Comparative Study of Efficacy of Muscle Energy Technique and Positional Release Therapy in Post ACL Reconstruction in Young Adults: A Randomised Clinical Trial

The anterior cruciate ligament (ACL), it is a dense connective tissue band originating from the medial wall of the lateral femoral condyl and inserts into the middle of the intercondylar region on the tibia. It is regarded as a crucial component in the knee joint because it resists anterior tibial translation and rotational load. Young athletes who participate in sports that demand turning, decelerating, and jumping are at high risk for ACL injury. People who participate in Pivoting sports are likely to have them (e.g. football, basketball, netball, soccer, European team handball, gymnastics, downhill skiing). Environmental (e.g., high friction between shoes and the playing surface) and anatomical variables are also risk factors for ACL injury (e.g. narrow femoral intercondylar notch). Knee instability causes a reduction in activity, which can result in a decrease in knee-related quality of life. ACL injury risk factors have been classified as either internal or external to a person. Type of competition, footwear and surface, and environmental conditions are all external risk factors. Anatomical, hormonal, and neuromuscular risk factors are all internal risk factors. Pre-protocol Article Ingale et al.; JPRI, 33(46B): 163-167, 2021; Article no.JPRI.74884 164 Aim and Objective: to compare the efficacy of Myofacial Release Technique versus Positional Release Therapy on range of motion post ACL reconstruction. Methodology: In this study total 45 patients with post ACL reconstruction will be divided into two groups, one group will receive muscle energy technique and other group will received positional release therapy. The treatment will be given for 5 sessions per week for six weeks. The assessment will be done at day one of treatment at the end of treatment at the end of first week and at the end of six week. Discussion: This study will find the better technique for improving Range of motion Post ACL reconstruction. Conclusion: Conclusion of the study will be drawn after the statistical analysis of the data gathered from the individuals enrolled in the study.


INTRODUCTION
The human knee is the body's largest joint, with a complex anatomy. It's a movable a pivotal hinge joint that can stretch and rotate medially and laterally. The knee bears nearly all of the body's weight, it is vulnerable to both acute injury and osteoarthritis. The anterior cruciate ligament (ACL) is a ligament that connects the two halves of the knee [1] To avoid ACL injuries, it's important to identify risk factors and to investigate the most common causes [2]. Women have a higher rate of anterior cruciate ligament injury to the contralateral knee following surgery than men [3].
Restoring ROM post surgery is an important aspect of normal human function. A variety of range of motion strategies can be used to increase ROM, although little work has been done to compare these techniques. The objective of this study is to compare the efficacy of muscle energy technique (MET) and positional release technique (PRT) in post ACL reconstruction patients in young adults [4].
Muscle energy technique is an osteopathic technique that utilizes a muscle's own energy in the form of moderate isometric contractions to relax and stretch it through autogenic or reciprocal inhibition [5].
Positional release therapy, also known as strain counterstrain, is a clinical procedure in which the body, its appendages, and tissues are placed in a comfortable position to resolve somatic dysfunction. Somatic dysfunction is characterised as a disruption in the sensory or proprioceptive system that causes facilitation and inhibition of spinal segmental tissue. The tissues become kinked or knotted as a result of somatic dysfunction, resulting in discomfort, spasm, and a loss of range of motion.PRT untangles tissues in the same way as a knotted necklace is untangled: by gently twisting and pressing the tissues together to relieve tension. When one link in the chain is untangled, it causes those nearby to untangle as well, resulting in significant pain relief, More than 200,000 ACL injures occur each year, with 100,000 of these knees requiring reconstruction. The majority of ACL occurrences are caused by non-contact processes, with direct contact accounting for the remaining 30% [6].

Aim and Objective
The aim of this study is to compare the efficacy of muscle energy technique and positional release technique in improving range of motion in post-ACL reconstruction patients.

Study design
After getting approval from Institutional Ethics Committee of Data Meghe Institute of Medical Sciences, Deemed to be university, the participants will be recruited from physiotherapy OPD of Acharya Vinoba Bhave Rural Hospital, Sawangi Meghe, Wardha, Maharashtra. Before inclusion, participants will be explained about the objectives and approaches of the study. written consent form will be signed by them.

Study population
Individuals undergone ACL reconstruction.

Sample size calculation
The sample size was calculated by using Cochran formula. There will be 22 individuals in one group and 23 individuals in the other group.

Sample size
n= 45 patients will be needed in the study [7].

Study design
Randomised Clinical Trial.

Study type
Interventional Study.

Randomization
Simple Random Sampling.

Sample Size Calculation
The sample size was calculated by using Cochran formula. There will be 22 individuals in one group and 23 individuals in the other group.

Sample Size
n= 45 patients will be needed in the study [7].

Inclusion criteria
The individuals within 18-30 years, male and female, diagnosed with ACL injury and have undergone ACL reconstruction surgery.

Exclusion criteria
The individuals above 30 years of age and those who have not underwent surgery.

Participant Timeline
Each patient will be required to complete 2 weeks of rehabilitation after enrolment in the study. The evaluations will be performed at baseline and at last session.

Implementation
Research coordinator and principal investigator will supervise randomization. Participants will be asked to select from the envelope, sealed group allocation for the recruitment into either group.

Blinding
Tester(s) will be blinded to assign the subjects to the group. To ensure binding, subjects will be mandated not to reveal any details of their treatment to the tester.

Dependent variables
Range of motion, pain, muscle strength.

Independent variables
Muscle energy technique, positional release therapy.

Positional release therapy (PRT)
PRT Performance Care focuses on reducing constraints that limit full range of motion and restoring complete function and performance to soft tissues that have been compromised. This approach can lead to considerable improvements in power, strength, range of motion and flexibility [8].
 Position the patient in comfortable position, most often in lying down.  Palpate the affected areas that may be associated due to referred pain.  Palpate the selected tender points(TP) _ instruct the patient to relax the area. Passively move the appropriate body part to release tension at the tender point. Stop movement when the pain stops and patient only feels pressure.  Release the pressure-but maintain light contact over the TP to monitor response.  Maintain the position for 90 seconds. Hold longer if patient feels a therapeutic pulse, change in tissue tension or movement [6].  Encourage patient to relax-slowly return to neutral position.  Active and passive mobilization will be performed. It includes multidirectional mobilizations for patella once a day for at least 2 weeks. Passive extension of knee and active and passive mobilization towards flexion should be done in first 4 weeks.  Calf, hamstring, and quadriceps (vastusmedialis) strengthening exercises can all be done for 2-3 times a day to improve the strength of the muscles [9].

Muscle energy technique (MET)
The Reciprocal Inhibition MET technique is performed as follows:  The affected muscle is placed in a midrange position.  The patient pushes towards the restriction/barrier whereas the therapist completely resists this effort (isometric) or allows a movement towards it (isotonic).  This is followed by relaxation of the patient along with exhalation, and the therapist applies a passive stretch to the new barrier [5].  The individual performed a moderate about (35-40% of maximum contraction) knee flexion isometric contraction against the examiner's shoulder for 7-10 seconds. This will be followed by 2-3 seconds of relaxation [10].  Then the leg will be passively stretched to the palpated barrier or tolerance to stretch and held for 30 seconds.  This will be given 1-2 repetitions per day for 2 weeks.  Active and passive mobilization will be performed. It includes multidirectional mobilizations for patella once a day for atleast 8 weeks. Passive extension of knee and active and passive mobilization towards flexion should be done in first 4 weeks.  Calf, hamstring, and quadriceps (vastusmedialis) strengthening exercises can all be done for 2-3 times per day to improve the muscle strength.

Goniometer: A goniometer is an instrument
that measures the available range of motion at a joint. The art and science of measuring the joint ranges in each plane of the joint are called goniometry [1]. If a patient or client is suffering from decreased range of motion in a particular joint, the therapist can use a goniometer to assess what the range of motion is at the initial assessment, and then make sure the intervention is working by using the goniometer in subsequent sessions [11]

Numerical pain rating scale
The Numeric Pain Rating Scale (NPRS) is a single dimensional measure of pain intensity in adults. The 11-point numeric scale ranges from '0' representing one pain extreme (e.g. "no pain") to '10' representing the other pain extreme (e.g. "pain as bad as you can imagine" or "worst pain imaginable"[13].

Data collection
Data collection and reporting will be performed under the guidance of the chief investigators. Documentation for the analysis will be carefully scrutinised for accuracy. The excel spreadsheet will be issued to an allocation blinded statistician at the end of the study to perform the required analysis, after which the groups will be unblended. The trial's data will be stored in a safe, locked storage area with restricted access for later analysis by a biostatistician and the lead researcher. Checklists are used to avoid data from being lost due to inadequate personnel procedures.

DISCUSSION
The protocol will be conducted to see the effect of muscle energy technique versus positional release therapy on increasing range of motion in post ACL reconstruction patients in young adults.

CONCLUSION
The study will be carried out to see the efficacy of muscle energy technique and positional release therapy on increasing range of motion in patients will post ACL reconstruction in young adults. The conclusion will be drawn after analysis of the data CONSENT Principal investigator will obtain the written inform consent from the participant on a printed from (local language) with signatures and give the proof of confindentiality.

ETHICAL APPROVAL AND DISSEMINA-TION
The participant individuals of the study and DMIMSU who will fund it will be able to retrieve findings of study. After completion of study and publication of results data will be stored in the DMIMSU data repository.

CONFIDENTIALITY
The study program will be explained to the participant, the principal investigator will take subjective information. The consent form will include the confidentiality statement and signatures of the principal investigator, patient and a witnesses. If required to disclose some information for the study, consent will be taken from the patient with complete assurance of his confidentiality.