RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE CANDIDATE AND ADDRESS

SHRIJAN TIMSINA SHARSWOTI TOAL, LOKANTHALLI 17, BHAKTAPUR, NEPAl

2. NAME OF THE INSTITUTION

KEMPEGOWDA INSTITUTE OF PHYSIOTHERAPY,K.R.ROAD,V.V.PURAM, BANGALORE-560 004

3. COURSE OF THE STUDY M.P.T.(MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY)

4. DATE OF ADMISSION 21/07/ 2013

5. TITLE OF THE TOPIC:

A STUDY TO COMPARE THE EFFECTIVENESS OF TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION WITH RETROWALKING VERSUS ULTRASOUND THERAPY WITH RETEROWALKING IN CHRONIC OESTEOARTHRITIS OF KNEE.

Brief resume of the intended work :

6.1 Need for the study:

Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease or osteoarthrosis, they were group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone [1]

The word ‘osteoarthritis’ originated from the Greek word“osteo”, meaning “of the bone”, “arthro”, meaning of the “joint”, and “itis”, meaning of inflammation, although the “itis” of osteoarthritis is somewhat of a misnomer – inflammation is not a conspicuous feature which is present in rheumatoid or autoimmune types of arthritis. Some clinicians refer to this condition as osteoarthrosis to signify the lack of inflammatory response [2] Osteoarthritis traditionally was considered as a disease of articular cartilage. Now it is thought to involve the entire joint tissues, synovial, capsule, bone and ligaments leading to subchondral bone attrition and remodeling, meniscal degeneration, ligamentous laxity, fat pad extrusion, and impairments of neuromuscular control etc..[3]

Osteoarthritis (OA) is the most common joint disorder, and there is evidence that a majority of individuals over the age of 65 have radiographic and/or clinical evidence of OA. The most frequently affected sites are the hands, knees, hips and spine. In this study the researcher have selected the osteoarthritis of knee joint. Importantly, the symptoms are often associated with significant functional impairment, as well as signs and symptoms of inflammation, including pain, stiffness and loss of mobility[4] Multiple factors have been shown to affect the progression of Osteoarthritis, including the presence of polyarticular disease, increasing age, associated intra-articular crystal deposition, obesity, joint instability and/or malalignment, muscle weakness and peripheral neuropathy. These factors can be segregated into categories that include hereditary contributions, mechanical factors and the effects of ageing.[5]

Patho-physiology-

The articular surface plays an essential role in load transfer across the joint and there is good evidence that conditions that produce increased load transfer and/or altered patterns of load distribution can accelerate the initiation and progression of Osteoarthritis [6] The primary risk factor for Osteoarthritis is age. The aging process contributes to Osteoarthritis pathogenesis in several ways. The first relates to the influence of the ageing process on the structural organization and material properties of the cartilage extracellular matrix (ECM).[7]

There is evidence that the major components of the ECM, which consists of type II collagen and proteoglycan, undergo structural changes during the ageing process. There is evidence of accumulation of advanced glycation end products (AGEs). This process has been shown to enhance collagen cross-linking and likely is a significant contributing factor to the increase in cartilage stiffness and altered biomechanical properties that has been observed with ageing.[8]

The chondrocyte is the only cell type inhabiting the cartilage matrix. This cell is relatively metabolically inert and has little regenerative capacity. There is evidence

6.

that its capacity to remodel and repair the cartilage ECM diminishes with age, and this appears to be related primarily to a decreased anabolic capacity.[9]

Finally, more information is needed regarding the origin of pain and related symptoms in Osteoarthritis, since there is already a large segment of the population who are significantly disabled and suffering from this common joint disorder.[9]

Risk factorsOA knee increases with age (older than 50 years), especially in women. According to a number of published reports, anywhere from 6% to over 13% of men, but between 7% and 19% of women, over 45 years of age are affected, resulting in a 45% less risk of incidence in men. Additional factors that increase the risk of developing OA of the knee include genetics and obesity3. Genetic factors appear to influence risk of developing primary OA though they may influence disease differently in men and women. Twin studies suggest that generalised OA in women has a heritability rate of 39 to 65%. [10]

Signs & Symptoms.[2,28]

Signs: Coarse Crepitus due to irregularity of articular surface, Bony enlargement due to remodeling and osteophytes, Deformity, instability, restricted ability and stress pain.

Symptoms: Pain is due to stimulation of capsular pain fibers, mechanoreceptors

(increased intra-articular pressure due to synovial hypertrophy), periosteal nerve fibers and by perception of subchondral micro fractures or

painful enthuses and bursa. Stiffness is due to gelling of joint after inactivity with differences in initiating

movement. Joint swelling, deformity and crepitus.

ClassificationOsteoarthritis can be classified into either primary or secondary osteoarthritis, in this study the primary osteoarthritis patients with grade-2 kellagran-lawerance scale were taken.[1]

1. Primary OAPrimary osteoarthritis is a chronic degenerative disorder related to aging, pathophysiology of osteoarthritis involves a combination of mechanical, cellular, and biochemical processes. The interaction of these processes leads to changes in the composition and mechanical properties of the articular cartilage.[1]

2. Secondary OAThis type of OA is caused by other factors but the resulting pathology is the same as for primary OA.[1]

Kellgren-Lawrence Classification: Knee Osteoarthritis.[12]

Grade I : Unlikely narrowing of the joint space, possible osteophytes

Grade II:  Small osteophytes, possible narrowing of the joint

Grade III: Multiple, moderately sized osteophytes, definite joint space narrowing, some sclerotic areas, possible deformation of bone ends

Grade IV: Multiple large osteophytes, severe joint space narrowing, marked sclerosis and definite bony end deformity.

In this study the researcher has taken only grade II samples of scale There are various electrical modalities for treating chronic osteoarthritis were as the researcher have opted TENS treatment for group A patients and ultrasound treatment for group B patients as a ideal modalities to see their chief effect between the groups. Both the group people were given retro walking as a common exercise protocol to measure pain reduction and range of motion of knee joint.

Group –A patients were treated with Transcutaneous electrical nerve stimulation (TENS) which is an inexpensive, noninvasive intervention used to manage a wide variety of painful conditions. Transcutaneous electrical nerve stimulation (TENS) is a common treatment modality for musculoskeletal pain and has been demonstrated to be effective for managing chronic Osteoarthritis knee pain.[13 ] High frequency (100HZ) and low intensity TENS capable of stimulates A beta mechanoreceptors which are effective in reducing pain perception.[14] Transcutaneous electrical nerve stimulation was applied with 4 self-adhesive electrodes as a bracket method to the knee, Two electrodes were placed above the knee, and 2 were placed below. The current was delivered across the joint through 2 channels .[15]

Group- B patients were given therapeutic ultrasound treatment. Which is the best physical therapy modality suggested for the management of pain and loss of function due to OA. It is a form of mechanical energy consisting of high-frequency vibrations that can be continuous or pulsed. Pulsed ultrasound produces non-thermal effects and is used to aid in the reduction of inflammation, whereas continuous ultrasound generates thermal effects. Therapeutic ultrasound is also reported to reduce oedema, relieve pain and accelerate tissue repair.[16]

Both the group patients were given retro walking respectively,

People in daily life mainly move forward to do exercise because it is a habitual moving direction, but there are some different ways to do exercise, and sometimes that will be more efficient and saving strength than the original way. Another option of doing exercise is backward locomotion. The research team had ever seen that somebody challenged Guinness Book of World Records by “backward running” reported by TV news, therefore this study was interested in what advantages would be gained by “backward exercise” on osteoarthritis.[17-19]

Backward locomotion (walking or running) has gained popularity as one part of a program to rehabilitate certain knee injuries (Flynn & Soutas-Little 1993; Threlkeld et al. 1989). Backward walking training, or rehabilitation, has been reported to decrease patellofemorol joint compressive forces (Flynn & Soutas-Little 1995), to protect the anterior cruciate ligament (ACL) from overstretching (Mackie & Dean 1984), and to decrease eccentric loading of the knee extensors (Flynn & Soutas-Little 1993). 17-19 Backward walking, therefore, has been promoted as a treatment strategy to improve gait. Backward walking appears to create more muscle activity in proportion to effort than forward walking (Grassoet al, 1998 and Winter et al, 1989). Subjects underwent three sessions of Retro-walking per day (10 minutes. per session)

for 3 weeks on a flat surface at their maximum pace along with conventional treatment as mentioned above.[20]

Visual Analog Scale (V.A.S):A Visual Analog Scale of pain is an instrument used to measure the amount of pain a patient feels, according to Journal of Clinical Nursing. The visual analog scale of pain is usually a 100 mm-long horizontal line, which may contain word descriptors at each end. The patient represents their perception of the amount of pain she feels by marking a horizontal line between two points. The visual analog scale score is measured in millimeters from the left hand end of the line to the point indicated by the patient.[21]

Goniometer is an instrument to measure joint range of motion. It has fulcrum, protractor, fixed arm and mobile arm. In this study it is used to measure the knee range of motion. Measurement of knee flexion was performed in the supine position by simultaneously flexing the hip and knee, with the foot on the measured side resting on the table as far as possible. The opposite leg was kept extended on the able. Knee extension was also measured with patients lying supine on an examination couch with the leg kept straight, and the examiner supported the weight of the leg as the patient moved. The fully extended knee was considered zero position, and the degrees of maximum flexion, maximum extension, and extension deficit, when present, were recorded.[29]

Western Ontario and McMaster Universities Index of Osteoarthritis[WOMAC]: Since its development in 1982, it is most frequently used to assess pain, stiffness, and physical function in patients with knee Osteoarthritis. It is a self-reported scale which has proper reliability and validity.[22] WOMAC is a self-assessed, disease-specific measure for patients with osteoarthritis which, comprising 24 items in three dimensions: pain (five items), function (17 items) and stiffness (two items).[30]

Pain (5 items): during walking, using stairs, in bed, sitting or lying, and standing

Stiffness (2 items): after first waking and later in the day Physical Function (17 items): stair use, rising from sitting, standing, bending,

walking, getting in / out of a car, shopping, putting on / taking off socks, rising from bed, lying in bed, getting in / out of bath, sitting, getting on / off toilet, heavy household duties, light household duties

PURPOSE OF THE STUDY: To find out the effectiveness of Transcutaneous electrical nerve stimulation (TENS) with retro walking versus ultrasound therapy with retro walking in patient with chronic knee Osteoarthritis.

Hypothesis:

Null Hypothesis:

There will be no significant difference in WOMAC (knee disability index) and the V.A.S (measure of pain.) in subjects with chronic knee Osteoarthritis treated with Transcutaneous electrical nerve stimulation (TENS) with retro walking versus Ultrasound therapy with retro walking.

Alternative Hypothesis:

There will be significant difference in WOMAC (knee disability index) and the V.A.S (measure of pain.) in subjects with chronic knee Osteoarthritis treated with Transcutaneous electrical nerve stimulation (TENS) with retro walking versus Ultrasound therapy with retro walking.

6.2 Review of Literature : Felson DT, Zhang Y, Hannan MT, et al (1995) concluded that Osteoarthritis (OA) of the knee is the most common joint disease in the elderly and it is associated with significant physical disability.[1]

Solomon, et al (1997) concluded that Osteoarthritis (OA) is a primary disease of cartilage as it is characterized by the degradation of hyaline cartilage in the joints . It is believed to be a dynamic disease that reflects the balance between destruction and repair.[2]

Lawrence RC, Hochberg MC, Kelsey JL, et al (1989) concluded that OSTEOARTHRITIS (OA) is the most common degenerative joint disorder reported as major cause of significant morbidity. It is characterized by the deterioration of articular cartilage in the joints. Further it affects several joints, especially weight-bearing joints like knee joint.[23]

Van Saase J L C M, Van Romunde L K S, Cats A, Vandenbroucke J P, Valkenburg H A, et al, (1989) concluded that Osteoarthritis (OA) is a major public health problem in developed countries. Subjects over the age of 45 years and above population survey showed that the presence of radiographically determined OA of the knee.It varies between 14 and 30% and increases steadily with age.[24]

Di Cesare P, Abramson S, Samuels J ,et al (2009),concluded that Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease or osteoarthrosis, It is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone.[1]

Gladys L. Y. Cheing, Amy Y. Y. Tsui, Sing Kai Lo and Christina W. Y. Hui-Chan ,et al,(1986), concluded that, Osteoarthritis (OA) is the most prevalent form of arthritis in the USA and its prevalence increases with age . It is estimated that about 15.8 million of Americans are afflicted with OA . It occurs mostly in people over the age of 65 years and the knee is the most commonly affected site in the lower limb . The main complaints of patients suffering from OA are pain, stiffness, crepitation, instability, loss of function, joint enlargement and impaired muscle strength.[27]

Mao-Hsiung Huang*, Rei-Cheng Yang,Chia-Ling Lee, Tien-Wen Chen, Ming-Cheng Wang,et al,(2005) concluded that Osteoarthritis (OA) is the most prevalent disease associated with significant morbidity, and is one of the most common causes of functional limitation and dependency. OA of the knee is particularly disabling due to symptoms such as pain, stiffness, and muscle weaknessOA is characterized by noninflammatory deterioration of the articular cartilage with reactive new bone formation at the joint's surface and margins. high muscle wasting, is an important factor in knee OA because the earliest description and treatment of OA traditionally include exercises specifically intended to increase quadriceps strength.[29]

Felson DT. Clinical practice , et al (2006) concluded that Osteoarthritis (OA) is the most common joint disorder, and there is evidence that a majority of individuals over the age of 65 have radiographic or clinical evidence of OA.[2]

Rutjes AW, Nüesch E, Sterchi R, et al(2010) concluded that, Therapeutic ultrasound is one of the physical therapy modality suggested for the management of pain and loss of function due to OA. Therapeutic ultrasound is also reported to reduce oedema, relieve pain and accelerate tissue repair.[16]

Mirsad Muftic and Ksenija Miladinovic , (2013) concluded that Therapeutic ultrasound is a physical modality which is constantly expanding range of indications. The analgesic effect of ultrasound is still under discussion. The extensive application of pulsed and continuous ultrasound has a better analgesic effect explained by its mechanism of action.[25]

Cochrane Database of Systematic Reviews.(2010 ) Concluded that, The two group of OA-knee patients were treated with ultrasound.the first group of patients were treated with 10 applications of continuous ultrasound with frequency of 1 MHz, intensity of 0.4 W/cm2 for 8 minutes, and the other group with 10 applications of ultrasound with frequency of 1 MHz, intensity 0.8 W/cm2 for 4 minutes.[25]

Mirsad Muftic and Ksenija Miladinovic (2013) concluded that Therapeutic ultrasound (UZ) is a physical modality that has the broadest application and is commonly used in clinical practice. Earlier it was primarily used for its thermal effect, and is now it increasingly used for nonthermal effects. Thermal effects are attributed to the continuous UZ and no thermal effects to the pulsed UZ of small intensity (LIPUS Low-Intensity Pulsed Ultrasound)[28]

Cochrane Database of Systematic Reviews.et al (2010 ) concluded that, The thermal effect of ultrasound has greatest analgesic effect because it leads to increased metabolic activity in the tissue, which improves the circulation and relaxes the rigid structure of the soft tissue which was seen in degenerative musculoskeletal system.[25]

Cochrane Database of Systematic Reviews.et al (2010 ) concluded that, Results of the survey conducted in Australia 2007 had shown that the therapeutic ultrasound remains the most popular physical agent that is used in physiotherapy practice. . The survey that was conducted in the U.S. showed that the therapeutic UZ had reduced pain of 83.6% of patients,Further the UZ is being applied to reduce inflammation of the soft tissues of about 70.9% of cases.[25]

Rutjes AW, Nüesch E, Sterchi R, et al, (2010) concluded that, Therapeutic ultrasound (US) has been used to treat many musculoskeletal diseases, and is reputed to reduce edema, relieve pain, increase the ROM , and accelerate joint tissue repair. In reviewing the effectiveness of US in treating musculoskeletal conditions, Falconer et al found that most reports revealed that therapeutic US appears to relieve OA pain. Some investigations have applied US to enhance the flexibility of connective tissues.[16]

Judith Falconer PhD, OTR Assistant Professor, Karen W. Hayes PhD, PT, et al,(2010), concluded that, Ultrasound increases soft tissue extensibility and may be an effective adjunct in the treatment of knee contractures secondary to connective tissue shortening. A randomized clinical trial was conducted to determine the effectiveness of ultrasound in relieving stiffness and pain in patients (age x = 67.5 years, SD = 13.0) who had osteoarthritis (OA) and a chronic knee contracture.[16]

Gladys LY Cheing, Christina WY Hui-Chan, KM Chan, et al ( 2002) concluded that ,Transcutaneous electrical nerve stimulation (TENS) is a non-invasive modality used in physiotherapy for control of pain. Seven studies using TENS in people with knee osteoarthritis (OA) were identified for device setting, application and outcomes measures were studied.The active TENS and ’acupuncture like’ TENS (AL-TENS) treatment were given for four weeks effectively to reduce pain. Further the Knee stiffness also improved significantly.[13-15]

Lawrence RC, Hochberg MC, Kelsey JL, et al (1989) concluded that Physical therapy agents most widely prescribed by physicians They are shortwave diathermy (SWD), transcutaneous electrical nerve stimulation (TENS), and interferential currents (IFCs). These physical therapy agents are claimed to be effective in the management of knee OA.[23]

Berlant SR,et al,(1984), concluded that, Transcutaneous electrical nerve stimulation (TENS) is one of the commonly used physical modalities for managing OA knee.[15]

Carol Grace T. Vance, Barbara A. Rakel, Nicole P. Blodgett, et al (2003) concluded that The Transcutaneous electrical nerve stimulation (TENS) is commonly used for reducing the pain.[26]

John Low and Ann Read,et al concluded that Transcutaneous electrical nerve stimulation (TENS) is an inexpensive, noninvasive intervention used to manage a wide variety of painful conditions. Previous studies showed that TENS increases pressure and heat pain thresholds in people who are healthy and reduces mechanical and heat hyperalgesia inarthritic animals.[14]

Berlant SR, et al,(1984),concluded that, TENS has a greater effect on

movement-evoked pain and subsequently results in improved function.[15]

Duysens,Grasso et al, (1998) concluded that Backward walking has been promoted as a treatment strategy to improve gait. Backward walking appears to create more muscle Activity than forward walking. walking backward can reducemoving pressure of joints than forward locomotion backward locomotion also can enhance the strength of shank muscles.[18]

Flynn&Soutas-Little,Threlkeld et al(1993) concluded that, Backward locomotion (Retro walking) is the Popular rehabilitation program to certain knee injuries, Further Backward walking training, or rehabilitation, has been reported to decrease patellofemoral joint compressive forces to protect the anterior cruciate ligament (ACL) from overstretching (Mackie & Dean 1984),and decrease eccentric loading of the knee extensors.[19]

Mao- Hsiung Huang, et al, (2005), concluded that The active ROM was measured with a large, plastic goniometer with 25cm movable double arms, marked in 1-degree increments. This device is reportedly reliable if the patient remains in one position for all measurements . Measurement of knee flexion was performed in the supine position by simultaneously flexing the hip and knee, with the foot on the measured side resting on the table as far as possible. The opposite leg was kept extended on the table. Knee extension was also measured with patients lying supine on an examination couch with the leg kept straight, and the examiner supported the weight of the leg as the patient moved. The fully extended knee was considered zero position, and the degrees of maximum flexion, maximum extension, and extension deficit, when present, were recorded.[28]

Bijur PE, Silwer W Gallagher EJ ,et al,(2001) concluded that, The severity of knee pain was evaluated by the VAS after patients had remained in a weight-bearing position (walking or standing) for 5 minutes. The instrument consisted of 10-cm horizontal or vertical lines, with anchor points of 0 (no pain) and 10 (maximum pain).[21]

6.3 Objective of the study:

1. To assess the effectiveness of transcutaneous electrical nerve stimulation (TENS) with Retro walking in chronic Osteoarthritis of Knee.

2. To assess the effectiveness of ultrasound therapy with retro walking in chronic Osteoarthritis of knee.

3. To compare the effect of Transcutaneous electrical nerve stimulation (TENS) with retro walking versus ultrasound therapy with retro walking in chronic Osteoarthritis of knee.

8. 7 Materials and Methods

7.1 Source of data:

Outpatient department of Kempegowda Institute of Physiotherapy, Bangalore.

Orthopedic outpatient department of Kempegowda Institute of Medical Sciences, Hospital and Research Centre, Bangalore.

7.2 Methods of collection of Data:

a. Study Design: Randomized study design.

Sample Size: 60 Subjects (30 in each group). Sample Method: simple Random sample technique. a. Materials used:

Couch Ultrasound machine. Transcutaneous electrical nerve stimulator (TENS) machine. Four Rubber Pad electrodes. Velcro strap. Pillow. Cotton. Gel. Towel Roll. Data collection /record sheet. Visual Analogous Scale. goniometer Western Ontario McMaster osteoarthritis Index (WOMAC)

scale.

b. Inclusion Criteria: Patient suffering with Osteoarthritis knee for three months

without any cognitive deficit. Unilateral Osteoarthritis of Knee (tibio femoral compartment)

with x-ray findings showing symptoms of Grade-II Kellgren-Lawrence Classification Knee OsteoarthritisBoth Gender age group between 45-60 years

Crepitus on active range of motion Tenderness on the joint line Grade-II Kellgren-Lawrence Classification: Knee Osteoarthritis

c. Exclusion Criteria: Traumatic knee pain Inflammatory and Infectious knee condition Fracture around knee joint

Ruptured ligament of knee joint Rheumatoid Arthritis, Gouty Arthritis, Psoriatic

Arthritis Active synovitis Meniscopathy acute knee Osteoarthritis Any recent Surgical intervention of knee joint Tumors/malignancy of knee joint Grade I, III, IV Kellgren-Lawrence Classification: Knee

Osteoarthritis Osteoarthritis who had undergone TKR/THR OA of hip and OA of foot Any previous corticosteroid, hyaluronic acid injection to

knee joint. Any knee surgery for soft tissue problem

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: Patients who fulfill inclusion criteria are taken for the study. Intervention is explained to the patients in a language understood by them. Informed written consent is taken from the patient or family.

Subjects will be divided in two groups by simple random sampling method.

The patients in Group A will be given High (conventional) TENS in supine lying position, Two channels with 4 electrodes in bracket method were selected, electrode size ranges (5cm lengthx3.5cm width.) over painful knee region were patient felt tactile sensation threshold Intensity of the current .Channel 1- two electrodes ‘A’ superiorly and ‘A1’ inferiorly in the medial aspect of painful knee region. Channel 2- Two electrodes ‘B’ superiorly and ‘B1’ inferiorly in the lateral aspect of painful knee region. Each session lasted 20 minutes, with Frequency-40-150HZ, 5 times a week, for 3 weeks followed by supervised retro walking performed on a plane surface in a straight line with great pace for 10 minutes 3 sessions in a day.[13-15,20]

The patients in Group B will be given ultrasound therapy in supine lying position, over painful knee region with intensity of 1mzh, 0.8 watts/cm2 ,.for 5 minutes,5 times a week for 3 weeks Followed by supervised retro walking performed on a plane surface in a straight line with great pace for 10 minutes 3 sessions in a day[25,20]

The subjects pain was assessed through VAS scale, range of motion were assessed through goniometer, and pain, stiffness and physical function through WOMAC scale.

In VAS scale when assessing the pain, the patient is instructed to choose a number from 0 to 10 that best describes their current pain. 0 would mean ‘No pain’ and 10 would mean ‘Worst possible pain’.

WOMAC scale has 24 parameters under which the patient is assessed for pain, stiffness and physical function. Each sub group is scored On a 0-4 scale as : 0- None 1- slight 2-moderate 3-severe 4-extreme.Goniometer is used to assess the range of motion of knee joint, (both flexion and extension)

All the 3 outcome measures were measured on day 1,1st week 2nd week and 3rd week respectively.

Statistical analysis: Comparison of collected data will be made by using Repeated ANOVA test.

7.4 Has Ethical clearance been obtained from your institution in case of 7.3?

List of references:

1 Di Cesare P, Abramson S, Samuels J. Pathogenesis of osteoarthritis. In: Firestein GS, Kelley WN, eds. Kelley’s Textbook of Rheumatology. 8th ed. Philadelphia, Pa.: Saunders Elsevier; 2009: 1525-40

2 Buckwalter JA, Mankin HJ. Instructional course lectures, the American Academy of Orthopaedic Surgeons – articular cartilage. Part II: degeneration and osteoarthrosis, repair, regeneration, and transplantation. J Bone Joint Surg 1997; 79: 612-32.

3 Sellam J, Berenbaum F. The role of synovitis in osteoarthritis. Nat Rev Rheumatol 2010; 6: 625-35..

4 Felson DT. Clinical practice. Osteoarthritis of the knee. N Engl J Med 2006; 354:841-848.

5 Lohmander LS, Felson D. Can we identify a ‘high risk’ patient profile to determine who will experience rapid progression of osteoarthritis? Osteoarthritis Cartilage 2004; 12:S49-52.

6 Lohmander LS, Ostenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve yearsafter anterior cruciate ligament injury. Arthritis Rheum 2004; 50:3145-3152.

7 Carrington JL. Aging bone and cartilage: cross-cutting issues. Biochem Biophy Res Commun 2005; 328:700-708.

8 Verzijl N, Bank RA, TeKoppele JM, DeGroot J. AGEing and osteoarthritis: a different perspective. Curr Opin Rheumatol 2003; 15:616-622.

9 Loeser RF, Shakoor N. Aging or osteoarthritis: which is the problems? Rheum Dis Clin North Am 2003; 29:653-673.

10 Loughlin J. Genetic epidemiology of primary osteoarthritis. Curr Opin Rheumatol 2001; 13(2): 111-16.

11 Das SK, Ramakrishnan S. Osteoarthritis. In: Manual of Rheumatology (editors) Pispati PK, Borges NE, Nadkar MY, 2nd edition Indian Rheumatology Association, The National Book Depot, Mumbai, India. 2002 :240-59

12 Flores RH, Hochberg MC (1998) Definition and classification of Osteoarthritis. In: Brandt K, Doherty M, Lohmander LS (eds) Osteoarthritis. Oxford University Press, New York, pp 1–12

13 Gladys LY Cheing, Christina WY Hui-Chan, KM Chan. Does four weeks of TENS and/or isometric exercise produce cumulative reduction of Osteoarthritic knee pain? Clinical Rehabilitation 2002; 16: 749-60

14 John Low and Ann Read.Electrical stimulation of nerve and muscle;3rd edition :page no.94

15 Berlant SR Method of determining optimal stimulation sites for transcutaneous electrical nerve stimulation. Phys Ther. 1984;64:924–928.

16 Rutjes AW, Nüesch E, Sterchi R, et al: Therapeutic ultrasound for osteoarthritis of the knee or hip. Cochrane Database Syst Rev 2010; 1: CD003132. 

17 Bates, B.T., Morrison, E., Hamill, J. (1984) A comparison between forward and backward running. In: Adrian, M., Deutsch, H. (Eds.), The 1984 Olympic Scientific Congress Proceedings, Microform Publications, Eugene, OR, 127 -135.

18 Buford, J.A. and Smith, J.L. (1990) Adaptive control for backward quadrupedal walking II. Hindlimb muscle synergies, J Neurophysiol, 64, 756–766.

19 Chaloupka, E.C., Kang, J., Mastrangelo, M.A. and Donnelly, M.S. (1997) Cardiorespiratory and metabolic responses during forward

and backward walking, Journal of Orthopaedic & Sports Physical Therapy, 25, 302–306.

20  Kugler LM, Amstrong CW, Moleski B. Comparative analysis of the kinematics and kinetics of forward and backward human locomotion. ISBS. 1988;6:451–64.

21. Bijur PE, Silwer W Gallagher EJ : ‘ Reliability of Visual Analog Scale for the measurement of Acute pain ’, concluded reliability was high .2001

22 American college of rheumatology WOMAC index available from: http://www.rheumatology.org/practice/clinical/clinicianresearchers/outcomes-instrumentation/WOMAC.asp

. 23 Lawrence RC, Hochberg MC, Kelsey JL, et al. Estimates of the prevalence of selected arthritic and musculoskeletal diseases in the United States. J Rheumatol 1989;16:427-41.

24 Van Saase J L C M, Van Romunde L K S, Cats A, Vandenbroucke J P, Valkenburg H A. Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other populations. Anni Rheum Dis 1989; 48: 271-

25 Cochrane Database of Systematic Reviews. 2010;(1) Art.No: CD003132. doi: 10.1002/14651858.CD003132.pub2.

26 Chesterton LS, Foster NE, Wright CC, et al. Effects of TENS frequency, intensity and stimulation site parameter manipulation on pressure pain thresholds in healthy human subjects. Pain. 2003;106:73–80.

27 Cooke TDV, Dwosh IL. Clinical features of osteoarthritis in the elderly. Clin Rheum Dis 1986; 12: 155–172.

28 Dicesare PE, Abramson SB. Pathogenesis of Osteoarthritis.In :Harris ED, Budd RC, Genovese MC et al (editors) .Kelley’s Textbook of Rheumatology, volume II, 7th edition, Elsevier Saunders. 2005: 1493-1513

29 McAlindon TE, Cooper C, Kirwan JR, Dieppe PA. Determinants of disability in osteoarthritis of the knee. Ann Rheum Dis 1993; 52:258–62.

30 Bellamy N. WOMAC osteoarthritis index. User guide IV. 2000.

9. SIGNATURE OF THE CANDIDATE:

10. REMARKS OF THE GUIDE:

11. NAMES AND DESIGNATION OF:

11.1 GUIDE: DR. RAJA.R (M.P.T)ASSOCIATE PROFESSOR.

11.2 SIGNATURE:

11. 11.3 CO-GUIDE(s): DR.SOMASHEKAR .M.S. ORTHO ASSOCIATE PROFESSORDEPARTMENT OF ORTHOPEDICS

11.4 SIGNATURE(s):

11.5 HEAD OF THE PROF. R. BALASARVANAN

DEPARTMENT: PRINCIPAL KIPT.

11.6 SIGNATURE :

12. 12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL:

12.2 Signature: