Dissertation submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2012. / Background: Attempts to determine the association between the radiographic and clinical findings of knee pathology have produced conflicting results. It is also not yet known how knee radiographs influence the conservative management of patients with knee pain. Objectives: 1. To determine the association between the clinical and radiographic diagnoses of knee pain. 2. To record the consultation at which a radiograph of the knee was requested by the student or clinician and the reasons thereof. 3. To record the suspected clinical diagnoses and management of the patients prior to referral for radiographs of the knee. 4. To determine the number of incidental radiographic findings in the selected radiographs. 5. To determine any change in the clinical diagnoses and management following radiographic reporting of the selected radiographs. Method: Radiographic and clinical data from 1 January 1997 to 31 December 2010 were retrospectively collected from knee radiographs and corresponding patient files from the archives of the Chiropractic Day Clinic (CDC). Statistical analysis included the use of percentages, mean, standard deviation, range and frequency counts for the descriptive objectives. Diagnoses were categorized into specific groups and to construct two-by-two tables of absence or presence of radiographic vs. clinical diagnosis for each specific diagnosis to determine the association indicator variables were used. Results: The overall agreement between the clinical and radiographic diagnoses was 85.5%. For degenerative joint disease there was a 97.8% agreement while in Osgood Schlatter’s disease the agreement was 100%, and in chondromalacia patella the agreement was 50%. However, there was no agreement between the clinical and radiographic diagnoses for each of the other specific conditions. Degenerative changes were the most common radiographic findings. The iv majority of the knee radiographs were requested at the initial consultation and as the length of treatment increased, the frequency of radiograph requests decreased. The most common reasons for referral for radiographs were to identify degenerative changes (47.5%) and to assess for unspecified pathology (37.4%). Of the 146 patients in this study, 125 patients did not have a change in diagnosis after radiographs were obtained which means that 85.6% of the diagnoses remained the same after radiographic examination. There was a wide range of treatment modalities utilized in the management of patients with knee pain, including soft tissue therapy, electrotherapeutic modalities and manual therapy (manipulation and mobilization). The use of manual therapy increased from 67.8% prior to radiographs being taken to 82.9% after radiographs were obtained. Conclusion: Knee radiographs were over-utilized at the CDC and the findings on radiography did not have much influence on the diagnosis and the management of the patient presenting with knee pain. The majority of the clinical diagnoses were degenerative causes of knee pain. / Durban University of Technology Research Fund

Introduction: Studies show that Total Knee Arthroplasty (TKA) is successful for the majority of patients however some continue to experience some functional limitations and anecdotal evidence indicates that stiffness is a common complaint. Some studies have suggested an association between stiffness and functional limitations however there has been no previous work which has attempted to objectively quantify knee joint stiffness following TKA. The purpose of this study was to pilot and evaluate a method for the quantitative evaluation in joint stiffness in replaced knees, OA knees and healthy controls and to explore whether there is an association between stiffness and functional limitations post-TKA surgery. Methods: The first part of the study created a biomechanical model of knee stiffness and built a system from which stiffness could be calculated. A torque transducer was used to measure the resistance as the knee was flexed and extended passively and an electrogoniometer concurrently measured the angular displacement. Stiffness was calculated from the slope of the line relating the passive resistive torque and displacement. The torque and joint angle at which stiffness was seen to increase greatly was also noted. The system was bench tested and found to be reliable and valid. Further tests on 6 volunteers found stiffness calculations to have acceptable intra-day reliability. The second part was conducted on three groups: those with end-stage knee OA (n = 8); those who were 1 year post-TKA (n = 15) and age matched healthy controls (n = 12). Knee range of motion was recorded and participants then completed the WOMAC, the SF-12 and a Visual Analogue Score for stiffness as well as indicating words to describe their stiffness. Four performance based tests – the Timed Up and Go (TUG), the stair ascent/descent, the 13m walk and a quadriceps strength test were also undertaken. Finally, passive stiffness at the affected knee was measured. Results: 100% of OA, 80% of TKA and 58% of controls reported some stiffness at the knee. The OA group reported significantly higher stiffness than the OA or TKA groups. There was no difference in self-reported stiffness between the TKA and control groups. Of the total number of words used to describe stiffness, 52% related to difficulty with movement, 35% were pain related and 13% related to sensations. No significantly differences were found between groups in the objective stiffness measures. Significant differences were found however in threshold flexion stiffness angles between groups. When this angle was normalised, differences between groups were not significant. No significant differences were found between groups in the threshold stiffness torque. Greater self-reported stiffness was found to be associated with worse self-reported function. A higher flexion stiffness threshold angle was associated with slower timed tests of function but also with better quadriceps muscle strength. Conclusions: The results support anecdotal reports that perceived stiffness is a common complaint following TKA but there was no evidence to show that patients with TKA have greater stiffness than a control group. There was however evidence to show that patients’ were unable to distinguish between sensations of stiffness and other factors such as pain. Self-perceived increased stiffness was associated with worse functional performance. Greater stiffness however was not necessarily negative. Stiffness increases earlier in flexion range were associated with better functional performance. These results suggest that an ideal threshold range for stiffness may exist; above which negative perceptions of the knee result in worse function but below which, knee laxity and instability may also result in worse function.

A dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic, Durban Institute of Technology, 2006. / To determine the efficacy of the Harpago and celery seed cream in mild to moderate degenerative joint disease of the knee in terms of subjective and objective clinical findings / M

Thesis (M.S.)--Boston University

Osteoarthritis (OA) is one of the leading causes of global disability. Surgical intervention in the form of Total Knee Arthroplasty (TKA) has been established as an excellent treatment modality for people with OA who experience joint symptoms that have a substantial impact on their quality of life and are refractory to non-surgical treatment. In the 1970s the concept of implanting TKAs in mechanical alignment (MA) was developed as a compromise to confer mechanical advantage to the prosthesis, ignoring the patient's natural anatomy, to prevent early failure of the implant. Until now, this compromise has not been revisited. Satisfaction following TKA remains inferior to total hip arthroplasty. The cause of this dissatisfaction is not clear. Implant survival is no longer comparable to that of the early designs of TKA, and recent studies have suggested that deviation from neutral alignment does not have the detrimental effect on survivorship as previously thought. In an attempt to improve patient satisfaction following TKA a new technique has been developed whereby the prostheses are implanted in such a way as to recreate the alignment of the knee in the patient's pre-arthritic state. This has been termed natural or kinematic alignment (KA). This thesis examines the impact of KA in TKA with the primary hypothesis that TKA performed utilising KA would lead to improved functional outcome following surgery compared to that of MA. An initial single surgeon proof of concept case series of 25 patients was performed to look at the precision of new patient specific cutting blocks. The results suggested that the cutting blocks were accurate in producing the desired cuts. Following the proof of concept case series, a feasibility study was then performed comparing the new KA technique with the standard MA technique. The feasibility study familiarised the operating surgeons with the new technology in preparation for a Randomised Control Trial (RCT). A prospective blinded RCT was performed to compare the functional outcome of patients implanted with TKA in MA with that of KA. A total of 71 patients undergoing TKA were randomised to either MA (n=35) or KA (n=36). Preand post-operative hip knee ankle (HKA) radiographs were analysed. A number of patient reported outcome measures and functional tests were assessed pre-operatively, 6 weeks, 3 months, 6 months, and at 1 year post-operation. The cutting guides were accurate. There were no statistically significant differences between the MA and KA groups at 1 year. A cohort of post-menopausal women with unilateral osteoarthritis treated with TKA utilising the KA philosophy had dual energy x-ray absorptiometry scans 1.5 years post-operatively using a modified validated densitometric analysis protocol, to assess peri-prosthetic Bone Mineral Density (BMD). The contralateral knee was scanned so that relative bone mineral density could be calculated. Statistical analysis revealed no significant difference in relative peri-prosthetic bone mineral density due to variation in implant position with respect to the Lateral Distal Femoral Angle (LDFA) and the Medial Proximal Tibial Angle (MPTA). There was a significant correlation with overall HKA angle and the relative BMD under the medial side of the tibial tray. KA TKAs appear to have comparable short-term results to MA TKAs with no significant differences in function 1 year post-operatively. Overall HKA angle rather than the individual component position caused change in relative BMD under the tibial tray, therefore aiming for an anatomical joint line may improve kinematics without a detrimental effect on the implant. Further research is required to see if any theoretical long-term functional benefits of KA are realised or if there are any potential effects on implant survival.

The objective of this study was to investigate the accuracy of eleven prediction equations and one prediction table when estimating isoinertial knee extension and leg press one repetition maximum (1-RM) performance in subjects with knee injuries and knee osteoarthritis. Study Design: A descriptive quantitative research study was undertaken utilizing a cross-sectional design. Background: Traumatic injuries and osteoarthritis are common musculoskeletal pathologies that can disrupt normal function of the knee joint. A frequent sequela of these pathologies is quadriceps femoris muscle weakness. Such weakness can contribute to disability and diminished levels of functional and recreational activity. Therefore, safe and accurate methods of measuring maximal strength are required to identify and quantify quadriceps strength deficits. One option proposed in the literature is the use of 1-RM prediction equations which estimate 1-RM performance from the number of repetitions completed with sub-maximal loads. These equations have been investigated previously using healthy populations and subjects with calf muscle injuries. However, to date, no known study has investigated their accuracy in individuals with joint pathologies. Method: Machine-weight seated knee extension and seated leg press exercises were investigated in this study. Twenty subjects with knee injuries and 12 subjects with knee OA completed the testing procedures for the knee extension exercise. Nineteen subjects with knee injuries and 18 subjects with knee OA completed the testing procedures for the leg press exercise. All subjects attended the testing venue on three occasions. At the first visit a familiarization session was carried out. At the second and third visits each subject was randomly assigned to perform either actual or predicted 1-RM testing for both of the exercises. Twelve different prediction methods were used to estimate 1-RM performance from the results. The estimates of 1-RM strength were then compared to actual 1-RM performance to assess the level of conformity between these measures. Statistical procedures including Bland and Altman analyses, intraclass correlation coefficients, typical error and total error of measurement were used in the analyses of the results. In addition, paired t-tests were performed to determine whether actual 1-RM values were significantly different across the control and affected limbs and whether there were any significant differences in predictive accuracy for each equation across the control and affected limbs. Finally, the number of subjects with predicted 1-RM values within 5% or less of their actual 1-RM values was determined for each equation. Results: When the knee injury group performed the knee extension exercise, the Brown, Brzycki, Epley, Lander, Mayhew et al., Poliquin and Wathen prediction methods demonstrated the greatest levels of predictive accuracy. When two atypical subjects were identified and excluded from the analyses, the accuracy of these equations improved further. Following the removal of these two subjects, no significant differences in predictive accuracy were found for any of the equations across the affected and control limbs (p > 0.05). Typical errors and total errors were low for the more accurate prediction methods ranging from 2.4-2.8% and from 2.4-3.5%, respectively. Overall, the Poliquin table appeared to be the most accurate prediction method for this sample (affected limbs: bias 0.3 kg, 95% limits of agreement (LOA) -5.8 to 6.4 kg, typical error as a coefficient of variation (COV) 2.4%, total error of measurement (total error) 2.4%; control limbs: bias -1.3 kg, 95% LOA -9.0 to 6.3 kg, typical error as a COV 2.7%, total error 2.8%). When the knee OA group performed the knee extension exercise, the Brown, Brzycki, Epley, Lander, Mayhew et al., Poliquin and Wathen prediction methods demonstrated the greatest levels of predictive accuracy. No significant differences in predictive accuracy were found for any of the equations across the affected and control limbs (p > 0.05). When an atypical subject was identified and excluded from the analyses, the accuracy of the equations improved further. Typical errors as COVs and total errors for the more accurate prediction methods ranged from 2.5-2.7% and from 2.4-2.9%, respectively. Overall, the Poliquin table appeared to be the most accurate prediction method for this sample (affected limbs: bias 0.9 kg, 95% LOA -4.5 to 6.3 kg, typical error as a COV 2.5%, total error 2.5%; control limbs: bias -0.1 kg, 95% LOA -6.0 to 5.9 kg, typical error as a COV 2.5%, total error 2.4%). When the knee injury group performed the leg press, the Adams, Berger, Lombardi and O’Connor equations demonstrated the greatest levels of predictive accuracy. No significant differences in predictive accuracy were found for any of the equations across the affected and control limbs (p > 0.05). Typical errors as COVs and total errors for the more accurate equations ranged from 2.8-3.2% and from 2.9-3.3%, respectively. Overall, the Berger (affected limbs: bias -0.4 kg, 95% LOA -7.2 to 6.3 kg, typical error as a COV 3.2%, total error 3.2%; control limbs: bias 0.1 kg, 95% LOA -6.6 to 6.7 kg, typical error as a COV 3.1%, total error 3.0%) and O’Connor equations (affected limbs: bias -0.6 kg, 95% LOA-6.8 to 5.7 kg, typical error as a COV 2.9%, total error 3.0%; control limbs: bias -0.2 kg, 95% LOA -6.9 to 6.4 kg, typical error as a COV 2.9%, total error 2.9%) appeared to be the most accurate prediction methods for this sample. When the knee OA group performed the leg press, the Adams, Berger, KLW, Lombardi and O’Connor equations demonstrated the greatest levels of predictive accuracy. No significant differences in predictive accuracy were found for any of the equations across the affected and control limbs (p > 0.05). The typical errors as COVs and the total error values for the more accurate prediction methods were the highest observed in this study, ranging from 5.8-6.0% and from 5.7-6.2%, respectively. Overall, the Adams, Berger, KLW and O’Connor equations appeared to be the most accurate prediction methods for this sample. However, it is possible that the predicted leg press 1-RM values produced by the knee OA group might not have matched actual 1-RM values closely enough to be clinically acceptable for some purposes. Conclusion: The findings of the current study suggested that the Poliquin table produced the most accurate estimates of knee extension 1-RM performance for both the knee injury and knee OA groups. In contrast, the Berger and O’Connor equations produced the most accurate estimates of leg press 1-RM performance for the knee injury group, while the Adams, Berger, KLW and O’Connor equations produced the most accurate results for the knee OA group. However, the higher error values observed for the knee OA group suggested that predicted leg press 1-RM performance might not be accurate enough for some clinical purposes. Finally, it can be concluded that no single prediction equation was able to accurately estimate both knee extension and leg press 1-RM performance in subjects with knee injuries and knee OA.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Orthopaedic Surgery / Master / Master of Philosophy