relieving ain. The resent study showed reduction of ain level, as quantified by the VAS with the alication of both ultrasound with atellar and ultrasound with isometric exercises is consistent with findings of revious studies including ultrasound with atellar and ultrasound with isometric exercises in reducing ain in atients with PPS in ain score on VAS and imroved functional disability on WOAC scale. This study aimed to examine the effectiveness of each of these techniques in isolation for one week and in combination for one week. In isolation, quadrices stretching and quadrices strengthening resulted in more imrovements than taing. Combining these treatments is recommended as the initial aroach to treating atellofemoral ain but further individualized more functional, global treatment is essential and also the result of the study shows an overall imrovement in ain score on VAS and imrovement in functional activity on WOAC scale in grou 2 in comarison to grou 1. rom the resent study it can be concluded both grous showed significant imrovement in terms of ain and functional disability in atients with PPS. But grou 2 showed better result as comared to grou 1. In the resent study, within grou analysis showed ain relief and increased range of motion which was statistically significant in both the grous (<0.001) whereas the between grou analysis revealed that (ultrasound with isometric exercises) was highly significant (<0.001) as comared to. Limitation of the study: Samle size was small, It is limited by the fact daily activities of the subjects were not monitored which could have influenced, Duration of the study is also short, Occuation relevance was not comared. uture scoe of the study: Studies with longer duration are recommended with longer follow-u eriod to assess long term benefits, Conduct the study with larger samle size. 3. Heintjes E, Berger, Bierma-Zeinstra SA, Bernsen RD, Verhaar JAN, Koes BW. Exercise theray for atellofemoral ain syndrome (Review). The Cochrane Collaboration and ublished in The Cochrane Library. 2009, 1. 4. Cristina aria Nunes Cabral1, Angela aria de Oliveira elim, Isabel de Camargo Neves Sacco, Amelia Pasqual arques. Effect of a closed kinetic chain exercise rotocol on atellofemoral syndrome rehabilitation., Ouro Preto Brazil, ISBS Symosium. 2007, 688. 5. Carina D Lowry, anagement of Patients with Patellofemoral Pain Syndrome Using a ultimodal Aroach: A Case Series. Journal of orthoaedic & sorts hysical theray. 2008; 38(11):691. 6. Christian J Barton, Hilton B enz. Evaluation of the Scoe and Quality of Systematic Reviews on Non-harmacological Conservative Treatment for Patellofemoral Pain Syndrome. Journal of orthoaedic & sorts hysical theray. 2008; 38(9):529. 7. The effect of atella taing on atellar osition and atellofemoral ain. Brian Stinton, 2004. 8. Patellofemoral ain syndrome (PPS): A Systematic review of anatomy and otential risk factors. Dynamic edicine 2008; 7:9. 9. Patellofemoral ain syndrome (PPS): A Systematic review of anatomy and otential risk factors. Dynamic edicine 2008; 7:9. 10. Konstantinos D Paadooulos, Jane Noyes, oyra Barnes, Jeremy G Jones, Jeanette Thom. How do hysiotheraists assess and treat atellofemoral ain syndrome in North Wales? A mixed method study. International Journal of Theray and Rehabilitation, 2012; 19:5. 11. ST Green Patellofemoral syndrome, Judah Street 2717, San rancisco, Journal of Bodywork and ovement Theraies. 2005; 9:16-26. 12. Naoko Aminaka, Phili A Gribble. A systematic review of the effect of theraeutic taing on atellofemoral ain syndrome. Journal of Athletic Training, 2005; 40(4):341-351. 13. Richards J, Thewis D, Selfe J, Cunningham A, Hayes C. A biomechanical investigation of a single limb squat:imlication for lower extremity rehabilitation exercise. J Athl Train, 2008; 43(5):477-482. 14. Young Soon Park, Yong Kim, Byung Song. Comarison of electrical activity between V and VL according to the difference of angle of the femoral anteversion. 2006; 13(4). 15. Joshi J, Kotwal P. Essentials of Orthoaedics, Alied Physiotheray, 1 st ed. New Delhi. B.I. Churchill Livingstone inc. 1999, 557-58. 16.. Boling, D. Padua et al. gender differences in the incidence and revalence of PPS. 17. Anna aria Carlsson. Assessment of chronic ain. I. asects of reliability and validity of VAS. 18. Crossley K Patella taing is clinical success suorted by scientific evidence. anual theray. 2000; 5(3):142-150. Conclusion Both grous statistically showed significant resonses to their interventions. Ultrasound with isometric exercises was found to be more effective than the ultrasound with atellar taing to reduce the ain and to decrease functional disability in atients with atellofemoral ain syndrome. References 1. GY, AQ Zhang a. Biofeedback exercise imroved the EG activity ratio of the medial and lateral vasti muscles in subjects with atellofemoral ain syndrome. G.Y.. Ng et al. / Journal of Electromyograhy and Kinesiology. 2008; 18:128-133. 2. Erik Witvrouw, Werner S, ikkelsen C, Tiggelen D Van, L Vanden Berghe, G Cerulli. Clinical classification of atellofemoral ain syndrome: guidelines for non-oerative treatment. Knee Surg Sorts Traumatol Arthrosc. 2005; 13:122-130. ~ 16 ~