Extension Lag
Extension Lag
Extension Lag
www.biomedres.info
Abstract
The weakness of quadriceps and reduced activation has been identified as a major cause of activity
limitations post Total knee replacement (TKR). There is a need to evaluate various available techniques
in their effectiveness in improving quadriceps strength and minimizing functional limitations after total
knee replacement. Objective of this study was to determine the effectiveness of strength training as
compared to functional training in improving knee extension lag after first four weeks of Total Knee
Replacement. This Randomized control trial was conducted at Ghurki trust teaching hospital, from
June to December 2015.Patients with total knee replacement were selected consecutively and then
randomly assigned to control group (n=33) and treatment group (n=31). Primary and secondary
outcome measures were goniometry and Visual Analogue Scale (VAS) respectively. There was no
significant difference found in knee extension Lag between the two groups (p-value>0.05). The mean
Value for pain on visual analogue scale was 1.78 (SD=3.03) for control group and 1.33 (SD=3.32) for
treatment group. The difference in mean scores for pain was significantly different for both groups (p-
value<0.05). Both strength training and functional training were found equally effective in improving
quadriceps lag, however, functional training exercises resulted in significant reduction in post-operative
knee pain compare to resistance training. It is recommended to make functional exercises an essential
part of physical rehabilitation post total knee replacement.
Keywords: Arthroplasty, Exercise therapy, Knee joint, pain, Outcome assessment, Resistance training, Visual analogue
scale.
Accepted on May 08, 2017
total knee replacement. [10]. The persistent quadriceps Osteoarthritis of Knee (2) having first TKR surgery, (3) having
weakness and the resulting functional limitations after TKR are post-operative goal to ambulate with or without walking aids
attributed to ineffective post-operative rehabilitation (4) willing to undertake physical therapy interventions and
approaches. A universally accepted protocol for post-operative follow up. Patients for whom total knee arthroplasty was
rehabilitation for total knee replacement is lacking. A recent indicated due traumatic knee injury, rheumatoid arthritis or
study on the post-operative care after TKR has revealed that bone tumors were excluded. Of the 4 surgeons involved in the
26% patients get the out-patient based physical rehabilitation study, 2 were high volume knee replacement surgeons (Defined
after their discharge which can have profound effects on the as more than 80 Total Knee Replacement Surgeries) and 2
long term well-being and quality of life of the patients [11]. surgeons were low volume surgeons. Patients from high and
low volume surgeons were evenly divided in 2 groups.
Strength training with high resistance has been shown to
improve quadriceps strength and activation [4]. Progressive
strength training has been proposed to be started as early as 1
Sample size
to 2 days post op in order to minimize strength deficits in Sample of 64 patients was taken consecutively.
quadriceps [12]. Small to moderate improvements in range of
motion and functional status have been observed with Blinding
functional exercise after 3-4 months of total knee replacement.
Home based unsupervised exercises have also been speculated Treatment protocols were managed to hide from patients and
to reduce pain and disability. But the efficacy of home base assessors. Clinicians, however, had the idea of treatment
exercises and functional exercises in providing long term approach to particular groups. This double blinding was
improvements in range of motion and functional status is maintained throughout course of trial. Outcome assessment
unclear [13]. Therefore there is a need to evaluate the was blinded and carried out by Physical Therapists who were
effectiveness of various techniques in improving quadriceps not involved in intervention tasks. This physical therapist was
strength and minimizing functional limitations after total knee trained in using outcome measures especially the primary one
replacement. Current study hypothesized that functional in this study i.e. Goniometer. Assessor physical therapist and
training program is more effective as compared to conventional patients were blinded from the mode of treatment.
strength training in reducing quadriceps lag after total knee
replacement. Interventions
Control group received muscle strengthening program once per
Objective day for 5 days a week. It consisted of ankle cuff weights.
The objective of this study was to determine the effectiveness Different weight sandbags were used for this purpose. Patients
of strength training as compared to functional training in were demonstrated the procedure and the methods were
improving knee extension lag after first four weeks of Total observed by experienced physical therapist. Treatment group
Knee Replacement. was given functional activities. Functional activities included
squats, lunges and steps (step up, step down).
Material and Methods Functional activities were demonstrated to the treatment group
by trained physical therapists. Patients were observed while
Methods performing those functional activities. They were provided
with illustrated pamphlet of exercises as a home exercise plan.
It was a Randomized Controlled Trial conducted with 4 weeks
follow up. Patients in control group were given strength Primary outcome measure was Goniometry. The range of knee
training and those in treatment group were given functional joint was measured through same procedures. While Visual
training. So the primary variables of study were strengthening Analogue Scale (VAS) was used as secondary outcome
exercises given as outpatient basis and strengthening through measure to measure pain level [14].
functional activities given as home plan. The details of these
variables are mentioned in next section under the heading Statistical calculations and analysis
“Intervention”. The subjects were selected through purposive
Analysis was based on “intention to treat” basis. Means,
sampling technique and then randomly allocated to either
medians, standard deviations were generated for major
control or experimental group by using lottery method. The
variables of study. The data was analyzed through SPSS 20.0.
allocation process was concealed and was performed by a
Paired sample t-test was used and the change in knee extension
research assistant who was not involved in any further step of
lag and pain level were measured at different levels of follow
research (Figure 1).
up, because improvement in quadriceps lag was primary
outcome and improvement in pain was major secondary
Patients outcome of trial.
Participants were taken from the list of patients that were
waiting for Total Knee Replacement. Patients who met
following eligibility criteria were selected: (1) diagnosed with
Ethical approval and data storage **TKR in which surgeon applied a separate piece on backside of patella to
Co-Morbidities
Table 1. Baseline characteristics of treatment and control groups- Hypertension 28 (54) 31 (57)
demographics and surgical intervention.
Diabetes 9 (17) 13 (24)
Demographics Treatment Group Control Group p-value Kidney Disease 3 (6) 1 (2)
n=31 Mean(SD) n=33 Mean(SD)
Neurologic Disease 0 (0) 1 (2)
Age, Years 60 (10) 71 (12) 0.69
Strength of Quadriceps 23 (12) 24 (11)
Body Mass Index 32 (6) 31 (5) 0.40
SF-Bodily Pain 39 (17) 38 (117)
Female, n (%) 39 (60) 33 (50) 0.29
SF-Mental Health 73 (16) 74 (16)
Diagnosis of Osteoarthritis, n 63 (96) 64 (97) 0.51
SF-Social Function 68 (28) 67 (27)
(%)
SF-Role Emotional 66 (39) 60 (43)
No Co Morbid Condition, n (%) 28 (70) 22 (55) 0.36
post-operative rehabilitation after TKR. Balance and functional the secondary outcome i.e. pain for the participants in
training have been studied for their effectiveness in improving interventional group. This supports the use of functional
balance after TKR [6] but current study focuses on two activities over strengthening exercises. These results would be
different treatment regimens for correction of extensor lag. helpful in improving quality of life of patients who are unable
Current study has shown that the difference in effectiveness of to get the outpatient physical therapy treatment and prefer a
strength training and functional training in reducing extensor home based plan of exercise instead.
lag was not significant. Significant improvement was found in
Table 3. Comparison of average values of Pain on Visual analogue scale and knee extension Lag in degrees between control and treatment groups.
Post Opp. 1st Day of Group A: Pain Level on VAS 7.56 (1.33) 8.00 7.67 (1.00) 8.00
Post Opp. 2nd Week of Group A: Pain Level on VAS 5.89 (1.69) 6.00 4.56 (0.88) 5.00
Post Opp. 4th Week of Group A: Pain Level on VAS 5.00 (0.71) 5.00 2.22 (1.30) 2.00
Post Opp. 1st Day of Group A: Extension Lag in Degrees 5.00 (4.85) 5.00 7.33 (9.01) 5.00
Post Opp. 2nd Week of Group A: Extension Lag in Degrees 4.44 (4.93) 3.00 4.11 (4.49) 3.00
Post Opp. 4th Week of Group A: Extension Lag in Degrees 1.78 (3.03) .00 1.33 (3.32) .00
Strengthening through functional activities was used in this replacement surgery: a cross-sectional observation study.
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