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The ability to kneel is an important function of the knee joint, as it is required for many daily activities, including religious practices, professional occupations and recreational pursuits. The inability to kneel following total knee arthroplasty (TKA) is frequently a source of disappointment. This work investigates patients' understanding of the term 'kneeling' and what proportion of patients can kneel before and after TKA, as well as identifying the factors that can affect the ability to kneel following TKA. The underlying hypothesis tested was: 'There are no differences between kneeling ability before and after TKA'. Kneeling ability after TKA may be affected by many factors, including patient-specific factors, the extent of wear on RPC (Retro patellar Cartilage), postoperative AKP (Anterior Knee Pain) and post-operative ROM (Range of Motion). Thus a consecutive series of TKA patients were assessed to test the afore-mentioned hypothesis. In particular, the thesis has examined: • Interpretation of kneeling and perceptions of kneeling ability after TKA. • The extent of wear on Retro Patellar Cartilage (RPC) and its correlation to kneeling ability. • Sensory changes in the knee after TKA. • Preoperative and Postoperative Anterior Knee Pain (AKP) assessment. • The reality of kneeling ability before and after TKA. • Postoperative ROM of the knee and its correlation to kneeling function. The advice offered by healthcare professionals may contribute to a low postoperative rate of kneeling. The patellofemoral joint plays an essential role in knee function and a person's kneeling ability, may be greatly affected by the performance of this joint. Firstly, this study analysed the responses of two samples of participants drawn from diverse cultural backgrounds (Christian and Muslim), it examined their primary interpretation of what kneeling constitutes, along with a subjective assessment of the importance of kneeling in their everyday lives. Secondly, it explored patients' perceptions of their kneeling ability after TKA, with a comparative analysis of their responses to the kneeling questionnaire specifically constructed by the author and also the question in relation to kneeling in the Oxford Knee Score (OKS). The third component investigated retro-patellar cartilage (RPC) morphology using intraoperative examination and standardised photography. Fourthly, a cohort of patients listed for TKAs was followed prospectively, in order to assess their kneeling ability prior to and following treatment, along with identifying the factors that could affect this function, i.e. knee pain, range of motion, sensory changes and sensitivity to pain on the anterior aspect of the knee as assessed with dolorimetry. Differences were detected in the subjective interpretation of the kneeling function, as well as its importance, for the two diverse cultures involved in this study. Pain, as opposed to poor range of movement, was identified as the main reason which led to kneeling difficulties. The majority of respondents reported that it was either extremely difficult or impossible to kneel on the operated knee. The high flexed position (required for prayer in certain cultures) was the most difficult position to achieve for most of the patients. Prior to surgery, 30 patients were seen during this period, 15 (50%) out of 30 consecutive patients were unable to kneel in any position whatsoever. Of those who could kneel to some degree, the most common posture that they could achieve was the upright kneeling position. Considerable variations were found to occur in patients' understanding of the term 'kneeling'. Consequently, this has significant implications for the design and interpretation of questions in relation to kneeling for diverse cultures, which are characterised by distinct lifestyles. The current patient-based selfV administered questionnaires, such as the OKS, although useful as a simple measure of overall knee function, were found to have limitations as an effective assessment tool in the measurement of kneeling function either before or after TKA and indicate that there is a need for a culturally appropriate questionnaire to assess kneeling function. Retro-patellar cartilage lesions were very prevalent in patients undergoing TKA. However, no significant correlation existed between the total amount of retro-patellar cartilage wear and the ability to kneel. Patients were more likely to be able to kneel if the cartilage of the superior facets of the patella were disease free (P=0.02). At the six months post-surgery stage, of the 14 consecutive patients, who could kneel pre-operatively 6 were able to kneel post-operatively. Of the 13 consecutive patients who were unable to kneel pre-operatively, all were unable to kneel post-operatively. Knee pain was the main reason attributed to this difficulty. However, no link was found to occur between sensory changes and kneeling function in the patients who participated in the study, after TKA performed via an anterior midline incision.

Thesis (Ph. D.)--University of Missouri--Columbia, 2003. / Typescript. Vita. Includes bibliographical references (leaves 162-175). Also available on the Internet.

[Truncated abstract] Knee osteoarthritis (OA) patients have high levels of pain, functional and strength deficits of the quadriceps, decreased proprioceptive acuity, and increased co-contraction and knee joint loading in gait, compared to age matched controls. The increased knee joint loading in this population occurs most commonly in the medial tibio-femoral compartment, due to increased external adduction moments, and with increasing disease severity there is a concomitant increase in the knee adduction moments. A key finding within the knee OA literature is that dynamic loading in gait, due to increased external adduction moments, strongly predicts pain and radiographic disease progression. Current research has shown that exercise interventions reduce pain and time to complete functional activities; however, the effect of these interventions on knee joint loading and muscular activation in gait is still unclear. In addition, the need for specific knee joint strengthening to cause these alterations has not been investigated and it remains unknown if improvements occur due to specific muscle strengthening or due to some general effect of exercise. Therefore, the primary aim of this research study was to examine the effects of general (upper body) and specific (lower body) resistance training interventions on self-perceived outcomes, neuromuscular function and kinematic, kinetic and muscle activation during gait of OA patients compared with asymptomatic controls. ... The examination of gait data following exercise (Study 4) showed trends for changes in the muscle co-contraction ratios. Specifically, the medial/lateral co-contraction ratio (MLCCR) displayed a trend in early stance where the upper body exercise group increased their lateral muscle activity and the lower body group reduced their lateral muscle activity, and the medial/lateral hamstring co-contraction ratio (HAMCCR) displayed this same trend during loading. The trend toward reduced lateral muscle activation, following lower body resistance training, suggests that specific muscle strengthening may have the ability to alter the load distribution. The kinematic and kinetic variables of gait were unchanged by the exercise interventions, highlighting the sensitivity of muscle activation pattern changes due to muscle strengthening. This thesis provides new insights into the co-contraction strategies utilised by knee OA patients. The directed co-contraction strategy employed by knee OA patients and its relationship to the external adduction moment in gait suggest an attempt to redistribute the loading within the knee joint, most likely in response to pain. Further, we have separated the effects of exercise and found differences in self-perceived outcomes based on exercise specificity. This first examination into muscle co-contraction following resistance training of knee OA patients has highlighted the possibility of alterations to the co-contraction patterns following lower body exercise. However, the implications of altering this muscle activation strategy and the consequent effect on distribution of load within the knee joint requires further consideration.

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Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2013. / Background : It has become practically impossible for practitioners to remain current with clinical developments. Additionally the demand from patients and third party payors for quality evidence is increasing. A systematic review is one manner in which information can be graded, summarised and presented in a succinct format for use by practitioners, patients and third party payors. Objectives : To identify the current knowledge available on the conservative management of iliotibial band syndrome (ITBS) and to evaluate the scientific and methodological rigor of that knowledge. The systematic review of these studies identified the level and type of evidence that currently exists in the support of conservative management of ITBS and the specific interventions and combinations of interventions currently employed. Method : A systematic review of ITBS studies was conducted. ITBS studies were identified using key indexing terms (iliotibial band syndrome, treatment, conservative and intervention) on several databases (EBSCOhost, Google Scholar, Metalib, Pubmed, Science Direct and Springerlink), all studies were included up until the date of ethics approval (21st May 2012) . The gathered studies were screened for compliance with the inclusion criteria, and then reviewed by blinded independent reviewers (reviewer criteria included qualification, clinical experience, academic experience, research experience and discipline). Data collection and analysis : The reviewers rated the methodological rigour of the ITBS studies utilising an appropriate scale (e.g. PEDro Scale). Feedback was collated and analysed for discordance. Studies were then analysed, ranked and followed by a discussion in the context of their clinical outcomes, thus formulating a structured summary of the known clinical data with regards to the clinical management of ITBS. Results: The identified citations (4130) were screened and sorted by study type. This resulted in 167 citations that were reviewed by abstract for compliance with the inclusion criteria. A final total of 23 studies meet eligibility criteria. Eight articles reported on a combination of interventions, four discussed biomechanical and causative factors, and the remaining eleven articles investigated individual interventions in the treatment of ITBS. After review and analysis, combination interventions were supported by the strongest level of evidence, thus advocating the use of a combination of interventions in the management of ITBS in providing better clinical outcomes. Moderate evidence favoured the use of customised orthoses, injectable corticosteroids, phonophoresis and addressing biomechanical and causative factors. However, there was moderate evidence against the use of deep tissue frictions, as no improvement was found. This outcome suggests a need for further evidence to advocate the appropriateness of these interventions in clinical care of ITBS. Hip abductor strengthening and stretch therapy were found to have limited evidence. However, no evidence was found to support the application of active release technique, corrective neuromuscular approach, custom dry floatation cushions and talar joint manipulation in the management of ITBS. This latter outcome indicated a need for studies to investigate their appropriateness or inappropriateness in clinical care. Conclusion : The systematic review of ITBS studies revealed that use of a combination of conservative therapies was found to have the strongest level of evidence, which may indicate its appropriateness in the management of patients suffering from ITBS. Specific combinations of conservative therapies and the use of individual therapies require future research in order to better delineate their contribution to the management of ITBS. Randomised controlled trials are the gold standard for research, as they have the greatest level of methodological quality, and should be used where possible when investigating the efficiency of interventions in the treatment of ITBS. Studies, which were not randomised controlled trials, but adopted the principles of a randomised controlled trial structure, contributed positively towards the methodological rigor of these studies.

Thesis (M.Tech.: Chiropractic)-Dept. of Chiropractic, Durban Institute of Technology, 2003 xvi, 121 leaves / The purpose of the investigation was to evaluate the presence and extent of Quadriceps Femoris weakness in subjects with patellofemoral pain syndrome by the use of an isokinetic dynamometer.

Mini-dissertation submitted in partial compliance with the requirements for the Masters Degree in Technology: Chiropractic, Durban University of Technology, 2010. / Iliotibial Band Friction Syndrome (ITBFS) is an overuse injury induced by friction of the iliotibial band (ITB) over the lateral epicondyle of the femur (LFE) with secondary inflammation. ITBFS is a prevalent condition and is the most common cause of lateral knee pain in long distance runners and cyclists. There are a significant number of aetiological factors related to ITBFS. As a result of this the general chiropractic approach to the treatment of ITBFS is multimodal and include interventions such as joint manipulation, cryotherapy, orthotics, massage, electrical stimulation, acupuncture type procedures and therapeutic exercise. Dry-needling is an effective therapy in the treatment of active Myofascial Trigger Points (MFTP’s) that are associated with ITBFS. However, the available literature suggests that to determine its efficacy, it should be performed in isolation. The association of sacroiliac joint dysfunction in ITBFS has also been addressed and are thought to co-exist and perpetuate one another. It is recommended that chiropractors include pelvic manipulation in their treatment protocol for ITBFS however there is a paucity of literature showing its effectiveness in the treatment of this condition. There appears to be a need for further research in the form of randomized controlled clinical trials with regard to chiropractic specific procedures, performed in isolation, in the treatment of ITBFS. Therefore this study aimed to add to the literature by assessing the effect of the sacroiliac joint manipulation and dry needling in the treatment of ITBFS. Objectives The study aimed to determine the comparative effectiveness of dry needling alone versus manipulation alone, as well as a combination of the two interventions in the treatment of ITBFS. Methods This study was a randomised, open label trial. 47 participants with ITBFS were divided into three groups, each group receiving a different intervention i.e.: group one received dry needling of the active MFTP’s in the Tensor Fascia Lata (TFL) and ITB, group two received sacroiliac joint manipulation, group three received a combination of the two interventions. Subjective measurements, in the form of the Numerical Pain Rating Scale-101 (NRS-101), and objective measurements, in the form of algometer readings in the TFL, ITB and Nobles Compression test as well as digital inclinometer readings of Modified Obers test, were utilised to determine the effects of the respective interventions. These measurements were recorded twice, once prior to commencing the treatment programme. These values were then evaluated to compare the efficacy of the different treatment interventions. Each participant received four treatments over a two week period. Results There were no statistically significant differences between the three treatment groups as they all seemed to parallel one another with regards to overall improvement in subjective and objective measurements (P<0.5). However on closer examination subtle differences between the groups were noted. An interesting endpoint is that the combination group did not fair the best throughout the study, which was contrary to the original hypothesis. The groups receiving only the single intervention appeared to fair marginally better over the combination group. A secondary endpoint that became evident during the study and on analysis of the data, was that hip joint instability must also be considered when treating ITBFS when there is concomitant sacroiliac joint dysfunction. Conclusion A decision needs to be made with regard to which intervention best suits the individual at the time. A combination therapy, which originally was thought to be the best treatment option, should possibly be reconsidered. Perhaps a single intervention of manipulation or dry needling should be decided upon. In totality, all intervention proved to be effective in the treatment of ITBFS.

Introduction: The incidence of anterior cruciate ligament (ACL) injuries in female floorball is relativley high, and the risk for sustaining a second ACL injury is greater compared to previously uninjured. Existing evaluation tests in rehabilition may not be discriminative enough to guide decisions on return to sport Aim: To evaluate the withinAsession and testAretest reliability of knee kinematics in floorball athletes and controls during a hop encompassing a sudden unanticipated change of direction. A second aim was to investigate the discriminative validity by comparing the test outcomes between the athletes and a control group of nonAathletes. Method: 11 elite floorball athletes and 8 controls were tested on two occassions separated by one to three weeks. Knee kinematics, ground contact time and number of succesfull hops were analyzed. Relative reliability was quantifyed by Intraclass correlation coefficient (ICC) and absolute reliability by standard error of measurement (SEM). Results: ICCs for knee kinematics withinAsession reliability were excellent (0.83A0.96) for athletes and poor to excellent (0.40A0.94) for the controls. For the testAretest reliability, the athletes had good to excellent (0.56A0.96) reliability and the controls had poor to excellent (0.26A0.93) reliability. Only two measured kinematic variables were significantly different between the groups. Conclusion: This pilot study indictate good to excellent reliability for the majority of the kinematic variables tested and, therefore, it could be assumed to be adequatley reliable. Discriminative validity needs to be further evaluated in a larger material.

As a therapist within the multi-disciplinary setting, one is confronted with a wide array of pathology and diagnoses. Care is taken to optimize treatment outcomes and overall return of function to every patient admitted to the various rehabilitation facilities. Treatment is often standardized to ensure quality care benchmarked against outcome parameters. The aforementioned is also true for medical practitioners, pharmacists and other auxiliary service providers. Research is aimed at improving quality of care, finding and establishing the best practises through all hospitals and care facilities. Medical care has undergone a transformation over the past few decades with a strong emphasis being placed on protocols and procedures. Through applying standardized care, protocols and procedures, the researcher have come to realize that certain denominators within patient care have no prediction or outcome control. After more than a decade of treating patients in various rehabilitation settings the researcher have come to realize that one complaint exists with each and every patient under my care – pain. This was even more evident within the group of joint replacement patients. No two patients presented with the exact same pain profile or pain reports despite various commonalities such as anthropometric data (age, gender, length, mass), surgical procedure, attending physician, care facility, pathway exposure, diagnosis, radiographic findings and pharmaceutical intervention. If all the obvious factors were identical – what accounted for the different pain reports? This question is at the heart of the study – why do pain reports differ in the presence of so many similarities between patients? It soon became apparent that pain is recognized in the organic form. Organic pain can be measured and is expected with injury, illness or surgical intervention. The entire multi-disciplinary team is aware of organic pain and ready to intervene with medication, surgery and a pathway of care. All vigorously record organic pain and adapt treatment according to the pain levels as organic pain is real pain: real pain existing through exposure to real surgical intervention. Still the question remained: if all the factors prior to surgery, during surgery and after surgery were the same, why are patients experiencing and reporting very different pain levels? This question was the catalyst for the research and lead to keen focus during patient interviews. Every patient receiving an educational session prior to surgery had very vivid ideas about the pain they will experience post-operatively. The majority of patients formed pre-conceived notions about pain prior to undergoing surgery. They presented with a clear pain rating of what they expected to feel post-operatively. The pre-conceived pain rating was constructed in almost all the cases after some form of information obtained during consultation with their surgeon or a member of the multidisciplinary team. This pain notion existed as a tangible and measurable rating in the client’s mind prior to undergoing the knee replacement surgery. In select cases perceived pain was constructed as a result of information obtained from family or friends that underwent the same procedure while other clients constructed perceived pain due to a lack of information on the proposed surgery. It became evident that education or lack thereof on surgical interventions played a primary role in the construct of perceived pain. Patients were entering theatres for procedures and already experienced a form of perceived pain. If pain could be constructed prior to experiencing surgical intervention – can perceived pain then translate into actual organic pain and account for the variable pain reports post surgery? Against this backdrop, research was directed at understanding perceived pain and the factors that aid the construction of perceived pain. As education was found to be at the heart of every pain construct, the doctor-patient consultation was evaluated as a core component to ascertain the impact this relationship has on perceived pain. Measurement of perceived pain was also performed to conclude on the impact of this pain form on organic pain. The study is aimed at addressing the variant pain reports that no pathway or procedure can predict and provide for. It is an attempt to validate pain as constructed by the patient that impacts on their post-surgical pain ratings and behaviour. This research might contribute towards existing knowledge and understanding of the influence of doctor-patient interaction as well as the significance of this interaction on pain. As only scant research on perception of pain has been undertaken this research can prove insightful for further studies or as supplement to existing views and opinions. It can also serve as a foundation in developing practices that will manage pain by enhancing doctor-patient interaction in the health setting. / MA, Medical Sociology, North-West University, Vaal Triangle Campus, 2012