RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. Name of the Candidate : SHWETA AUL

Address: PN-508, Purva Panorma,

Bannerghatta Road, Kalena

Agrahara Village,

Bangalore 560076

2. Name of the institution: Kempegowda Institute of

Physiotherapy, Bangalore

3.Course of the study and MPT ( Musculoskeletal and

subject: Sports Physiotherapy )

4. Date of admission to course:

14th June 2007

5. Title of the topic:

“ A STUDY ON THE EFFECTIVENESS OF TENS WITH EXERCISES

VERSES ULTRASOUND WITH EXERCISES TO REDUCE PAIN AND

ENHANCE FUNCTIONAL PERFORMANCE IN MEDIAL

COMPARTMENT OSTEOARTHRITIS KNEE. “

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6. Brief resume of the intended work:

6.1 Purpose of the study

Osteoarthritis is a condition of synovial joints characterized by focal

loss of articular hyaline cartilage with proliferation of new bone and
remodelling of joint contour.1

Osteoarthritis is a disorder of diarthrodial joints characterized

clinically by pain and functional limitation, radiographically by
osteophytes and joint space narrowing, histopathologically by
alteration in cartilage integrity.2
There is a steady rise in prevalence from age 30 such that by 65,
80% of people have radiographic evidence of osteoarthritis though
only 25-30% are symptomatic.1

Under the age of 55 years, the joint distribution of osteoarthritis in

men and woman is similar. Radiographic evidence of knee
osteoarthritis, is more common in woman than in men. 3

The diagnosis of osteoarthritis can usually be made clinically and

then confirmed by radiographically .The main features that suggest
the diagnosis include pain, stiffness, reduced range of movement,
swelling,crepitus and increased age, in the absence of systemic
features (fever).4

The joint pain of osteoarthritis is exacerbated by activity and relieved

by rest. in more advanced case it is painful at rest and during night. 4

Knee osteoarthritis principally targets the patello-femoral and medial

tibio-femoral compartments of the knee.1

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Local examination findings are periarticular tenderness, varus
deformity, weakness and wasting of quadriceps muscle, restricted
flexion -extension movements, swelling around the joint line and
crepitations.

Common functional difficulties are prolonged walking, rising from a

chair, getting in and out of a car, on bending to put shoes or socks. 1
Therapeutic approach is mainly directed at symptoms and many
treatment options such as pharmacological (NSAIDS) and non-
pharmacological such as physiotherapy, weight reduction, supportive
braces, and orthotics etc.4
Various studies in physiotherapy have shown the therapeutic
interventions like TENS, ULTRASOUND and EXERCISES have been
effective in the treatment of medial compartment osteoarthritis knee.
TENS is proved effective in controlling pain in medial compartment
knee osteoarthritis5.
Heat therapy is applied to obtain analgesia, decrease muscle spasm,
increase collagen extensibility and accelerate metabolic process.
Therapeutic ultrasound may produce temperature elevations of 4-5C
at depth of 4cm6.
Strengthening exercise programmes may produce long term
improvements in pain and physical performance in people with knee
osteoarthritis.1
No previous studies have compared the effectiveness between TENS
and ULRASOUND in treatment of medial compartment knee
osteoarthritis. So in my study I would like to compare these two
interventions with exercises and find the most effective one in
reducing pain and improving functional performance in medial
compartment osteoarthritis knee patients.

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6.2 Literature Review

VA Robinson (2007) conducted a study among 220 patients

with osteoarthritis knee, to compare therapeutic ultrasound to an
active therapy (galvanic current and shortwave diathermy) which
showed no statistical difference between ultrasound, galvanic
current and shortwave diathermy for the outcome of pain. 7

Aiyejusunle CB et al(2007),conducted a study among 20 patients
with osteoarthritis knee, who were given either TENS or Sodium
salicylate Iontophoresis for six weeks, showed significant reduction
in pain and functional disability in both groups. 8

KG Auw Yang et al(2007) conducted a study among 100 patients
with osteoarthritis knee, which validates the short form WOMAC
scale for assessment of conservative treatment of osteoarthritis
knee.9

Law PP et al (2004) has conducted a study among 34 subjects with
osteoarthritis knee. They found that 2 weeks of repeated
applications of TENS stimulation at 2hz ,100hz,or 2/100hz
produced similar treatment effects for people suffering from
osteoarthritis knee.10

Erkan Kozanoglu et al (2003) conducted a study among 60 patients
with osteoarthritis knee, to evaluate the short term efficacy of
ibuprofen phonophoresis versus continuous Ultrasound therapy
and concluded both therapeutic modalities were equally effective
and well tolerated after 10 therapy sessions. 6

Poll.E.Bijur et al (2001) conducted a study to find reliable and valid
measures of pain and concluded reliability of Visual Analog Scale
for acute pain measurement to be .97.11

Deyle GB et al (2000), conducted a study among 83 patients with
osteoarthritis knee to evaluate the effectiveness of a combined

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 regimen of physical therapy and exercise. They concluded that with
8 weeks of range of movement and strengthening exercises there
is improvement in functional ability, pain and stiffness. 12

6.2 Objective of the Study

To evaluate whether TENS with exercises is effective than
ultrasound with exercises or vice versa in reducing pain and
enhancing functional performance of patients with unilateral (medial
compartment) of Osteoarthritis knee.

6.3 Inclusion Criteria

 Patients above 40 years and below 60 years of age with either
sex.
 Unilateral medial compartment osteoarthritis knee.
 Western Ontario and Mc Master Universities Osteoarthritis Index
total score > 25.
 Acute and sub acute osteoarthritis knee.
 Morning stiffness that lasts 10 to 30 minutes.
 Average pain > 3cm on a 10 cm Visual Analog Scale.
 Normal skin sensation on affected limb.

6.4 Exclusion criteria

 Patients with Dermatological problems.
 Patients below 40 years and above 60 years of age.
 Patients with chronic osteoarthritis knee.
 Patients who have undergone knee surgery (previous 12 months)
 Patients with lower limb joint replacement.
 Patients who received Intraarticular steroid injection(previous 6
months)

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  Patients with Deep Vein Thrombosis.
 Patients with synovitis and haemotoma in knee joint.
 Patients with any post fracture secondary osteoarthritis.
 Patients with very severe swelling in knee osteoarthritis.

7 Source of data:

All patients coming to KEMPEGOWDA INSTITUTE OF MEDICAL

SCIENCES, HOSPITAL AND RESEARCH CENTER AND
KEMPEGOWDA INSTITUTE OF PHSIOTHERAPY with clinical
diagnosis of osteoarthritis by a orthopaedician , and who are fulfilling
the inclusion and exclusion criteria.

7.1 Methods of collection of data.

Study design: Comparative study

Sample size: 60 (30 in each group)

Period of study: 1 year

Sampling method: Random sampling method

7.2 Method

Consent of all patients will be taken. The patients who are fulfilling
inclusion and exclusion criteria will be included in the study.
Subjects will be divided into 2 groups. Group A and group B with each
group consisting of 30 patients.
Group A will be treated with TENS and exercises.
Group B will be treated with Ultrasound and exercises.

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 Both the groups will be treated daily for period of 4 weeks. At end of
every week range of motion, Visual Analog Scale, WOMAC Scale
values will be recorded and compared with both groups to find which
treatment intervention has shown good improvement.

Study variables:
 Range of motion of knee by Goniometer.
 Functional performance by WOMAC scale.
 Visual Analogue scale for pain.

7.3 Materials used:

 Goniometer
 Inch tape
INTERVENTIONS
ULTRASOUND6

Mode -Pulsed mode

Dosage -.8 to 1.2 W/cm2
Treatment time -5 minutes
Frequency -1 Megahertz
Coupling medium -Aquasonic Gel
Ultrasound applied to the supero-medial and infero-medial
parts of knee.

TENS13

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 Electrode placement -over supero-medial and infero-
medial parts of knee.
Pulse pattern - Continuous
Pulse frequency -80 to 100 hertz
Pulse duration -100 to 200 microseconds
Pulse Amplitude -increase intensity to produce a
strong but comfortable tingling.
Duration of stimulation - 12 minutes

EXERCISES MEASURES

Range of motion exercises

In long sitting position knee mid flexion to Two 30 sec bouts with 3 seconds hold
end range extension. at end range.
In long sitting position knee mid flexion to Two 30 sec bouts with 3 seconds hold
end range flexion . at end range.
Strengthening exercises
Static quadriceps sets in knee
extension. Hold 5 seconds. 3 sets of 12
Lying supine 1 leg flexed other repetitions.
extended.
Slowly raise extended leg 6 to 8 inches
while contracting quadriceps. Hold 5 seconds. 3 sets of 12
Lying prone raise one leg 2 to 4 inches. repetitions.

7.4 Hypothesis

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Alternate hypothesis: After the treatment, it may be seen that Group A
patients who have been treated with TENS shows better results than
group B patients who have been treated with Ultrasound.
Null Hypothesis: After the treatment, it may be seen that Group B
patients who have been treated with Ultrasound shows better result
than Group A patients who have been treated with TENS.

7.5 FOLLOW UP
The patients address and telephone numbers will be taken and they
will be informed on the previous day for treatment.

7.6 STATISTICAL ANALYSIS

This will be done using students t-test and chi-square test for drawing
valid conclusions.

7.7 Does study need interventions on human subjects :

Yes, an intervention on human subject is required.

7.8 Has Ethical clearance been obtained from your institution?

Yes

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8. REFRENCES

1. Nicholas.A.Boon,Nichi.R.Colledge,Brain.R.Walker,John.A.A.Hunter.Davidson`s
Principles and Practice of Medicine;20thEdition.p.1096-1100.
2. Bennetland Plum,Gill,Kokko,Handell et al. Textbook of Medicine;20 th
Edition.Volume 2.p.1517.
3. Fauci,Braunwald,Isselbacher,Wilson,Martin. Harrissons Principles of Internal
Medicine;14thEdition.Volume-2.p.1935.
4. David J Hunter,David T Felson.Osteoarthritis. Clinical Review.BMJ
2006;332:639-642(18March).
5. Philip Taylor,Mark Hallett,Lorraine Flaherty. Treatment of osteoarthritis of the
knee with transcutaneous electrical nerve stimulation.Research Report.
Pain,Volume 11,Issue2,October 1981,p.233-240.
6. Erkan Kozanoglu,Sibel Basaran,Rengin Guzel,Fusun Guler-Uysal. Short term
efficacy of ibuprofen phonophoresis versus continous ultrasounm therapy in knee
osteoarthritis.SWISS MED WKLY 2003;133:333-338.
7. VA Robinson.Therapeutic ultrasound for osteoarthritis of the knee. Cochrane Rev
Abstract.2007.
8. Aiyejusunle CB, Kola-Korolo TA, Ajiboye OA. Comparison of the effects of
tens and sodium salicylate iontophoresis in the management of osteoarthritis of
the knee. Nig Q J Hosp Med.2007 Jan-Mar;17 (1): 30-4
9. KG. Auw Yang, MD. Validation of the short form WOMAC function scale for the
evaluation of osteoarthritis of the knee. Journal of Bone and Joint Surgery-British
Volume, Vol 89-B, Issue 1, 50-56.
10. Law PP, Cheing GL. Optimal stimulation frequency of transcutaneous electrical
nerve stimulation on people with knee osteoarthritis. J Rehabil Med. 2003
Mar;35(2):62-8.
11. Polly E. Bijur, PhD, Wendy Silver, MA and E. John Gallagher, MD. Reliability of
the Visual Analog Scale for Measurement of Acute pain. Acad Emerg Med.
Volume 8, issue 12 1153-1157.

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12. Deyle GD, Henderson NE, Matekel RL et al. Effectiveness of manual physical
therapy and exercise in osteoarthritis of the knee. A randomized controlled trial.
Ann Med 2000 Feb 1;132:173-81.
13. Sheila Kitchen. Electrotherapy Evidence-based Practice; Eleventh Edition. p.278 .

9. Signature of the Candidate : (Shweta Aul)

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10. REMARKS OF THE GUIDE THIS STUDY IS PERFORMED TO
EVALUATE THE EFFECTIVENESS OF
TENS(TRANSCUTANEOUS
ELECTRICAL NERVE STIMULATION)
WITH EXERCISES VERSES
ULTRASOUND WITH EXERCISES, TO
REDUCE PAIN AND ENHANCE
FUNCTIONAL PERFORMANCE IN
MEDIAL COMPARTMENT
OSTEOARTHRITIS KNEE.
11. NAME AND DESIGNATION OF:

11.1 GUIDE: R. RAJA. MPT

ASSISTANT PROFESSOR
KEMPEGOWDA INSTITUTE OF
PHYSIOTHERAPY
SIGNATURE

11.2 CO GUIDE Dr. H.B. SHIVAKUMAR, MS,( ORTHO)

ASSOCIATE PROFESSOR
DEPARTMENT OF ORTHOPAEDICS
KEMPEGOWDA INSTITUTE OF
MEDICAL SCIENCES.
SIGNATURE

11.3 HEAD OF THE DEPARTMENT PROFESSOR R. BALA SARAVANAN,

MPT
PRINCIPAL.
DEPARTMENT OF PHYSIOTHERAPY,
KEMPEGOWDA INSTITUTE OF
MEDICAL SCIENCES.
SIGNATURE

12 REMARKS OF THE THIS STUDY IS PERFORMED TO

CHAIRMAN AND PRINCIPAL EVALUATE THE EFFECTIVENESS OF
TENS WITH EXERCISES VERSES
ULTRASOUND WITH EXERCISES, TO
REDUCE PAIN AND ENHANCE
FUNCTIONAL PERFORMANCE IN
MEDIAL COMPARTMENT
OSTEOARTHRITIS KNEE
SIGNATURE

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