STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS

STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS Submitted by: DIVYA AHUJA (Enrolment no.:12sptpt11001) JANVI AJMERA (Enrolment no.:12sptpt11002) 6 th Semester, June, 2015 Guided by: DR. CHANDANI PARSANIA BPT (PHYSIOTHERAPIST), TEACHING ASSISTANT, SOPT, RKU STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS ii

CERTIFICATE This is to certify that the project work entitled Study to correlate quadriceps strength, pain and functional disability among osteoarthritis knee patients has been undertaken and written under OUR supervision and it describes the original research work carried out by Ms. Divya Ahuja and Janvi Ajmera registered at RK University under the Faculty of Dr. Chandni Parsania for the Degree of Bachelors of Physiotherapy. Signature of Guide Name: Dr. Chandni Parsania Degree: BPT Designation: (PHYSIOTHERAPIST) TEACHING ASSISTANT, SOPT, RKU STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS iii

DECLARATION We hereby certify that we are the authors of this project work and that neither any part of this project work nor the whole of the project has been submitted for a degree to any other University or Institution. We certify that, to the best of our knowledge, our project does not infringe upon anyone s copyright nor violate any proprietary rights and that any ideas, techniques, quotations, or any other material from the work of other people included in our project published or otherwise, are fully acknowledged in accordance with the standard referencing practices. Furthermore, to the extent that we have included copyrighted material that surpasses the bounds of fair dealing within the meaning of the Indian Copyright Act, we certify that we have obtained a written permission from the copyright owner(s) to include such material(s) in our project and have included copies of such copyright clearances to our appendix. We declare that this is a true copy of my project, including any final revisions, as approved by our project review committee. Signature of candidate: Signature of candidate: Full name of candidate: Divya Ahuja Full name of candidate: Janvi Ajmera Enrolment no.: 12sptpt11001 Enrolment no.: 12sptpt11002 Date: 2 nd July 2015 Date: 2 nd July 2015 Place: Rajkot Place: Rajkot STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS iv

ACKNOWLEGEMENT First and foremost we would like to thank our parents MR. GIRISH AHUJA, MRS. VARSHA AHUJA and MR. BHARAT AJMERA, MRS. KIRAN AJMERA who are our living Gods and my brother KAPIL AHUJA for their valuable support and encouragement, blessing and love which has always been a source of inspiration and strength in accomplishing this academic task. Our heartfelt gratitude to almighty God who has guided us this far and to whom goes all the honor and glory for the successful completion of this study. We wish to express our regards to our Director _DR. PRIYANSHU RATHOD School of Physiotherapy, R.K.University for his whole hearted guidance and meticulous suggestions in the completion of this work and for all the facilities and support extended to us during this study. We are extremely thankful for his constant encouragement and inspiration during the course of this study. With due respect, we would like to express our sincere thanks to our guide DR.CHANDANI PARSANIA teaching assistant school of physiotherapy, R.K.University, for her judicious information, expert suggestions, valuable guidance, continuous support, incessant reassurance during every stage of this work and interest shown in this dissertation without which this work would not have been possible. We would like to extend our heartfelt thanks to assistant lecturer, DR. KAJAL ANADKAT for their valuable guidance, constant help and support throughout this study and all the STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS v

lecturers of our college who have taught us and gave their valuable suggestions during the course of the study. Our sincere thanks to DR. SHWETA RAKHOLIYA and DR. VAIBHAVI VED for taking keen interest in our study, guiding us through the path, giving us support and motivation during the course of study. We wish to express our thanks to HARSHAL SIR our librarian for their timely help in lending us books and journals for my reference all the time. We shall fail our duties if we don t acknowledge my Colleagues and Friends for their suggestions and criticism while assisting US in this study. Last but not the least we would like to thanks all the Individuals in our study without whom this task would not have been possible. Our sincere thanks to all the contributors whose names we might have missed but who truly deserve our gratitude. We would like to thank once again to all who have helped us all the while. Signature Name: Divya Ahuja Signature Name: Janvi Ajmera STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS vi

LIST OF ABBREVATIONS 1. SST: Sit To Stand 2. NPRS: Numerical Pain Rating Scale 3. WOMAC: Western Ontario Mac Master Univerisity Osteoarthritis Index 4. OA : Osteoarthritis V : STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS vii

ABSTRACT Study to correlate quadriceps strength, pain and functional disability among osteoarthritis knee patients Submitted By: Divya Ahuja Janvi Ajmera Guided By: Dr. Chandni Parsania (Physiotherapist) Teaching assistant SOPT, RKU. Background: Osteoarthritis of knee is one of the most common disabling degenerative diseases. Knee pain is the hallmark symptom of knee osteoarthritis. We have taken correlation between pain, quadriceps strength and functional disability. Aim: Study to correlate quadriceps strength, pain and functional disability among osteoarthritis knee patients Methodology: Study design: observational study Inclusion criteria: 40-55 years individuals Sample size: 30 Sampling technique: purposive sampling technique Study setting: Different Clinics of Rajkot. Results and Discussion: In this study we have taken Karl Persons Spearmen s test. We found correlation between NPRS AND WOMAC which has positive correlation. Second we have found inverse correlation of NPRS and SST. Third we have found correlation of WOMAC and SST which also has inverse correlation. So it says that as pain increases functional ability decreases and second correlation says that ass pain increases strength decreases third correlation says that as strength deceases functional ability of osteoarthritis knee decreases. Conclusion: In conclusion the result of this study indicates that Quadriceps strength is related with pain and disability in patients suffering with Osteoarthritis knee. Patients with more quadriceps strength are found to have less pain and disability. Keywords Quadriceps strength, pain and functional disability STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS viii

TABLE OF CONTENTS Sr. No. Title Page No. 1 List of Tables I 2 List of Figures II 3 List of Symbols, Abbreviations and Nomenclature III 4 Structured Abstract IV 5 Introduction 1 6 Need of the Study 4 7 Aim & Objectives of the study 6 8 Hypothesis 8 9 Review of literature 10 10 Methodology 12 10.1 Criteria for Selection 14 10.2 Material used in Study 15 10.3 Method 16 11 Results 20 11.1 Correlation of NPRS with WOMAC 22 11.2 Correlation of NPRS with SST 23 11.3 Correlation of SST with WOMAC 24 12 Discussion 25 13 Summary and Conclusion 29,31 14 References 33 15 Annexure 36 STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS ix

LIST OF TABLE SR. NO. TABLE PG NO 1 CLASSIFICATION SHOWING CORRELATION 21 STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS x

LIST OF FIGURES AND GRAPH SR.NO. FIGURE AND GRAPHS PG. NO. 1 Knee joint (fig. 1.1) 2 Correlation between NPRS and WOMAC (fig. 6.2) 3 Correlation between NPRS and SST (fig. 6.3) 4 Correlation between SST and WOMAC (fig. 6.4) 3 22 23 24 STUDY TO CORRELATE QUADRICEPS STRENGTH, PAIN AND FUNCTIONAL DISABILITY AMONG OSTEOARTHRITIS KNEE PATIENTS xi

INTRODUCTION

INTRODUCTION Osteoarthritis, commonly known as wear-and-tear arthritis, is a condition in which the natural cushioning between joints cartilage wears away. When this happens, the bones of the joints rub more closely against one another with less of the shockabsorbing benefits of cartilage. The rubbing results in pain, swelling, stiffness, decreased ability to move and, sometimes, the formation of bone spurs. Osteoarthritis of knee is one of the most common disabling degenerative diseases. Knee pain is the hallmark symptom of knee osteoarthritis. Despite of very high prevalence, the causes of knee are still poorly understood. (1) The aetiology of osteoarthritis is both biomechanical and biochemical, and there is no cure making effective rehabilitation particularly important. The knee is weight bearing joint most commonly affected by osteoarthritis and is second in overall osteoarthritis incidence. Compared with those without knee osteoarthritis, those with knee osteoarthritis demonstrate slower performance and increases need for functional modifications. This is particularly the case for those reduced lower limb sensory motor function.. Impaired quadriceps strength and proprioception have been linked with knee osteoarthritis (13, 17, 23). Some studies have also found increased knee extensor strength decreased risk of developing symptomatic knee osteoarthritis. Therefore there needs to better understand potentially modifiable risk factors for development of knee osteoarthritis and disablement. (2) The two large surveys conducted in India revealed a significant higher prevalence of knee pain in rural (13.9) compared with the urban (6.0%) community. (3) Here is the study to find whether the quadriceps strength is associated with pain and functional ability in an individual with osteoarthritis Knee. In this cross sectional study, we have taken NPRS and Sit to stand to measure pain and quadriceps strength respectively in osteoarthritis knee patients. We have taken WOMAC to test the functional ability of osteoarthritis knee patients. (1)` Page 2

FIGURE: (1.1) PATHOLOGICAL CHANGES IN OSTEOARTHRITIS OF KNEE JOINT. Page 3

NEED OF THE STUDY Page 4

NEED OF THE STUDY The need of the present study is to check to quadriceps strength, pain, physical disability among the patients suffering from osteoarthritis knee. Page 5

AIMS AND OBJECTIVES Page 6

AIMS & OBJECTIVES AIMS:- Study to correlate quadriceps strength, pain and functional activities among osteoarthritis knee patients OBJECTIVES:- 1) To determine whether the quadriceps weakness is a predisposing factor to osteoarthritis. 2) To correlate strength deficit and pain. 3) To correlate strength deficit and function. Page 7

HYPOTHESIS Page 8

HYPOTHESIS NULL HYPOTHESIS: - There is no significant correlation between pain, disability and quadriceps strength among osteoarthritis knee patients. ALTERNATIVE HYPOTHESIS: - There is a significant correlation between pain, disability and quadriceps strength among osteoarthritis knee patients. Page 9

REVIEW OF LITERATURE Page 10

REVIEW OF LITERATURE N A Glass, at al (2013) The relationship between quadriceps muscle weakness and worsening of knee pain in the MOST cohort: a 5-year Longitudinal study To determine whether quadriceps weakness is associated with elevated risk of Worsening knee pain over 5 years. Quadriceps weakness was associated an increased risk of worsening of knee pain over 5 years in women, but not in men. Alex.N Bastick,at al (2015) What Are the Prognostic Factors for Radiographic progrsssion of knee osteoarthritis? Meta analysis The purpose of this study is to provide an updated systematic review of available evidence regarding prognostic factors for radiographic knee OA Marlene Farsen, at al(2011) The epidemiology of osteoarthritis in Asia An update of what is currently known about the prevalence of hip and knee OA from population-based studies conducted in the Asian region is presented in this review. Many of the recent studies have conducted comparisons between urban and rural areas and poor and affluent communities. The results of Asian-based studies evaluating risk factors from population-based cohorts or case control studies, and the current evidence on OA morbidity burden in Asia is also outlined Stephanie c. Petterson, at al(2008) Mechanisms Underlying Quadriceps Weakness in Knee Osteoarthritis To identify determinants of quadriceps weakness among persons with endstage knee osteoarthritis. Both reduced CAR and LMCSA contribute to muscle weakness in persons with knee OA. Similar to healthy elders, the best predictor of strength in the contra lateral, no diseased limb was largely determined by LMCSA, whereas CAR was found to be the primary determinant of strength in the OA limb. Deficits in CAR may undermine the effectiveness of volitional strengthening programs in targeting quadriceps weakness in the OA population. Fiona Dobson, at al Recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis Although the tests in the recommended set were selected based on global expert opinion and available clinimetric evidence, none of the tests fulfil all desirable criteria, limiting the ability for a definitive core set of tests to be defined Page 11

METHODOLOGY Page 12

METHODOLOGY STUDY DESIGN:- Observational study STUDY SETTINGS:- Subjects will be taken from the Rajkot city. SAMPLING TECHNIQUE:- Purposive sampling technique will be used for osteoarthritis knee patients. SAMPLING POPULATION:- 30 radiological confirmed knee osteoarthritis patients will be taken. SAMPLE SIZE:- 30 patients Page 13

CRITERIA FOR SELECTION INCLUSION CRITERIA:- 1. Diagnosed or radiological confirmed osteoarthritis knee patients. 2. Subjects from age 40-55yrs. EXCLUSION CRITERIA:- 1. Treatment taken for 6 months. 2. Cases of rheumatoid arthritis and other arthritis taken as well as no post operative patients. 3. Cases of neurological disorder. Page 14

MATERIALS USED IN THE STUDY TOOLS AND MATERIAL:- 1. Stopwatch 2. Straight back chair with a 44cm (17 inch) seat height, preferably with arms CHAIR STOPWATCH Page 15

METHOD Description The maximum number of chair stand repetitions possible in a 60 second period (2-4). Preparation Environment Ensure the chair cannot slide backwards by placing the back of the chair against a wall. Participant Comfortable walking footwear (e.g. tennis shoes/cross trainers) should be worn. The participant sits in the chair in a position that allows them to place their feet flat on the floor, shoulder width apart, with knees flexed slightly more than 90 degrees so that their heels are somewhat closer to the chair than the back of their knees. The arms are crossed at the wrists and held close to the chest (across chest). Tester The tester stands close to the side of the chair for safety and so as they can observe the technique, ensure that the participant comes to a full stand and full sit position during the test. Practice A practice trial of one or two slow paced repetitions is recommended before testing to check technique and understanding. Procedure From the sitting position, the participant stands up completely up so hips and knees are fully extended, then completely back down, so that the bottom fully touches the seat. This is repeated for 60 seconds. Same chair should be used for re-testing within site. If the person cannot stand even once then allow the hands to be placed on their legs or use their regular mobility aid. This is then scored as an adapted test score. 8 Page 16

Verbal instructions For this test, do the best you can by going as fast as you can but don t push yourself to a point of overexertion or beyond what you think is safe for you. 1. Place your hands on the opposite shoulder so that your arms are crossed at the wrists and held close across your chest. Keep your arms in this position for the test. 2. Keep your feet flat on the floor and at shoulder width apart. 3. On the signal to begin, stand up to a full stand position and then sit back down again so as your bottom fully touches the seat. 4. Keep going for 60 seconds and until I say stop. 5. Get ready and START. Scoring On the signal to begin, start the stop watch. Count the total number of chair stands (up and down equals one stand) completed in 60 seconds. If a full stand has been completed at 60 seconds (i.e. standing fully erect or on the way down to the sitting position), then this final stand is counted in the total. The participant can stop and rest if they become tired. The time keeps going. If a person cannot stand even once then the score for the test is zero. Next, allow the hands to be placed on their legs or use their regular mobility aid. If the person can stand with adaptions, then record the number of stands as an adapted test score (see score sheet). Indicate the adaptations made to the test. Page 17

FIGURE SHOWING THERAPIST PERFORMING SST ON PATIENTS. Page 18

FIGURE SHOWS THERAPIST PERFORMING SST ON PATIENTS. Page 19

RESULT Page 20

RESULTS Here in this study we have involved 30 individuals to find out the correlation between pain, strength and functional disability. The mean of NPRS, SST and WOMAC was found to be 5.2, 9.067, 28.1 respectively. In this study we have taken Karl Persons Spearmen s test. We found correlation between NPRS AND WOMAC which has positive correlation. Second we have found inverse correlation of NPRS and SST. Third we have found correlation of WOMAC and SST which also has inverse correlation. So it says that as pain increases functional ability decreases and second correlation says that ass pain increases strength decreases third correlation says that as strength deceases functional ability of osteoarthritis knee decreases. COMPONENTS NPRS SST WOMAC NO OF PARTICIPANTS 30 30 30 Mean 5.2 9.067 28.1 Std. Deviation 1.349 3.542 14.72 Spearman r 0.7247-0.7252-0.6388 95% confidence interval 0.4846 to 0.8632-0.8635 to -0.4855-0.8160 to -0.3520 P value (two-tailed) < 0.0001 < 0.0001 0.0001 Table (6.1) CLASSIFICATION SHOWING CORRELATION. Page 21

Correlation of NPRS with WOMAC 80 Data 1 60 womac 40 20 0 NPRS This graph shows that there is positive correlation of NPRS with WOMAC as pain increases functional disability increases.(fig. 6.2) Page 22

Correlation of NPRS with SST 20 15 SST 10 5 0 0 2 4 6 8 10 NPRS There is negative correlation of SST and NPRS as the pain increases strength decreases. (FIG. 6.3) Page 23

Correlation of SST and WOMAC 80 60 womac 40 20 0 0 5 10 15 20 SST There is negative correlation of SST with WOMAC that strength increases then functional disability decreases.( FIG. 6.4) Page 24

DISCUSSION Page 25

. DISCUSSION This study correlates quadriceps strength, pain and functional disability among osteoarthritis knee patients. It is observed that higher levels of quadriceps strength correlate with higher physical activity in knee OA patients. We also found that quadriceps weakness was associated with worsening knee pain. Our evaluation also found out that quadriceps weakness predicts worsening knee pain because the quadriceps muscle is a primary dynamic contributor to knee joint stability. By definition, stability at the knee joint requires internal forces of sufficient magnitude to counteract external forces acting at the knee. The quadriceps muscle absorbs loads and provides dynamic stability withness of the quadriceps may alter local contact, stress in a manner detrimental to artricular cartilage. (14) It may also lead to increases impulse loading, which has benn associated with knee pain and may contribute to knee osteoarthritis. (20,33). This suggests that if excess laoding is predictive of osteoarthritis increases quadriceps strength may protect the knee. Weakness could reduce shock absorption and neuromuscular control and impair structural integrity of the knee joint. This may lead to abnormal loading and subsequent structural pathology associated with knee symptoms, such as bone marrow lesions or bone attrition. Some articles also mention that exact reason that quadriceps strength does not predict the majority of variance in physical activity is unknown but there are likely multiple other factors that influence physical activity in patients with knee OA. Knee OA is a multifactorial condition that includes injury and disease of multiple joint structures. Strength or activation of multiple lower Extremity muscles affect contact forces at the knee, many of which may uniquely contribute to explaining a portion of the diminished physical activity seen in patients with knee OA. Additionally, the inability to tolerate pain during locomotion may explain additional variance regarding physical activity, as fear of pain during ambulation may decrease physical activity. Non-physiological factors such as Socioeconomic status may be associated with lower leisure-time physical activity. It is possible that severity of joint damage at the time of testing may have contributed to explain a proportion of variance among osteoarthritis knee patients. Although the sassociation between OA progression and strength is not clear, quadriceps weakness remains a hallmark physical impairment. This is what are study contains along with the contradictions we found in research done by others. Page 26

LIMITATIONS AND FURTHER RECOMENDATIONS Page 27

LIMITATIONS OF THE STUDY Only 40-55 age group of people were selected in this study. Small sample size was taken for study i.e. 30 As manoeuvres are to be performed by the subject, the result greatly depends on confidence level and skill of subjects. Excessive repetitions if performed by the subject can lead to exersion which affects the result. FURTHER RECOMMENDATION The study can be carried out on more number of subjects Other tests like using dynamometer, sea bags isometric exercise can also be selected for this study. In sequence further interventional studies may be done on quadriceps endurance and neuromuscular control of the same. Longitudinal studies of this component can help to see their effect on prognosis of osteoarthritis knee. Page 28

CONCLUSION Page 29

CONCLUSION In conclusion the result of this study indicates that Quadriceps strength is related with pain and disability in patients suffering with Osteoarthritis knee. Patients with more quadriceps strength are found to have less pain and disability. Moreover, there is a significant correlation between pain and functional disability, the more is the pain the more is disability. The study is significant clinically as it can be inferred from the result that increasing and maintaining quadriceps strength can help the patient to control pain and reduce disability. Page 30

SUMMARY Page 31

SUMMARY This observational study is to correlate quadriceps strength, pain and functional disability among osteoarthritis knee patients. As it is a degenerative disease, the population selected for study is 40 to 55 years of age. Diagnosed cases or radiological confirmed 30 patients were selected on the base of inclusion and exclusion criteria. The outcome measures used for quadriceps strength, pain and functional disability is to Sit To Stand test (SST),NPRS and WOMAC respectively. The mean of WOMAC scale is 28.10 of the same patients is 9.067, mean of NPRS is 5.200 and mean of WOMAC scale is 28.10 of the same patients. Karl Pearson s correlation test was applied to study whether there is any correlation among these components. It was found that there is positive correlation between NPRS and WOMAC. NPRS and SST are correlated inversely and the correlation between SST and WOMAC is also an inverse correlation. It implies that an increase in pain increases functional disability, increase in pain increases functional disability, increase in strength may decrease the pain and disability. Page 32

BIBLOGRAPHY Page 33

BIBLIOGRAPHY Alex N. Bastick MD, MSc, Janneke N. Belo MD, PhD, Jos Runhaar PhD, Sita M. A. Bierma-Zeinstra PhD What Are the Prognostic Factors for Radiographic Progression of Knee Osteoarthritis? A Meta-analysis Received: 5 January 2015 / Accepted: 5 May 2015 M Elboim-Gabyzon1,N Rozen2,Y Laufer1 Quadriceps femoris muscle fatigue in patients with knee osteoarthritis Brian Pietrosimone, PhD, ATC1,Abbey C. Thomas, PhD, ATC2,Susan A. Saliba, PhD, PT, ATC3Christopher D. Ingersoll, PhD, ATC4 ASSOCIATION BETWEEN QUADRICEPS STRENGTH AND SELF REPORTED PHYSICAL ACTIVITY IN PEOPLEWITH KNEE OSTEOARTHRITIS N.A. Glass, J.C. Torner, L.A. Frey Law, K. Wang, T. Yang, M.C. Nevitt, D.T. Felson#, C.E. Lewis, and N.A. Segal,,,* The relationship between quadriceps muscle weakness and worsening of knee pain in the MOST cohort: a 5-year longitudinal study Osteoarthritis Cartilage. 2013 September ; 21(9): 1154 1159. doi:10.1016/j.joca.2013.05.016 Marlene FRANSEN,1 Lisa BRIDGETT,1 Lyn MARCH,2 Damian HOY,3 Ester PENSERGA4 and Peter BROOKS The epidemiology of osteoarthritis in Asia International Journal of Rheumatic Diseases 2011; 14: 113 121 Neil A. Segal, MD, MS1, Natalie A. Glass, MA1, David T. Felson, MD, MPH2, Michael Hurley, PT, PhD3, Mei Yang, DsC2, Michael Nevitt, PhD4, Cora E. Lewis, MD, MSPH5, and James C. Torner, PhD1 The Effect of Quadriceps Strength and Proprioception on Risk for Knee Osteoarthritis Med Sci Sports Exerc. 2010 November ; 42(11): 2081 2088 Neil A. Segal, MD, MS, CSCS1,2,3, Christian Findlay, BFA1, Ke Wang, MSc4, James C. Torner, PhD2, and Michael C. Nevitt, PhD5 for the MOST Investigative Group The longitudinal relationship between thigh muscle mass and the development of knee osteoarthritis Osteoarthritis Cartilage. 2012 December ; 20(12): 1534 1540 Kristen A. Scopaz, MD, MS, Sara R. Piva, PT, PhD, Alexandra B. Gil, PT MS, Jason D. Woollard, MPT, Chester V. Oddis, MD, and G. Kelley Fitzgerald, PT, PhD The Effect of Baseline Quadriceps Activation on Changes in Quadriceps Page 34

Strength After Exercise Therapy in Subjects with Knee Osteoarthritis Arthritis Rheum. 2009 July 15; 61(7): 951 957 Shreyasee Amin, MDCM, FRCP(C), MPH1, Kristin Baker, PhD2, Jingbo Niu, MD, DSc2,Margaret Clancy, MPH2, Joyce Goggins, MPH2, Ali Guermazi MD3, Mikayel Grigoryan,MD4, David J. Hunter, MBBS, PhD2, and David T. Felson, MD, MPH2 Quadriceps Strength and the Risk of Cartilage Loss and Symptom Progression in Knee Osteoarthritis Arthritis Rheum. 2009 January ; 60(1): 189 198 Irfan Koca1)*, Ahmet Boyaci2), Ahmet Tutoglu2), Nurefsan Boyaci3), Ayhan Ozkur4) The Relationship between Quadriceps Thickness, Radiological Staging, and Clinical Parameters in Knee Osteoarthritis J. Phys. Ther. Sci. 26: 931 936, 2014 STEPHANIE C. PETTERSON1,2, PETER BARRANCE3, THOMAS BUCHANAN4, STUART BINDER-MACLEOD2, and LYNN SNYDER- MACKLER2 Mechanisms Undlerlying Quadriceps Weakness in Knee Osteoarthritis Med Sci Sports Exerc. 2008 March ; 40(3): 422 427 C. Veenhof y*, P.A. Huisman yz, J.A. Barten yz, T. Takken zx, M.F. Pisters yzk Factors associated with physical activity in patients with osteoarthritis of the hip or knee: a systematic review Osteoarthritis and Cartilage 20 (2012) 6e12 Page 35

ANNEXURES Page 36

ANNEXURE 10.1 CONSENT FORM Page 37

ANNEXURE 10.2 DATA COLLECTION FORM ASESSMENT FORM SR.NO: NAME: SEX AND AGE: WEIGHT: HEIGHT: OCUPATION: ADDRESS: MOBILE NO: PAIN HISTORY: 1) SITE: 2) TYPE: 3) DURATION: 4) ONSET: 5) FREQUENCY: 6) AGGRAVATING FACTORS: 7) RELIVING FACTORS: 8) CREPITIOUS: X-RAY: DATA COLLECTION TABLE: NAME GENDER BMI NPRS SST WOMAC REMARKS: Page 38

ANNEXURE 10.3 MEASUREMENT TOOL 1. Stopwatch 2. Straight back chair with a 44cm (17 inch) seat height, preferably with arms CHAIR STOPWATCH Page 39

MASTER SHEET SR.NO NAME AGE GENDER BMI NPRS SST WOMAC Page 40

ANNEXURE 10.4 SCALES USED IN OUTCOME MEASURES Page 41

SCALES USED IN OUTCOME MEASURES Page 42

MASTER SHEET SR. NO NAME OF PATIENT AGE GENDER BMI NPRS SST WOMAC 1 PRAGJIBHAI PARMAR 52 MALE 25.6 7 8 26 2 CHANDRIKABEN VAJA 46 FEMALE 42.15 8 7 74 3 MUKTABEN 45 FEMALE 20.7 8 7 41 4 NIRMALABEN GAMDHA 43 FEMALE 27.4 4 12 18 5 PRATIBHABEN OZA 55 FEMALE 27.4 5 11 44 6 SURESHBHAI LIMBASIYA 48 MALE 23.1 4 12 17 7 RAMJIBHAI PARMAR 55 MALE 24.9 4 12 19 8 BILKISHBHAI BHARMAL 46 MALE 29.1 5 10 24 9 SAVITABEN VADHER 54 FEMALE 26.2 5 5 39 10 SUPRIYABEN 43 MALE 28.1 4 12 7 11 PANKAJBHAI SOJITRA 52 MALE 26.44 6 10 32 12 ARJUNBHAI JALLU 52 MALE 33.8 5 11 7 13 BHIMANI LAXMIBEN 55 FEMALE 25.5 5 10 25 14 DINESHBHAI PATEL 43 MALE 26.58 5 8 24 15 MEENABEN LIMBASIYA 43 FEMALE 27.81 4 15 31 16 RASHILABEN RAJPUT 52 FEMALE 31.56 6 7 30 17 MAYURBHAI THARESHA 54 MALE 26.7 2 15 12 18 HEERABEN KUMBHANI 52 FEMALE 21.33 5 3 30 19 DEVYANIBEN PARMAR 44 FEMALE 26.37 7 3 38 20 MANHARLAL HARILAL 52 MALE 20.28 5 10 25 21 REETABEN PAREKH 53 FEMALE 36.1 6 13 25 22 MAYURISHRIVASTAV 48 FEMALE 24.76 5 9 19 23 DHOLIBEN RANGANI 50 FEMALE 26 7 2 50 24 KANABHAI RATHOD 55 MALE 28.36 7 2 50 25 JENTIBHAI KOYARI 45 MALE 23.04 5 7 22 26 CHANDUBHAI CHAUHAN 49 MALE 23.89 4 10 17 27 RAMBHABEN PATEL 50 FEMALE 22.90 5 10 16 28 GEETABEN RAMOLIYA 43 FEMALE 25.73 4 12 14 29 VASANTABEN GORIYA 49 FEMALE 24.4 4 12 15 30 ANIRUDDH AKHANI 50 MALE 24.9 5 7 33 Page 43