Scientific Research Journal of India

Scientific Research Journal of India
(Multidisciplinary, Peer Reviewed, Open Access, Journal of science) ISSN: 2277-1700 Vol: 2, Issue: 3, Year: 2013
Editor in Chief Dr. Krishna N. Sharma (PT) Editors Dr. Popiha Bordoloi Dr. Kuki Bordoloi Dr. Sudeep Kale Dr. Waqar Naqvi Junior Editor Mrityunjay Sharma
Office Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403 Website http://srji.drkrishna.co.in URL Forwarded to http://sites.google.com/site/scientificrji Email editor.srji@gmail.com Contact +91-9320699167
Declaration: The contents of the articles and the views expressed therein are the sole responsibility of the authors, and the editorial board will not be held responsible for the same. Copyright 2013 Scientific Research Journal of India All rights reserved.
CONTENTS
Title Editorial Effect of core stabilization
Author/s Dr. Krishna N. Sharma
Department
Page i
training on endurance of trunk extensor and functional capacity in subjects with mechanical low back pain Effect of trunk muscles
Ranjeet Kumar, Dr. Prosenjit Patra
Physiotherapy
stabilization exercises and general exercises on disability in recurrent non specific low back ache Study of respiratory capacity and core muscle strength in Indian classical singers Aerobic capacity, body mass
Kumar Amit, Gupta Manish, Kumar Satish, Katyal Taruna Physiotherapy 9
Shweta S. Devare Phadke, Sukhada Prabhu, Sujata Yardi Physiotherapy 18
index and fat fold measurements of healthy athletes in Dehradun A cross sectional study Effects of bimanual functional practice training on functional performance of upper extremity in chronic stroke A comparison study on physical impairments and functional
Sharma Chetan, Dr. Dar Shahid Mohd.
Physiotherapy
24
Dr Jasmine Anandabai, Dr Manish Gupta
Physiotherapy
30
limitations of patients: 1 year after total knee arthroplasty versus control subjects Respiratory physiotherapy in
Amit Murli Patel
Physiotherapy
40
Shanmuga Raju P, Renkha Rao, Rajendhra Kumar J, SuryaNaryana Reddy V Physiotherapy 55
triple vessel disease with post coronary artery bypass grafting surgery (CABG)
ISSN: 2277-1700 Website: http://srji.drkrishna.co.in URL Forwarded to: http://sites.google.com/site/scientificrji
Occupational therapy marketing indian prospective Annotated bibliography of studies w.r.t statistical methods
Koushik Sau
Occupational Therapy
59
Neha Dewan
Physiotherapy
67
iv
EDITORIAL
Dear Readers! I am very pleased to present this issue of the Scientific Research Journal of India (SRJI). With this issue. This issue of the multidisciplinary and open access Journal of science contains total 8 papers in Physiotherapy, and 1 paper in Occupational Therapy. I hope youll find these papers informative.
Here I would like to bring one more thing to your notice that new and permanent URL is http://SRJI.DrKrishna.co.in and it will be directed to http://sites.google.com/site/scientificrji .
Do drop a mail to us (editor.srji@gmail.com) if you have any comment and suggestion.
Happy Reading.
Regards,
Dr. Krishna N. Sharma Editor in Chief
EFFECT OF CORE STABILIZATION TRAINING ON ENDURANCE OF TRUNK EXTENSOR AND FUNCTIONAL CAPACITY IN SUBJECTS WITH MECHANICAL LOW BACK PAIN
Ranjeet Kumar, MPT (Musculoskeletal Disorder)*, Dr. Prosenjit Patra, MPT (Cardiopulmonary)**
ABSTRACT STUDY OBJECTIVES: To determine the effect of Core stabilization training on trunk extensor endurance and functional capacity in subjects with mechanical low back pain. DESIGN: Experimental study. SETTING: All the Subjects were taken from Dolphin (PG) Institute Of Biomedical and Natural Science, Dehradun and the community in and community in and around Dehradun. SUBJECTS: A total of 30 subjects (M: 14, F: 16) were recruited for the study on the basis of inclusion and exclusion criteria after signing the informed consent form. METHODS: A total of 30 subjects (M: 14, F: 16) were recruited for the study on the basis of inclusion and exclusion criteria after signing the informed consent form. The subjects were then divided into two groups, (Group A= Core Stabilization and Endurance Training & Group B= Endurance Training). All the subjects were asked to perform 5 min warm-up exercise before the intervention. The total duration of the protocol was 6 weeks and frequency of exercise performed is 3 times per weeks. OUTCOME MEASURE: Trunk Extensor Endurance Test was measured using Prone Double Straight-Leg Raise Test, & Functional Capacity was assessed using Modified Oswestry Disability Index. RESULTS: The result of the study demonstrates that both the Groups showed significant improvement when comparison is made within the groups with p=0.001 for both trunk extensor endurance test and functional capacity. However, Group A shows significant improvement between the groups post intervention p=0.023 & p=.000 respectively.
1
CONCLUSION: From the present study it can be concluded that core stabilization training is effective in increasing trunk extensor endurance and functional capacity in subjects with mechanical low back pain.
KEY WORDS: Core stabilization training, Endurance training, Trunk extensor endurance, Mechanical low back pain, Trunk Extensor Endurance
INTRODUCTION Low back pain is one of the most common and costly musculo-skeletal pain syndromes, affecting up to 80% of people at some point during their lifetime. The re-occurrence rate of low back pain is high and these disorders often develop into a chronic fluctuating problem with intermittent flares.6 Caring for chronic low back pain, is one of the most difficult and unrewarding problems in clinical medicine, as no approach to diagnose or any form of treatment, has been shown to be clearly definitive or effective. One possible explanation for the inability to identify effective treatment protocols is the lack of success in defining groups of patients who are most likely to respond to a specific treatment approach.6 For most patients with acute low back pain, the etiology is thought to be a mechanical cause involving the spine and surrounding structures.12 A wide range of terms is used for non-specific mechanical causes, including low back strain/sprain, facet joint syndrome, sacroiliac syndrome, segmental
extremities, which will increase the predisposition to chronic injuries.5 The core has been described as a box with the abdominals in the front, paraspinal and gluteals in the back, the diaphragm as the roof and the pelvic floor and hip girdle musculature as the bottom. Therefore, the core serves as a muscular corset that works as a unit to stabilize the body and spine.1 Panjabi (1992) describe the spinal
stabilization system is conceptualized as consisting of three subsystems; passive muscular skeletal subsystem, which includes vertebra facet
orientation, intervertebral disc, spinal ligament and joint capsules, as well as the passive mechanical properties of the muscles. The active muscular skeletal subsystem consists of muscles and tendons that surround the spinal column. The neural and feedback subsystem consists of various force and motion transducers located in ligaments, tendons, muscles and neural control centers. These passive, active and neural control subsystems - although conceptually separate are functionally
independent. The passive subsystem does not provide any significant stability to the spine in the vicinity of the neutral position. It is towards the ends of the ranges of motion that the ligaments develop reactive forces that resist spinal motion. The active subsystem is the means through which the spinal stabilization system generates forces and provides the required stability to the spine. The
dysfunction, somatic dysfunction, ligamentous strain and myofascial strain.3 Biomechanics may be altered due to low back pain or injury to the spine, producing weakness and loss of muscle control, which leads to further injury because the joints are not appropriately supported again, this may result in over-compensation by the pelvis or lower
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Scientific Research Journal of India Volume: 2, Issue: 3, Year: 2013
magnitude of the force generated in each muscle is measured muscles.15 Therefore, this aspect of the tendons may be part of the neural control subsystem. Within the neutral zone of motion, (that part of the range of physiological intervertebral motion, measured from the normal position, within which the spinal motion is produced with a minimal internal resistance - it is the region of high flexibility around the mid-zone of motion) the restraints and control for bending, rotating and shear force are largely provided by the muscles that surround and act on the spinal segment. The neural subsystem receives information from the various transducers, determines specific requirements for spinal by the force transducers (signal
pain intensity, alleviate functional disability and improve core stability and back extension strength, mobility and endurance.17 According to Chok et al. (1999), poor endurance of the trunk muscles may induce strain on the passive structures of the lumbar spine, eventually leading to low back pain. Evidence suggests that muscle endurance is lower for people with low back pain than for individuals without low back pain. Due to endurance being less in trunk muscles, fatigue can affect the ability of people with low back pain to respond to the demands of an unexpected load. Fatigue, after repetitive loading, also leads to loss of control and precision, which may predispose an individual to developing low back pain. Therefore, trunk muscle endurance training has been recommended to elevate fatigue threshold and improve
producing devices) located in the tendons of the
stability and causes the active subsystem to achieve the stability goal.16 Well-developed core stability allows for improved force output, increased neuromuscular efficiency and a decrease in the incidence of overuse injuries.9 The normal function of the stabilization system is to provide sufficient stability to the spine to match instantaneous varying stability demands made by changes in spinal posture, static and dynamic load.15 Hicks et al, suggest that core stability system has a role in ensuring spinal stability and according to van Dillin et al. (2001), a decrease in spinal stability places stress and excessive load on the spinal joints and tissues, which eventually results in low back pain.
19
performance, thus, reducing disability of the lumbar spine.4 Endurance training of back extensor muscles, including the multifidus, has long been recognized as a crucial preventative of recurrent low back pain. The function and coordination of the muscles that stabilize the lumbar spine, especially the lumbar extensor muscles, are often impaired in patients with low back pain.13 The role of trunk stabilizers is to retain the musculature; to control, coordinate and optimize function. Trunk fatigue, which occurs during intense training or matches, produces a loss in synchrony between upper and lower extremities, which may cause a reduction in muscle strength. This may in turn prevent a proper transfer of force resulting in inappropriate compensation by the body while performing a particular function.5 Dynamic trunk stability training includes building muscle strength, endurance and using
Control of back pain and prevention of its occurrence can be assisted by enhancing muscle control of the spinal segment through core stability exercises. Therefore, exercise programs, which are based on active rehabilitation, can reduce low back
neuromuscular control to maintain dynamic trunk stability.

10
Rest-1minute
METHODOLOGY An experimental study was conducted on 30 subjects (14 male and 16 female) who were recruited Biomedical from and Dolphin Natural (PG) Institute and of the 3. Abdominal crunch o Sets-2 o Repetition-8 o Rest-1minute
Science
community in and around Dehradun based on the inclusion and exclusion criteria and they were divided into two groups after informed consent was obtained. Group A (Core Stabilization and Endurance Training) & Group B (Endurance Training). Pre intervention measurement of Trunk Extensor Endurance Test was measured using Prone Double Straight2-Leg Raise Test, & Functional Capacity was assessed using Modified Oswestry Disability Index8. For both the groups 5 min of warm exercise was given before the intervention. The total duration of protocol was 6 weeks and frequency of exercise was 3 times per week. Protocol for Group A: All subjects in this group received Core stabilization training and Endurance training on a Swiss ball. 1. Lunge Sets-2 Repetition-8 Rest-1minute
4. Supine Russian twist o Sets-2 o Repetition-8 o Rest-1minute
Protocol for Group B: All subjects in this group received Endurance training on a Swiss ball. 1. Bilateral shoulder lifts Sets-6 Repeatation-5 Rest-1 minute Holding-20sec
2. Supine lateral roll. Sets-2 Repetition-8

4
2. Contra-lateral arm and leg lifts o Sets-2 o Repeatation-8 o Rest-1 minute o Holding-20sec
t-test was used for data analysis within the group A and group B for Extensor muscle endurance test and Modified Oswestry Low Back Pain Disability Index. Independent t-test was used for data analysis between the group A and group B for Modified Oswestry Low Back Pain Disability Index. The p value was set at (<0.05). RESULTS Data was analysed for 30 participants: 15 in each Group A & Group B.
3.
Bilateral shoulder lifts with hands behind the head o Sets-2 o Repeatation-8 o Rest-1 minute o Holding-20sec Table1.1: Comparison of mean value for age between group A and B
4. Bilateral shoulder lifts with arms in full elevation o Sets-2 o Repeatation-8 o Rest-1 minute o Holding-20sec
Table 1.2: Comparison of Pre and Post EET score for group A and group B
Table1.3: Comparison of Pre and Post MODI score for group A and group B
DATA ANALYSIS Data was analysed using statistical package of social sciences SPSS software (version 14.0). Pair
Table 1.4: Comparison of Pre and Post EET score between group A and group B
given Core stabilization training and Endurance training on a Swiss ball and Group B was given Endurance training on a Swiss ball. Both groups received training three times a week for six weeks. The changes observed in this study were noteworthy. Within group comparison showed significant changes with improvement in isometric
Table 1.5: Comparison of Pre and Post MODI score between group A and group B
hold time and functional capacity in both groups A and B. In between groups, statistically significance difference was found in isometric hold time and functional capacity. According to Moffroid, Progression of loading through postural changes produces
increases in endurance time of the back extensors, as measured by the Sorensen Test. These postural progressions increase the load moment on the Results of the study showed that there is improvement in trunk extensor endurance and functional capacity after the intervention in both the groups. This improvement in pressure spine and thereby stress the erector spinae muscles, multifidus and others.14 In addition adoptive changes occur in skeletal muscle during endurance training ie, slower rate of glycogenolysis, slower rate of lactate production during submaximal exercise occurs due to raise in the lactate threshold both in absolute and relatives terms ie, o2 uptake(VO2)at LT and vo2 max at LT, increased mitochondrial enzyme activity and increase capillary density.7 Therefore, it is reasonable to expect DISCUSSION The present study investigated the effect of core stabilization training on endurance of trunk extensor and functional capacity in subjects with mechanical low back pain. Endurance of Trunk extensor and functional capacity was measured 2 times: pre-intervention and post-intervention increased endurance of trunk extensor muscle in group B subjects who only underwent endurance training. Core stabilization training has a theoretical basis in treatment and prevention of various musculoskeletal conditions. Core stabilization training is hypothesized to increase muscle activation by increasing motor unit recruitment, rate and synchronization of firing11
threshold was found to be statistically significant. Group A (Trunk Extensor Endurance & Core Stabilization) showed more improvement when compared to Group A and this was found to be statistically significant with p=0.023 & p=.000 respectively.
through prone double straight leg raise test and Modified Oswestry Low Back Pain Disability Index respectively. Subjects were divided into two groups as Group A and Group B. Group A was
Richardson found that individual with low back pain exhibits delayed activation of the transversus abdominis muscle when compared with normal individual. Low back pain patient have an impaired ability to consciously contract transversus abdominis and this is an important component of abdominal stability training.17 Performance of exercises on unstable surfaces like Swiss ball has been shown to increase the activity of the rectus abdominis. It also causes changes in muscle activity and force output and may be another way of potentially altering neuromuscular recruitment pattern
17
stabilize their form better during performance of prone double leg raise test, thereby resulting in longer hold times than subjects who only underwent endurance training.18 So over all core stabilization training increases abdominus, muscle lumbar activation (transversus alters
multifidus),
neuromuscular control and also increases spinal stability, leading to decreased pain which may
have led to the increased isometric hold time and functional capacity in group A subjects as compared to subjects in group B. Limitation of the study are sample size was limited and no blinding was done during the study. So the further recommendation for future studies need to be done with broader dimensions, EMG could be used to quantify the activation of core muscle and it can also be used to track global muscle activation during core stability testing. Bio-mechanical marker can be measured.
Spinal instability occurs generally as a result of delayed recruitment of core muscle/local muscle like transversus abdominus, multifidus and core stabilization training address these core muscle, thereby increase spinal stability.
17
Study by Kimitake Satoand Monique Mokha has shown that core stabilization training let to an increase in 5000meter run time performance. The proposed mechanism was that subjects who underwent core stabilization were conscious of using their core muscle to stabilize their running form. A similar mechanism may exist in our study where by subjects who underwent core stabilization training were able to
CONCLUSION From the present study it can be concluded that core stabilization training is effective in increasing trunk extensor endurance and functional capacity in subjects with mechanical low back pain.
REFERENCES
1. Akuthota V. and Nadler, S.F. Core Strengthening. Physical Medicine and Rehabilitation. 2004; 85(1): 86-92. 2. Arab A M, SalawatiMahyar, Mohhammad E. Sensitivity, specificity and predictive value of the clinical trunk muscle endurance tests in low back pain. Clinical Rehabilitation. 2007;21:640-647 3. Atlas, S.J. and Deyo, R.A. Evaluating and Managing Acute Low Back Pain in the Primary Care Setting. Journal of General Internal Medicine. 2001; 16(2): 120-131. 4. Chok, B., Raymond. L., Latimer, J. and SeangBeng, T. Endurance Training of the Trunk Extensor Muscles in People With Sub Acute Low Back Pain. Physical Therapy. 1999; 79(11):1032-1042.
5. Cholewicki, J. and McGills, S.M. Lumbar Posterior Ligament Involvement During Extremely Heavy Lifts Estimated from Fluroscopeic Measurement. Journal of Biomechanics. 1992; 25:17-28. 8) 6. Dankaerts, W., OSullivian, P.B., Straker, L.M, Burnett, A.F. and Skouen, J.S. The Inter- Examiner Reliability of a Classification Method for non- Specific Chronic Low Back Patients with Motor Control Impairment. Manual Therapy.2005; 2:1-12. 7. Edward F, Coyle H, Martin, Susan A, Bloomfield, Oliver H, Lowry, John O, Holloszy. Effects of detraining on response to submaximal exercises. J.Appl. Physiol.1985 59(3): 853-859 8. Fritz JM, Irrgang JJ. A Comparison of a Modified Oswestry Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther 2001; 81:776-788. 9. Hedrick, A. Training the Trunk for Improved Athletic Performance. Strength and Conditioning Journal. 2000; 22(3), 50-61. 10. Hubley-Kozey, C.L. and Vezina, M.J. Muscle Activation During Exercise to Improve Trunk Stability in Men With Low Back Pain. Journal of Physical Medicine and Rehabilitation. 2002; 83(8): 11001108 11. Kisner C, Colby LA. Therapeutic Exercise Foundations and Techniques. 5th ed.Philadelphia: F.A Davis Company; 2007. 12. Krismer, M. and van Tulder, M. Low Back Pain (non-specific). Journal of Biomechanics. 2007; 21(1): 79-91. 13. Liebenson, C. Spinal Stabilization Training: The Therapeutic Alternative to Weight Training. The Journal of Body Work and Movement Therapies. 1997; 1 (2): 87-90 14. Moffroid MT, Haugh LD, Haig AJ, et al. Endurance training of trunk extensor muscles. Phys Ther. 1993; 73:10 17. 15. Panjabi, M.M. The stabilizing system of the spine, Part 1: Neutral zone and instability hypothesis. Journal of Spinal Disorder. 1992; 5(4) 383 389. 16. Panjabi, M.M. The stabilizing system of the spine, Part 2: Neutral zone and instability hypothesis. Journal of Spinal Disorders. 1992; 5(4): 390 397. 17. Richardson C.A. and Jull G.A. Muscle control-pain control. What exercise would you prescribe?.Manual Therapy. 1995; 1: 2-10. 18. Sato K, Mokha M Does core strength training influence Running kinetics, lower-extremity stability, And 5000-m performance in runners? Journal of Strength and Conditioning Research. 2009; 23(1):133-140 19. VanDillin, L.R., Sahrmann, S.A., Norton, B.J., Coldwall, C.A., Flemming, D., McDonell, M.K. and Bloom, N.J. Effect of Active Limb Movements on Symptoms in Patients with Low Back Pain. Journal of Orthopaedic and Sports Physical Therapy. 2001; 31 (8): 402-4144. 20. http://www.exercise-ball-exercises.com/list-free-exercise-ball-exercises.htm
CORRESPONDENCE
** Asst. Prof. Dolphin (PG) Institute, Dehradun (UK) * Student Researcher, Dolphin (PG) Institute, Dehradun (UK)
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EFFECT OF TRUNK MUSCLES STABILIZATION EXERCISES AND GENERAL EXERCISES ON DISABILITY IN RECURRENT NON SPECIFIC LOW BACK ACHE
Kumar Amit*, Gupta Manish, Kumar Satish**, Katyal Taruna***
ABSTRACT OBJECTIVE: To study the Effect Of Trunk Muscles Stabilization Exercises And General Exercises On Disability In Recurrent Non Specific Low Back Ache. DESIGN: Pre-test and Post test control group design. SETTING: Inpatient and rehabilitation hospital. PARTICIPANTS: A total number of 80 patients with recurrent non specific low back pain are allocated randomly into 1 of 2 groups; control group received general exercise only (n=40) and experimental group received specific stabilization (n=40)
INTERVENTION Both groups received 6 weeks exercise intervention with 30-40 min per session, thrice per week and written advice. Main Outcome Measures: A Rolland Morris low back disability questionnaire were used to measure disability. Outcomes were measured before and after intervention. RESULTS: The calculated t-values for the RMDQ showed a significant variation at p=0.00. It showed that there is fulfilled improvement in post test RMDQ values when compared to pretest ODQ values in both the groups. The mean improvements between the two groups of low back pain patients were tested for significance using student ttest. The calculated t-values for the RMDQ scale was significant at p=0.011. This shows that mean improvement in the group II that received core strengthening is higher when compared to the group I that received conventional exercise program. CONCLUSION: This study concludes that specific stabilization exercise is beneficial in reducing disability and improved function in chronic non specific low back pain.
KEYWORDS: Exercise, Low Back Pain, Stabilization, muscle, pain, disability
INTRODUCTION Technological and organizational changes in the industrial countries during last few decades have markedly increased the number of jobs performed in Monotonous and constrained
exercise. A more recent study that compared stabilization exercise against 2 other general back extensor exercise regiments in patients with nonspecific chronic low back pain demonstrated positive results for multifidus muscle
crosssectional area increase in favor of one of the general exercise approach9. A study found that a General exercise program can be improved in reducing disability in short term than specific stabilization and general exercises in subjects with recurrent nonspecific low back pain10 Though conventional back care exercises and stabilization exercises are proved to be effective in chronic mechanical low back pain patients, no literature comparing the effectiveness on each other were found which necessitated the present study to compare the outcome of conventional and
postures. Low back pain is one of the most Common musculoskeletal health problem in the industrialized countries affecting about 80% to 90% of the population at sometime during their lives. Out of these 30% develop chronic low back pain. Chronic low back disability appears to be increasing faster than any other form of incapacity1. Deep trunk muscles eg, transversus abdominis and multifidus responsible for maintaining the stability of the spine2. So strengthening of these muscle and their restoration should be effective in the management of persistent LBP.Therapeutic workouts for
stabilization exercises in in chronic non specific low back pain.
superficial and the deep muscles seem to be effective in the treatment of CLBP3. Trunk muscles exercises activate the abdominal and paraspinal muscles as a whole and at a relatively high contraction level4. There are many METHODOLOGY A total number of 80 subjects, with nonspecific low back pain, were recruited from the physiotherapy department of Sir Ganga Ram Hospital, New Delhi, India. All the subjects to the physical department were referred from orthopedic outpatient after proper detailed assessment by an orthopaedician. A total 150 subjects and
randomized
controlled
trials
RCTS on the
usefulness of classic trunk exercises5, 6, increasing attention recently has been paid to the preferential retraining of the local stabilizing muscles of the spine7, 8. No randomized control trial has done that stabilization training is beneficial in a sample of patients with sub acute or chronic nonspecific low back pain using pain and disability as outcome. Two relevent randomized control trial have been conducted in specific subgroup of patients with low back pain7, 8. But, in these trial, the specific effect of the trunk stabilization exercise regiment was not compare to general back and abdominal
10
performed 120 subjects clinical evaluation by their physician including radiograph images. 40 subjects are dropped out and therefore sample consisted of 80 subjects with nonspecific CLBP.
Inclusion criteria were: 1. Patients who had a history of recurrent LBP (repeated episodes of pain in past
year collectively lasting less than 6 months), 2. Patients who have nonspecific nature of pain 3. Patients who are willing to participate in the exercise program and willing to travel independently to the hospital from the home10 4. Mean age of subject is 30-50yr 5. Both gender are included.
exercise only flexion and extension exercise and group-II received specific trunk muscle
stabilization exercise . Functional disability were assessed by the Rolland morris disability
questionnaires, were considered most appropriate and yield reliable and valid data. Suitable patients were asked to complete a number of
questionnaires of the Rolland Morris low back pain disability questionnaire that were repeated immediately and after 6 weeks. Interventions were conducted over 6 weeks duration and each class
Exclusion criteria were:
duration of 30-40 min for thrice per week for both groups. Common components of the 2 programs
1. Patients with previous spinal surgery 2. Patients who have signs and symptoms of gross spinal of instability radiological or
included Short wave diathermy given for 15 minutes to relieve pain.For Group-l, Simple classic exercises for extensor Paraspinals and flexor abdominals muscle groups were administrated appendix. If subjects were able to progress each week to a new level, on graded exposure exercise principle, otherwise they remained at the same exercise level.The exercises were repeated at home, for a maximum of half an hour 3 times per weeks, from the beginning of the program. For Group-II, exercises were instructed as previous recommendation appendix. The first session was given individually for subjects assigned to this group and lasted 30-45 minute. Initially exercises with low intensityfor local stabilizing muscles was initially administered with no movements
diagnosis
spondylolysis
spondylolisthesis 3. Patients who had red flags suggesting serious spinal pathology11. 4. Patients with cardio pulmonary diseases 5. Patients with tumor, infection and fracture 6. Patients with rheumatic and inflammatory condition 7. Patients with disc disease 8. Lumbar strain or sprain 9. Lumbar canal stenosis 10. Bowel and bladder dysfunction
The patients were not aware of the theoretical basis of each of the exercise regimes but they were briefed the study objective. All the subjects were interviewed and examined by a clinical
isometric and in minimally loading positions. The holding time and the number of contractions were increased progressively in these positions up to 10 contractions repetitions x 10 sec duration each 1st and 2nd week. To ensure correct activation of the transverse abdominis muscle was to observe a slight drawing in maneuvers of the lower part of the anterior abdominal wall below the umbilical level consistent with the action of this muscle.
physiotherapist of Sir Ganga Ram Hospital who was unaware of their group. By using random sampling method, the subjects with non specific low back pain were assigned to 1 of 2 treatment groups. GroupI received general low back
11
Various tactile and pressure cues and auditory cues were given to the patient to enhance the contractions and to get maximum corrective position and outcomes. Too much effort of initial contraction Integration of with muscles dynamic was discouraged. through
between the two groups of low back pain patients were tested for significance using student t- test. The calculated t-values for the RMDQ scale was significant at p=0.011.
function
Table No 1: Comparison of disability (Rolland Morris) within Control group.
incorporation of the stabilizing muscles cocontraction into light function tasks was advised next 4-6 weeks as soon as the specific pattern of co-activation was achieved in the minimally loading position and the subjects could
comfortable performed 10 contraction repetition x 10 sec duration each. A senior clinical physical therapist assessed the outcome measures of this study. All subjects received an information booklet providing the latest scientific facts on low back pain management at the beginning of the program. The disability in the control group has decreased post intervention, as in shown by their means, Further analysis on the scores revealed that these changes are statistically highly
significant in the control group (t=9.79, p=0.00) RESULTS The outcome of the data was analyzed, using bar-graphical representation, mean, standard
deviation of the pre test and post test values of the two groups individually. Comparison of mean within the group was done and the difference of mean, standard deviation between the group is also done. Calculation was done according to M.S excel soft ware. The mean improvements between the two groups of low back pain patients were tested for significance using student t- test. The calculated tvalues for the RMDQ showed a significant variation at p=0.00. It showed that there is fulfilled improvement in post test RMDQ values when compared to pretest RMDQ values in both the groups., but the mean improvement in the group II that received core strengthening is higher when compared to the group I that received conventional exercise program. The mean improvements Table No 2: Comparison of disability ((Rolland Morris) within Experimental group. Graph No 1: Comparison of disability ((Rolland Morris) within control group.
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The disability in the experimental group has decreased post intervention, as in shown by their means, Further analysis on the scores revealed that these changes are statistically highly
significant in the control group (t=6.79, p=0.00)
Graph No 3: Experimental Vs control groupDisability (post pre difference)
Interpretation: The table-1and 2 showed that there is highly significance difference between pre and post test Graph No 2: Comparison of disability within experimental group. values of VAS within the groups. The calculated tvalues for the RMDQ showed a significant variation at p=0.00. It showed that there is fulfilled Table No 3: Experimental Vs control groupDisability (post pre difference) improvement in post test RMDQ values when compared to pretest RMDQ values in both the groups
The table-3 showed that there is highly significance difference between pre and post test values of RMDQ between the two groups.The calculated p value showed a significance of difference in improvement at p=0.011, which The disability in the experimental & control group has decreased post intervention, as in shown by their means, though the change in the experimental group was much higher than in the control group. Further analysis on the scores revealed that these changes are statistically significant. (t=2.73, p=0.011) DISCUSSION Our findings suggest that stabilization indicates that experimental group has higher gains in improvement in RMDQ scale than control group.
exercises reduce subjects pain more effectively immediately after the end of treatment protocol over general exercise protocol with statistical significant. The results of this study support the initial hypothesis that specific exercise training of the "stability" muscles of the trunk is effective in
13
reducing
pain
in
patients
with
chronically
demonstrable benefits, based on previous studies of similar or less exercise duration5,17,15,18. Increase in doses of exercise, increase in benefit of exercise15. However, the stabilizing function of trunk musculature is especially important around the neutral posture, where the spine exhibits the least stiffness. Increased neutral zone, a region of low stiffness around the neutral spine had been suggested first by Punjabi19. Richardson suggested that the simultaneous isometric contraction
symptomatic low back pain. Analysis of the pain revealed that there is a difference in improvements between both the groups. This treatment approach was more effective than other conservative treatment approaches which mainly involved conventional exercise programs. This is in support of Punjabis hypothesis that the stability of the lumbar spine is dependent not solely on the basic morphology of the spine, but also the correct functioning of the neuromuscular system.
exercise for the local deep muscle TrA and LM is most beneficial for re-educating the stabilizing muscle and can incoporated with dynamic functional exercise. In addition, both disuse and reflex inhibition are likely to affect the slow twitch or tonic holding contraction at a low level would be most effective in retraining the stability function of these muscle20. The other advantages of core stability strengthening program is that, they apart from improving core strength and stability also improved flexibility, posture, ease of
Therefore, if the basic morphology of the lumbar spine is compromised, as in the case with symptomatic CLBP, the neuromuscular system may be trained to compensate, to provide dynamic stability to the spine during the demands of daily living.Consistent with these findings, McGill reported that lumbar stability is maintained in vivo by increasing the activity (stiffness) of the lumbar segmental muscles, and highlighted the importance of motor control to coordinate muscle recruitment between large trunk muscles and small intrinsic muscles during functional activities, to ensure stability is maintained. The trunk muscle stabilization exercise group exercised the TrA and LM muscle . In individual with low back pain, the TrA has decreased anticipatory capacity, meaning that it has reduced segmental protective function . Rodacki et al, suggested that abdominal exercises are associated with low back pain improvement, since during abdominal contraction disks the was pressure decreased on the as a
15 14
movement, heightened body awareness, balance and coordination. Hence, it showed more
significant in early phase of treatment than the later phase. In non specific low back pain patients the neutral zone muscles gets more affected than the other muscles of back. Hence, early
rehabilitation of these muscles produced good results within short time.
CONCLUSION Both the exercise groups showed statistical significance but stabilization exercise exercise group showed more significant over general exercise group in reducing disability in nonspecific low back pain. Specific stabilization exercise improves TrA and LM muscle activation capacity. So specific stabilization exercise was superior in
intervertebral
consequence of the increased intra abdominal pressure. However, no improvement on TrA capacity were observed . From methodological point of view the frequency and duration of the study were deemed appropriate to produce
16
14
reducing disability than general exercise group. Limitation of the study were no intermediate and long-term follow up examination.
Biopsychosocial factors were not observed in this study.
REFERENCES
1.
A randomized clinical trial of three active therapies for chronic low back pains, Spine, 24(23), 2435-48 (1999)
2.
Luciana G. Macedo, Christopher G. Maher, Jane Latimer and James H. McAuley, Motor Control Exercise for Persistent, Nonspecific Low Back pain: A Systematic Review, Physical Therapy, 89, 9-25 (2009)
3.
Franca F.R., Burke T.N., Hanada E.S. and Marques AP: Segmental Stabilization and muscular Strengthening in chronic low back pain a comparative study, Clinics, 65(10), 10131017(2010)
4.
Stuart M McGill, Low Back Exercises, Evidence for Improving Exercise Regimens, Physical Therapy, volume 78, 754-764 (1998)
5.
Hansen F.R. and Bendix T., et al: Intensive, dynamic backmuscle exercises, conventional physiotherapy, or placebocontrol treatment of low-back pain. A randomized, observer-blind trial, Spine, 18, 98-108 (1993)
6.
Rich S.V. and Norvell N.K., et al: Lumbar strengthening in chronic low back pain patients. Physiologic and psychological benefits. Spine , 18(2), 232-8 (1993)
7.
OSullivan P.B., Phyty G.D., Twomey L.T. and Allison G.T., Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis, Spine 22(24), 2959-67 (1997)
8.
Hides J.A., Richardson C.A. and Jull G.A., Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain, Spine, 21(23), 2763-9 (1996)
9.
Danneels L.A., Cambier D.C., Vanderstraeten G.C., Witvrouw E.E. and Bourgois J., Effect of three different training modalities on the cross-sectional area of the lumbar multifidus muscle in patients with chronic low back pain, Br J Sport, 35, 186-191 (2001)
10.
George A. Kounmanatakis, Paul J. Watson and Trunk Muscle Stabilization Training Plus General Exercise Versus General Exercise Only: Randomized Controlled Trial of Patients With Recurrent Low Back Pain, Apta Physical Therapy, 85, 209-225 (2005)
11.
OSullivan P.B., Lumbar segmental instability, clinical presentation and specific stabilizing exercise management manual therapy, 5(2),112 (2000)
12.
Fairbank J.C.T. and Pynsent P.B., Oswestry Disability Questionnaire, Spine, 25(22), 2940-2953 (2000)
13.
Bayar Kilichan, Bayar Banu, Yakut Edibe, Yakut Yuvuz, Reliability and construct validity of the Oswestry Low Back Pain Disability Questionnaire in the elderly with low back pain, Spine 26(24), 2738-2743 (2001)
15
14.
Segmental stabilization and muscular strengthening in chronic low back pain a comparative study 65(10), 1013 1017 (2010)
15.
Lindstrom I., Ohlud C. et al, Mobility, strength and fitness after a graded activity program for patients with subacute low back pain, A randomized prospective clinical study with a behavioural therapy approach, spine , 17(6), 641-52 (1976)
16. 17.
Rodacki CLN et al; Spinal unloading after abdominal exercise, Cli Biomech, 23, 8-14 (2008) Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and , 319(7205), 279 283 (1999)
18.
Moffett J.K. and Togerson et al, Randomised controlled trial of exercise for low back pain, clinical outcomes, costs, and preferences, BMJ, 7205, 279-83 (1999)
19.
Panjabi M.M., The stabilizing system of the spine.Part l.Function, Dysfunction, adaptation, and enhancement, J Spinal Disord, 5(4), 385- 9 (1992)
20.
C.A. Richardson and G.A. Jull, Muscle Control- pain control. What exercises would you prescribe Manual Therapy, 1-16 (1995)
21.
Ariponnammal S., A Novel Method of Using Refractive Index as a Tool for Finding the Adultration of Oils, Res.J.Recent Sci., 1(7), 77-79 (2012)
22.
Ipatova V.M., Convergence of Numerical Solutions of the Data Assimilation Problem for the Atmospheric GeneralCirculationModel, I. Res.J.Recent Sci., 1(6), 16- 21(2012) 23. Yousef Zandi and Vefa Akpinar M., An Experimental Study on Separately Ground and together Grinding Portland Slag Cements Strength Properties, Res.J.Recent Sci., 1(4), 27- 40(2012)
23.
Behmaneshfar Ali, Shahbazi S. and Vaezi S., Analysis of the Sampling in Quality Control Charts in non uniform Process by using a New Statistical Algorithm Res.J.Recent Sci., 1(8), 36-41 (2012)
24.
Nasiripour A.A., Masoudi-asl I. and Hesami F., The Relationship between Nurses Organizational Participation and Patient Safety Culture in Jahrom Motahari Hospital, Iran Res.J.Recent Sci., 1(8), 73 76 (2012)
25.
Dysmenorrhea Tofighi Niaki M., Zafari M. and Aghamohammady A., Comparison of the effect of Vitamin B1 and Acupuncture on Treatment of Primary ISCA J. Biological Sci., 1(1), 62-66 (2012)
26.
Balamuralitharan S. and Rajasekaran S., Stability of the Six Equilibrium States between CN and G-CSF with Infectives Growth Rate Progression: A FFT Study, ISCA J. Biological Sci., 1(2), 55-60 (2012)
27.
Bhatt T.K., Phylogenetic Studies on tRNA Dependent Amidotransferase from Plasmodium Falciparum, ISCA J. Biological Sci., 1(3), 20-24 (2012)
28.
Lakhani Leena, Khatri Amrita and Choudhary Preeti, Effect of Dimethoate on Testicular Histomorphology of the Earthworm Eudichogaster Kinneari (Stephenson) I. Res. J. Biological Sci., 1(4), 77-80 (2012)
29.
Gorham K. and Hokeness K., Effects of Mold Exposure on Murine Splenic Leukocytes, I. Res.
16
J. Biological Sci., 1(5), 53-56 (2012)
CORRESPONDENCE
*PhD Research Scholar , Singhania University, Pacheri Bari, RajasthanIndia **Consultant, Sir Ganga Ram Hospital, New Delhi, India ***Asst. Professor, PDM Group Of Institutions, Bahadurgarh, Haryana, India
17
STUDY OF RESPIRATORY CAPACITY AND CORE MUSCLE STRENGTH IN INDIAN CLASSICAL SINGERS
Shweta S. Devare Phadke*, Sukhada Prabhu**, Sujata Yardi***
ABSTRACT Classical singers are elite athletes. Their art requires total mind & body integration. Body alignment and breathing has an effect on phonation. Proper breathing technique leads to better control over breath and quality of tone. Core muscles supports the work of lungs and larynx to produce better tone production and ability to sing extended phrases and sustain notes for longer.1 OBJECTIVE: To compare core muscle strength and respiratory parameters like peak expiratory flow rate and breathe holding time between Indian classical singers and age matched non singers. METHODOLOGY: Group 1 Indian classical singers between age group of 15 to 30 years, practicing minimum since 1 year. Group 2 Normal healthy adults between age group of 15 to 30 years who are not engaged in any type of singing and fitness activity. After explaining about the aims and objectives of the study , consent taken. Height, weight, core muscle strength assessment by Richardson and Joule's grading, breath holding time and peak expiratory flow rate with mini Wright's peak flow meter measured. The data was analyzed using GraphPadInstat Version3.10, 32 for Windows. RESULT: The core muscle strength and Breath holding time of classical singers is significantly more than age matched normals. There is mean difference in PEFR of singers and age matched normals which is statistically non significant. The study reveals that singers have good core strength and breath holding time. For quality singing training in breathing capacity and core muscle strength will help. KEYWORDS: core muscle strength, indian classical singer, respiratory capacity.
18
INTRODUCTION Singing requires exceptional co-ordination, endurance and fine motor control. Body alignment impacts vocal techniques. Breating capacity have effect on specialised phonation like singing. 3 The physiological effects of proper breathing
Type of study Cross Sectional Study setting Community Indian
classical singer Inclusion criteria Indian classical singers between age group of 15 to 30 years, practicing minimum since 1 year. Normal healthy adults between age group of 15 to 30 years who are not engaged in any type of singing activity. Exclusion criteria Indian classical singers with any lung or cardiac pathology (HTN, pregnant women, delivery ). Singers engaged in any other physical exercise or wind instruments. Singers less than 1 yr of training and singers who are not undergoing appropriate training. Normal age matched adults involved in any type of physical fitness activity. MATERIAL USED Stabilizers pressure biofeedback unit within 6 months post
techniques are increased lung capacity, increase in lung volume, improved all over stamina or endurance of respiratory muscles, and better oxygenation of entire body.
1
According to Pilates, core strength and stability is of tremendous benefit for breathing. The core muscle encompasses all muscles that coordinate the joints of lower spine, pelvis, hip and stabilize lower torso. Most of these muscles also assist in respiration. The core muscles help singers to enhance endurance of respiratory muscles and in turn increase the breathing capacity.3 If muscles that support the breathing mechanism are well toned, singing will be energy efficient.2 Core
muscles works by contracting the abdominal muscles, creating higher pressure in abdomen , allowing diaphragms relaxation, upward rise to be more carefully controlled. Core muscle gives singer a means of controlling their sound or phonation.1 Breath holding time is a rough index of cardiopulmonary reserve measured by length of time that a subject can voluntarily stop breathing after a deep inspiration. Learning to catch and time the breath for each song is critical for a quality performance.5 Thus, we hypothesised, the core muscle strength and respiratory capacity measured by peak expiratory flow rate and breath holding time of Indian classical singers are higher than age matched healthy adults.
Mini Wrights peak expiratory flow meter
Weighing scale Measuring tape and stop watch
METHODOLOGY
19
Procedure 1.Core muscle strength was measured by
plinth. 2A- Unilateral heel slide with other leg off the plinth in hip knee flexion. 2B- Unilateral heel slide with leg 5cm off the plinth and leg off the plinth in hip knee flexion. 2. Peak expiratory flow rate was measured by Mini Wrights peak expiratory flow meter, a small handheld device. Subject was in standing position without any support. They were instructed to take a deep inspiration through nose with device held in mouth, and to blow out or expire forcefully through mouth. 3 readings were taken, out of which the best value was considered.17 3. Breath holding time was measured with the help of stop watch. Subjects were in sitting position. They were instructed to take a deep inspiration through nose and to hold their breath as long as possible. The normal duration was 30 seconds or longer, diminished cardiac or pulmonary reserve was indicated by duration of 20 seconds or less.5
Stabilizers pressure biofeedback unit, with help of Richardson and Joules core muscle grading method. This grading method was used as it is reliable and valid method of testing core muscle strength.18 The subject was instructed to be in supine position with both lower limbs hip and knee flexed. Drawing in maneuver i.e transverse abdominis muscle activation was taught to the subject. The inflatable bag was placed in lumbar lordosis and pressure was raised till 40mm of Hg. Subjects were instructed to take their umbilicus upward and inward and maintaining this they were graded as per following grades191A- Unilateral heel slide, with other leg in hip knee flexion resting on plinth. 1B- Unilateral heel slide with leg 5cms off the plinth and other leg in hip knee flexion resting on
RESULT Table 1: Comparison of core muscle strength by richardson and joules grading Singers Mean Standard diviation 'P' value 2.9 1.248 <0.0001 Normals 1.433 0.5683
Table 2: Comparision of breath holding time Singers Mean Standard diviation 'P' value 48.7 9.963 >0.01 Normals 37.9 8.588 >0.01
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Table 3: Comparision of peak expiratory flow rate Singers Mean Standard diviation 'P' value 371.33 42.160 >0.10 Normals 359 55.108 >0.10
DISCUSSION In our study, total 60 subjects participated, 30 in each group. Subjects were explained about the study and a prior consent was taken. The age, height (in cms), weight (in kgs), no.of training years of the study subjects were noted. Subjects were assessed on parameters like core muscle strength, breath holding time, peak expiratory flow rate (PEFR) in random order. The data revealed that maximum no. of singers are trained for 5-6 years. In order to maintain homogeneous distribution these subjects were matched based on age, height (singers- 160.4 cms, normals- 160.04 cms), and weight (singers61.66 kgs, normals- 60.86 kgs). The maximum no. of study subjects assessed were females (singers86.6% and normals- 90%). The statistical analysis shows that core muscle strength of classical singers was vibrate. If a singer tends to push, a stronger core will make it possible to push a little harder.3 Core strength and stability is of tremendous benefit for breath co-ordination during singing. Core
strengthening exercises that strengthen the core muscle along with abdominal muscle, back muscle, muscle around pelvis are recommended for singers as daily exercise program along with their singing practice to sustain notes for longer duration. This will also minimize work related musculoskeletal disorders. Breath holding time of classical singers is significantly higher than age matched normals. Singers require a higher rate of breath management capabilities as they need to extend the normal breath cycle by maintaining inspiratory position for as long as possible.3 Breathing strategies rely on ability to inhale a substantial quantity of air and release it steadily. This physiological mechanism of breathing is relevant to singers as it provides energy to tone and ability to sustain longer notes. Without diaphragm and the muscles surrounding that support its work, air can neither enter nor leave from lungs. Without air expulsion the vocal cords cannot vibrate and without vibration sound cant be produced.1 Cardiopulmonary fitness plays important role in singing. It includes efficient circulation of oxygen throughout the body and ability to make good use of it.3 Efficient oxygen consumption benefits singing techniques by
21
significantly high (P value-0.0009 ). This goes along with our hypothesis that singers need to build strength and flexibility throughout the torso. The strong core muscle supports the muscles of spine and lower ribs. which help to enhance rib movement, resulting in improved breath capacity. Thus core muscle strength if developed in proper fashion helps to improve breath capacity in singers.3 A good core encourages singer in pushing. Pushing results when vocal cords are squeezed together with such force that only excessive breath pressure will allow them to
allowing singer to sustain longer phrases. Building strong core strength leads to less work of breathing.3 There are 2 schools of teaching about breath management 1 Supporting the breath by compressing abdomen exhalation) Relaxing abdominal muscle as much as possible during inhalation and phonation, allowing diaphragm to work on inhalation and riding its relaxation on outgoing breath (i.e. during phonation) during phonation (i.e. on
and steady expiration is recommended for singers to sustain longer notes. Thus cardiopulmonary fitness and core muscle strengthening plays important role in improving quality of singing. The study reveals that singers require good core strengthening and breath holding time for quality singing. Hence clinically singer fitness programme must include core muscle strength training and breathing exercises.
Acknowledgements We are heartily thankful to Yashsree Sangeet Vidyalaya,Kalva and the staff of Dept. Of Physiotherapy, Pad.Dr.D.Y.Patil University, who supported us from the preliminary stages of the
In our study as breath holding time was higher in singers so we would like to emphasis that inspiratory training would help singers to sustain notes for longer. From the study it is evident that there is no much significant difference in PEFR of singers as compared to age matched normals. PEFR is persons maximum speed of expiration. PEFR measures airflow through bronchi and thus degree of obstruction in the airways.6 The PEFR values of singer are nearly same as those of normals may be because singers have to concentrate more on inspiratory capacity and breath holding. Relaxed
project.
Conflict of Interest We, Phadke S,Prabhu S, Yardi S state that there is no conflict of interests with other people or organizations about our work.
Source of funding Study was self funded.
Ethical Clearance Study has cleared by ethical committee of Padmashree Dr. D.Y. Patil University.
REFERENCES 1. Sing wise effective and proper breathing- An information based resource for singers. Karyn O Connor, 2011, page no1. 2. Sing wise effective and proper breathing- An information based resource for singers. Karyn O Connor, 2011, page no2. 3. Sports specific training for vocal athlete- how exercise can support your vocal techniques. Claudia Freidlander, CPT, part 1. 4. Exercise to improve your core strength- by Mayoclinic staff. Mayo foundation for medical education and research.
22
5. Breath holding after breathing of oxygen. F.J. klocke and H. Rahn. Journal of applied physiology, American physiological society. 6. Peak expiratory flow rate. The Indian journal of pediatrics. Nov-Dec 1994, volume 61, issue 6, page no. 701 . 7. An investigation of abdominal muscle recruitment for sustained phonation in 25 healthy singers. Ian MacDonald, John S. Rubin, Ed Blake et all. Journal of voice, volume 26, issue 6, Nov 2012, page nos. 815e.9-815e.16 8. Reduced pulmonary function in wind instrument players. Omer Deniz, Sema Savci, Ergun
Tozkoparan et al. Archives of Medical Research, volume 37, issue 4, May 2006, page nos. 506-517. 9. Respiratory muscle training for singers by using respiratory muscle training device.Do Hyun Nam, Jan Yol Lim, Chul Min Ahn et al.Yonsei Medical Journal, volume 45, issue 5, 2004, page nos.810 817 10. Study on breathing method for improving singing skills. Tae-seon-Cho Book- Green and smart technology with sensor application, volume-338, 2012, page nos.372-377 11. Principles and practice of cardiopulmonary physical therapy (3rd edition) Donna Frownfelter, Elizabeth Dean. 12. Reliability of test measuring transverses abdominis muscle recruitment with a pressure biofeedback unit. Katharnia von Garnier et al. Physiotherapy, volume 95, issue 1, March 2009, page nos. 8-14 13. Inefficient muscular stabilization of lumbar spine associated with low back pain; a motor control evaluation of transverses abdominis muscle. Hodges PW, Richardson CA, 1996, issue 35, page nos. 783-805. 14. Tidys physiotherapy by Staurt Porter. 14th edition.
CORRESPONDING AUTHOR: *Asst. Professore, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y. Patil Medical College Bldg., Sector 5, Nerul, Navi Mumbai. **Intern, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y. Patil Medical College Bldg., Sector 5, Nerul, Navi Mumbai. ***Professore & Director, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y. Patil Medical College Bldg., Sector 5, Nerul, Navi Mumbai.
23
AEROBIC CAPACITY, BODY MASS INDEX AND FAT FOLD MEASUREMENTS OF HEALTHY ATHLETES IN DEHRADUN A CROSS SECTIONAL STUDY
Sharma Chetan, MPT (Sports), Dr. Dar Shahid Mohd., MPT (Orthopedic and Sports)
ABSTRACT PURPOSE: The Aim of Present study was done to assess the Percent Body fat, Body Mass Index and VO2 Max for the athletes of Dehradun. The study would create a data for athletes in Dehradun involved in various sporting activities which would catagorised the subject having recommended parameters of fitness. METHODOLOGY: A survey Study with measurement of Aerobic capacity, Body Mass Index and Percent Body Fat was done. Total of 96 subjects was included based on the inclusion and exclusion criteria. Convenience Sampling was used for the selection of participants. Descriptive Statistics has been used for the analysis of the data. RESULTS: A sample of 96 Athletes with Mean Age (15.6342.54 years) had a mean Percent Body Fat 10.5373.51 percent, mean Body Mass Index 18.6541.64 kg/m2 and mean VO2 Max is 41.9436.777 ml/kg/min. CONCLUSION: There was no significant correlation found between VO2 max, Body Mass Index and Percent Body Fat. KEY WORDS: Aerobic capacity, Body Mass Index, VO2 Max, Percent Body Fat, 20 m Shuttle Run Test.
INTRODUCTION Direct measurement of maximum oxygen uptake (VO2max) is recognized as the best single index of aerobic fitness, but the test of the direct measurement of cardiorespiratory endurance
(VO2max) itself is difficult, exhausting and often hazardous to perform regardless the type of ergometer used. Since the direct testing procedure is rather complicated on larger populations, several indirect running and walking field tests have been
24
developed. Scientists often calculate VO2max with indirect protocols. It has been stated that equations for predicting VO2max indirectly using field tests are very sensitive to populations tested on. Therefore, before applying any indirect protocol for prediction of VO2max, the validity of the test should be established in a particular population.4 Body mass index (BMI) is used as a surrogate for percent fat in classifying obesity. However, there is no established criterion for percent fat and health risk, and few studies have examined the validity of Body Mass Index as a measure of Percent fat. Body Mass Index is used to classify athletes and young adults as obese. Consequently, it is critical to understand the accuracy of Body Mass Index in this populations.1 Body mass index is currently the most frequently used and widely accepted method to classify medical risk according to weight status. Body Mass Index is a useful measure of adiposity in young and middle-aged athletes. Body composition
5
environment. The accuracy of predicting percent fat from skinfolds is approximately 3.5% assuming that appropriate techniques and equations have been used.1
METHODOLOGY
Design This is a Cross sectional study. All the subjects were recruited from the various sports center from Dehradun.
Sampling Total of 96 subjects were chosen as per the inclusion and exclusion criteria, and informed consent was obtained from all the subjects after the procedure was explained to them.
Procedure: 20 Meter shuttle run test: The 20 Meter Shuttle Run Test was administered in a sports field
determined
from
using the original protocol (Leger and Lambert, 1986) but utilizing a different scoring system developed by the Human Performance Laboratory at The Queen's University of Belfast.7 The 20 Meter Shuttle Run test involves running between two lines set 20 meters apart at a pace dictated by a cassette recording emitting tones at appropriate intervals. The test score achieved by the subject is the number of 20 meter laps completed before the subject either withdraws voluntarily from the test. Scoring by aps differs from the "paliers", 6 used in the original version of the test. The test is made up of 23 levels where each level lasts approximately one minute. Each level comprises of a series of 20m shuttle runs where the starting speed is 8.5 km/hr and increases by 0.5km/hr at each level. On the tape/Compact Disc a single beep indicates the
skinfold measurements correlates well (r = 0.70 0.90) with body composition determined by hydro densitometry. The principle behind this technique is that the amount of subcutaneous fat is proportional to the total amount of body fat. It is assumed that close to one third of the total fat is located subcutaneously. The exact proportion of subcutaneous-to-total fat varies with sex, age, and ethnicity. Therefore, regression equations used to convert sum of skinfolds to percent body fat must consider these variables for greatest accuracy. To improve the accuracy of the measurement, it is recommended that one train with a skilled technician, use video media that demonstrate proper technique, participate in workshops, and increase experience in a supervised practical
25
end of a shuttle and 3 beeps indicates the start of the next level. Body Mass Index: The Body Mass Index is used to assess weight relative to height and is calculated by dividing body weight in kilograms by height in meters squared (kg.m ).
-2 1
Percent body fat, Body mass index and VO2 max in total no of subjects.
Table 2: Correlation between Body Mass Index and VO2 Max as well as Percent Body fat and Vo2 max in total no. of Subjects.
Skinfold Measurement: Body composition determined from skin fold measurements. Seven Site Formula for Men (chest, mid-axillary, triceps, subscapular, abdomen, Supra iliac, thigh). Body density = 1.112 - 0.00043499 (sum of seven skinfolds)
2 1
0.00000055
(sum
of
seven No significant variation was observed (p > 0.05) between the values of Body Mass Index and
skinfolds) - 0.00028826 (age) ~3.5% fat).
[SEE 0.008 or
RESULTS: Means and standard deviations of athletes in Dehradun, predicted VO2max by the 20-m multi stage shuttle run test, Age, Body mass index and Percent body fat were presented in the Table 1.
VO2max as well as Percent Body Fat and Vo2 max. Correlation was done for comparison between Percent Body fat and VO2 Max was found that r = 0.058 which is not significant (p = 0.576) and another Correlation has been done between Body Mass Index and VO2 max was found to be r = -0.037 which is also not significant (p = 0.721), thus finding not significant between the respective variables.
Table 1:- Mean and Standard deviation for Age, Percent Body fat, Body Mass Index and Vo2 max in total no. of subjects.
DISCUSSION The Aim of Present study was done to assess the Percent Body fat, Body Mass Index and VO2 Max for the athletes of Dehradun. The athletes were recruited mainly from different types of sports those who participate in sporting activities in different colleges and academies. A sample of 96 Athletes with Mean Age
(15.6342.54 years) had a mean Percent Body Fat 10.5373.51 percent, mean Body Mass Index 18.6541.64 kg/m2 and mean VO2 Max is 41.9436.777 ml/kg/min. In this study Pearson Correlation was done for comparison between Figure 1: Mean with Standard deviation of Age,
26
Percent Body fat and VO2 Max was found that r =
0.058 which is not significant (p > .05) and another Correlation has been done between Body Mass Index and VO2 max was found to be r = 0.037 which is also not significant (p > .05), thus finding not significant between the respective variables. In the present study it has been found that Mean Vo2 max for 96 active athletes of age group of 10-30 years in five different kinds of sports is (41.943 ml/kg/min), while in a similar study was done by S. K. VERMA et al. Department of Human Biology, Punjabi University, Patiala who found that the mean V02 max in 96 active athletes age group of 17-25 years was 48.4 5.1 ml/kg/min with a highest value of 56.4 ml/kg/min and lowest value of 44.2 ml/kg/min. Which is slightly higher as compared to V02 max values recorded in the present study, this probably can be due to the greater body surface area of athletes in S.K. Vermas study where the age group of the subjects was greater (17-25 years). Where as in the present study the maximum sample obtained was in the range of 10-20 years because of non-availability of the athletes in the elder age group. As the age increases the body surface area increases as is already proved and the increase in the aerobic capacity with age is also a well-established fact,4 so our values of less vo2max readings in subjects of lesser age group than readings of other studies is quite well understood. Hence forth we recommend that in future the studies should make sure that the sample possess the even distribution of all age groups i.e. 10-30 years. As far as Body Mass Index of male athletes in Dehradun is concerned, the present study found that the mean of Body Mass Index was 18.6541.64 kg/m . Percent body fat is 10.5373.51 percentage. In support of present
2 9
study Wan Nudri WD et al. from Division of Human Nutrition, Institute for Medical Research, Kuala Lumpur, has found mean Body Mass Index of athletes with age of (23.94.2 years) is (22.93.5 kg/m2)10 the probable reason for the difference between Body Mass Index of both study is the age. However it was clear that the athletes who had reduced level of Body Mass Index were due to lean muscle mass.28 From 5 to 16 years of age, boys relative muscle mass increases from about 4254% of body mass.2 A paper review done by American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine stated that the male athletes with the lowest estimates of body fat (less than 6%) include middle-distance and long-distance runners and bodybuilders, whereas male basketball players, cyclists, and gymnasts, wrestlers
sprinters,
jumpers,
triathletes,
average between 6% to 15% body fat. Male athletes involved in power sports such as football, rugby, and ice and field hockey have slightly more variable body fat levels 6% to 19%.8 The present study is done on population of Dehradun, India. Although, there may be racial differences between both the populations, it was found that level of percent body fat had a similarity. In this study a Correlation between percent body fat and Vo2max also was done and study found that the two variables are not significantly correlated (r=.058, p > .05) . Similarly Body Mass Index and Vo2max also were found to be correlated non-significantly (r = -.037, p > .05). This is in contradiction with other studies done in the past who have found a positive correlation between BMI and Percent body fat with VO2 max.10 The reason for non-significant correlation in present study could be due to the non-
27
homogeneity of the sample of our study, i.e.in present study athletes from all the games with different Body Composition were included, which could have given a unexpected result.
athletes,
found
out
Mean
VO2
max
was
41.9436.777 ml/kg/min, mean Body mass index was 18.6541.64 kg/m2 and mean Percent body fat was 10.5373.51 percent. There was no significant correlation was found between Variables which
CONCLUSION: Study is done to access VO2 max, Body mass index and Percent body fat in a sample of 96 REFERENCES:
could have been because of non-homogenous group.
1. Armstrong L, phd, FACSM, Balady G. J., MD, Berry M.J., phd, FACSM. ACSM's guidelines for exercise testing and prescription. 7thed. New York. Lippincott Williams & Wilkins 2006; p. 64. 2. Armstrong N, Grant R Tomkinson GR, Ekelund Ulf. Aerobic fitness and its relationship to sport, exercise training and habitual physical activity during youth. Br J Sports Med. 2011; 45:849858. doi:10.1136/850 bjsports-2011-090200. 3. Eliakim A, Burke G S, Cooper D M. Fitness, fatness, and the effect of training assessed by magnetic resonance imaging and skinfold-thickness measurements in healthy adolescent females. Am J Cliii Nutr. 1997; 66: 223-31. 4. Leger L, Gadoury C et al. Validity of the 20 m shuttle run test with 1 min stages to predict VO2max in adults. Can J Sport Sci. 1989; 14(1):21-6. 5. Leitzmann MF, Moore sc, Koster a, Harris tb, Park y, et al. (2011) Waist Circumference as Compared with Body-Mass Index in Predicting Mortality from Specific Causes. Plos One. 2011 April; 6(4): e18582. Doi:10.1371. 6. Mechelen W.V, Hlobil H, Kemper H.C.G. Validation of two running tests as estimates of maximal aerobic power in children. European journal of applied physiology and occupational physiology. 1986; 55 (5), 503-506, DOI: 10.1007/BF00421645. 7. Paliczka V.J, Nichols A.K, boreham C.A.G. A multi-stage shuttle runs as a predictor of running performance and maximal oxygen uptake in adults. Brit.j.sports med. 1987; 21(4): pp. 163-165. 8. The American College of Sports Medicine, The American Dietetic Association, The Dietitians of Canada. Nutrition and Athletic Performance. Medicine & science in sports & exercise. 2000; 01959131/00/3212-2130/0. 9. Verma S. K, L. S. Sidhu, Kansal D. K. Aerobic work capacity in young sedentary men and Active athletes in India. Brit. J. Sports Med. 1979; 13: 98-102. 10. Wan Nudri WD, Ismail MN and Zawiak H. Anthropometric measurements and body composition of selected national athletes. Mal J Nutr. 1996; 2: 138-147.
CORRESPONDING AUTHOR:
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*M.P.T. (Neurology)., F.N.R., P.G.C.D.E. Health Care Consultant, Bharathidasan Matric Hr Sec School, Kanchipuram, Tamilnadu, India. & Consultant Physical Therapist, Star Health Care Center, Kanchipuram, Tamilnadu, India. **Bachelors in Physiotherapy (India), PG Dip Sci - Exercise Rehabilitation (Clinical Exercise Physiology), University of Auckland, New Zealand.
29
EFFECTS OF BIMANUAL FUNCTIONAL PRACTICE TRAINING ON FUNCTIONAL PERFORMANCE OF UPPER EXTREMITY IN CHRONIC STROKE
Dr Jasmine Anandabai*, Dr Manish Gupta**
ABSTRACT OBJECTIVE: To study the effects of bimanual functional practice training on functional performance of upper extremity in chronic stroke. DESIGN: Pre-test and Post test design. SETTING: Inpatient and rehabilitation hospital. PARTICIPANTS: Patients were randomized to receive bimanual functional practice (n=15) at 3-4 months post-stroke onset. INTERVENTION: Supervised bimanual training for 50 minutes on 5 days week over 2 weeks using a standardized program. MAIN OUTCOME MEASURES: Upper extremity outcomes were assessed by Graded Wolf-Motor Function Test (GWMFT) and Fugl-Meyer scale (F.M.S). RESULTS: Significant differences were found within the group in mean performance time -p=0.002 and there were significant difference found in functional ability scale (GWMFT-FAS p=0.00, similarly, there were significant changes in Fugl-Meyer score p=0.00. CONCLUSION: This study suggests that 2 sessions of 25 minutes a day of bilateral training of functionally related tasks is effective for upper limb functional recovery in chronic stroke patients, regardless of the initial severity of the impairment. Further more, for recovery of functional motor performance, bimanual practices appears more beneficial. Several other studies have found benefits of bimanual training: therefore, this approach can be accepted as an upper limb intervention in stroke on the basis of finding of this study.
KEYWORDS: Stroke, Functional Performance, Bimanual Functional Practice Training
30
INTRODUCTION Stroke is an acute onset of neurological dysfunction due to an abnormality in cerebral circulation with resultant signs and symptoms that corresponds to involvement of focal areas of the brain1. This can be due to ischemia (lack of blood supply) caused by thrombosis or embolism or due to a hemorrhage. As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech or inability to see one side of the visual field. In the past, stroke was referred to as cerebrovascular accident or CVA, but the term "stroke" is now preferred. The traditional definition of stroke, devised by the World Health Organization in the 1970s, is a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours". Strokes can be classified into two major categories: ischemic and
origin); this constitutes 30-40% of all ischemic strokes. Ischemic: Ischemic stroke occurs due to a loss of blood supply to part of the brain, initiating the ischemic cascade. Brain tissue ceases to function if deprived of oxygen for more than 60 to 90 seconds and after a few hours will suffer irreversible injury possibly leading to death of the tissue, i.e., infarction. Hemorrhagic: Hemorrhagic strokes result in tissue injury by causing compression of tissue from an expanding hematoma or hematomas. This can distort and injure tissue. In addition, the pressure may lead to a loss of blood supply to affected tissue with resulting infarction. Epidemiology: Stroke is a major global health problem. It is the third most common cause of death in world and risk factors for stroke onset are high blood pressure, smoking, diabetes, heart failure, carotid artery stenosis and hyperlipidemia (SBU 1992; Gresham et al. 1995). 3 Approximately 85% of all stroke cases are ischemic, and most ischemic strokes affect one of the cerebral hemispheres by occlusion of the middle cerebral artery (MCA). In the acute stage, mechanisms such as oxygen depletion, necrosis, brain edema, excitotoxicity and inflammatory processes are at play. After the acute stage there is a phase of regeneration with neuronal plasticity and (partial) functional recovery (Dahlquist 2003).4 The effectiveness is based on
hemorrhagic. Ischemia is due to interruption of the blood supply, while hemorrhage is due to rupture of a blood vessel or an abnormal vascular structure. 80% of strokes are due to ischemia; the remainders are due to hemorrhage. Some
hemorrhages develop inside areas of ischemia ("hemorrhagic transformation"). In an ischemic
stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen: thrombosis (obstruction of a blood vessel by a blood clot forming locally), embolism (idem due to an embolus from elsewhere in the body, see below), systemic hypo perfusion (general decrease in blood supply, e.g. in shock) and venous thrombosis. Stroke without an obvious explanation is termed "cryptogenic" (of unknown
31
neurodevelopment techniques, repetitive unilateral or bilateral training techniques; sensoriomotor training or constraint induced movement therapy has been evaluated on motor performance of the affected arm of subjects with stroke. The Constraint induced movement therapy concept has
been derived from basic research with monkeys and consists of a family of techniques, i.e., constraining movements of the less affected arm and intensively training of the more affected arm (Taub et al. 1993; Taub et al. 1999; Morris and Taub 2001).
4
function relative to non-affected side (at least 100 of wrist extension and at least 100 of active extension of each metacarpophalengeal joint and interphalengeal joint of all digits. 5. 6. 7. No multiple infarctions. Intact cognitive functions Patients with right hand dominance with
Bilateral training activities may increase the activity of the affected hemisphere and decrease the activity of unaffected hemisphere providing a balancing effect between
5
affected left Hemispheres.
hemispheric
Exclusion Criteria: 1. Insufficient stamina to participate.
cortocomotorneuron exitibility. The practice of
bilateral
symmetrical
2. Other neurological disorders 3. Previous participation in other pharmalogical or Physical intervention studies.
movements may allow the activation of the intact hemisphere to facilitate the activation of the damaged hemisphere leading to improve
4. Any severe contractures and deformity in upper Extremity. 5. Aphasia with inability to follow 2 step commands.
movement control of impaired limb promoting neural plasticity. Bimanual practice is getting both hands to work co-operatively to hold and manipulate an object using each hand to perform different actions. Thus the objective of this study is to establish the efficacy of bimanual functional practice on functional performance of upper extremity in chronic stroke. METHODOLOGY A total of 15 subjects (12 males and 3 females), at O.P.D. of various hospitals, were included in the study. They were given bimanual practice intervention for 5 days a week for 2 weeks. Each treatment session will be of 1 hour.
On the first visit a complete neurological assessment was done. Subjects found suitable for participants in the study as per the inclusion and exclusion criteria were requested to sign the consent form. A detailed subjective examination was taken regarding type, side, duration,
occurrence of stroke, handedness and motor functions. All the selected subjects were informed in detail about the type and nature of the study and asked to sign the informed consent. After taking down the demographic data the measurement of functional performance were
Inclusion Criteria: 1. All Participants suffering from stoke for the
assessed by Fugl- Mayer assessment scale and Graded Wolf Motor Function test. Participants activity. Participants were encouraged to do the bimanual practices for 25 minutes with 10 minutes were trained for bimanual
first time. 2. 3. 4. Onset from 3-9 months Age group 40-60 yrs. Most component of movement present in affected extremity but impairment of
32
rest periods. The total time period of the bimanual practice was one hour, which was divided into two training sessions (25*2=50 min) and one rest period of 10 minutes. Participants were trained for following
task was practiced for 5 minutes in two sessions. 5. Asked the patient to hold the lock with non-
affected hand and open the lock or move the key in the lock clockwise and anticlockwise for 5 minutes daily in two sessions.
bimanual task practices (15). Pouring of water from one cup to another cup with arm held up. Using the telephone (one hand to hold receiver and another to dial the number Rolling up a towel Unscrewing a jar. Turning the key in lock
RESULTS The results in table 5.4 show that MPT of Wolf-motor Function Scale after 2 weeks of bilateral training program was significantly less. Similarly FAS score improved significantly after a 2 weeks training program.
Table-1 Group Analysis
Each
participants
were
taught
about
individually and Sitting at the chair comfortably in front of the table.
1.
To ask the patient to hold the one cup with The results showed that there was significant difference in the bilateral arm training group, both pre intervention and again after 2 weeks of training.
one hand (non-affected) which was initially filled with water and asked to hold the cup with other hand (affected) and both hands held up the table. Instruct the patient to pour the water first from non-affected hand to affected hand and then affected hand to non-affected. This task was performed for 5 minutes daily in two sessions. 2. To ask the patients to hold the receiver with DISCUSSION The study compared the effects of bilateral upper limb-task training on upper limb motor functions during post stroke rehabilitation. The result of this study showed that there was a significant improvement in functional performance of upper extremity on G.W.M.F.T. and FuglMeyer scale in chronic stroke patients after 2 weeks of bimanual functional practice. The result of the study showed that there was significant difference in bimanual Pre and Post practice group on GWMFT (Pre MPT: p=0.70 &
33
one hand (non-affected) and the numbers with another hand (affected) again this task performed alternately hold the receiver with affected hand and dials the numbers with affected hand. 3. Initially fold the towel lengthwise and asked
the patient to roll the towel with both hands up to the towel end. 4. Asked the patients to hold the jar with non-
affected and practiced to open the jar or move the cup of the jar to clockwise and anticlockwise. This
Post MPT: p=0.75 and Pre FAS: p=0.32 & Post FAS: p=0.312) and Fugl-Meyer score. (Pre: p=0.519 and Post: p=0.43) Participants of bimanual practice group showed a decrease in performance time (p=0.002) and increase on functional ability score (p=0.00) and showed highly significant improvement on motor functional performance of Fugl-Meyer scale (p=0.00).The mean time to perform 15 tasks in GWMFT was (17.13+4.60) which decreased after 2 weeks of bimanual practice training
processing information from the non-paretic limb, while simultaneously attempting to perform new, progressively changing, relatively complex precise motor goals with both arms may have provided a dual-task challenge greater than in other studies. The effectiveness of bilateral movement training in promoting stroke recovery is also likely to depend on the extent of damage sustained to direct corticospinal pathways58. While bilateral movements may also help recruit secondary motor areas in both hemispheres, recovery promoted by these areas will be less than that obtained through direct corticospinal projections
58, 59
(15.80+5.53) and the functional ability score (1.75+0.46) improved after training
. This can be
(2.05+0.57).The result showed that 2 weeks of bimanual training improved motor functional performance on Fugl-Meyer scale (42.87+5.25). The result showed that 2 weeks of bimanual training improves motor functional performance on Fugl-Meyer scale (44.53+6.20). The result of the study suggested that, training involving the practice of actions bilaterally and simultaneously is effective in promoting recovery of upper limb motor function in chronic stroke patients. Of particular importance was significant increase in participants of the bilateral training group in functional ability of the upper limb, demonstrating a generalization from the training of a specific movement to general upper limb function. Individuals receiving bilateral training showed improvements in the time to complete the graded wolf motor function test (GWMFT) movement with the impaired limb . In the study, participants were trained in complex multi joint functionally relevant tasks, whereas other bilateral training studies have involved
35, 15
explained by the changes in the functional ability of impaired limb as evidenced by GWMFT scores and in motor performance by Fugl-Meyer score in the patient group used in the study. Recent research has shown that lesion location greatly influences the pattern of motor cortex excitability observed 60. Intervention timing may have influenced outcomes. The study showed significant effects of bilateral training in chronic stroke participants, whereas some studies showed no effects of bilateral training in patients with acute stroke
34
Stroke appears to alter normal transcallosal inhibition resulting in increased intact hemisphere excitability during hemiparetic arm movement that may be inhibitory in nature, thus suppressing output from the damaged hemisphere
23
Depending on the lesion site and size, these over activation appear transient, and more normal contralateral activation pattern resume over time
49
. Identical motor commands generated in each during bilateral movement may
hemisphere
protocols
36
using
simple
48
repetitive or auditory and
modulate transcallosal inhibition, balancing stroke related interhemspheric over activity and
movements with electric stimulation cueing . Furthermore
visualizing
facilitating output from the damage hemisphere as
34
well as from normally inhibited ipsilateral pathway of the undamaged hemisphere to augment movement of the paretic arm 50. there is a strong neurophysiological evidence to suggest that when the impaired and non impaired arms are moved symmetrically, crossed facilitatory drive from the intact hemisphere will be produced increase excitability in homologous motor pathways in the impaired limb
50, 51
bimanually.Initially, just after stroke, bimanual movement enhanced activation in the primary motor cortex M1 of the affected hemisphere did not differ between unimanual paretic hand and bimanual movement 14. The frequency and duration of the program may not have been optimal. One may ask whether 20 25-minutes sessions devoted to the bimanual task are sufficient to trigger brain reorganization and to observe a change. This scheduled was based on practical reason and although it is similar to that used in previous study 34, 61, The study does not suggest the training characteristics, such as the nature of the tasks and strength of inter limb coupling required for effects , may influenced outcomes: therefore future work should examined the optimal timing, dose and training tasks that might optimize the already known facilitatory effects of interlimb coupling. CONCLUSION This study suggest that 2 sessions of 25 minutes a day of bilateral training of functionally related tasks is effective for upper limb functional recovery in chronic stroke patients, regardless of the initial severity of the impairment. Furthermore, for recovery of functional motor performance, bilateral training appears beneficial. Several other studies have found benefits of bimanual training: therefore, this approach can be accepted as an upper limb intervention in stroke on the basis of finding this study. The study does not suggest the training characteristics, such as the nature of the tasks and strength of inter limb coupling required for effects, may influenced outcomes: therefore future work should examine the optimal timing, dose and training tasks that might optimize the already known facilitatory effects of interlimb coupling.
35
Additionally, cortical damage from stroke produces hyperexcitability of the contralesional M1

52
leading to abnormally high levels of
transcollasal inhibition (TCI) on the legend hemisphere, thereby further impairing motor performance of the paretic hand 53. There is recent evidence of improved affected hand performance in chronic stroke patients from reducing the abnormal inhibitory drive to the ipsilesional hemisphere
54, 55
Further
56
more,
balanced
interhemspheric interactions appear necessary for normal voluntary movements of the normal
57
and the restitution the two
balance
between
hemispheres has been linked to better recovery following stroke . It has been hypothesized that
practicing by lateral symmetrical movements may facilitate motor output from the ipsilesional hemisphere by normalizing (TCI) influences. Interestingly, in the subset of patients assessed with wolf motor function test and Fugl-Meyer scale in the study the bilateral trained patients exhibiting the largest increase in functional ability. In addition, bilateral training may promote increased involvement of pathways not
investigated in the present study such as spared corticopropriospinal pathways 50. The chronic nature of stroke might have allowed the plastic nature of brain to adjust to the various levels of tasks to be performed
Thus, null-hypothesis proved.
REFRENCES 1. Gresham GE, Duncan PW and Stason WB (1995). Post-stroke rehabilitation; Clinical practice guideline. [Vol. 16 AHCPR.] 2. Broeks JG, Lankhorst GJ, Rumping K and Prevo AJH (1999). The long- term outcome of arm function after stroke: results of a follow up study. [Disability and Rehabilitation (21) 357-364.] 3. Ostendorf C and Wolf SL (1981). Effect of forced use of the upper extremity of a hemiplegic patient on changes in function. Physical Therapy (61)1022-1028. 4. Morris DM and Taub E (2001). Constraint-induced therapy approach to restoring function after neurological injury. Top Stroke Rehabil (8) 16-30. 5. Senesac .D, Davis SB, Richards LG, Generalization in repetitive bilateral training in stroke. 6. Nagako Murase et al, Julie Duque et al .Influence of Interhemispheric Interactions on motor function in chronic stroke. Ann Neurol 2004; 55:400-409. 7. Patricia S. pohl, et al Carl W.Luchies et al and Pamela W. Duncan et al. Upper Extremity Control in Adults Post with Mild Residual Impairment. Neurorehabitation and neural repair,2000, Vol 14, No.1,33-41 8. D T Wade et al, V A Wood and R L Hewer et al Recovery after Stroke - - the First 3 months. Journal of Neurology, Neurosurgery and psychiatry 1985; 48:7-13. 9. Leeanne M. Carey et al, David F. Abbott and Gary F. Egan et al. Motor Impairment and Recovery in the Upper Limb after Stroke. Stroke 2005; 36:625-629. 10. Hirofumi Nakayama et al and Henrik Stig Jorgensen et al. Recovery of Upper Extremity Function in Stroke Patients: The Copenhagen Stroke Study. Arch Phys Med Rehabil Val 75, April 1994, 394-398. 11. Judith D. Schaechter et al. Motor Rehabilitation and Brain Plasticity after hemiparesis. Progress in Neurobiology Volume 73, issue 1, May 2004, 61-72. 12. Gert Kwakkel et al Robert C. Wagenaar et al and Tim W. Koelman et al. Effects of Intensity of Rehabilitation After Stroke. Stroke. 1997;28:1550-1556 13. Koichi Hiraoka et al. Rehabilitation effort to Improve Upper Extremity Function in Post Stroke Patients: A Meta Analysis. Journal of Physical Therapy Science, 2001, Vol 13; No. 1: 5-9. 14. W.R. Staines et al and W.E. Mcilory et al. Bilateral Movements Enhances ipsilesional cortical activity in acute stroke: A pilot functional MRI study. Neurology 2001;56:401-404 15. Mudie MH et al and Matyas TA et al. Can simultaneous bilateral movement involve the undamaged hemisphere in reconstruction of neural networks damaged by stroke? Disabil Rehabil, 2000 Jan 1020; 22(1-2). 16. C. L. Cunningham et al, M. E. Phillips Stoykov et al and C. B. Walter. Bilateral facilitation of motor control in chronic hemiplegic. Acta Psychologica 17. Michael I. Garry et al and Ian M. Franks et al. Spatially precise bilateral arm movements are controlled by the contralateral hemisphere. Exp Brain Res (2002) 142-:292-296.
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18. Lang, Catherine E et al and Wagner et al. Upper Extremity use in people with hemiperesis in the first few weeks after stroke. Journal of Neurologic Physical Therapy , Jun 2007;31: 56-63 19. Nestor A. Bayona et al and Jamie Bitensky et al. The role of task specific training in rehabilitation therapies. Topics in Stroke Rehabilitation. Aug 19, 2005 Volume 12 No.3, 58-65. 20. Fischer et al, Heidi C et al and Stubblefield et al. Hand rehabilitation following stroke: a pilot study of assisted fingure extension training in a virtual environment. Topics in stroke rehabil Jan 2007. 21. Y. Laufer et al, L. Gattenio et al and B. Sinai et al. The time related changes in motor performance of upper extremity ipsilateral to the side of the lesion in stroke survivors. Neurorehabilitation and neural repair2001 Vol 15 No.3 167-172 22. Michaelsen et al and Stella Maris et al. Specific training with trunk restraint on arm recovery in stroke: RCT. Stroke 2006 Vol 37(1) 186-192. 23. Liepert et al. Treatment induced cortical reorganization after stroke in humans. Stroke 2000, 31 12101216. 24. Timothy J. Carrroll et al and Michael Lee et al. Unilateral practice of a ballistic movement causes bilateral increases in performance and corticospinal excitability. J. Appl. Physiology 2008; 104: 16561664. 25. Carole G. Ostendorf et al and Steven L. Wolf et al. Effect of forced use of upper extremity of a hemiplegic patient on changes in function. Physical Therapy July 1981, Vol 61 No.7, 1022-1028. 26. Johanna H. Van der Lee et al and Robert C. Wagenaar et al. Forced use of the upper extremity in chronic stroke patients. Stroke 1999: 30, 2369-2375. 27. Edward Taub et al, Neal E. Miller et al and Thomas et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil April 1993; Vol 74: 347-354 28. Wolfgang H.R. Miltner et al and Monika Sommer et al. Effects of constant induced movement therapy on patients with chronic motor deficit after stroke. Stroke, 1999; 30: 586-592. 29. Steven L. Wolf et al, Carolee J. Winstein et al and Philip Miller et al and Edward Taub et al. Effect of constant induced movement therapy on upper extremity function in 3 to 9 months after stroke. JAMA 2006; 296:2095-2104. 30. Cathrin Butefisch et al and Horst Hummelsheim et al. Repetitive training of isolated movements improves the outcome of motor rehabilitation of centrally paretic hand. Journal of neurological sciences 1995; 130: 59-68. 31. Sandy McCombe Waller et al and Jill Whitall et al. Fine Motor Control in adults with and without chronic hemiperesis: Baseline comparison to nondisabled and effects of bilateral arm training. Adults. Arch Phys Med Rehabil July 2004; Vol 85: 1076-1082. 32. Dorian K. Rose et al and Carolee J. Winstein et al. Bimanual training after stroke: Are Two hands better than one? Topics in Stroke Rehabil, 2004; 11(4): 22-30. 33. Jeffery J. Summers et al, Florian A. Kagerer et al, Michael I. Garry and James H. Cauraugh et al. Bilateral and unilateral movements training on upper limb functions in chronic stroke patients; A TMS Study. Journal of Neurological sciences 2007; 252: 76-82.
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34. Jacqui H. Morris et al, Frederike van Wijck et al and Sara Joice et al. A comparison of bilateral and unilateral upper limb task training in early post stroke rehabilitation: A RCT. Arch Phys Med Rehabil July 2008; Vol 89: 1237-1245. 35. Jill Whitall et al, Sandy McCombe Waller et al and Richard F. Macko et al. Repetitive bilateral arm training with rhythmic auditory cueing improves motor function in chronic hemiparetic stroke. Stroke 2000; 31: 2390-2395 36. Andreas R. Luft et al, Sandy McCombe Waller et al and Jill Whiltall et al. Repetitive bilateral arm training and motor cortex activation in chronic stroke. JAMA October 20, 2004; Vol 292, No.15: 1853-1861. 37. Steven L. Wolf et al, Pamela A. Catlin et al and Michael Ellis et al.Assessing wolf motor function test as outcome measure for research in patients after stroke. Stroke 2001; 32: 1635-1639. 38. Pamela W.Duncan et al , Larry B. Goldstein et al and David Matchar et al. Measurement of motor recovery after stroke: Outcome assessment by Fugl Meyer Scale. Stroke 1992; 23: 1084-1089. 39. Evelyn Lee Teng et al and Helena Chang Chui et al. The modified mini-mental state (3MS) examination. J. Clin. Psychiatry 1987; 48: 314-318. 40. Janet Car, Roberta Shepherd: Bimanual Practice Neurological Rehabilitation Optimizing Motor Performance (1998;142-145) 41. Dickstein R, Hocherman S, Pillar T, Shaham, R. Three exersice therapy approaches. Physical Therapy 1986: 66; 1233-38. 42. Kelso JA, Southard DL, Goodman D. On the nature of human interlimb coordination. Science 1979; 203; 1029-31. 43. Canningham CL, Stoykov ME, Walter CB. Bilateral facilitation of motor control in chronic hemiplegia. Acta Psychol (Amst) 2002: 110: 321-37. 44. Lewis GN, Byblow WD. Neurophysiological and behavioral adaptation to a a bilateral training intervention in individuals following stroke. Clin Rehabil 2004; 18: 48-59. 45. Dorian K. Rose and Carolee J. Winstein. Bimanual training after stroke: Are two hands batter than one? Topics in stroke rehabil, 2004; 11(4):20-30. 46. Hesse S, Suhulte-Tigges G, Konard M, Baradeleben A, Werner C. Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects. Arch Phys Med Rehabil 2003; 84; 915-920. 47. Janet Car, Roberta Shepherd: Bimanual Practice Neurological Rehabilitation Optimizing Motor Performance (1998;142-145) 48. Cauraugh JH, Kim S. Two coupled motor recovery protocols are batter than one: electomyogramtriggered neuromuscular stimulation and bilateral movements. Stroke 2002; 33: 1589-94. 49. Feydy A, Carlier R, Roby-Brami A. Longitudinal study of motor recovery after stroke: recruitment and focusing of brain activation. Stroke 2002; 33; 1610-1617. 50. Cauraugh JH, Summers JJ. Neural plasticity and bilateral movements: a rehabilitation approach for chronic stroke. Prog. Neurbio. 2005; 75: 309-20.
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51. Carson RG. Neural pathways mediating bilateral interaction between the upper limbs. Brain Res. Rev. 2005; 49: 641-62. 52. Shimizu T, Hosaki A, Hino T, Sato M, Hiraiand S. Motor cortical disinhibition in the non-affected hemisphere after unilateral cortical stroke. Brain 2002; 125; 1896-907. 53. Murase N, Duque J, Mazzocchio R, Cohen LG. Influence of interhemispheric interactions on motor function in patients with chronic stroke. Ann. Neurol. 2004; 55; 400-9. 54. Feol A, Nagorsen U, Werhahn KJ, Ravindran S, Birbaumer N. Influence of somatosensary input on motor function in patients with chronic stroke. Ann. Neurol. 2004; 56: 206-12. 55. Contralesional primary motor cortex improves hand function after stroke. Stroke 2005; 36: 1553-66. 56. Ferbert A, Vielhaber S, Meincke U, Buchner H. Transcranial magnetic stimulation in pontine infarction: correlation to degree of paresis. J. Neurol. Neurosurg. Psychiatry 1992: 55; 294-9.
57. Calutti C, Baron JC, Functional neuroimagining studies of motor recovery after stroke in adults: a
rewiew. Stroke 2003; 34: 1553-66.
CORRESPONDING AUTHOR: *PhD Research Scholar, Singhania University **Consultant Orthopaedics, Kapoor Medical Center
39
A COMPARISON STUDY ON PHYSICAL IMPAIRMENTS AND FUNCTIONAL LIMITATIONS OF PATIENTS: 1 YEAR AFTER TOTAL KNEE ARTHROPLASTY VERSUS CONTROL SUBJECTS
Amit Murli Patel*
ABSTRACT BACK GROUND AND PURPOSE: The purpose of this study was to examine the physical impairments and functional limitations of individuals with total knee arthroplasty (TKA), as compared with individuals with no diagnosed knee disease (control subjects). Subiects. Forty-nine individuals 1 year following TKA (30 women, 19 men) and 40 age- and gender-matched control subjects (28 women, 26 men) were assessed. METHODS: Walking speed, stair climbing ability, knee torque (in newton meters), and total work performed during 15 repeated contractions were evaluated. RESULTS: Walking speeds for men with TKA were 13% and 17% slower at normal and fast speeds, respectively. Their stair climbing ability was even more compromised (51 % slower). Walking speeds for women with TKA were 17% and 18% slower at normal and fast speeds, respectively. Similarly, their stair-climbing time was more compromised (43% slower). Men with TKA were 37% to 39% weaker and performed 36% to 37% less total work of their knee extensors compared with the control subjects. Similarly, women with TKA had knee extensor strength deficits of 28% to 29% and performed 24% less total work. CONCLUSION AND DISCUSSION: One year after TKA, marked physical impairments and functional limitations persisted. KEY WORDS: Total Knee Arthroplasty, Physical Impairment, Knee osteoarthritis, Knee Strength
INTRODUCTION In India and in other industrialized nations,
the high prevalence of osteoarthritis (OA of the knee been

40
1-3
and OA's severe impact on disability have documented4. When conservative
well
management is ineffective, the surgical treatment of choice for individuals with severe, end-stage OA is often total knee arthroplasty (TKA). Previous research evaluating surgical success following TKA disability
11-12
reduced activity consequent to OA and the TKA may also impair function of the side without surgery. Jevsevar et al13 compared men and
women who had undergone TKA 1 or more years previously with a control group of subjects with no diagnosed knee disease and found that the subjects with TKA had deficits in angular velocity during the stance phase while performing activities of daily living, including walking and stair climbing. There is a need to document the persistent physical impairments and functional limitations in men and women following TKA. The direct goals of physical therapy are often related to function. The purpose of our study was to examine the physical impairments (knee ROM, muscle torque, and total work) and functional limitations (walking and stair climbing) of individuals 1 year after TKA, as compared with of age and Gender
focused on either end of the (impairment-disability).We
spectrum
believe that a complete description of treatment outcome requires measures across all levels (i.e, pathology, impairment, functional limitations, and disability) of Nagi's model of disablement .The pathophysiology of OA of the knee6 and the effects of alternative surgical interventions have been investigated . Isolated measurements of impairment, including measurements of pain and knee range of motion (ROM), have frequently been made9. The current trend is to evaluate the effectiveness of surgical interventions using patient-reported quality of life measures
10-12 7-8 5
Extensive research regarding disability has led to an appreciation of the gains expected in patient of reported quality of life following TKA .What is not well described in the literature is the degree of physical impairment and functional limitation in individuals following TKA
13 11
matched individuals with no diagnosed knee disease. We considered the peak torque (in newton meters) developed during five maximal
contractions to be an indication of muscle strength. We considered the total work (in joules) performed during 15 concentric contractions at angular velocities of 90 and 120/s to be an
compared
with
individuals without knee disease. Kroll and colleagues limitations of male quantified functional female patients
indicator of Isokinetic knee extensor and flexor endurance.
and
preoperatively and at 5 and 13 months following TKA. They noted a reduced walking speed (22%16%) in patients with TKA relative to that of older men with no diagnosed knee disease. Berman et all
14
Method : Subjects The subjects with TKA were 49 consecutive, consenting individuals (30 women, 19 men) who had undergone TKA at a single tertiary care orthopedic hospital. All individuals were assessed approximately 1 year after surgery (X= 12.6 months, SD= 1.5, range= 11-17). Eight of these individuals had bilateral knee replacements. Fifty four similarly aged, control subjects (28 women,
compared knee flexor (hamstring) muscle
function between limbs with TKA and limbs without TKA. Their results suggest that maximal recovery of hamstring muscle peak torque occurs by 7 to 12 months postsurgery. It may not be appropriate, however, to use the side without surgery for comparison because bilateral OA or
41
26 men) were recruited from the community through Patients relatives, working individuals etc. The control subjects were free of any known knee pathology and reported no functional limitations during walking or stair climbing. Control subjects were matched to patients with TKA based on gender and age ( 2 years). Written informed consent was obtained from each subject prior to clinical testing.
study, the same physical therapist using the same goniometer assessed knee ROM. Subjects lay on a plinth in the supine position with the knee to be measured maximally flexed and the foot flat on the plinth. Specifically, as described by Norkin and White24 the fulcrum of the goniometer was aligned with the lateral midline of the femur using the greater trochanter for reference. Finally, the distal arm of the goniometer was aligned with the lateral midline of the fibula using the lateral malleolus for
Procedure Standardized methods for measuring weight (wt) , height (ht), and girths at the waist and the hip
16 17
reference. Goniometer alignment for measuring knee extension was identical. While in the supine position, the knee was fully extended and a 10.2 cm (4 inch) rolled towel was placed under the ankle of the lower extremity to be assessed. Subjects were asked to maximally straighten their knee, and the measurement was recorded. There was no difference in height between the groups. The subjects with TKA, however, were heavier, with higher BMI scores and greater percentages of body fat, than the age- and gendermatched control subjects (Table 1). Despite a difference in AROM of knee flexion between groups, all Individuals with TKA had a knee AROM of 90 degrees of flexion, which is adequate for everyday function. Similarly, subjects with TKA had an extension loss of 10 degrees, although the men showed a difference between groups in extension. Estimated thigh muscle volume did not differ between groups for the men. Women with TKA had a higher estimated muscle volume value than the women in the control group had (Table 2). Concentric isokinetic knee torque and total work were evaluated on both lower extremities using a LIDO Active Isokinetic dynamometer. Subjects with one TKA were tested so that the limb that did not undergo surgery was tested first.
were used. Chum lea et al
reported a
technical error of measurement of waist girth of 0.48 cm in elderly men and of 1.15 cm in elderly women. Malina et al reported a technical error of measurement of hip girth of 1.23 cm for intrameasurer errors. M'ilmore and Behnke19 reported a correlation of 0.99 between
2 l8
measurements obtained 1 day apart in young male subjects. Body mass index (BMI : Wt /ht ) and waist-to-hip ratios (WHR : waist girth/hip girth) were calculated from the measurements.
Percentage of body fat was estimated from measurements of body reactance and resistance obtained with a bioelectric impedance device (BIA 101 Body Composition Analyzer). Muscle volume of the thigh was estimated from anthropometric measurements using the method of Jones and Pearson.20 Knee active range of motion (AROM) was measured bilaterally, to the nearest degree, using a goniometer. It is generally reported21-23 that the reliability of goniometric measurements improves when the assessment is performed by the same individual, who uses the same measurement tool with a standard test position and protocol. In our
42
This limb was tested first to limit apprehension that would interfere with testing. For all other subjects, the choice of limb to be tested first was determined by convenience. All tests were performed while the subjects were in a seated position with the hips flexed to approximately 80 degrees. The dynamometer was preset, using software controls, to evaluate torque (peak torque (developed during five voluntary maximal
been reported by Patterson and Spivey 25 After the subjects practiced bending and straightening their knee for two to three
repetitions, they were instructed to "bend and straighten your knee as hard and as fast as you can" to elicit five continuous maximal voluntary contractions of the knee extensors and flexors. Verbal encouragement was standardized by
repeating the same phrase (ie, "kick up, pull down, kick up, pull down; work as hard and as fast as you can") during all isokinetic tests. Torque curves were accepted only when the coefficient of variation for the five repetitions was less than 10%. Mean peak torque (in newton-meters) was calculated as the average of the highest torque values for the five repetitions. Thus, the mean peak torque recorded during five concentric
contractions) through a preset knee range of motion from 20 2 to 90 2 degrees of flexion in the sagittal plane. The manufacturer of the LIDO Active system claims that the device is selfcalibrating, and we did not test this claim. Prior to each test session, the device is supposed to compensate for gravity by weighing the patient's limb through the preset range of motion at an angular velocity of 5/s. We did not check whether these determinations were correct. The validity and reliability of measurements obtained with the LIDO Active isokinetic system have previously
contractions at angular velocities of 90 and 120/s was used as an indicator of muscle strength of the knee extensors and flexors.
Table 1 Physical Characteristics and Activity Level of Study Participants by Group and Gender TKA Group (n=49) Variable Female (n = 30) Physical characteristics Age (y) Weight (kg) Height (cm) WHR BMI (kg/m2) 61.3 1.3 76.0 2.9 160.8 1.9 0.81 0.2 29.5 1.3 66.4 1.7 89.1 3.9 170.3 1.8 0.93 0.01 30.9 1.4 61.9 1.1 64.2 2.6 158.3 2.1 0.77 0.01 25.2 0.91 63.6 1.4 76.4 1.8 171.5 1.3 0.93 0.008 25.9 0.45 Male (n = 19) Female (n = 28) Male (n = 26) Control Group (n=54)
43
Percentage of body fat Knee active range of motion Flexion Extension Total score on physical activity Questionnaire for elderly people
37.8 2
25.3 2
31.3 2
21.2 1
114 4.65 - 1 1.43
110 3.74 - 0.4 1.18
143 1.54 - 7 1.37
142 1.16 - 6 0.56
23.6 3.71
15.3 2.23
18.2 2.43
19.5 1.56
Table 2 Muscle Thigh Volume and Cross-sectional Area of Study Participants by Group and Gender TKA Group (n=49) Variable Female (n = 30) Thigh muscle volume (cm3) Limb with TKA Limb without TKA Thigh Muscle Cross-sectional area (cm2) Limb with TKA Limb without TKA 13.1 0.4 13.9 0.4 .. .. 3413.7 119.8 3921.3 159.9 .. .. Male (n = 19) Female (n = 28) Male (n = 26) Control Group (n=54)
3453.7 217.2
3979.2 200.2
2852.7 155.0
4020.0 199.3
12.7 0.2
13.3 0.4
11.7 0.3
13.5 0.2
Table 3 Knee Muscle Peak Torque (in Newton-meters) for Concentric lsokinetic Knee Extension and Flexion at an Angular Velocity of 90/s
44
TKA Group (n=49) Muscle group Female (n = 30) Knee extensors Limb with TKA Limb without TKA Knee flexors Limb with TKA Limb without TKA 26.3 6.9 31.7 5.0 40.0 6.3 51.9 6.8 44.8 7.5 46.3 8.1 69.5 8.7 82.6 13.0 Male (n = 19)
Control Group (n=54) Female (n = 28) Male (n = 26)
.. 63.0 3.5
.. 113.6 6.4
.. 36.0 1.7
.. 61.4 2.3
RESULT Angular velocity of 120/s. Compared with the angular velocity of 90/s, mean peak torque values were lower at the faster speed in all subjects except the women with TKA. For these
male control subjects. At the angular velocity of 120/s, knee peak torque torque of the limb with the TKA of all individuals who had undergone surgery was diminished when compared with that of the control subjects (Table 4).
individuals, the mean peak torques were slightly higher for both muscle groups (extensors and flexors) on the side without the TKA and for the knee flexors on the side with the TKA at 120/s compared with their values at 90/s. When assessed at the angular velocity of 120/s, knee peak torque of the women with TKA improved relative to that of the female control subjects. For example, their limb with the TKA had achieved extensor and flexor mean peak torques of 72% to 85%, respectively, of the values of the female control subjects. In the male subjects with TKA, the decrement in mean peak torque relative to that of the control subjects was markedly greater at 120/s than at 90/s. At the faster angular velocity, extensor and flexor mean peak torques were just 63% to 65% of those of the
Knee Total Work Angular velocity of at 90/s. Deficits in knee extensor and flexor concentric peak torque and total work were still present 1 year
postoperatively, not only in the limb with the TKA but in the limb without the TKA of individuals who had undergone surgery. On average, total work of the extensors and flexors of the subjects with TKA was 76% to 73%, respectively, of the values for the control subjects. Extensor endurance performance, measured as the total work of the limb without the TKA in women who had undergone surgery, was assessed to be 18% less than in the control subjects. Compared with the control subjects, the performance of the male subjects with TKA on muscular endurance testing was generally poorer than on peak torque
45
testing. The total work of the extensors and flexors at 90/s accomplished by the male subjects with TKA was only 64% and 55%, respectively, of that of the control subjects (Table 5).
frequently reported by the subjects with TKA. Persistent knee pain was reported by the subjects with TKA following fast walking. Mean ( SD) pain scores were 0.8 0.98 for the men with TKA and 1.8 2.69 for the women with TKA, where 0 represents "no pain" and 10 represents "maximal
Angular velocity of 120/s. As expected, less work was produced at the faster angular velocity of 120/s compared with the angular velocity of 90/s. This pattern was evident across both genders and groups. Similar to patterns at the slower angular velocity of 90/s, deficits in total work at 120/s during 15 maximum repetitions were evident in the female subjects with TKA. Specifically, they achieved 76% and 74% of the extensor and flexor work, respectively, of that achieved by the female control subjects. Extensor and flexor total work decrements were less in the limb without the TKA (87% and 90%,
pain." These scores were both statistically significant (P .02) and clinically significant compared with those of the control group.
Stair-Climbing Performance Both women and men with TKA took more than twice as long to ascend and descend a flight of 10 stairs than it took the control subjects (Table 8). Although both men and women performed at a slower pace, the women with TKA reported a greater perceived effort and pain in completing the stair-climbing task. Although all subjects were instructed to try to ascend and descend the stairs without using a handrail, six subjects with TKA (including one subject with bilateral TKA) required this assistance. All except eight subjects with TKA (including two subjects with bilateral TKA) used a reciprocal stepping pattern. One individual declined performing this task due to fatigue.
respectively) of the subjects who had undergone surgery compared with the control subjects. Male subjects who had undergone surgery produced similarly low extensor and flexor total work values (63% and 57%, respectively) in the limb with the TKA compared to the male control subjects (Table 6).
Self- Paced Walking Individuals with TKA achieved over 80% of the normal and fast walking speeds of their age and gender matched counterparts 1 year after surgery (Table 7). Ratings of perceived exertion and heart rates were similar between the groups, despite the slower walking speeds at both normal and fast selected paces in the subjects with TKA. A perceived exertion rating of 2, anchored by the expression "slight" on the Borg Scale, was
Physical Activity The subjects with TKA did not differ from the control subjects in their reported total level of physical activity, as measured ( X SEM) using the physical activity questionnaire for elderly people30 (19 2.2 versus 19 1.4, respectively). Large standard deviations for all groups indicate the diverse physical activity habits of our study participants (Table. 1).
46
Table 4 Knee Muscle Peak Torque (in Newton-meters) for Concentric lsokinetic Knee Extension and Flexion at an Angular Velocity of 120/s
.. 59.0 2.3
.. 105.2 5.7
.. 35.7 1.5
.. 62.0 2.8
Table 5 Total Work (in Joules) for Concentric lsokinetic Knee Extensors and Flexors at an Angular Velocity of 90/s
.. 816.8 28.6
.. 1397.4 73.0
.. 482.5 19.8
.. 849.4 31.4
Table 6 Total Work (in Joules) for Concentric lsokinetic Knee Extensors and Flexors at an Angular Velocity of 120/s
47
TKA Group (n=49) Muscle group Female (n = 30) Knee extensors Limb with TKA Limb without TKA Knee flexors Limb with TKA Limb without TKA 331.2 64.8 440.0 42.9 523.3 75.8 810.1 66.7 Male (n = 19)
..
..
600.2 112.1
934.4 124.9
..
..
401.8 70.5
563.4 47.6
447.9 23.5
766.1 32.4
Table 7 Performance for the 160-m Walk Test at Normal and Fast Self-paced Walking Speeds
TKA Group (n=49) Variable Female (n = 30) Male (n = 19)
Normal self paced walking speed Speed (m/s) Pain ( 0 10 ) RPE ( 0 10 ) 1.17 0.05 1.0 0.7 1.2 0.4 1.31 0.05 0.5 0.3 2.2 0.4 1.38 0.03 0.0 0.0 0.5 0.2 1.51 0.03 0.0 0.0 0.7 0.2
Fast self paced walking speed Speed (m/s) Pain ( 0 10 ) RPE ( 0 10 ) 1.36 0.1 1.6 0.7 1.6 0.4 1.53 0.06 0.8 0.4 2.6 0.5 1.65 0.03 0.0 0.0 1.6 0.2 1.84 0.03 0.0 0.0 1.8 0.2
48
Table 8 Group x Gender Performance While Ascending and Descending One Flight of 10 Steps
TKA Group (n=49) Variable Female (n = 30) Stair time (s) Pain ( 0 10 ) RPE ( 0 10 ) 31.10 0.49 1.9 1.0 2.4 0.6 Male (n = 19) 23.33 2.3 0.9 0.6 2.2 0.4
Control Group (n=54) Female (n = 28) 12.45 0.47 0.0 0.0 0.4 0.2 Male (n = 26) 11.81 0.31 0.0 0.0 1.2 0.5
DISCUSSION AND CONCLUSIONS Our findings indicate that marked control subjects. We are unable, therefore, to delineate the effects of obesity from those of TKA on function. Volunteers are known to have better health and higher functional abilities than the general population.34 The results of both the subjects with TKA and the control subjects may have been influenced by this volunteer effect. The body composition measurements (weight, BMI),
impairments and some functional limitations persist in individuals even 1 year following TKA. The relative absence of pain but elevated rating of perceived exertion and heart rate responses to physical activity and decreased concentric muscle strength suggest that physical deconditioning may strongly contribute to the decreased function in these individuals. Alternative explanations for the observations composition include or differences in body of
although different between the subjects with TKA and the control subjects, were similar to age and gender matched normative values from a Canadian survey.16 Walking speed was within approximately 1 standard deviation of age-predicted values for men and wornen at both self-selected paces35 These comparisons suggest that our control sample was representative of healthy older people. Although no survey data on individuals with TKA are currently available, data from other studies suggest that our subjects with TKA may have had higher than average functional levels. Berman et all4 reported a normal walking speed for men and women who were tested 2 to 3 years after TKA (0.90 m/s) that was slower than our mean
49
biomechanical
efficiency
walking between the subjects with TKA and the control subjects. The subjects with TKA were heavier (12-13 kg) and had a higher percentage of body fat (4%-6%) compared with their age- and gender-matched control subjects. Osteoarthritis is typically associated with increased body fat even in earlier stages of the disease33 but our study provides evidence that differences persist even 1 year after TKA. The values for BMI obtained for the subjects with TKA are associated with increased risk of morbidity and mortality16. One of the limitations of our study is that the subjects with TKA had increased body fat compared with the
value (1.25 m/s) at the normal walking speed. Mattsson and colleagues
36
of low intensity activities did not appear to be an adequate stimulus to rebuild muscle torque, total work, or aerobic condition, nor was the resumption of active living adequate to reduce obesity. Impairment in muscle function was evident from the reductions in mean peak torque and total work for knee flexion and extension. Force generation is expected to decrease as the speed of movement increase40 but this decrease was not observed in our female subjects with TKA. We also expected that functional deficits would relate to the degree of muscle atrophy assessed by anthropometry. We found no such relationship. No reduction in muscle volume was evident in the male subjects with TKA when compared with the control subjects, and the female subjects with TKA had a greater muscle volume and estimated cross-sectional area
reported a maximal
walking speed over 4 minutes of 1.25 m/s for 12 men and 16 women who were tested 1 year after TKA. Free walking speed 1 year after TKA for1 7 men and 11 women was 1.07 m/s in the study by Kroll et al13 The higher walking speed observed for our subjects suggests that our estimates of the degree of impairment 1 year after TKA may be conservative relative to other individuals who have TKA surgery. Osteoarthritis is associated with altered gait mechanics Previous studies
37 38,39
however, suggest
that biomechanical differences in gait between subjects with TKA and subjects with no diagnosed knee pathology are minor. Our observation of only minor deficits in ROM supports those
observations. Reduced physical activity may be both a cause and a consequence of physical impairment and functional limitation. Pain associated with OA limits physical activity, and surgical intervention that decreases pain should allow resumption of normal activities. If reduced physical activity has become habitual, however, this might contribute to continuing obesity and deficits in physical capacity. Our findings indicate no differences in total physical activity scores between subjects with TKA and control subjects. The physical activity questionnaire for elderly people30 used in our study divides activities into low, medium, and high categories. It was evident that few of either the control subjects or the subjects with TKA were active in more physically demanding activities (ie, sporting activities). Only 38% of the subjects with TKA and only 47% of the control subjects reported involvement in any sporting activity during the previous year. Spontaneous resumption
compared with the control subjects (Table 2). Clinical examination of the study participants ruled out thigh edema as a contributing factor. Given Overend and colleagues' poor success in validating estimates of thigh cross sectional area and volume using computed tomography (CT) in groups of young and old men41 and Sipila and Suominen's finding of no relationship between either cross-sectional area or lean tissue to isometric quadriceps femoris muscle strength when measured by CT scan and ultrasonography in 66- to 85 year old female athletes and agematched controls42 perhaps our finding is not surprising. The explanation for this discrepancy may be two fold. First, changes in intramuscular fat would not be detectable with the
anthropometric measures used in our study. Second, changes in neuromuscular recruitment that may alter mean torque output were not evaluated. Using the limb without the TKA as a control, as other Researchers43,44 have done, may
50
underestimate the magnitude of the deficit in the limb with the TKA. Jevsevar et al suggested that it may not be appropriate to use the side without the TKA as a comparison because bilateral OA or reduced activity consequent to OA may impair function of the limb without the TKA. The subjects with TKA had lower peak torque and total work values for the limb without the TKA compared with the control subjects. The reduced muscle performance may be due to continuing effects of inactivity both before and following surgery or to nonsymptomatic OA of the knee without the TKA. Questionnaire responses did not reveal differences in physical activity between the control subjects and the subjects who had undergone TKA. The absence of a difference in thigh cross-sectional area and estimated muscle volume suggests that decreased muscle size does riot explain all of the group differences (Table 2). Walking and stair climbing have been identified by clinicians and patients
15,45,46 l5
subjects
with
TKA
demonstrated
greater
functional limitations on the stair climbing test, with slower times and increased pain and exertion. Male subjects with TKA demonstrated smaller deficits during the stair-climbing test but larger decreases in muscle strength and local muscular endurance. Performance on the SPW test at both normal and fast paces was reduced more in the female subjects, placing many more of them (62% at a normal pace and 31% at a fast pace, compared with 25% and 6%, respectively, for the male subjects) below the threshold required for safe crossing of street intersections. Our findings suggest that data for men and women regarding walking, stair-climbing performance, and
concentric knee strength and local muscular endurance should not be pooled. Pain is a critical aspect of disability due to OA that can be resolved successfully by surgery.45 One year postoperatively, little pain was reported in activities such as walking, stair climbing, and concentric muscle strength testing.29 Yet, in the relative absence of pain, physical capacity remains diminished. The consequences of a diminished physical capacity are evident in slower walking speeds and a higher physiological cost demanding greater exertion during physical activity. The most serious consequences of reduced physical capacity may be evident as aging further reduces the reserve capacity of these individuals. Adequate reserve capacity is an important factor in the ability of older adults to maintain their independence. A rehabilitation program that focuses on weight may reduction enhance the and aerobic of
as
critical functional activities. Our findings suggest that although TKA is very successful in reducing knee pain (a prime motivation for surgery), patients are still limited in their functional activities compared with their age-matched
counterparts. When the normal SPW speed of our subjects with TKA was compared with the locally required speed to cross a traffic intersection (1.2 m/ s )47 it became clear that a large proportion of these individuals (55%, n= 16) must walk at a faster pace than they normally use in order to successfully clear the intersection before the light changes. Indeed even at the fast walking pace, 17% (n=5) of these individuals would not be able to cross safely at a typical city intersection. Our analyses suggest that men and women are affected to differing degrees by TKA. Female
conditioning
ability
individuals with TKA to perform important activities such as walking and stair climbing. This program may benefit patients with orthopedic
51
problems in the years immediately following the surgery and, perhaps more importantly, may also help preserve their reserve capacity and allow
them to maintain functional independence for a longer period in the future.
REFERENCES 1. Felsor DT, Nainlark A, Anderson J, et al. The prevalence of knee osteoarthritis in the elderly. Arthritts Rheum. 1987; 30:914-918. 2. Kovar PA, Allegrante JP, Mdckenzie CR, et al. Supervised fitness walking in patients with osteoarthritis of the knee: a randomized controlled trial. Ann Intern M P ~1.9 92;116:529-534. 3. Quam JP, Michet CJ, Wilson MG, et al. Total knee arthroplasty: a population-based study. Mayo Clin Proc. 1991; 66:589-595. 4. Verbrugge LM. Women, men, and osteoarthritis. Arthritir Cart C Research. 1995;8:2 12-220. 5. Nagi S. Disability concepts revisited: implications for prevention. In: Pope AM, Tarlov AR, eds. Disability in America: Toward a National Agenda fm Prmmtion. bvashington, DC National Academy Press: 1991:309-327. 6. Bland JH, Cooper SM. Osteoarthritis: a review of the cell biology involved and evidence for reversibility-management rationally related to known genesis and pathophysiology. Sermin Arthritis Rheum. 1984;14: 106-133. 7. Laughman RK, Stauffer RN, Ilstrup DM, Chao EYS. Functional evaluation of total knee replacement. J Orthop Res. 1984;2:307-313. 8. Andriacchi TP. Biomechanics and gait analysis in total knee replacement. Orthop Ra,. 1988;17:470473. 9. FlettJL, Burnham RS, Saboe L.et al. Effect of measurement time and mode on amount of flexion following total knee arthroplasty. Canadian Journal of Rehabililation. 1992;5:145-149. 10. Kantz M, Harris W, Levitsky K, et al. Methods for assessing condition-specific and generic functional status outcomes after total knee replacement. Med Care. 1992;30:MS240-MS2.52. 11. Ritter MA. Albohm MJ, Keating EM, et al. Comparative outcomes of total joint arthroplasty. JArthrqfdnsty. 1995;10:737-741. 12. McGuigan EX, Hozack U'J, Moriarty L, et al. Predicting quality of life outcomes following total joint arthroplasty. J Arthropla~ty. 1995;l0: 742-747. 13. Kroll MA, Otis JC, Sculco TP, et al. The relationship of stride characteristics to pain before and after total knee arthroplasty. Clin Orthop. 1989;239:191-195. 14. Berman AT, Bosacco SJ, Israelite C. Evaluation of total knee arthroplasty using isokinetic testing. Clin Orthq. 1991;271:106-113. 15. ,Jevsevar DS, Riley PO, Hodge MTA. Krebs DE.Knee kinematics and kinetics during locomotor activities of daily living in subjects with knee arthroplasty and in healthy control subjects. Phys Ther. 1993;73:229-242.
52
16. Canadian Standarised Test of Fitness (CSTF) Operations .Manual. 3rd ed. Ottawa, Ontario, Canada: Fitness and Amateur Sport Canada; 1987. 17. Chumlea WC, Roche AF, Rogers E. Replicability for anthropometry in the elderly, Biol, 1984;56:329-337, 18. Malina RM, Roche AF. Manual Physical Status and Performance in Childhood, Volume 2: Physical Performance New York, NY: Plenum Publishing Corp; 1983 19. Wilmore JH, Behnke AR. An anthropometric estimation of body density and lean body weight in young women. Am J clin Nutr. 1970;23:267-274 20. Jones P, Pearson P. Anthropometric determination of leg fat and muscle plus bone volumes in young male and female adults. J Physiol Paris. 1969;294:63-66. 21. Clarkson HM, Gilewich GB. Musculoskeletal Assessment: Joint Range of Motion and Manual Muscle Strength. Baltimore, Md: U'illianis & Wilkins; 1989: 14. 22. Watkins MA. Riddle DL, Lamb RL, Personius WJ. Reliability of goniometric measurements and visual estimates of' knee range of motion obtained in a clinical setting. Phys Thrr: 1991;71:C30-97. 23. Rothstein 151. Miller PI, Roettger RF. Goniometric reliability in a clinical setting: elbow and knee measurements. Phys Thr. 1983;63:1611-1615. 24. Norkin CC, White DJ. Measurement of joint motion; A guide to Goniometry, Philadelphia PA.FA Davis Co: 1987:88. 25. Patterson LA, Spiwey WE. Validity and reliability of the LIDO Active Isokinetic svstem. J Orthop Sports Phys ther. 1992;15:32-36. 26. Bassey EJ, Fentem PH, MacDonald IC, Scriven PM. Self-paced walking as a method for exercise testing in elderly and young men. Clin Sri. 1976;31:609-612. 27. Borg GAV. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377-38. 28. Cunningham DA, Rechnirzer PA, Donner AP. Exercise training and the speed of self-selected walking pace in men at retirement. Canadian journal of Aging 1986;5(1):12-26. 29. M. Functional Outcome measures: individuals One year post Total Knee arthroplasty Versus Healthy Controls. Toronto, Ontario, Canada: University of Toronto; 1995. Master's thesis. 30. Voorrips LE, Ravelli AC, Dongelmans PC, et al. A physical activity questionnaire for the elderly. Med Sci .Sports Exerr. 1991:23:974-979. 31. Baecke JA, Burcma J, Frijters JE. A short questionnaire for the measurement of habitual physical activity in epidemiological studies. Am J Clin Nutr 1982;36:936-942. 32. Bink B, Van der Sluys BH. Assessment of the Energy Expenditure by Indirect Time and Motion Study. In Edang EK, Anderson KL, eds. Physical Activity in Health an disease: Proceedings of the Bertostolen Symposium, Oslo Norway Oslo University; 1996:207-214. 33. Hochberg MC, Lethbridge-Cejku M, Scott WWJ, et al. The association of body weight, body fatness, and body fat distribution with osteoarthritis of the knee: data from the Baltimore Longitudinal Study of Aging. J Rheumatol. 1995;22:488-493. 34. Sackett DL. Bias in analytic research. J Chronic Dis. 1979;32:51-63.
53
35. Himann JE, Cunningham DA, Rechnitzer PA, Paterson DH. Age related changes in speed of walking. Med Sci. Sports Exerc. 1988;20:161-166. 36. Mattsson E, Brostom LA, Linnarsson D. Changes in walking ability after knee replacement. Int Orthop. 1990:14:277-280 37. Messier SP, Loeser RF, Hoover JL.et al. Osteoarthritis of the knee: effects on gait, strength, and flexibility. Arch Phys Med Rehabili 1992 73:29-36. 38. Weidenhielm L, Olsson E, Brostrom LA, et al. Improvement of gait one year after surgery for knee osteoarthritis: a comparision between high tibial osteotomv and prosthetic replacement in a prospective randomized study. Scand J Rehabil Med. 1993:23:25-31. 39. Andriacchi TP. Functional analysis of pre- and post-knee surgery total knee arthroplasty and ACL reconstruction J Biomech. 1993; 115:575-581. 40. Lieber RL. Skeletal Muscle Physiology: Skeletal Muscle Structure and function- Implications for Rehabilitation and Sports Medicine. Baltimore, Md: Williams & Wilkins; 1992:60-61. 41. Overend TJ. Cunningham DA, Paterson DH. Lefcoe HS. Anthropometric and computed tomographic assessment of the thigh in young and old men. Can J Appl Physiol. 1993;18:26.3-273. 42. Sipila S, Suominen H. Knee extension strength and walking speed in relation to quadriceps muscle composition and training in elderly women. Cli11 Physiol. 1994;14:433-442. 43. Gross MT, Credle JK, Hopkins LA, Kollins M. Validity of knee flexion and extension peak torque prediction models. Phys Ther. 1990;70:3-10. 44. Krebs DE. Isokinetic, Electrophysiologic and clinical function relationships following tourniquet aided arthrotomy. Phys Thpr. 1989;69: 804-815. 45. Bellamy N, Buchanan MW. A preliminary evaluation of the dimensionality and clinical importance of pain and disability in osteoarthritis of the hip and knee. Clin Rheumatol. 1986; 5.231-241. 46. Ettinger WH, Afable RF. Physical disability from Knee Osteoarthritis; the role of exercise as an intervention. Med Sci. Sports Exerc. 1994;26; 1435-1444.
CORRESPONDING AUTHOR:
*BPT, MPT-Orthopaedics, Senior Physical therapist, Ahmedabad, Gujarat.
54
RESPIRATORY PHYSIOTHERAPY IN TRIPLE VESSEL DISEASE WITH POST CORONARY ARTERY BYPASS GRAFTING SURGERY (CABG)
Shanmuga Raju P (MPT)*, Renkha Rao (MCh), Rajendhra Kumar J (MD), SuryaNaryana Reddy V (MS)
ABSTRACT We are presenting a case of 47 years of old female with triple vessel disease and coronary artery bypass graft surgery. Her complaint was chest pain and shortness of breath since last 5 months. Coronary angiogram revealed triple vessel disease and she underwent three coronary artery graft surgery on 24th February, 2013. Second day aftter CABG, she developed dyspnoea, reduced chest expansion and decreased arterial O2 saturation. She was treated with daily session involving positioning, chest percussion, deep breathing exercise, manual mobilization exercise and passive and active limb movements. We observed that receiving chest physiotherapy has significant effect in recovery of post CABG patient after 3 weeks of follow up. Our aim of case study is to describe effects of respiratory physiotherapy in post operative CABG in triple vessel disease. Keywords: Triple vessel disease, Coronary artery bypass grafting, respiratory physiotherapy
INTRODUCTION India have 29.8 million symptomatic patients with coronary artery disease (CAD).
55
Approximately, one sixth of the world population lives in India

(1)
. Coronary artery bypass graft
(CABG) surgery is challenging for coronary artery
disease. CABG is associated with an occurrence of pulmonary complications,

(2)
eosinophils 03%, monocytes 05%, basophilis 00% and ESR is 30mm/1hours. Biochemistry: Sodium 136 mmol/L, potassium 4.1 mmol/L, chlorides 106 mmol/L, fasting serum glucose 103 mg/dL. Urine level is 100ml. Blood group is O negative. Chest expansion
defined
as
any
pulmonary abnormality that occurs during the post operative period . A decrease in pulmonary
function is well known after open heart surgery. Chest physiotherapy is routinely used in order to prevent or reduce pulmonary complications after surgery. Post operative treatment includes early mobilization, change in position,
(3)
measurements were 58 cm at axilla level, 83 cm at nipple level and, 79 cm at xiphoid level.
breathing
exercises and coughing techniques .
CASE REPORT A 47 year old female patient was diagnosed to have triple vessel disease; coronary angiogram revealed triple vessel coronary artery disease and was referred to department of cardiothoracic surgery at Chalmeda AnandRao Institute of Medical Sciences, Karimanagar on 24th February 2013. Medical history was chest pain and shortness of breathlessness since last 5 months. She was known case of type to II Diabetes mellitus, but no history of hypertension. Coronary angiogram showed triple vessel disease with left ventricular dysfunction. She underwent coronary artery bypass grafts surgery and three grafts were placed, one graft was placed to obtuse marginal 1 (OM 1), second graft was placed to left anterior descending artery and third graft was placed to right coronary artery. She was hemodynamically stable on first post operative day but on second postoperative day, she had aspirated gastric contents and developed hypoxia due to asphyxia. Her blood pressure was 149/81 mm/Hg, pulse 106 per/minute, heart rate 123 per/minute, respiration rate 16 breaths per/minute, and temperature was 1000 F. Complete blood picture show hemoglobin 6.5 gm/cumm, WBC 5,800 cells/cumm, neutrophils 78%, lymphocytes 17%, DISCUSSION Patient undergoing cardiac surgery (CS), in most number of cases post operative pulmonary
56
Figure:
Before
CABG
and
respiratory
physiotherapy transthoracic 2D echo cardiogram show decrease Left ventricular systolic function (LV ejection fraction (EF) 20.3 %).
Figure:
After
CABG
and
respiratory
physiotherapy transthoracic 2D echocardiogram show improve LV systolic function (LV ejection fraction 55.3 %).
dysfunction developed with a significant reduction in lung volume, respiratory function, and lung compliance and increased work of breathing
(4-5)
anteroseptal wall and apical part of LV were hypokinetic and reduced LV systolic function. Second day after surgical procedure (CABG) she had aspirated gastric contents and developed hypoxia due to asphyxia. Three week after respiratory physiotherapy treatment, her chest expansion, arterial O2 saturation and cardiac function were improved (EF 55%). She was discharge and advised follow-up.
Atelectasis and hypoxemia are among the main pulmonary complications post operatively of CABG
(6)
. Respiratory therapy is often used in the
prevention and treatment of post operative complications as retention of secretions, atelectasis and pneumonia . In our case, before CABG, an
(7)
electrocardiogram shows Q wave in V1 V2 V3 & V4 chest lead are poor progression of R wave in chest lead V5 and V6. After CABG Q wave are present in V1 and V4 chest lead, no new ST- T changes. Before surgical procedures transthoracic 2D echocardiogram shown normal valves and normal size chambers. Anterior wall, lateral wall,
CONCLUSION Our case report showing that post operative respiratory physiotherapy is an effective
management for a patient with coronary bypass graft surgery for reducing in pulmonary
complications.
REFERENCES 1. Aggarwal A, Sourabh A, Goel A, Sharma V, Dwivedi S. A retrospective case control study of modifiable risk factors and cutaneous markers in India patients with young coronary artery disease. J R Soc Med Cardio 2012, vol:1(38); p: 1-8. 2. O Donohue WJ Jr. Postoperative pulmonary complications. When are preventive and therapeutic measures necessary? Post grad Med 1992, 91(3): 167-170. 3. Westerdahl E, Lindmark B, Almgren SO, Tenling A. Chest physiotherapy after coronary artery bypass graft surgery- A comparison of three different deep breathing techniques. J Rehab Med 2001; 33: 79-84. 4. Westerdahl E, Lindmark B, Eriksson T, Friberg O, Hedenstierna G, Tenling A. Deep breathing exercises reduce atelectasis and improve pulmonary function after coronary artery bypass surgery. Chest. 2005; 128(5): 3482-8. 5. Feltrim MIZ, Jatene FB, Bernardo WM. Em pacientes de alto risco, submetidosa revascularizacao do miocardio, a fisiotherapia respiratioria pre-operatoria previne as complica coes pulmonares? Rev Assoc Med Brac.2007; 53(1): 1-12. 6. Renault JA, Costa- Val R, Rossetti MB. Respiratory physiotherapy in pulmonary dysfunction after cardiac surgery. Rev Bras Cir Cardiovasc.2008; 23(4): 562-9.
57
7. Lopes C, Brandao CM de A, Nozawa E, Auler Junior JOC. Benefits of non-invasive ventilation after extubation in the post operative period of heart surgery. Rev Bras Cir Cardio Vasc 2008; 23 (3): 344-350.
CORRESPONDING AUTHOR: *Dr. P. Shanmuga Raju, MPT, Asst. Professor & I/C Head, Department of Physical Medicine & Rehabilitation, Chalmeda Anand Rao Institute of Medical Sciences, Karimngar- 505001, Andhra Pradesh, INDIA. E-mail: shanmugampt@rediffmail.com
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OCCUPATIONAL THERAPY MARKETING INDIAN PROSPECTIVE

Koushik Sau*
ABSTRACT
OBJECTIVES: The purpose of this study is to find out the present scenario of occupational therapy marketing in India. METHODOLOGY: An author designed survey questionnaire is used for this study. Other Allied health staff, other rehabilitation staff and local occupational therapist revised the questionnaire in three stages. After the three-staged revision final survey questioners was made and send to different occupational therapist working in various parts of India. RESULT: All participants (100%) are agreeing with that there is a need of marketing. But they are not satisfied with the present marketing scenario of occupational therapy in India. CONCLUSION: This study can use by practitioner for marketing guidance KEYWORDS: Occupational Therapy, Marketing, Health Care Marketing, Occupational Therapy Marketing.
1. INTRODUCTION According to the American marketing association Marketing is the process of
planning
and
executing
the
conception,
pricing, promotion and distribution of ideas services and goods, to create exchanges that satisfy
59
individual
and
organizational
objectives[1] Simply marketing consists of meeting peoples needs in the most efficient and therefore profitable manner(marketing OT Services, 1984, p.4) [2] . Marketing can use as medium of orientation which makes satisfying the customers requirements [2]. Marketing beings by asking what are the requirements and desires of consumers [3]. Marketing also includes the analysis of the competition and then decide on a positioning plan for the product or service, in other words finding the market position, the pricing of the products and services, and then promote the products or services through continue
according to demographic charter, political and regulatory system, socio cultural status, economical and geographical background [2]. With each variation basic aim is to improve clients health through preventive action or restoration of good health from a state of ill health. Management of health care is becoming more and more common as the demands of cost containment are placed on providers of care [4]. In this regards marketing can help health care profession. Because it is an important aspect of service delivery that all health cares practitioners should understand it [5]. Of course, there is no denying that using health information in order for healthcare marketing does run the risk of invades
advertising, promotions, public relations and sales.
1.1 Health care marketing Marketing programs sale everything in todays life including health care. Though it was once thought to be inappropriate or unethical to use in health care professional [2]. According to Willard and Spacksman (1993) health care marketing evolved in the middle of 1970 when concerns arose about increased regulation of health care, decrease resources, increased resources struggle and for those in inadequate
privacy. Some time people thought that health care marketing carelessly handled their
sensitive information. In fact, sometimes health care marketing might cause shameful offenses to a person's sense of independence and self-respect. During marketing health care professional should consider this aspect.
1.2 Present occupational therapy marketing scenario in India As occupational therapy professional we should focused on the marketing for profit of our profession. Because all of our best efforts over more than fifty years the profession still largely unknown to the general public and our referral sources. Only providing good service is not enough to grow as a profession. It needs
change
reimbursement
practice for health care [3]. The health care market is one of the most complicated one because health care
professional always face a challenge with different necessities for same kind of
diagnosis. After each diagnosis there are requirement of various treatments planning
60
marketing strategies to develop knowledge and faith on our profession. In India the health care services generally regulated by state government and have rights to select service area for normal population. In nineteenth century scenario changed and private sector started to deliver health service and person starts to pay for treatment. Changing scenario society has placed increase responsibility to consumers in concerning to their own health care choice. Challenges are increasing for the occupational therapy
find out the present scenario of occupational therapy marketing in India and find out the possible procedure of occupational therapy marketing in India through open ended survey questioner.
1.3 Research question What is the present scenario of
occupational therapy marketing in India? What are the possible procedures of marketing occupational therapy in India?
professional and necessary to undertake some marketing strategies that help them to develop awareness about occupational therapy services and there benefits. Consumer goes through relative reference about the outcome of different treatment options. They rely on different information which are getting from different source like mouth of patient, service provider, and referral sources etc. Marketing help occupational therapy profession to aware those resources through valuable information. In India many individuals and organization have been putting significant effort into creating ways to increase the visibility and awareness of our profession but there is a lack of collective work. Efforts in individuals label are not enough to overcome barriers of marketing. Present scenario is not good for occupational therapy professions in India they understand the need but dont know how to market the profession or dont bother to spent time for marketing. This study is a primary effort to
61
1.4
Objectives of the study Find out the present scenario of
occupational therapy marketing in India. Find out the possible occupational therapy marketing procedure.
2.
MATERIAL & METHOD
2.1 Subject: Occupational therapist graduate were
included for these study. Interns and student were excluded from this study.
2.2 Survey questioner:
2.2.1 Questioner development: An authors design survey questioner was used for this study [6], [7]. Questions were definite, concrete and pre-determined,
structured and open ended subjective question [7]. Same wording and ordering are maintained for all target people[7]. Three steps were taken to modify the
question for final study. First these questions were provided to five allied
percentage of respond generally less 20 to 30 percentages [6],[7] . The survey was mailed to six hundred occupational
health professional . In second stage these questioner were provided to different rehabilitation staff, After getting their input about the clarity of the questioner such as the wording of the questioner, grammar usage, simplicity of questions and case of understand [6],[8] was incorporated to
therapist throughout India After getting all the responses from respondents thank giving mailed was send to each participant separately. 3. RESULT: 3.1 Natures of respondents: Total 137 (22.83 %) response were received. Not included 16 responses for not matching the inclusion criteria. Total 121 (20.16%) responds were included for this study. Charterstic of respondents was provided in table 1. Table 1 : Charterstic of respondent (N= 121)
revise the initial draft of the questioner and a revised survey was generated. In third stage revised questioner were send to five local occupational therapists. Those
occupational therapists were asked to complete the questioner and provide
comments and suggestion. Comments and suggestion from the participants
occupational therapist were examined by the investigator and incorporate those into the revision of the questioner.
2.2.2. The final version of questioner Final version of questioner consisted two parts (see appendix). First part concerned about personal details about participant. Second part of questioner was consisted of twelve questions. It concerned about the different aspect of occupational therapy marketing procedure to frame the possible guideline.
2.2.3. Implementation procedure Survey type research study generally use large number of sample, because the 3.2 Nature of respond:
62
A few numbers of respondents (10) belief that All participants (100%) are belief that they are not satisfy with the present scenario of occupational therapy profession in India. All were belief that after fifty years it may not be useful. There are mix responses about marketing style. According to response individuals marketing and group marketing both is useful for occupational therapy profession. Most of the respondents (112) are thought that there should be change in present marketing style in context of present health care environment. Some respondents (9) are not sure the change is require or not in present marketing style. According to most respondents belief electronic media is the best option for promoting occupational therapy profession in India. But other beliefs that print media can be also is another option. Respondents belief that, well documentation of profession is needful for marketing. There are so many variation is found in the response of last question. Respondents suggested that advertisement should be
occupational therapy not captured enough market in Indian Allied health field.
Almost all participants (114) are not presently flowing nitch marketing strategies. Only few (7) participants are following nitch marketing style. All participants are agreed in the point that we are able to fulfill the need sets of consumer to capture rehabilitation market place. In case of fifth question respondents responds was different. According some respondents (67) All India Occupational Therapist (AIOTA) is responsible for
marketing our profession. Some respondents (30) belief it is a responsibility of AIOTA and ACOT. Few respondents (7) belief AIOTA brunches, occupational therapy institution should take the responsibility. In the other hand some respondents (15) belief it is a duty of an individuals occupational therapist. Two ( 2) respondents belief government or
publishes in regular basis. Awareness came, spatial clinic, speech by occupational therapist in local language is also help in occupational therapy marketing. Videotapes, documentary film can be use to promote our services, our occupational therapy achievement. Physician awareness also can be use as a technique because still date they are the main referral for our services. Some suggested there should be one liner to promote our profession.
government health policy are the responsible. Every respondents are belief that our profession should be promoted and they suggested different method for that like formation of own council, awareness through media, pass the information through simple and lay mans word. Most of the
4. DISCUSSIONS Key finding of this study is that every participant is not satisfied about present
63
respondents(111) belief is that, surveys is necessary for occupational therapy marketing.
marketing scenario of occupational therapy after fifty years as a profession. Though there are differences in there beliefs, marketing is necessary for occupational therapy in present health care scenario. Without this a profession can grow. We know there are no ideal strategies for marketing occupational therapy in India. Because India is country of diversity in terms of culture, language, religious. But there should be some guidance about marketing, which can help a professional to capture large market. Through this study tried to cover most of the component of marketing in India through 12 questions. Respondents provided there view point regarding that. In twenty first century marketing is an important aspect of any profession. Gradually marketing becomes common practice in health care profession also. This study gathered information about marketing can use to market our profession in India. First strength of this study we use structure question to gather information from sample so there is no chance of interview bias. Second, this study collected data from various parts of country through email so it is low cost
procedure and easily approach to occupational therapist over India. Mail were send six hundred occupational therapist in India. So this result cannot be generalized. Last limitation is respondents rate was (22.83 %).
5. CONCLUSION: In India occupational therapists are either private practitioner or working in private sector. There a few numbers of people are working in government sector. So most of the time we have to prove as a better treatment option compare to other profession. In this regard we can use marketing for survival. This study can help professional in marketing occupational therapy profession in better way.
6. ACKNOWLEDGEMENT I want to thanks to our entire respondent for their valuable support. I also thanks to everyone, who helped me to reevaluate questioner for developed final version of questioner.
REFERENCES 1. Nosse. L.J., Friberg D.G., Kovacek P.R.: Markrting its more than selling. In : Managerial and supervisory principles for physical therapist:2nd edition: Lippincott William and wilkins.2005: 277-290 2. Jacobs K: Marketing Occupational therapy. American journal of Occupational Therapy, 1987:41:5, 315-320
64
3. Perinchief J.M: marketing: in service management: in Willard and Spackmans Occupational Therapy: 2nd edition:Philadelphia, J.B. lippincote company,1993:396-398 4. Cohn R. Strategies for positioning in the managed health care marketplace. Journal of hand therapy, 1994:7(1), 5-9 5. Jacobs k. innovational to action: Marketing occupational Therapy American journal of Occupational Therapy, 1998:52:8,618-620. 6. Lannin N. and Cusck A: factors effecting patient requirements in an acute rehabilitation: randomized control trail. American journal of occupational therapy. 2006:60, 117-181. 7. Kothari. C. R., Research methodology:methods and techniques. 2nd ed. New delhi, New age international publisher ltd. 2004: 95-117. 8. Mu. K. Lohman H. and Scheirton. L.: occupational therapy practice errors in physical rehabilitation and geriatrics setting: A national survey study.. American journal of occupational therapy: 60,288297.
APPENDIX Personal details: Participant Name & Designation: Age & Sex: Qualification: Organization name & Experience (in terms of year): Clinical experience/ teaching experience: Marketing questionnaires. 1) Are you satisfied with the present marketing scenario of occupational therapy profession in India? 2) After fifty years as a profession, has occupational therapy captured enough market in Indian rehabilitation field? 3) According to you our profession is presently following nitch marketing or any other marketing strategies in India? 4) According to you our profession is able to fulfill need sets of consumer to capture rehabilitation market place? 5) According to you who are responsible for marketing occupational therapy profession in India? 6) For marketing of occupational therapy, does it need to be promoted and if yes point out the methods of that?
65
7) Is there any need of consumer surveys prior to marketing of the profession? 8) In the present scenario individual marketing or group marketing is essential for occupational therapy profession in India? 9) According to you with changing health care environment what modification is needed in the present marketing style? 10) According to you presently which media is effective for promoting occupational therapy marketing in India? 11) Is there any role of documentation in occupational therapy marketing? 12) According to you how occupational therapy marketing should be done in present situation in India?
CORRESPONDING AUTHOR: * Department of Occupational Therapy, School of Allied Health Science, Manipal University, Karnataka, India. Email: koushiksau@gmail.com
66
ANNOTATED BIBLIOGRAPHY OF STUDIES W.R.T STATISTICAL METHODS

Neha Dewan*
An annotated bibliography is a list of citations to books, articles, and documents. Each citation is followed by a succinct descriptive summary and evaluative paragraph, the annotation. In the present article, we have provided annotated bibliography of studies from rehabilitation science that are well written with respect to (w.r.t) the statistical methods aspect of the paper. The identied studies represents a number of statistical topics addressed in the research. The purpose of present annotated bibliography is to provide the readers about the effective writing skills for representing results of statistical analysis in their research papers. The annotated bibliography mentioned below contains a brief statement of the statistical concepts effectively conveyed in the paper and a quote or two from the paper illustrating the statements which were found useful.
1.
Bastos FN, Vanderlei LCM, Nakamura FY,
Participants : 20 young male subjects (age: 212 years; height: 1758 cm; body mass: 7211 kg; body mass index: 23.52.1 kgm 2; VO2max: 47.13.1 mLkg 1min 1) were recruited for the study.
Bertollo M, Godoy MF, Hoshi RA, et al. Effects of Cold Water Immersion and Active Recovery on Post-Exercise Heart Rate Variability. Int J Sports Med. 2012; 33: 873879.
67
Results:
Also, significant differences in the
conservative dropout of approximately 20%, we will recruit 104 subjects into the study. This sample size will yield greater than 80% power to detect both statistically signicant and clinically meaningful changes in the other outcome variables. Sample-size estimation was performed with G*Power software, V 3.1.2.
time required to reach [Lac]peak were found between CWI and PR (6.32.4 vs. 9.83.1 min, respectively) as well as between AR and PR (7.132.71 vs. 9.843.07 min, respectively) (p<0.05, for all)
This can be a good example of the use of descriptive statistics in describing study This can be a good example of Sample size calculation as authors have provided the
participants as well as summarising the results. 2. Lewis JS, Wright C, Green A. Subacromial
information required for sample size calculation in terms of Z, Z, minimal clinical important difference(), standard deviation() and level of significance(). Further efforts are made in calculating sample size by taking anticipated drop out into consideration. Introduction: The null hypotheses for this 4. Barreca SR, Stratford PW, Lambert CL, et al. Test-retest reliability, validity, and sensitivity of the Chedoke Arm and Hand Activity Inventory: a new measure of upper-limb function for This can be a good example of clearly stating Null Hypothesis. Results: The ICC(2,1) was .98 (95% confidence 3. Rhon DI, Boyles RE, Cleland J, Brown DL. interval [CI], .96 .99). The SE of measurement was 2.8 CAHAI points (95% CI, 2.33.7) survivors of stroke. Arch Phys Med
impingement syndrome: the effect of changing posture on shoulder range of movement. J Orthop Sports Phys Ther. 2005;35:72-87.
investigation was that changing posture would have no effect on shoulder range of movement in asymptomatic subjects and on shoulder range of movement and pain in subjects with SIS.
Rehabil. 2005;86:16161622.
A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial. BMJ. 2011; Jan 1:1(2).
This
can
be
good
example
of
representation of Test retest reliability as authors have reported standard error. ICC with 95% CI and
Methods: The calculations were based on detecting a 12-point difference in the SPADI with a standard deviation of 10 points, a two-tailed test and an level = 0.05. This generates a sample size of 43 subjects per group. Allowing for a 5. Maly MR, Robbins SM, Stratford
PW, Birmingham TB, Callaghan JP. Cumulative knee adductor load distinguishes between healthy and osteoarthritic kneesA proof of principle
68
study. Gait Posture. 2012 Sep 17.pii: S09666362(12)00318-9. Results: The variances of CKAL were unequal for the two groups. The independent samples ttest [t = 3.97, df = 51, p = 0.001] revealed that CKAL was nearly two times larger in the OA group (80.80 44.54 kNm s) compared to the healthy control group (42.79 28.10 kNm s). This can be a good example of Independent sample-t test showing comparison of 2
Results: Post hoc analysis revealed that the manipulative procedure produced a greater increase of PPT in both elbows as compared to placebo or control interventions (P<.001), and no significant changes were found after the placebo or control conditions (P>.6).
independent samples using t value with degrees of freedom and level of significance.
6.
Wong OM, Cheung RT, Li RC. Isokinetic
knee function in healthy subjects with and without Kinesio taping. Phys Ther Sport. 2012 Nov;13(4):255-8. This can be a good example of presenting the conclusions of Post hoc analysis and use of box plots.
Results: There was no signicant difference in extension peak torque with and without KT and at different angular velocities (F(2,28) = 0.24, p = 0.79). Similarly, there was no signicant 8.
difference in exion peak torque in different conditions (F(2,28) = 0.16, p = 0.86). Rana Jaber, David J. Hewson, Jacques Duchne. Design and validation of the Grip-ball This can be a good example of Repeated measures of ANOVA as authors have reported F value with degrees of freedom and level of significance. Results: A linear relationship between the two readings can be observed (r = 0.997; 95% 7. M, Fernndez-de-las-Peas C, Prez-de-Heredia Brea-Rivero M, Miangolarra-Page JC. confidence interval 0.9950.998, p < 0.05). The linear relationship between the pressure recorded by the Grip-ball sensor and the Vigorimeter manometer was calculated as: Grip-Ball Sensor = 0.999 x Vigorimeter Manometer + 0.533 (1). The coefficient of
69
for measurement of hand grip strength. Medical Engineering & Physics. 2012;34(9):135661.
Immediate effects on pressure pain threshold following a single cervical spine manipulation in healthy subjects. J Orthop Sports Phys Ther. 2007;37:325-9.
determination was calculated as R2 = 0.994 (p < 0.05).
than 5, we regrouped ultrasound ndings into 2 categories and applied Fisher exact P. There was no statistically signicant difference in ultrasound ndings between the 2 groups (Fisher exact, P = .4209)
This can be a good example of Categorical analysis where expected frequencies are less than 5 in which case Fisher exact P gives the exact probability of obtaining the results.
This can be a good example of Correlation and Regression analysis where relationship has been reported clearly by r value within 95% CI and .05 as the level of significance. In addition, relationship has been presented mathematically using regression model and percentage of relationship has been expressed by R2.
10. Cromie JE, Robertson VJ, Best MO. WorkRelated Musculoskeletal Disorders in Physical Therapists: Prevalence, Severity, Risks, and Responses. Phys Ther. 2000;80(4):336-51.
Results: Male therapists had increased odds of reporting neck symptoms (OR=1.9, 95% CI=1.3 2.9), wrist symptoms (OR=2.0, 95% CI=1.33.2), and thumb symptoms (OR=2.2, 95% CI=1.53.4) in the last year compared with their female colleagues.
9.
Djordjevic OC, Vukicevic D, Katunac L,
Jovic S. Mobilization with movement and kinesiotaping compared with a supervised
exercise program for painful shoulder: results of a clinical trial. Journal of manipulative and physiological therapeutics. 2012 Jul;35(6):454 63. Results: Because there were frequencies less
This can be a good example of Odds ratio showing the association between gender and prevalence of work related musculoskeletal disorders.
CORRESPONDING AUTHOR: * MPT, PhD Student, School of Rehabilitation sciences, McMaster University, Hamilton, ON. Email: dewann@mcmaster.ca
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Title Editorial Effect of core stabilization

Author/s Dr. Krishna N. Sharma

Ranjeet Kumar, Dr. Prosenjit Patra

Kumar Amit, Gupta Manish, Kumar Satish, Katyal Taruna Physiotherapy 9

Shweta S. Devare Phadke, Sukhada Prabhu, Sujata Yardi Physiotherapy 18

Sharma Chetan, Dr. Dar Shahid Mohd.

Dr Jasmine Anandabai, Dr Manish Gupta

Amit Murli Patel

Shanmuga Raju P, Renkha Rao, Rajendhra Kumar J, SuryaNaryana Reddy V Physiotherapy 55

ISSN: 2277-1700 Website: http://srji.drkrishna.co.in URL Forwarded to: http://sites.google.com/site/scientificrji

Do drop a mail to us (editor.srji@gmail.com) if you have any comment and suggestion.

Dr. Krishna N. Sharma Editor in Chief

ISSN: 2277-1700 Website: http://srji.drkrishna.co.in URL Forwarded to: http://sites.google.com/site/scientificrji