The procedure has proven to both reliable and durable. A successful total knee replacement allows patient to resume almost all activities of daily living with minimal difficulty. In most cases patients no longer require external aids or chronic medications. Finally total knee replacement helps patients to maintain their overall self esteem.
Total knee replacement is indicated when there is unremitting severe pain in the knee with or without deformity. The pain/ deformity may be due to osteoarthritis, Rheumatoid arthritis and various non specific arthritis. It relieves pain, provides mobility and correct deformity.
Total knee replacement is a surgical procedure in which injured or damaged parts of the knee joint are replaced with artificial parts. The procedure is performed by seperating the muscles and ligaments around the knee to expose the knee capsule. The knee capsule is opened, exposed the inside of the joint. The end of the femur and tibial are removed. The artificial parts are cemented into place. The knee will consist of metal shell at the end of the femur, a metal and plastic trough on the tibia and if needed a plastic button in the cap. In a way this could be more appropriately called a Knee resurfacing operation.
The common pathology for total knee replacement is knee flexion contracture.
DEFINITION:
Flexion contracture is defined as the shortening of the connective tissue thereby stiffening the joint. It is due to tightening of the posterior capsule combined with the tightening of biceps femoris and collateral ligaments.
Hence rehabilitation program should be undertaken soon after TKA to maintain joint range of motion.
In particular this study examined the value of dynamic splinting in increasing range of motion and reducing the flexion contracture. Dynamic splinting utilizes the biomechanical adaptation of keeping the joint at end-range to achieve a physiological change of molecular realignment to elongate the connective tissue. This protocol of low-load, prolonged-duration stretch with dynamic tension continually reduces the contracture.
ANATOMY OF KNEE JOINT:
The knee joint is the largest and most complex joint in the body. It is synovial modified hinge joint. It is formed by fusion and medial tibio- femoral and patella- femoral joint.
ARTICULAR SURFACES:
It is comprised the
Femoral condyles: distal end of femur
Tibial condyles : proximal end of tibia.
Patellar facetes : posterior surface of patella.
Femoral condyles:
The articular surfaces of femur are pulley shaped. The femoral condyles are convex in both planes. They are extended interiorly by the pulley shaped patellar surfaces. The neck of the pulley is represented anteriorly by the central groove on the patellar surface and posteriorly by the intercondylar notch.
111
Tibial condyle:
The tibial surfaces are reciprocally curved and comprises two curved and concave parallel gutters which are separated by a blunt eminence running antero- posteriorly eminence lodges the two intercondylar tubercles.
Tibio-femoral joints:
The tibial condyles correspond to the femoral condyles while the inter condylar tibial tubercles come to within the femoral intercondylar notch, these surfaces constitute functionally the tibio-femoral joint.
Femero-patellar joints:
The facets of patella correspond to the patellar surface of the femur while the vertical ridge of the patella fits into the central groove of the femur.
LIGAMENTS OF KNEE JOINT:
Medial collateral ligament:
It is flattened band rhomboidal in outine. It is attached above to the medial epicondyle of femur, below to the medial margin and the adjoining medial surface of tibia.
Function:
restrain valgus rotation
Lateral collateral ligament:
Function:
restrain varus rotation and resist internal rotation
kneeanat
Anterior cruciate ligament:
It is attached below to the anterior part of the intercondylar area of tibia between the anterior ends of lateral and medial semilunar cartilages. Above it is attached to the posterior part of the medial surface of lateral femoral condyle.
Function:
To resist anterior displacement of the tibia on the femur when the knee is flexed
To resist varus or valgus rotation of the tibia, especially in the absence of the collateral ligaments
Resists internal rotation of the tibia.
Posterior cruciate ligament:
It is attached below to the posterior part of intercondylar area of tibia, posterior to the attachment of posterior end of medial semilunar cartilage. Above it is attached to the anterior part of lateral surface of the medial condyle of femur.
Function:
To allow femoral rollback in flexion
Resist posterior translation of the tibia relative to the femur
Controls external rotation of the tibia with increasing knee flexion.
Retention of the PCL in total knee replacement has been shown biomechanically to provide normal kinematic rollback of the femur on the tibia. This also is important for improving the lever arm of the quadriceps mechanism with flexion of the knee.
MUSCLES OF KNEE JOINT:
Quadriceps femoris
Popliteus
Semitendinosus
Semimembranous
Sartorius
Biceps femoris
Gastrocnemius
Plantaris
BURSAE AROUND THE KNEE JOINT:
Anteriorly:
The suprapatellar bursa
The prepatellar bursa
Superficial intrapatellar bursa
Deep infrapatellar bursa
Laterally:
A bursa between lateral collateral ligament and biceps tendon
A bursa between lateral collateral ligament and popliteus tendon
Popliteus bursa lies between the popliteus and lateral condyle of femur.
Medially:
The tibial inter tendinous bursa( pes anserine bursa)
A bursa between medial collateral ligament and semimembranous tendon
A bursa between semimembranous tendon and tibia.
Posteriorly:
A bursa between lateral head of gastrocnemius and capsule.
Semimembranous bursa(brodies bursa)
NERVE SUPPLY:
Femoral nerve
Sciatic nerve
Obturator nerve
BLOOD SUPPLY:
The arterial supply to knee joint, is from the branches of
Popliteal artery
Femoral artery
Tibial artery
TIBIO-FEMORAL ARTHROKINEMATICS:
Viewed in the sagittal plane, the femur’s articulating surface is convex while the tibia’s in concave. We can predict arthrokinematics based on the rules of concavity and convexity:
During Knee Extension
During Knee Flexion
Open Chain
Closed Chain
Open Chain
Closed Chain
Tibia Glides Anteriorly On Femur
Femur Glides Posteriorly On Tibia
Tibia Glides Posteriorly On Femur
Femur Glides Anteriorly On Tibia
from 20o knee flexion to full extension
from full knee extension to 20o flexion
Tibia rotates externally
Femur rotates internally on stable tibia
Tibia rotates internally
Femur rotates externally on stable tibia
THE “SCREW-HOME” MECHANISM:
Rotation between the tibia and femur occurs automatically between full extension (0o) and 20o of knee flexion. These figures illustrate the top of the right tibial plateau as we look down on it during knee motion.
top of tibial plateau
top of tibial plateau
top of tibial plateau
During Knee Extension, the tibia glides anteriorly on the femur.
During the last 20 degrees of knee extension, anterior tibial glide persists on the tibia’s medial condyle because its articular surface is longer in that dimension than the lateral condyle’s.
Prolonged anterior glide on the medial side produces external tibial rotation, the “screw-home” mechanism.
THE SCREW-HOME MECHANISM REVERSES DURING KNEE FLEXION
top of tibial plateau
top of tibial plateau
top of tibial plateau
When the knee begins to flex from a position of full extension, posterior tibial glide begins first on the longer medial condyle.
Between 0 deg. extension and 20 deg. of flexion, posterior glide on the medial side produces relative tibial internal rotation, a reversal of the screw-home mechanism.
TOTAL KNEE REPLACEMENT
Total knee replacement is indicated when there is unremitting severe pain in the knee with or without deformity. The pain/ deformity may e due to osteoarthritis, Rheumatoid arthritis and various non specific arthritis. It relieves pain, provides mobility and correct deformity.
Total knee replacement is a surgical procedure in which injured or damaged parts of the knee joint are replaced with artificial parts. The procedure is performed by seperating the muscles and ligaments around the knee to expose the knee capsule. The knee capsule is opened, exposed the inside of the joint. The end of the femur and tibial are removed. The artificial parts are cemented into place. The knee will consist of metal shell at the end of the femur, a metal and plastic trough on the tibia and if needed a plastic button in the cap. In a way this could be more appropriately called a Knee resurfacing operation.
E:New FolderNAGU PROJECTimAGESTotal-Knee-Replacement.jpg
The total knee replacement can be:
Unicompartmental arthroplasty: The Articular surface of femur and tibia, either the medial or lateral compartment of the knee are replaced by an implant. Eg: osteoathritis.
Bicomprtmental arthroplasty: In bicompartmental arthroplasty, the articular surface of tibia and femur of both medial and lateral compartments of the knee joints are replaced by an implant. The third compartment i.e.., the patellofemoral joint is however left intact.
Tricomprtmental arthroplasty: the articular surface of the lower femur, upper tibia and patella are replaced by prosthesis. Most commonly performed arthroplsty.
The prosthesis consists of a tibial component, a metal femoral component and a high molecular weight polyethylene button for articular surface of the patella.
TKA GOALS
Restore mechanical alignment [neutral tibiofemoral alignment =
4°-6° of anatomic valgus],
Horizontal joint line,
Soft tissue balance (ligament),
(Patella tracking (Q-angle)
INDICATION
Oteoarthritis
Rheumatoid arthritis
Hemophilic arthritis
Traumatic arthritis
Sero negative arthrides
Crystal deposition disease
Pigmented villonoular synovitis
Avascular necrosis
Bone dysplasias
Asymmetric arthrits
CONTRA INDICATION
Absolute contraindications
Recent or curren joint infection
Sepsis or systematic infection
Neuropathic arthropathy
Painful solid knee fusion
Relative contraindications
Severe osteoporosis
Debilated poor health
Non functioning extensor mechanism
Painless, well functioning arthrodesis
Significant peripheral vascular diseases
TKA Complications
Death: 0.53%
Periprosthetic Infection: 0.71%
Pulmonary emboli: 0.41%
Patella fracture:
Component Loosening:
Tibial tray wear:
Peroneal Nerve Palsy: 0.3% to 2%
Periprosthetic Femur Fracture:
Periprosthetic Tibial Fracture:
Wound Complications / Skin slough: rare
Patellar Clunk Syndrome: rare
Patellofemoral Instability: 0.5%-29%
DVT:
Instability:
Popliteal artery injury: 0.05%
Quadriceps Tendon Rupture: 0.1%
Patellar Tendon Rupture: <2%
Stiffness:
Fat Embolism
MCL rupture
NEED AND SIGNIFICANCE OF STUDY:
Need of the study:
To reduce flexion contracture
To improve range of motion
To improve functional activity
Significance of the study:
This study is to evaluate the efficacy of dynamic splinting for knee flexion contracture following a total knee arthroplasty.
Statement of the problem:
To study the efficacy of dynamic splinting for knee flexion contracture following a total knee arthroplasty.
Hence the study is entitled as “efficacy of dynamic splinting for knee flexion contracture following a total knee arthroplasty”.
Objectives:
To reduce flexion contracture
To improve range of motion
To analyze the effect of dynamic knee splint
Null hypothesis:
The null hypothesis can be stated as follows there is no significant difference in knee flexion contracture after the application of dynamic knee splint.
Alternate hypothesis:
The hypothesis can be stated as follows there is significant difference in knee flexion contracture after the application of dynamic knee splint.
2. REVIEW OF LITERATURE:
1. TOTAL KNEE ARTHROPLASTY:
Simon H Palmer, MD, Consultant Surgeon: Sep 21, 2010 Osteoarthritis destruction of the knee is the most common reason for total knee replacement.
Jayant joshi, prakash kotwal says that total knee replacement relieves pain, provides mobility & corrects deformity.
2. FLEXION CONTRACTURE:
J. Ilyas; A.H. Deakin; C. Brege; and F. Picard Flexion contracture is a common deformity encountered in patients requiring total knee arthroplasty (TKA).
Department of orthopaedics, golden jubilee national hospital, clydebank, glasgow, g81 4hx, uk. One hundred and four continuous TKA were completed by a single consultant using the OrthoPilot (BBraun, Aesculap) navigation system and Columbus implants. Seventy-four knees had preoperative flexion contracture (including neutral knees) while 30 were in hyperextension.
Ouellet D, Moffet H. Arthritis Rheum October 2002 Large movement deficits are present, especially in single-limb support pre-op and 2 months following TKA.
Huei-Ming Chai, PHD. November 24, 2008 total knee arthroplasty limits range of motion
3. DYNAMIC SPLINT:
Dennis l armstrong, m.d. Buck willis, phd evaluates the efficacy of dynamic knee extension splinting for knee flexion contracture following TKA.
Finger E, Willis FB Health Physical Education, Recreation, Texas State University, Cases Journal 2008, Physical therapy alone did not fully reduce the contracture and dynamic splinting was then prescribed for daily low-load, prolonged-duration stretch.
Finger E, Willis B 29Dec2008: Dynasplint offers extension Systems to aid in rehabilitation and recovery from flexion contracture.
Clinical studies have demonstrated greatest average reduction in rehabilitation time and cost with the use of Dynasplint Systems in conjunction with physical therapy.
Willis FB Biomechanics.2008 Jan; 15 After surgery, a patient is often left with shortened connective tissue and may have a difficult time walking normally again. Wearing a dynamic knee splint will lengthen and remodel the tissue to restore range of motion.
McClure P, Blackburn L, Dusold C Ideally, wearing your Dynasplint for 6-8 continuous hours yields the best results as it allows a safe, long lasting remodeling of the soft tissue.
Cliffordr.Wheeless, Iii, Md.December3, 2008. The purpose of this report is to review the use of external fixator for the gradual correction of severe knee flexion contractures that limit patient function.
James f. Mooney iii, md, l. Andrew koman Posted: 05/01/2001 Average preoperative flexion contracture was 80.5°. Each patient achieved full extension. There was one recurrence, despite bracing, which was managed with replacement of the fixator and soft tissue procedures
4. CONVENTIONAL PHYSICAL THERAPY FOR KNEE ARTHRITIS:
Jan.K.Richardson, Pt, Phd, Ocs Said that arthritis is a degenerative disease of the cartilage and bones that results in pain and stiffness in affected joint. There is no cure for arthritis, but physical therapy can make living easier and less painful.
Brigham And Women’s Hospital Department of Rehabilitation Services Physical Therapy .ROM along with proper soft tissue balance is required to ensure proper biomechanics in the knee joint. Aggressive post-operative PT has been shown to be effective in improving patient outcomes and shortening length of stay
Balint G And Sz Ebenyl.B Showed that therapeutic exercises decreases pain, increases muscle fatigue and range of motion as well as improve endurance and aerobic capacity. Weight reduction is proven in obese patients with OA of knee. Therapeutic heat and cold, electrotherapy, acupuncture are widely used.
Dr. Margriet van baar reported that significant beneficial effects from exercise therapy including improvements in self reported pain, disability, walking ability and overall sense of well being.
Dorr LD. J Arthroplasty June 2002 CPM helps achieve knee range of motion quicker in first post-op weeks but at final follow-ups, no difference in final range of motion
Byrne, et al. Clin Biomech October 2002 Deficits in knee strength balanced by increased hip extensor work; rehab should optimize bilateral hip and knee function after TKA
McManus et al 2006, Jorge et al 2006 the higher frequencies (90-130Hz) to stimulate the pain gate mechanisms & thereby mask the pain symptoms.
Ozcan et al, 2004 Low frequency nerve stimulation is physiologically effective (as with TENS and NMES) and this is the key to IFT intervention.
Adedoyin, R. A., et al. (2002).IFT acts primarily on the excitable (nerve) tissues, the strongest effects are likely to be those which are a direct result of such stimulation (i.e. pain relief and muscle stimulation).
National Taiwan University Hospital, November 2008 PNF stretching techniques has been used frequently for patients with total knee arthroplasty in clinical practice to increase range of motion effectively and reduced knee pain during exercise.
Huei-Ming Chai, PHD November 24, 2008 PNF stretching technique is a therapeutic technique using the PNF concept to the related muslces either to increase neuro-inhibition mechanism for releasing muscle spasm and elongating muscle length, or to increase neuro-excitation mechanism for enhancing muscle strength
Harold B. James H. Beaty, MD Range-of-motion exercises, muscle strengthening, gait training, and instruction in performing activities of daily living are important.
5. GONIOMETRIC MEASURENT FOR ROM:
Carlos Lavernia, MD, Range of motion assessment through direct observation without a goniometer provides inaccurate findings.
Mark D. Rossi, PhD, PT, CSCS The Journal of Arthroplasty Vol. 23 No. 6 Suppl. 1 2008 Measured scores using a goniometer provided an improved degree of accuracy, but results appear to be dependent on the clinician performing the measurement.
Richard l. Gajdosik Associate Professor Physical therapists may accept most knee goniometric measurements as clinically valid, and the evidence indicates that most of these measurements are reliable.
6. KNEE SOCIETY SCORE:
Gil Scuderi, MD-Chair; Jim Benjamin, MD; Jess Lonner, MD; Bob Bourne, MD and Norm Scott, MD, 2007,The Knee Society rating system (KSS) was first published in CORR in 1989 and has become the standard clinical evaluation system for reporting results for patients undergoing Total Knee Replacement.
John N. Insall, MD, Lawrence D. Dorr, Scott, MD Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989 Nov:The Knee Society has proposed this new rating system to be simple but more exacting and more objective.
MD, Richard D. Scott, MD, and W. Norman It is hoped the knee society rating system will become universally accepted and will be adopted by all authors, even if they wish to report results using a customary scoring method as well.
3. MATERIALS AND METHODOLOGY:
MATERIALS:
Evaluation tool:
Goniometry
Knee society score
Outcome measure:
Range of motion
Knee score
Function score
Material used:
Dynamic knee splint
METHODOLOGY:
(A) Study design:
30 subjects with flexion contracture following unilateral TKA assigned in two groups.
GROUP A:
15 subjects: Dynamic Splint Along With Conventional Physiotherapy.
GROUP B:
15 subjects: Conventional Physiotherapy.
(B) Study setting:
This study was carried out in the department of physical medicine and rehabilitation, Sri Ramakrishna hospital, Coimbatore.
(C) Study duration:
This study was carried out for a period of 6 months.
(D) Sampling:
Random sampling.
INCLUSION CRITERIA:
Age: 45 to 70 years.
Both sex
Flexion contracture : 20 – 12 deg (post operatively)
Unilateral TKA
Reduced flexibility in AROM of knee extension
Pain that is worsened by bending over while legs are straight
Impaired gait pattern
Ability to understand informed consent and experiment responsibilities
EXCLUSION CRITERIA:
Fractures
Bilateral TKA
TKA < 2 months
Knee sepsis
Osteomyelitis or any orthopedic infection
Extensor mechanism dysfunction
Psoriasis
Knee joint neuropathy
Previous Stroke or Brain Injury
STATISTICS TOOL:
The data collected was analyzed using independent t-test. The test was carried out between two groups. Independent’t’ test was used to compare the effectiveness of treatment between the groups.
t =
S =
X1 = Difference between pretest and posttest values of Group I
X2 = Difference between pretest and posttest values of Group II
= Mean difference of Group I
= Mean difference of Group II
n1 = No. of samples in Group I
n2 = No. of samples in Group II
S = Combined standard deviation
TREATMENT:
Dynamic knee Extension splint:
The Rebound Effect
http://www.dynasplint.com/uploads/user-uploads/rebound2.gif
53% Average Reduction in Time and Cost Associated with ROM Rehabilitation
“High-force, short-duration stretching favors recoverable, elastic tissue deformation, whereas low-force, long-duration stretching enhances permanent plastic deformation. In the clinical setting, high force application has a greater risk of causing pain and possibly ruptures of tissue. Dynasplint Systems improve range of motion by creating permanent, non-traumatic tissue elongation and remodeling, thus virtually eliminating the range of motion rebound effect often observed in the clinical setting.
RangerKnee2
Features & Benefits
LLPS (Low-Load, Prolonged-Duration Stretch) technology has been proven to successfully treat joint stiffness and limited range of motion.
Early application can reduce time and cost associated with range of motion rehabilitation
Simple, adjustable and reproducible bilateral tensioning System
Available for rent or purchase
Biomechanically correct
Comfortable to wear
Each Dynasplint System is recycled to reduce waste and help the environment
A Dynasplint Systems consultant will fit your patients and oversee their treatment to ensure the best possible results
Over a quarter of a million patients have been successfully treated with Dynasplint Systems
Conveniently labeled and easy to use
Patient Wearing Protocol
Please review the tension your Dynasplint consultant set for you initially.
In the beginning, the splint should be worn for 2-4 hours.
Do not increase the tension until you can tolerate overnight wear. Time is the most important factor and your first goal should be 6-8 hours of pain free wear.
After achieving this time goal, when you take the splint off if you have less than 1 hour of post-wear stiffness, turn tension up by one on both sides.
However if you are unable to wear the splint for a prolonged period of time, decrease the tension by a half to one full turn.
During the process of regaining your range of motion, if you have any question or concerns contact your Dynasplint consultant.
http://www.wheelessonline.com/images/i1/imk11.jpg
CONVENTIONAL TREATMENT:
MODALITIES FOR PAIN CONTROL, EDEMA REDUCTION:
Moist Heat
Functional electrical stimulation
Transcutaneous electrical stimulation
Ice therapy
Interferential therapy
Galvanic Stimulation
JOINT MOBILIZATION:
Flexion restriction
Position: patient seated
Posterior glide of tibia on femur-grade 3 Oscillation with 30 second hold, Repeated 5 times with patellar mobilization of inferior glides (5 mins)
Extension restriction
Position: patient prone with patella off of table
Anterior glide of tibia on femur- grade 3 oscillation and static hold (10 secs in 3 repetitions) with patellar mobilization superior glides (5 mins)
EXERCISE PROGRAM:
Closed and open kinetic chain strengthening exercises
Proprioceptive/balance exercises targeting the trunk and lower extremity musculature
Partial body weighted squats
Gait training
Range of motion exercises
Heel slide (supine& sitting)
Stretching (prone/supine) to increase knee extension ROM
GAIT TRAINING:
Forward Walking
Sidestepping
Backward or Retro-Walking
FUNCTIONAL TRAINING:
Standing
Transfer Activities
Lifting
Carrying
Pushing or Pulling
Squatting or Crouching
Return-to-Work Tasks
ENDURANCE TRAINING:
Upper body exercise.
Ambulation activities
One-leg cycling, using non-operative leg with resistance to motion.
BALANCE/PROPRIOCEPTION TRAINING:
Tandem Walking
Lateral Stepping over/around objects
Weight-Shifting Activities
Closed Kinetic Chain Activities
5. DATA ANALYSIS AND INTERPRETATION:
KNEE EXTENSION ROM: GROUP I
Pre test
(Two months after TKA)
Post test
(conventional PT with SPLINT)
Difference
X1
16
0
16
16
1
15
16
2
14
16
2
14
16
4
12
14
0
14
14
0
14
14
1
13
14
1
13
14
2
12
12
0
12
12
0
12
12
1
11
12
1
11
12
1
11
Mean=12.93
PRE TEST AND POST KNEE EXTENSION ROM: GROUP I
KNEE EXTENSION ROM: GROUP II
Pre test
(Two months after TKA)
Post test
(conventional PT without splint)
Difference
X2
18
7
11
18
6
12
18
6
12
18
6
12
18
4
14
16
7
9
16
7
9
16
4
12
16
4
12
16
4
12
14
3
11
14
4
10
14
4
12
14
2
12
14
2
12
Mean=11.46
t=2.82
s.dev=1.42
degrees of freedom = 28
The probability of this result, assuming the null hypothesis, is 0.009
PRE TEST AND POST KNEE EXTENSION ROM: GROUP II
KNEE SCORE AND FUNCTION SCORE:
S.No.
Parameters
Groups
Mean
S.D.Value
‘t’ Value
1.
Knee Scores
Group A
18
4.47
3.06
Group B
13
2.
Function Score
Group A
35.6
4.98
3.01
Group B
30.1
MEAN DIFFERENCE BETWEEN
KNEE SCORE AND FUNCTION SCORE
DEMOGRAPHIC DATA
THE AGE OF THE SAMPLES BETWEEN 45 -70 YEARS IN EACH GROUP
Age (years)
No. of Samples
Total
Group A
Group B
45-50
4
3
7
50-55
5
4
9
55-60
2
5
7
60-65
2
2
4
65-70
2
1
3
TOTAL NUMBER OF MALES AND FEMALES IN EACH GROUP
Sex
No. of Samples
Total
Group A
Group B
Male
8
10
18
Females
7
5
12
TOTAL NUMBER OF RIGHT AND LEFT SIDE INVOLVEMENT IN EACH GROUP
Side of involvement
No. of Samples
Total
Group A
Group B
Right
11
8
19
Left
4
7
11
5. DISCUSSION
Total knee arthroplasty (TKA) is considered the treatment of choice for patients with intractable pain and substantial functional disabilities who have not had acceptable relief and functional improvement after conservative treatment. Knee flexion contracture is a common pathology following TKA affecting up to 61% of these patients.
The purpose of the study is to determine the effectiveness of dynamic splinting in treating patients with flexion contracture following Unilateral TKA.
Literature review states that there is significant difference between dynamic splinting and conventional physiotherapy management in reducing flexion contracture following Unilateral TKA.
A total of thirty patients with unilateral TKA were selected under inclusive criteria and were randomly allocated into an experimental group and control group as Group A and group B respectively. In each group 15 Individuals were allotted
In Group A, dynamic splint along with conventional physiotherapy was given and in Group B, Conventional physiot
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