OBJECTIVE: Patellofemoral Pain Syndrome (PFPS) is the most common diagnosis in patients presenting knee pain (~25%), and one of the most common diagnosis in sports medicine centers. Here we examine believed risk factors in Patellofemoral Pain Syndrome (PFPS) and assess their relationship to PFPS. METHODS: The study was a retrospective study completed at Johns Hopkins Department of Orthopaedic Surgery. All patients, who were referred to physical therapy at Johns Hopkins Rehabilitation Therapy Services Clinic, were diagnosed with PFPS for the first time and were mostly recreational runners. Body mass indexes (BMI) were calculated from weight and height. Pain scores were taken using the visual analog scale. Strength measurements were taken from the left and right leg for the following measurements: hip abduction external rotation, hip abduction, knee extension, and hip extension. Balance measurements were also taken on the left and right sides measuring the postural sway with eyes open and eyes closed. Statistical analysis were accomplished using excel. RESULTS: A total of 23 patients were included in the present study, 9 females and 14 males. BMI's (lb/in^2) for the population was 25.1 (±4.2), males were 26.4 (±3.6) and females were 23.2 (±4.2). Pain scores were 6 (±1.9) out of 10 for the total population, males, and females. The total population had composite hip scores 35.0% and 22.9% for the right and left sides, while the knee extension was 50.7% and 51.7%. All hip scores were below 40 except for right hip ABD/ER in females and lower than knee extension scores in males, females, and total population. The ratio for right eyes closed to open was 34.2 (±62.7) and left eye closed to open was 24.7 (±44.3) for the total population CONCLUSION: This study demonstrated that age and BMI may have an effect on the development of PFPS but no statistical significance was confirmed. Results suggest that hip strength is a better indicator than knee strength in risk associated with PFPS. Balance appears to be more of an indicator of poor hip strength than as a measurement or potential risk factor for PFPS.

A great deal of research has shown decrements in force and power following static stretching. There has been little research investigating the acute effects of static stretching of the antagonist on the expression of strength and power. The purpose of this study was to investigate the effects of static stretching of the antagonist muscles on a variety of strength and power measures. Sixteen active males were tested for vertical jump height and isokinetic torque production in a slow knee extension (KES) at 60°/s and a fast knee extension (KEF) at 300°/s. Electromyography was taken during knee extension tests for the vastus lateralis and the biceps femoris muscles. Participants performed these tests in a randomized counterbalanced order with and without prior antagonist stretching. All variables for stretching and non-stretching treatments were compared using paired t tests at an alpha of .05. Paired samples t tests revealed a significant (p = .034) difference between stretch KEF and non-stretch KEF conditions. There was no significant (p > .05) difference between KES stretch and non-stretch conditions. Vertical jump height was significantly (p = .011) higher for the stretching treatment than the non-stretching treatment. Vertical jump power was also significantly higher (p = .005) in the stretch versus the non-stretch condition. Paired samples t test indicated no significant (p > .05) difference between testing conditions for electromyography, represented as a percentage of maximal voluntary contraction (MVC). These results suggest that stretching the antagonist hamstrings prior to high speed isokinetic knee extension increases torque production. It also demonstrated that stretching the hip flexors and dorsi flexors may enhance jump height and power. Practitioners may use this information to acutely enhance strength and power performances.

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A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Doctor of Philosophy Johannesburg, 2019 / Background Evidence shows that the global prevalence of knee osteoarthritis (KOA) is high, with limited data on the management of the disease. The use of novel modalities to treat the condition is low due to poor understanding of their clinical effects. Therefore there are gaps in the knowledge on the prevalence and treatment modalities for patients diagnosed with KOA. Aim: The aim was threefold; (i) to determine the prevalence of KOA in South Africa aged 45yrs-75yrs; (ii) to determine the current management of KOA; and (iii) to determine the effect of Low Level Laser therapy (LLLT) on the structural and functional components related to KOA in a South African cohort, aged 45-75yrs. Methods: The methodology will be discussed in terms of the three specified objectives; (i) prevalence study data - a self-reported data collection sheet listing 19 relevant ICD 10 codes; completed by South African medical aid providers. (ii) The treatment paradigm study, which encompassed a deemed KOA management paradigm validated questionnaire sent electronically to 742 general, specialist and allied practitioners, identifying the incidence of KOA and deemed efficacy and compliance of various management tool. These practitioners were identified from a database of medical and allied practitioners in both the private and public sector of South Africa. The questionnaire consisted of two close ended questions indicating the incidence of KOA and bilateral KOA patients consulted at the practice; one choice question indicating the most suggested mode of therapy from a choice of pharmaceutical, surgical, homeopathic, physical exercise therapy and LLLT and finally, 3 Likert type scale questions on the deemed efficacy and compliance of the modes of therapy as stated above. (iii) The intervention study which was a randomized controlled trial (RCT) utilizing pre marked questionnaire sheets on 111 participants. Participants were randomized into one of three intervention groups; (1) exercise group (n=39), (2) LLLT group (n=40), and (3) combined exercise-LLLT group (n=32). Data on knee circumference, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), knee range of motion (ROM) and the one minute timed sit–to-stand test was used. These tests were done at four time points: (T1) baseline, (T2) post-12 session intervention, (T3) one month post intervention and (T4) three months post intervention. Results: The results will be discussed in terms of the three specified objectives; (i) The prevalence of KOA was reported as 17.5%, 28.0% and 38.5% in a South African population over 45yrs. (ii) Four hundred and thirteen clinicians completed the questionnaire, reporting a KOA patient intake of 53%. Pharmacology (36.3%) and physical exercise (35.3%) was the most common management protocols compared to surgical intervention, homeopathy and LLLT. Pharmacotherapy (73%) and physical exercise (92%) were observed as effective treatments. Seventy five percent of all practitioners responded with an answer of “no comment” when asked the deemed efficacy of LLLT. Practitioners viewed patients with KOA to have low compliance with physical exercise and pharmacotherapy (iii) the participant demographic included 86 females and 25 males, the average age reported was 61.8 ± 5.6yrs. At 12-week follow-up, knee circumference decreased significantly in all groups (p<0.05), the effect was highest in the LLLT group. All groups experienced improvements in the WOMAC pain scale, but the LLLT group showed the greatest improvement (p<0.05). Knee ROM values improved significantly across all three groups; however, the effect of the intervention was most significant (p<0.005) in the combined LLLT-exercise group. Physical functionality scores showed a greater improvement in the combined LLLTexercise group at all three data collection points. Conclusions: The estimated prevalence of KOA is 17-35% based on data collected from a specified South African cohort. Pharmacotherapy is a commonly suggested KOA management mode, whilst clinicians view physical exercise as effective. LLLT was not a known tool for the treatment of KOA. In addition to the improved functionality observed, pain was lowered significantly, particularly in the combined exercise-LLLT group. Study results have shown that LLLT used in isolation or in combination with physical exercise is an effective management tool. / MT 2020

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Increased workload on our healthcare system calls for more automation, this too in the pre-operative planning of total knee arthroplasty (TKA) surgery. This should keep in mind however that success in TKA is measured through having proper limb alignment. This thesis project implemented a virtual positioning assessment software that provides an initial position based on its bone and implant inputs with their specific landmarks. Positions can be furtherly adapted and evaluated based on flexion facets, obtaining decreased pre-operative workloads. The software was validated through an analysis comparison of the femur positioning of nine cases with the former used analysis tool of the university Hospital of Ghent. The newly implemented software was concluded to approximate the patients’ pre-operative alignment better for all translational and rotational parameters, except anteroposterior translation and internal/external rotation of the femur.

Powered exoskeletons can assist patients suffering from motor dysfunctions. Recent researches are focused on how to improve the communication system between patient and device. Further research is needed in order to design an EMG based robotic assistive device able to convey intended motions to the patient. The primary need is the understanding of how EMG patterns from different muscles contribute to motions. Studies on muscle synergy have shown how different muscles of lower limbs contribute to gait. This study is aimed to expand the analysis to motions other than gait by analysing ten muscles around the right knee joint. The chosen muscle were soleus, gastrocnemius medialis, gastrocnemius lateralis, peroneus longus, tibialis anterior, rectus femoris, vastus medialis, vastus lateralis, biceps femoris and semitendinosus. The main hypothesis is that specific movements are controlled by specific muscle synergies. Motion data and EMG data of eight healthy subjects have been compared in order to outline a coordination pattern specific to four different movements: gait, gait stop and balance, sit to stand and stand to sit. Through the analysis of EMG signals, three muscle synergies have been identified including muscles from the same group, i.e. four plantar flexors, three quadriceps and two hamstrings. It was possible to conclude that the four movements were controlled by the same muscle synergies with different coordination patterns. Further research is recommended to expand the knowledge about muscle synergies.

An estimated 27 million Americans suffer from osteoarthritis (OA). Symptomatic OA is often treated with total knee replacement, a procedure which is expected to increase in number by 673% from 2005 to 2030, and costs to perform total knee replacement surgeries exceeded $11 billion in 2005. Subject-specific modeling and finite element (FE) predictions are state-of-the-art computational methods for anatomically accurate predictions of joint tissue loads in surgical-planning and rehabilitation. Knee joint FE models have been used to predict in-vivo joint kinematics, loads, stresses and strains, and joint contact area and pressure. Abnormal cartilage contact pressure is considered a risk factor for incidence and progression of OA. For this study, three subject-specific tibiofemoral knee FE models containing accurate geometry were developed from magnetic resonance images (MRIs). Linear (LIN), Neo-Hookean (NH), and poroelastic (PE) cartilage material models were implemented in each FE model for each subject under three loading cases to compare cartilage contact pressure predictions at each load case. An additional objective was to compare FE predictions of cartilage contact pressure for LIN, NH, and PE material models with experimental measurements of cartilage contact pressure. Because past studies on FE predictions of cartilage contact pressure using different material models and material property values have found differences in cartilage contact pressure, it was hypothesized that different FE predictions of cartilage contact pressure using LIN, NH, and PE material models for three subjects at three different loading cases would find statistically significant differences in cartilage contact pressure between the material models. It was further hypothesized that FE predictions of cartilage contact pressure for the PE cartilage material model would be statistically similar to experimental data, while the LIN and NH cartilage material models would be significantly different for all three loading cases. This study found FE and experimental measurements of cartilage contact pressure only showed significant statistical differences for LIN, NH, and PE predictions in the medial compartment at 1000N applied at 30 degrees, and for the PE prediction in the medial compartment at 500N applied at 0 degrees. FE predictions of cartilage contact pressure using the PE cartilage material model were considered less similar to experimental data than the LIN and NH cartilage material models. This is the first study to use LIN, NH, and PE material models to examine knee cartilage contact pressure predictions using FE methods for multiple subjects and multiple load cases. The results demonstrated that future subject specific knee joint FE studies would be advised to select LIN and NH cartilage material models for the purpose of making FE predictions of cartilage contact pressure.

Chronic pain is common in the United States, with studies suggesting that pain impacts 20% of adults annually. There are many pharmacological agents used to treat pain, including but not limited to opioids, gabapentin, oral analgesics, and antidepressants as analgesics. Acupuncture has been shown to be effective in reducing musculoskeletal pain, headaches, and chemotherapy-induced nausea and vomiting in adults. Children also suffer from chronic pain, but minimal research has examined the use of acupuncture for treatment of pediatric pain. The purpose of this retrospective chart review is to quantify pain reduction in pediatric joint pain treated with acupuncture. The pain scores prior to first and sixth acupuncture treatment for knee pain were compared for 14 pediatric patients. Daily activity and functions scores were obtained from 6 patients. Our results revealed a statistically significant reduction in median pain score (P=0.002). 47% of our sample reported clinically significant pain reduction (> 30% reduction in pain on numerical rating scale (NRS)) and 60% of individuals with baseline moderate-severe pain reported clinically significant pain reduction. The median interference of pain with daily activity was reduced in 5 of 7 daily activities. Our results suggest that acupuncture might be an effective treatment modality for pediatric knee pain and improving quality of life.