Download RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE BANGALORE

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE
BANGALORE
PERFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
NAME OF THE
CANDIDATE AND
ADDRESS
Kalyani Nambisan 48 MCHS Colony, 5B cross, 16th
main, BTM Layout 2nd stage, Bangalore – 560076.
2
NAME OF THE
INSTITUTION
Kempegowda Institute Of Physiotherapy.
K.R.road, V.V Puram, Bangalore-560004.
3
COURSE OF THE
STUDY
MPT(Musculoskeletal disorders and Sports)
4
DATE OF ADMISSION
5
TITLE OF THE TOPIC:
1
13-june-2009
“Effectiveness of CPM with Exercises to improve Range of Motion in Total
Knee Arthroplasty”.
6.
Brief resume of the intended work:
6.1 Need for the study:
The human knee is the largest and perhaps the most complex joint in the
body. It is a two joint structure composed of the tibiofemoral joint and the
patellofemoral joint. In addition to provide mobility the knee complex plays a
major role in supporting the body during static and dynamic activities.
The primary motions of the tibiofemoral joint are flexion and extension in
the sagittal plane and to a lesser extent, medial and lateral rotation. The range
of motion with regard to flexion and extension in normal activity ranges from 3
degrees of extension and 117 degrees of flexion. Increase speed of tibiofemoral
joint movement requires a greater range of motion.
The patella is a sesamoid bone which functions as an anatomic pulley by
increasing the moment arm of the quadriceps muscle, thus aiding knee
extension. It also allows wider distribution of compressive stress at the femur
by increasing the area of contact between the patella and femur.
Muscle forces have the greatest influence on the magnitude of the joint
reaction force. Both the tibiofemoral and the patello femoral joints are
subjected to great forces, which can reach several times the body weight in both
joints. Although the tibial plateaus are the main load bearing structure in the
knee apart from that the cartilage, menisci and ligaments also bear load.
OSTEOARTHRITIS - Osteoarthritis is a degenerative joint disorder. It’s a
non inflammatory disease characterized by progressive detioration of the
articular cartilage and formation of new osteophytes. The concept of wear and
tear is attributed as a cause of osteoarthritis. It is common in the weight bearing
joints such as hip and knee.
KNEE JOINT OSTEOARTHRITIS- There are various types of knee
osteoarthritis. In that the Chronic Primary osteoarthritis is more common in the
elderly individual’s knee joint.
CAUSES FOR CHRONIC PRIMARY OSTEOARTHRITIS - There is loss
of the ground substances of cartilage resulting in disturbance of dissipation of
stresses. Cartilage develops fissures, gets eroded and exposes the underlying
subcondral bone.
CLINICAL FEATURES FOR CHRONIC PRIMARY OSTEOARHRITIS
are:
Pain, Stiffness, Limitation of movement and Crepitations present at the joint
during movement.
There are various surgeries performed in elderly at the knee joint in case of
Chronic Primary Osteoarthritis. They are Unicompartment Repalcement
surgery, Bicompartment Replacement surgery and Tricompartent Replacement
surgery or TKR. In this study I am considering TKR as my sample.
TOTAL KNEE ARTHROPLASTY - Total knee replacement arthroplasty is
indicated when there is unremitting severe pain in the knee with or without
deformity. The pain or deformity may be due to chronic osteoarthritis (primary
or secondary).
TRICOMPARTMENTAL KNEE ARTHROPLASTY – The articular
surfaces of the lower femur upper tibia and the patella are replaced by
prostheses3.
CONTINUOUS PASSIVE MOTION ( CPM )
Continuous Passive Motion is a mechanical device that is capable of moving
joints passively and repeatedly through a specific portion of the physiologic
range of movement. The speed of movement and the ROM can be controlled.
Continuous passive motion devices are able to produce joint motion under low
loading conditions. It is easier to control loading with these devices than with
active movements thus avoiding the potentially deleterious compressive –
tensile stresses and strains produced by active muscle contractions4.
RANGE OF MOTION
Motion occurs in the sagittal plane around a medial – lateral axis. The range of
motion for flexion ranges from 0 to 142 degrees. Extension is not usually
measured and recorded because it is a return to the starting position from the
end of the knee flexion4.
6.1 HYPOTHESIS:
Null Hypothesis: CPM with Exercise may or may not improve Range of
Motion in Total Knee Arthroplasty.
Alternative Hypothesis: CPM with Exercises may improve Range of Motion in
Total Knee Arthroplasty.
6.2 Review of Literature:
S. Brent Brotzman et al concluded that eighty five patients develop medial
compartment Osteoarthritis and as the bone wears away they develop a Varus
or Bow-Legged deformity.
Jayant Joshi has concluded that Primary Osteoarthritis is most commonly found
in the knee joint.
Deborah M Kennedy et al January 2008 concluded that Osteoarthritis is one of
the most frequent causes of disability and for patients with end stage of
Osteoarthritis a Total Knee Arthroplasty is indicated and is said to be highly
beneficial5.
Jayant Joshi et al concluded that Total Knee Arthroplasty is indicated in
patients with with chronic osteoarthritis and with patients who have severe
unremitting pain.
Carola Cademartiri et al concluded that after a Total Knee Arthroplasty the first
objective is to improve the function of the operated knee and to as well as to
reduce the pain22.
P.Ververeli MD et al JUNE 1995: Conducted a study on Continuous Passive
Motion in Total Knee Arthroplasty and concluded that CPM is more efficacious
in increasing short term flexion.
D. Johnson, MD NOVEMBER 1992: conducted a study on Beneficial Effects
of Continuous Passive Motion After Total Condylar Knee Arthroplasty. And
concluded that, post operative use of CPM had a significant increase in both
early and late range of knee flexion in osteoarthritis.
S. Waisiely, MD MARCH 1990: Concluded that the CPM in TKR improved
wound healing, decreased incidence of thromoembolous, decrease pain and
improve ROM11.
Vince MD, et al DECEMBER 1987: Conducted a study on CPM after Total
Knee Arthroplasty and concluded that the use of CPM in rehabitilation after
TKA allows patients to achieve ROM more quickly and comfortably.
McInnes J , Larson MG, Brown T, Fossel AH et al 1992: Conducted a study
on CPM in the post operative management of patients undergoing Total Knee
Arthroplasty and concluded that for the average patient undergoing Total Knee
Arthroplasty, CPM is more effective in improving range of motion, decreasing
swelling and reducing the need for manipulation .
Waislewski MD et al, 1990 concluded that CPM given 2 hours a day (morning
and afternoon )11.
Vince MD et al December 1987, CPM machine works on electricity it helps in
bending and stretching the knee without active effort. This helps in regaining
early range of motion12.
Densie Mannkleinmen 2009: Conducted a study on strength training through
conventional rehabilitation measures after TKA and concluded that progressive
quadriceps strengthening programme may help TKA patients to approach better
functional levels13.
NASA 2007 said that an Isometric exercise is a form of exercise involving
static contraction of muscle without any visible movement in angle of the
joint14.
NASA 2009 has researched the use of isometrics in preventing muscle
atrophy15.
Valton A 1995 concluded that hamstring strengthening exercises should be
performed approximately 3 to 10 times a day16.
Heinonen A 2005 states that moving the foot up and down at the ankle joint to
its maximum will reduce the incidence of calf muscle17.
Pearse EO, Caldwell BF, et al. 2007, concluded that early mobilization protocol
resulted in reduction of post operative deep vein thrombosis8.
Petterson SC, Mizner RL, Raisis L et al 1991 said that progressive quadriceps
strengthing exercise enhances clinical improvement after Total Knee
Arthroplasty.
Carylon Kisner, Lynn Allen Colby 1994 said that passive range of motion may
be carefully initiated to major joints and active range of motion to ankle and
feet to minimize the possibilities of thrombus formation20.
Carylon Kisner, Lynn Allen Colby 1994 said that positioning of the patient in a
comfortable position and with proper body alignment will allow the patient to
move the segment in through the range of motion 20.
Chandrashekaran, Sivashankar, Ariaretnam August 2009 et al concluded that
early mobilization in the first 24 hours will reduce the incidence of deep vein
thrombosis9.
6.3 Objective of the Study:
 To find out the effectiveness of CPM with exercise to increase range
of motion in Total knee Arthroplasty.

7.
To find out the effectiveness of pre and post treatment CPM with
exercises to increase the ROM with Goniometer and decreasing the
pain by using VAS scale for Total Knee Arthroplasty.
Materials and Methods:
7.1 Source of Data:
 Patients referred to Kempegowda Institute of Physiotherapy.
 Patients undergoing TKR at HOSMAT Hospital Bangalore.
7.2 Methods of Collection of Data:
a) Study Design: one group pre and post test study design.
b) Sample size: 30 subjects.
c) Sample method: purposive sampling.
d) Materials Used:
 couch
 CPM
 Goniometer
 Towels
e) Inclusion Criteria:

Subjects with osteoarthritis who are undergoing tri-compartmental
uncemented knee Arthroplasty.

AGE: 55 to 70 years

Left or right knee

Subjects of either sex
f) Exclusion Criteria:







Ligament injury
Cardiac Pacemakers
Peripheral Nerve injuries
Sensory impairment
Diabetic Foot
Rheumatoid arthritis
Cardiac conditions
7.3 Does the study require any investigation or interventions to be
conducted on Patients or other humans or animals? If so, please describe
briefly:
Yes, an intervention on patients is required.
Methodology:
30 samples who fulfilled the inclusion criteria will be included in this study.
Written consent will be taken prior to the interventions from all the participants
of the study.
Instruction to the patient about CPM machine and range of motion (ROM)
exercises will be given. Prior to the treatment assessment of pain will be taken
using visual analogue scale and knee range of motion will be measured by
Goniometer. The exercises program which would be followed in this study is as
follows
Intervention :- EXERCISE PROTOCOL FOR TKR PATIENTS
Postoperative day 1
Ankle Pumps, quadriceps sets and gluteal sets.
Review of weight bearing status.
Bed mobility and transferring – Bed to the chair.
Postoperative day 2
Exercises- Active ROM, active assisted ROM and terminal knee extension.
Strengthing exercises for example quadriceps sets gleutal sets, heel slides
straight leg raises and isometrics hip adduction.
Gait training with an assistive device and functional transfer training such as
sit to stand, toilet training and bed mobility.
Postoperative day (3 -5)
Progression of range of motion and strengthening exercises up to the patient’s
tolerance.
Progression of ambulation on plane surfaces and stairs with the least restrictive
device.
Progression of ADL training.
Postoperative ( Day 5 to 4 weeks )
Strengthening exercises such as knee bends, seated leg extensions, standing hip
abduction and short arc quads.
Stretching of quadriceps and hamstrings muscles.
Progression of the distance in ambulation.
Progression of independence with ADL. Increase the CPM range
approximately for 5 to 10 degrees daily till patient attains 100 degrees of active
flexion.
Post intervention assessment of pain and range of motion will be done on 7th
day of intervention and on 30th day of intervention25.
Assessment of pain:
The Visual Analogue Scale (VAS) is designed to present to the respondent a
rating scale with minimum constraints. Respondents mark the location on the
10-centimeter line corresponding to the amount of pain they experienced. This
gives them the greatest freedom to choose their pain's exact intensity. VAS can
be derived by respondent prior and post treatment session.
Range of Motion:
Active Knee ROM for flexion and extension will be measured by
Goniometer prior and post treatment session.
Parameters :

Treatment time – 10min
Duration of the study: 1 Year.
Statistical analysis:
a) Descriptive Statistics namely percentage (%), Mean and Standard deviation
(SD).
b) Inferential statistics- paired “t” test or Wilcox1n signed rank depending on
normality of data.
7.4 Has Ethical clearance been obtained from your institution in case of
7.3?
Yes
8.
LIST OF REFERENCES
1) Cynthia C Norkin. PamelaK. Levangie: Knee joint Biomechanics: Joint
Structure and Function, Third Edition Chapter 11.
2) Margareta Nordin, Victor H. Frankel: Biomechanics of the Knee part two
chapter 6.
3) Jayant Joshi; Prakash Kotwal; Essentials of Orthopaedics and Applied
Physiothearpy. Elisever- New Delhi, No-292 -293 Total Knee Arthroplasty
-211- 212.
4) Cynthia C Norkin D.Joyce White, Measurement of joint motion- 3rd
edition; Jaypee page 230.
5) Deborah M Kennedy , Paul W Stratford, Daniel L Riddle, Steven E Hanna
and Jeffery D Gollish- Assessing the recovery and establishing the
prognosis following Total Knee Arthroplasty; January 2008, volume 88. Pp
22-32.
6) Abraham T Rasul Jr, Total Joint Replacement and e Medicine Specialities>
Physical Medicine and Rehablitation protocol.
7) P. Ververeli MD Continuous Passive Motion after Total Knee
Arthroplasty, Clinical Orthopaedics and Related Research; June 1995. No
321.
8) Pearse EO, Caldwell BF, Lockwood RJ, Hollard J Early Mobilisation after
Total Knee Arthroplasty, 2007 March 316-22.
9) Chandrashekaran, Sivashankar, Ariaretnam, Early Mobilisation after Total
Knee Arthroplasty; August 2009 Volume 79, Number 7-8; pp 526-529.
10) Waislewski MD et al, 1990 CPM given for 2 hours in morning and in
afternoon.
11) Vince MD, et al DECEMBER 1987; study on CPM.
12) Densie Mannkleinmen 2009; Research training to improve on quadriceps
strength of muscles.
13) NASA- 2007; Study on exercises involving static contraction.
14) NASA, 2009 - ; Research on use of isometrics exercises.
15) Valton, 1995 – concluded that hamstrings isometrics strengthing will
improve the strength.
16) Heinonen ,A 2005- moving foot up and down will reduce the deep vein
thrombosis
17) Pearse EO, Caldwell BE- March 2007 concludes that early mobilization
results in reduction of Deep Vein Thrombosis.
18) Peterson SC, Mizner- 1991; Research on strengthing programmes after the
Total Knee Arthroplasty.
19) Carolyn Kisner and Lynn Allen Colby, 4th edition pp 36-37 Passive Range
of Motion of the Knee.
20) Fredrick Montogomery and Eilasson; Department of Orthopaedics, Malmo
University Hospital Sweden; pp 7- 9.
21) Petterson SC, Mizner RL, Stevens JE et al ; Improved function from
progressive intervensions after total knee arthroplasty 2009 Feburary; pp
174-83 .
22) Carola Cademariti, Giovanni Sondni, Total Knee Arthroplasty, APTA
BioMedica Atened Parmense 2004 Volume 75 pp 56-62.
23) Jules M Rothstein, Peter J Miller, Goniometric Reliability in a Clinical
Setting: Knee measurements, Physical Therapy, Volume 63, No 10,
October 1993, pp 1611-1615.
24) Insall Scott Kelly@Institute for Orthopaedics and Sports Medicine.
9.
10.
Signature of the
Candidate:
Kalyani Nambisan
Remarks of the Guide:
11. Names and designation of:
11.1
Guide:
11.2
Signature:
Prof. R. Balasaravanan, M.P.T
Principal, K.I.P.T
Dr. Ravish.v.N,
11.3
Co-guide 1:
11.4
Signature:
11.5
Head of the Department:
11.6
Signature:
M.B.B.S, MS. Ortho
Assoc. Prof, Dept of Orthopaedics
KIMS.
Prof. R. Balasaravanan, M.P.T
Principal, K.I.P.T
12.1 Remarks of the Chairman & Principal:
12.
12.2 Signature :