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Source of data: 50 symptomatic patients of both sexes fulfilling inclusion criteria were taken from Govt. Wenlock Hospital, Mangalore, out patient department of Dr. M.V. Shetty Hospital, Mangalore and in some of the clinical settings in and around Mangalore. Ethical clearance for the study was obtained from the Ethical committee of Dr. M. V. Shetty College of Physiotherapy. To perform the study the patient randomly put in one group of 50 and written consent of each patient was taken.
Inclusion Criteria: Patient diagnosed by an Orthopaedician as Patellofemoral Pain Syndrome were included accor - Anterior knee pain. - Age group from 18 – 35 years. - Acute condition Exclusion Criteria: - Knee pain was caused by trauma in the preceding four weeks was reproduced with combined extension/rotation and side flexion of the lumbar spine to the ipsilateral side or on hip quadrant with overpressure. - Knee pain due to infection - Neoplastic disorder - Knee pain of acute inflammatory nature
- Undergone knee surgery within the past six weeks - No palpable tenderness over the lateral patellofemoral joint (since in this type, manual therapy would not normally be used).
Once the inclusion criterion is achieved, upon initial interview, patients are screened for Patellofemoral Pain Syndrome to determine their eligibility for the study. If eligible, written consent is taken and baseline measures of pain, range of motion and activity limitations is taken [Pre-test]. The validity, reliability and relative efficiency for these have been tested and have been proven to be a reliable and valid measurement tool.
Materials and measurement tools: - Patellofemoral Pain Severity Questionnaire (PFPSQ) - Goniometer - Step Test
Procedure: Once written consent has been taken from the subjects, they were explained about the study and the procedure. Following this, subjective assessment of the patient was done which includes name, age, gender, chief complaints, duration of the condition and history of the patient. After the patient’s subjective assessment is taken, he/she will be assigned for pre test.
Pre – Test: Pre-test includes 3 components:
- Patellofemoral Pain Severity Questionnaire (PFPSQ) - Active ROM - Step Test Each patient will undergo Pre-Test as base line measurement using Patellofemoral Pain Severity Questionnaire (PFPSQ), (Pain 8 items & Functional Activity of 8 items), [Active ROM (flexion & extension) & Step test (number/60 sec.)]
Patellofemoral Pain Severity Questionnaire (PFPSQ): Tracking the pain is a helpful diagnostic tool when dealing with any condition. Patellofemoral pain syndrome [PFPS] is a self administered scale developed by Laprade.39,72,73 This scale encompasses ten statements regarding PFPS pain in a visual analogue format. This scale is reliable and has demonstrated convergent validity making it a useful tool for monitoring rehabilitative or surgical outcomes in clients with PFPS. The questionnaire consists of ten common activities that often provoke anterior knee pain. These range from sedentary activities such as sitting and resting to vigorous activities including running/sprinting and participating in sport. Participants were instructed to mark the average level of pain that they had experienced in the previous week for a particular activity on a scale labeled ‘0’ at one end and ‘10’ at the other. If the participants had not attempted the particular activity, they recorded ‘not attempted’. After they had answered the questionnaire a mean of the scores of all the activities was taken as the pain score. The patellofemoral pain severity questionnaire is given in the annexure II.
ROM: A joint’s ROM is usually measured by the number of degree from the starting position of a segment to its position at the end of its full range of movement. The universal method to check the ROM of a subject is Goniometer.74,75,76 A Goniometer has two segments – a stationary arm and a movable arm. A stationary arm holding a protractor is placed parallel with a stationary body segment and a movable arm moves along a movable body segment. The pin (axis of the Goniometer) is placed over the joint. The movements in the knee joint to be assessed in this study are – • • Flexion Extension
Active knee flexion: Patient position: The patient is in prone lying over the plinth. Procedure: The hip is stabilized to prevent abduction, adduction, flexion, extension and rotation. The foot is over the edge of the plinth. The stationary arm of the goniometer is aligned along the lateral aspect of the femur. The movable arm is aligned along the lateral aspect of the tibia. The patient is then asked to flex his knee. The reading in the goniometer is recorded accordingly.38
Active knee extension: Patient position: The patient is in prone lying over the plinth with the knee is flexion.
Procedure: The hip is stabilized to prevent abduction, adduction, flexion, extension and rotation. The stationary arm of the goniometer is aligned along the lateral aspect of the femur. The movable arm is aligned along the lateral aspect of the tibia. The patient is then asked to extend his knee. The reading in the goniometer is recorded accordingly.38
Step Test: The participants were instructed to step up and down a 15cm step, leading with their painful leg, as many times as they could for 60sec. The number of steps taken by the subjects is recorded.37,77,78
MANUAL THERAPY TECHNIQUE: After the subject is being assessed for pretest, the manual therapy is given. Each patient received six sessions of manual therapy39 consisting of transverse frictions to the lateral retinaculum as described by Cyriax44 (1984) conducted both in the fully extended and fully flexed position, tilt patellofemoral stretches as described by Brukner20 et al (2001) and the application of a sustained medial glide during repeated flexion and extension of the knee39. Each session was given for 15–20 minutes. The technique of application and position of the patient and therapist are mentioned below. No other intervention (such as advice or exercise) is given during the trial.
CYRIAX TECHNIQUE: Fully extended position: Patient Position: The patient lies on the couch with the knee held in as full extension as possible. Procedure: Sit opposite to the patient’s affected knee and place the fingers on the inner and thumb on the outer side of the knee joint. The grip is strengthened by reinforcement with the middle finger. By alternately flexing and extending the wrist, move the fore finger to and fro over the lateral retinaculum keeping the thumb still to form the fulcrum. Then apply the transverse friction to the lateral retinaculum.44 Fully flexed position: Patient Position: The patient lies on the couch with knee well bent up. Procedure: Sit facing the knee, grasping it in such a way that the index finger lies at the central point of the lateral aspect of the joint line. Keep the finger tip on the lateral retinaculum, transverse friction by alternately flexing and extending the wrist. By using the thumb as fulcrum, the index finger is drawn backwards and forwards over the lateral retinaculum.
BRUKNER’S TECHNIQUE: The lateral retinaculum is stretched by applying the patellar glide. Technique:
The knee is extended and the patella is grasped between the thumb and the fore finger. The medial aspect of the patella is then compressed posteriorly while lateral aspect is elevated. This is tilting of the patella. Now patella is grasped in the resting position and then translated medially thus performing the sustained medial glide.20 Post-Test: Post-Test again includes 3 components: • • • Patellofemoral Pain Severity Questionnaire(PFPSQ) ROM Step Test
These components are similar to that of Pre-Test. Hence the procedure will also be the same as mentioned in Pre-Test. After the treatment for six days, the final results are recorded. Finally, participants were asked to fill out their satisfaction with treatment using the words ‘very satisfied’, ‘somewhat satisfied’, ‘somewhat dissatisfied’ or ‘very dissatisfied‘.
Fig. No. 4.1 Transverse friction to the lateral retinaculum in knee flexed position
Fig. No. 4.2 Transverse friction to the lateral retinaculum in knee extended position 39
Fig. No. 4.3 Sustained medial glide to the lateral retinaculum of the knee
Fig. No. 4.4 Tilt Patellofemoral stretches 40
Fig. No. 4.5 Step Test
Fig. No. 4.6 Goniometer 41
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