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Scientific Research Journal of India

(Multidisciplinary, Peer Reviewed, Open Access, Journal of science) ISSN: 2277-1700 Vol: 2, Issue: 4, Year: 2013

Editor in Chief (Current Issue) Dr. Gayatri Ajay Upadhyay (PT) Executive Editor Dr. Krishna N. Sharma Editors Dr. Popiha Bordoloi Dr. Kuki Bordoloi (PT) Dr. Sudeep Kale (PT) Dr. Waqar Naqvi (PT) Dr. Piyush Jain (PT) 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 +91-9839973156

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

Author/s Dr. Gayatri Ajay Upadhyay (PT)

Department

Page

Editorial

EFFECTS OF TASK RELATED SITTING BALANCE PATIENTS EFFECTIVENESS CONVENTIONAL OF PHYSICAL Amit Murli Patel Physiotherapy 10 TRAINING IN ON Dr. Vivek H. Ramanandi Physiotherapy 1

HEMIPLEGIC

THERAPY & C.P.M UNIT FOR FUNCTIONAL REHABILITATION AFTER TOTAL KNEE

ARTHROPLASTY EFFECTIVENESS SUPERVISED REPETITIVE SUPPLEMENTARY ON ARM OF GRADED ARM PROGRAM IN Dr.Harsha Tummala, Dr.V.Srikumari, Dr. K. Madhavi Physiotherapy 31

FUNCTION

SUBJECTS WITH STROKE EFFECTIVENESS STRENGTHENING TO SIDE REDUCE STRAIN OF CORE Omkar P.Padhye, Subin Solomen, Pravin Aaroon

EXERCISES OF IN

INCIDENCE INJURY

Physiotherapy

41

MEDIUM PACE BOWLERS A COMPARATIVE STUDY OF STANDING BALANCE Alagappan Thiyagarajan.T, Prem Karthik .GS Physiotherapy 53

PERFORMANCE BETWEEN OA KNEE PATIENTS COMPARED

WITH NORMAL AGE MATCHED CONTROLS THE EFFECTS OF BIT VERSUS MCIMT ON FUNCTIONAL OF UPPER Dr. Bhatri Pratim Dowarah Physiotherapy 64

PERFORMANCE

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EXTREMITY HEMIPARESIS

IN

CHRONIC

RARE PRESENTATION OF TYPE 1 DIABETES MELLITUS AS Srinivas Madoori, Kapil C, Mangath Bhukya, Sandeep Chilumoju Medicine 73

DIABETIC

KETOACIDOSIS

COMPLICATING INTO ACUTE PANCREATITIS: REPORT CASE REPORT VERY LARGE SUPPURATIVE PERICARDIAL A CASE

Dr. J. Rajendra Kumar, Dr. Mamta B. Kumbhare, Dr. P. Shanmuga Raju, Dr. M. Manjusha, Dr. M. Sumanth, Dr.Ch. Rachna Medicine 79

EFFUSION CAUSED BY GROUP A HEMOLYTIC IN THE

STREPTOCOCCUS: ANTIBIOTIC ERA. TECHNICAL

SOFTWARE Zunera Jalil, Nazia Tabbasum Computer Science 91

PROJECT MANAGER VS NON TECHNICAL PROJECT MANAGER SOFTWARE

iv

FROM EDITOR IN CHIEF - AN ERA OF OPEN ACCESS RESEARCH BEGINS


The key to sustained progress in this age of internet and free access to information is to make society at large avail with the open access articles. There are many primary sources of archives, manuscripts and collections often hindered by private ownership which permits either on a highly selective basis or not at all. Based on these facts we support open access scripts which involves dissemination of high quality researches. Open access journals make it easy for us to access new techniques and thereby benefit society at large. Through this journal we will try and provide updated information which will include high quality scientific publications that will profoundly influence PTs education.

The excitement of learning separates youth from old age. As long as youre learning, youre not old, and research articles comes from inquisitive questions that posits in our mind.

Dear Readers! Welcome to this issue of the Scientific Research Journal of India (SRJI), I hope that you are pleased with the contents. I am.

In this issue: Like previous issue this is also a multidisciplinary and open access journal that contains total 6 papers in Physiotherapy, 2 paper of Medicine and 1 from Computer Science. I hope youll find these papers informative.

Be aware that the journal also has a website, http://srji.drkrishna.co.in where subscribers can access the full content and also submit papers for future publication.

Please send me informal comments directly, or formal letters we can publish, about the journal. I welcome new ideas about topics (content) and process. Let me know your thoughts.

Thanks for the opportunity, and stay tuned for future editions.

-Gayatri Ajay Upadhyay, M.P.T. (Neuro)

EFFECTS OF TASK RELATED SITTING TRAINING ON BALANCE IN HEMIPLEGIC PATIENTS


Dr. Vivek H. Ramanandi M.P.T.(Neuro)*

ABSTRACT Introduction and purpose of study: The ability to balance in sitting is commonly impaired after stroke. Sitting ability is critical to several ADL. So here we tried To evaluate the efficacy of a 2-week task related sitting training program in improving patients sitting balance. Materials and methodology: This randomized placebo-controlled study included 31 subjects who had first stroke within last 6 months and were able to sit. Subjects with orthopaedic, visual, cognitive-perceptual and other neurological deficits were excluded. The group A (n=16) participated in a standardized training program involving practice of reaching beyond arms length along with the conventional therapy. The group B (n=15) received a sham training. Subjects were tested before and after the completion of 2 weeks training using t-BBS (Total Bergs balance scale score) and FRD (Functional reach distance). Results & Conclusion: This study provides strong evidence of the efficacy of task related sitting training in improving the ability to balance during seated reaching activities as well as other activities of ADL. Keywords: Stroke, Task related sitting training, Balance, Rehabilitation.

INTRODUCTION

Sitting involves not only the ability to

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maintain the seated posture, but also the ability to reach for a variety of objects located both within and beyond arms length [1]. Poor sitting ability is a common problem after stroke [2,3,4]. Recovery of sitting after stroke is important for individuals because sitting is a skill that is critical to independent living [5,6,7]. Furthermore, sitting ability has been shown to be a useful prognostic indicator of outcome for this population
[3,8,9,10].

focus of rehabilitation after stroke. Previous work has demonstrated the efficacy of a sitting training protocol in individuals who had suffered stroke
[1,14].

They

found

that

individuals who were trained specifically to improve their sitting by focusing on

appropriate loading of the affected foot were able to reach further and faster. In addition, these individuals were able to increase the load taken through the affected foot and increased the consistency of activation of muscles in the affected leg. However, it is not known whether this sitting training protocol is feasible and effective in improving trunk control and balance abilities associated with functions of daily living. The research questions for this study were: 1. Does completion of 2-week sitting

The

disability

associated with poor sitting arises primarily because of muscle weakness and loss of dexterity and also because of tendency to adapt behaviour to avoid threats to balance. In particular, it has been shown that in

comparison to healthy individuals, individuals after stroke are slower and do not load their affected foot or activate the muscle of their affected leg sufficiently when reaching beyond arms length in sitting [1]. Balance is defined as The ability to maintain the bodys center of mass over the base of support with minimal postural sway
[11]

training protocol improve balance ability associated with sitting? 2. Does completion of a 2-week sitting training protocol improve sitting ability and quality? Background Trunk control is having predictive value on comprehensive ADL function in stroke patients which implies that early assessment and management of trunk control after stroke should be emphasized
[9].

. The normal control of balance is known

to emerge as a result of integration of inputs from the vestibular, visual and somato-sensory systems. Balance forms The foundation for all voluntary motor skills
[12]

. Most studies

have measured balance impairments (i.e. postural sway, weight distribution or related parameters) rather than balance disability (i.e. static or dynamic balance while performing a task)
[13].

Sitting involves not

only the ability to maintain the seated posture, but also the ability to reach for a variety of objects located both within and beyond arms length [1]. Due to larger base of support, sitting

Intervention to train balance is a common


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Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

does not present same threat to stability as standing. During seated reaching activities muscle activation depends upon the level of support provided to feet. In both cases (i.e. whether feet are supported on ground or not), trunk muscles are active to stabilize the upper body as it moves about over the base of support [14]. Dean and Shepherd found out that individuals who were trained specifically to improve their sitting by focusing on

unaffected hemisphere, suggesting role of uncrossed pathways which are unaffected, in recovery of trunk function. Methods This randomized placebo controlled study was done at thedepartment of physical medicine and rehabilitation, Govt. hospital, Ahmedabad, Gujarat. Subjects were selected through convenient sampling. After having the

informed consent of 31 subjects (M: 17, F: 14) and fulfilment of inclusion criteria systematic randomization was done and the subject were assigned to the particular group according to their sequence of approach i.e. 1st, 3rd, 5th, 7th in group A and 2nd , 4th , 6th, 8th in group B . Group A participated in a standardized training program involving practice of

appropriate loading of the affected foot were able to reach further and faster. Previous work has demonstrated the efficacy of a sitting training protocol in individuals who had suffered a stroke 2-17 years back
[1].

Dean CM

et al concluded that the sitting training is both feasible and improving sitting ability, sitting quality and standing up early after stroke
[14].

reaching beyond arms length for 10 sessions in 2 weeks for 30 minutes daily along with the conventional therapy. The subjects reached with the unaffected hand to pick up and drink water from a glass under 3 reach direction conditions: Forward, 45o towards the unaffected side and 45o across the body towards affected side. Subject sat on the height adjustable stool with each foot resting completely on floor. Seat height was adjusted to 100% of lower leg length. The target (i.e. Glass) was kept at height adjusted to 75% of shoulder height. The training was advanced by increasing number of repetitions and

Cho G, Lee S & Woo Y compared improvements in the conventional physical therapy group & task related circuit groups and found out more improvement in task related training group [15]. Functional neuroimaging studies suggest that the gains produced in stroke patients by task oriented training are associated with increased activity in ipsilateral 1o sensorimotor cortex and redistribution of activity in several areas of sensorimotor network [16]. Leipert et al
[17] [18] [19]

, Nelles et al.

and Jang et al.

suggested that recovery of trunk function following stroke is associated with increased activation of paretic trunk muscles by
3

complexity of task over 2 weeks period. Each participant performed 250-350 reaches per session and average 3000 reaches over 2

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weeks. Group B received a sham training involving cognitive-manipulative tasks within arms length for same duration. It was added to avoid any effect due to placebo. Subject performed task while sitting n completely supported position and arm resting upon the table.

stroke rehabilitation including measures for [20]: Improving muscle force Improving ROM Reducing muscle tone Improving sensory function Improving integrity Training functional activities e.g. sit to stand, standing, transfers, gait etc. Results and discussion Both of the groups showed clinically flexibility and joint

significant improvement in t-BBS and FRD


Figure 1: Schematic diagram showing seated reachout performance

when compared for within group and between group comparisons.

Workspace was confined to 50% of arm length. This minimized any perturbations to balance. Training was progressed over the 2week period by increasing the number of repetitions and cognitive tasks. difficulty Thus of this A 33.31 + 7.55 B 34.80 + 5.33 44.37 + 6.11 44.20 + 5.68 120 <0.0001 Table:1 The Mean t-BBS before and after intervention Group Pre Post Wvalue 136 p Value <0.0001

cognitive-manipulative

training was unlikely to lead improvements in sitting balance and FRD. Both groups participated in training protocols that were standardized in relation to amount of practice. As a minimum, each participant in the control group spent approximately the same amount of time in the sitting position and performed an equivalent number of reaches as those in experimental group.

Table:2 The Mean FRD(inches) before and after intervention Group Pre Post tp

Both the groups were given conventional


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Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

value A 10.08 +3.02 B 10.08 +2.95 12.80 +2.52 11.33 +2.43 10.07 9

Value <0.0001

15 10

12.8 10.088

11.33 10.087 Pre

Post

5.173

<0.0001

0 Group A Group B

Figure 3: Comparison of FRD


11.5 11 10.5 10 9.5 9 8.5

Table : 3 The mean of differences of t-BBS between the groups N A B 16 15 Mean 11 9.4 SD 2.280 1.724 SE 0.5701 0.4451

11

9.4

Group A

Group B

Figure 4: Mean of differences in t-BBS


3 2.5 2 1.5 1 0.5 0 2.72

Table : 4 The mean of differences of FRD (inches) between the groups N A B 16 15 Mean 2.72 1.25 SD 1.079 0.933 SE 0.269 0.241

1.25

Group A

Group B

Figure 5: Mean of differences in FRD Results of within group analysis for the present study showed extremely significant improvement in t-BBS and FRD (p<0.0001) for both the groups.

50 40 30 20 10 0

44.37 33.31 34.8

44.2

Results of between the group analysis


Pre Post

showed

more

improvements

in

FRD

(p<0.0003) and t-BBS (p<0.03) in group A as compared to group B.

Group A

Group B

Both the groups improved significantly in Figure 2 : Comparison of t-BBS both the outcome measures but FRD showed statistically
5

significant

improvements

as

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compared to t-BBS. Previous studies by Dean CM et al Cheng P.T. et al Shepherd RB


[1] [21] [14]

specifically to improve their sitting by ; focusing on appropriate loading of the affected foot were able to reach further and faster. They were able to increase the load taken through the affected foot and increased the consistency of activation of muscles in the affected leg. The carry over to standing up was observed. Shepherd and Gentile (1994)
[25]

and Dean CM and

suggest that the sitting

training protocol is both feasible and effective in improving sitting and standing up early after stroke and somewhat effective 6 months later. Many studies have proven efficacy of task related training in improving the ability to balance during seated reaching activities after stroke as well as improved sit to stand task along with less mediolateral sway when rising and sitting down. Studies by Chen IC, Cheng PT. Chen Cl et al (2002) [22]; Cheng PT, Wu SH, Liaw MY (2001) (2002)
[21] [23]

showed biomechanical similarities between reaching in sitting and the pre-extension phase of standing, which supports the carry over effects of seated reaching training to sit to stand and walking. During sitting training, subjects practiced moving their trunk forward rapidly over the centre of mass whilst loading their legs. Although these components were practiced with the intention of improving sitting ability, they are also critical

and Mudie MH, Radwan S et al proved improvements in symmetry

of weight bearing and distribution by task related training after stroke. Cho G, Lee S & Woo y (2004)
[15]

components of biomechanics of early phase of sit to stand activity. Present study supports the concept of specificity of training, which has been discussed in relation to the able bodied subjects by Rutherford OM (1988)
[26]

proved improvements in

symmetry of weight bearing distribution by task related training after stroke. Salbach NM, Mayo NE, et al (2005) [24] has proved efficacy of task oriented walking interventions in improving balance self-efficacy during selfinitiated gait activities. The results of the

and

proposed as a means of rehabilitating the movement disabled by Carr and Shepherd


[27,28].

present study showing improvements in functional activities, sitting quality and

The results of present study showing

better improvements in the seated balance outcomes can be explained on the basis of the same mechanism as proposed by above mentioned case studies. Functional neuroimaging studies suggest

functional reach performance by the sitting training along with the conventional therapy is in accordance with results of above mentioned studies. Studies by Dean CM et al (2007)
[14]

that the functional gains produced in stroke patients by task related training are associated
6

concluded that individuals who were trained

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

with increased activity in ipsileisonal primary sensory motor cortex and re-distributon of activity in several areas of sensorimotor network. This view is supported by the studies of Leipert et al (2000)
[18] [16] [17],

stage of rehabilitation when there is greatest potential for neuroplasticity. Limitations: 1. Smaller sample size. 2. Lack of long term follow ups to confirm persistence of interventional gains. 3. Exclusion of subjects who were not able to sit and reach. 4. Lack of training for seated reach training on dynamic surface. Conclusion

Nelles et al (2001)
[19].

and Jang et al (2003) used

Fujiwara et al magnetic

(2001)

transcranial

stimulation and suggested that recovery of trunk function following stroke is associated with increased activation of paretic trunk muscles by the unaffected hemisphere,

suggesting role of compensatory activation of uncrossed pathways in recovery of trunk function. The study have implications for

rehabilitation, demonstrating that the stroke patients can improve their performance in functions of daily living by inclusion of short task related seated reach training that takes into account normative biomechanics related to trunk and lower limb function. It can be included in treatment intervention at an early
REFERENCES

Task related sitting training is an effective measure of improving balance not only in sitting but also during other functional activities when given with conventional treatment. It should be included early in treatment to gain maximum outcome benefits in short training period.

[1]

Dean CM, RB shepherd: Task-related training improves performance of seated reaching tasks after stroke: a

randomized controlled trial. Stroke 1997;28:722-728 . [2] Dean CM, Mackey FH: Motor assessment scale scores as a measure of rehabilitation outcome following stroke.

Australian Journal of Physiotherapy 1992; 38: 31-35. [3] Morgan P: The relationship between sitting balance and mobility outcome in stroke. Australian Journal of

Physiotherapy 1994; 40: 91-96. [4] Harley C, Boyd JE, Cockburn J, Collin C, Haggard P, Wann JP, and Wade DT: Disruption of sitting balance

after stroke: Influence of spoken output. Journal of Neurology, Neurosurgery and Psychiatry 2006; 77: 647-676. [5] Dean CM, Shepherd RB, Adams R: Optimizing sitting balance after stroke: from science to the clinic. Canadian

Journal of Rehabilitation 1998; 11: 193-194. [6] Dean CM, Shepherd RB and Adams R: Sitting balance I: trunk-arm coordination and the contribution of the

lower limbs during self paced reaching in sitting. Gait and Posture 1999a; 10: 135-146.
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ISSN: 2277-1700 Website: http://srji.drkrishna.co.in URL Forwarded to: http://sites.google.com/site/scientificrji

[7]

Dean CM, Shepherd RB and Adams R: Sitting balance II: reach direction and thigh support affect the

contribution of lower limbs when reaching beyond arms length in sitting. Gait and Posture 1999b; 10: 147-153. [8] 78-81. [9] 86. [10] Van de Port IG, Kwakkel G, Shepers VP, Lindeman E: Predicting mobility outcome one year after stroke: a Sandin KJ, Smith BS: The measure of balance in sitting in stroke rehabilitation prognosis. Stroke 1990; 21: 82Loewen SC, Anderson BA: Predictors of stroke outcome using objective measurement scales. Stroke 1990; 21:

prospective cohort study. Journal of Rehabilitation Medicine 2006; 30: 218-223. [11] Shumway-Cook A, et al:Postural sway biofeedback : its effects in reestablishing stance stability in hemiplegic

patients. Arch Phys Med rehabilitation 1988; 69: 395-40. [12] Massion J, Woollacott MH, In: Brainstein A, Brandt T & Woollacott M, Editors. Clinical disorders of balance,

posture and gait. London: Arnold; 1996: pp.1-18. [13] Tyson SF, Hanley M, CHillala J, Selley A and Raymond CT: Balance disability after stroke. Phys ther 2006;

86(1): pp. 30-38. [14] Dean CM, Channon EF, Hall JM. Sitting training early after stroke improves sitting ability and quality and

carries over to standing up but not to walking: a randomized controlled trial. Australian Journal of Physiotherapy. 2007; 53: 97-102. [15] Cho G, Lee S & Woo Y. The effects of task related circuit program on functional improvements in stroke

patients. KAUTPT vol.11 no.3, 2004. [16] Fujiwara T, Sonoda S, Okajima Y, Chino N. The relationship trunk function and findings of transcranial

magnetic stimulation among patients with stroke. J Rehabil Med 2001; 33:249-55. [17] Leipert J, Graef S, Uhde I, Leidner O, Weiller C. Training induced changes of motor cortex representations in

stroke patients. Acta Neurol Scand 2000 a ;101: 321-326. [18] Nelles G, Jentzen W, Juepetner M, Muller S, Diener HC. Arm training induced brain plasticity studied with

serial positron emission tomography. Neuroimage 2001; 13: 1146-1154. [19] Jang SH, Kim YH, Cho SH, Lee JH, Park JW, Kwon YH. Cortical reorganization induced by task oriented Susan B OSullivan, Thomas J Schmitz: Physical Rehabilitation, 5thedi.; Chapter !8- Stroke. Pp 705-776. Jaypee

training in chronic hemiplegic stroke patients. Neuroreport 2003b; 14: 137-141. [20]

publication. [21] Cheng PT, Wu SH, Liaw MY, Wong AM, Tang FT. symmetrical body weight distribution training in stroke

patients and its effects on fall prevention. Arch Phys Med Rehabil 2001;82(12): 1650-1654. [22] Chen IC, Cheng PT, Chen CL, Chen SC, Chung CY et al. effects of balance training on hemiplegic stroke

patients. Cheng Gung Medical Journal. 2002; Sep: 25(9):583-590. [23] Mudie MH, Winzeler Mercay U, Radwan S, Lee L. Training symmetry of weight distribution after stroke: a

randomized controlled pilot study comparing task related reach, Bobath & feedback training approaches. Clin rehabil 2002; 16(6): 582-592. [24] Salbach NM, Mayo NE, Robichaud-Ekstrand S, Hanley JA, Richards CL, Wood-dauphinee S. The effects of task

oriented walking intervention on improving balance self efficacy poststroke: a randomized controlled trial. J Am Geriatr Soc 2005; 53(4): 576-582. [25] Shepherd RB, Gentile AM. Sit to stand: functional relationship between upper and lower body segments. Human

Movement Sciences 1994; 13: 817-840.

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[26]

Rutherford OM. Muscular coordination & strength training implications for injury rehabilitation. Sports Med Carr JH, Shepherd R. A Motor Relearning Programme for Stroke. 2nd ed. Oxford, UK: William Heinmann

1988; 5: 196-202.

[27] [28]

Medical Books; 1987. Carr JH, Shepherd RB. A motor learning model for stroke rehabilitation. Physiotherapy. 1989; 89: 372-380.

CORRESPONDENCE

* Lecturer, Pioneer Physiotherapy College, Vadodara, Gujarat, India. vivekramanandi@gmail.com

EFFECTIVENESS OF CONVENTIONAL PHYSICAL THERAPY & C.P.M UNIT FOR FUNCTIONAL REHABILITATION AFTER TOTAL KNEE ARTHROPLASTY
Amit Murli Patel, MPT (Orthopaedics)*

ABSTRACT Background and Purpose: This randomized clinical trial was conducted to compare the effectiveness of 3 inhospital rehabilitation programs with and without continuous passive motion (CPM) for range of motion (ROM) in knee flexion and knee extension, functional ability, and length of stay after primary total knee arthroplasty (TKA). Subjects: Eighty-one subjects who underwent TKA for a diagnosis of osteoarthritis were recruited. Methods: All subjects were randomly assigned to 1 of 3 groups immediately after TKA: a control group, which received conventional physical therapy intervention only; experimental group 1, which received conventional physical therapy and 35 minutes of CPM applications daily; and experimental group 2, which received conventional physical therapy and 2 hours of CPM applications daily. All subjects were evaluated once before TKA and at discharge. The primary outcome measure was active ROM in knee flexion at discharge. Active ROM in knee extension, Timed Up & Go Test results, Western Ontario and McMaster Universities Osteoarthritis Index questionnaire scores, and length of stay were the secondary outcome measures. Results: The characteristics of and outcome measurements for the subjects in the 3 groups were similar at baseline. No significant difference among the 3 groups was demonstrated in primary or secondary outcomes at discharge. Discussion and Conclusion: The results of this study do not support the addition of CPM applications to conventional physical therapy in rehabilitation programs after primary TKA, as applied in this clinical trial, because they did not further reduce knee impairments or disability or reduce the length of

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Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

the hospital stay.

Key Words: Continuous Passive Motion, Osteoarthritis, Knee Arthroplasty, Rehabilitation

INTRODUCTION

gains of between 7 and 22 degrees (relative to results for control groups)4,9,10,13,17 or faster knee flexion recovery during the hospital stay.4,12,17,19 In these studies, duration of CPM applications could vary from 10 hours to 24 hours per day and were performed during 2 to 7 days after TKA.4,9,10,12,17,19 In the majority of these studies, subjects knees in the control group were immobilized for 2 to 7 days, whereas subjects in the experimental groups received early postoperative CPM applications.4,9,13,17 These results cannot be applied to contemporary practice, because a long period of immobilization is no longer recommended after TKA, and early movement is always promoted in the TKA population. In addition, description and standardization of knee flexion measurements have been

The biological concept of continuous passive motion (CPM) unit was introduced by RB Salter in the late 1970s. He demonstrated that CPM for rabbit knees after cartilage injury enhanced cartilage healing and regeneration compared with pro-longed articular rest.1,2 Later, his research focused on the effects of CPM on a variety of injuries in rabbits and in clinical applications for human subjects.3 Coutts et al4 first initiated CPM use

immediately after total knee arthroplasty (TKA). Their reasoning was based on Salters research and the postulate that CPM enhanced collagen tissue healing with better fiber orientation, avoiding cross-linking and thus generating better movement restoration.4,5 The effectiveness of postoperative CPM applications has been studied in a large variety of protocols after TKA. Knee flexion range of motion (ROM) was usually the primary outcome measure, evaluating either short-term effectiveness (measured at the end of the hospital stay) or long-term effectiveness (measured 212 months after TKA). Most authors6,15 agree on the lack of efficacy of long-term CPM for knee flexion ROM; however, there is still controversy regarding its short-term effectiveness. Many researchers have reported significant knee flexion ROM
11

neglected in many experiments, and only a few studies have provided Other detailed researchmethodology.6,9,15,20,21 ers
6,8,11,18,20,22,25

have concluded that CPM

applications do not provide any additional gains in knee flexion at the end of the hospital stay. In a large proportion of these studies, knee flexion exercises in the control group began when CPM applications were initiated in the experimental either knee groups.6,11,20,22,24,25 flexion ROM

However,

measurements were performed 1122 days

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after TKA18,19,22,23,25 or CPM application parameters were not applicable for actual practice.8,11,24 Besides knee flexion ROM, length of stay (LOS) and function also have been used to measure CPM efficacy after TKA. In some studies, LOS was reduced by 2 to 5 days in groups receiving CPM applications. However discharge criteria other than knee flexion ROM were not always clear enough to make inferences about the influence of CPM on LOS.
4,15,17,18,22,26 8,10,14,20,23

in conjunction with conventional physical therapy, there would be no additional benefit in terms of knee flexion ROM, functional ability, or LOS, compared with results obtained with conventional physical therapy alone.

METHOD Subjects This study was conducted between December 2011 and May 2013 at Shivam Hospital, where over 150 TKAs are performed every year. Subjects were asked to participate if they had a diagnosis of knee osteoarthritis, were expecting primary TKA, were ambulatory, and were literate. Subjects with previous major lower-limb surgery, such as contralateral TKA or total hip arthroplasty, were included, as long as the previous surgery had occurred at least 12 months before the current TKA. Exclusion criteria were: (1) medical conditions or diseases that could interfere with test performance, (2) collaboration or

In some studies,

function was measured with questionnaires at various times, between 6 weeks and 2 years, after surgery. Comparable results on these questionnaires were observed for groups receiving and groups not receiving CPM applications. At Shivam Orthopaedic Hospital, the effectiveness of CPM applications was

questioned when rehabilitation protocols after TKA were revised. The applications were performed for 35 minutes per day every day until discharge. The question was to decide whether or not to maintain these low-intensity CPM applications or whether to add

comprehension problems, (3) neuromuscular or neurodegenerative disease, (4) concurrent intervention during surgery that could interfere with outcomes (eg: collateral ligament repair), (5) infection of the affected knee, and (6) any major health complication during the hospital stay (eg: pulmonary embolism, heart attack, problems with scar healing).

applications of moderate intensity as part of the rehabilitation protocols after TKA. The purpose of this single-blind randomized clinical trial was to compare the effectiveness of 3 in hospital rehabilitation programs with various intensities of CPM applications for knee flexion ROM, functional ability, and LOS after primary TKA. Our hypothesis was that when CPM applications were performed
12

Recruitment The eligibility of subjects was verified on the basis of their medical files obtained from the

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

orthopedic surgeons waiting list. Subjects were asked to participate when they attended their routine preoperative medical visit. All participants signed an informed consent form.

and clinical characteristics were reported, including sex, age, weight, height, social status, comorbid conditions, previous disease or surgeries, and time from the onset of symptoms. A questionnaire also was

Study Design All subjects were assessed twice by an experienced Physiotherapist: once at the preoperative visit, 2 to 4 weeks before TKA, for baseline measurements and again at discharge, 7 or 8 days after TKA.

administered to measure the frequency and intensity performed of by physical the activity usually same subjects.27The

measurements were taken at baseline and at discharge. The primary outcome was maximal active ROM in knee flexion in a seated position. The secondary outcomes were active

Randomization After surgery, all subjects were randomly assigned to one of the following 3 groups: (1) a control group (CTL), which received conventional physical therapy intervention only, without CPM applications; (2)

ROM in knee extension, Timed Up & Go Test (TUG) results, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire scores. The

theoretical LOS and the real LOS also were reported. All assessments at discharge were performed at the same time of day, that is, in the morning before physiotherapy

experimental group 1 (EXP1), which received conventional physical therapy intervention and CPM applications for 35 minutes daily (low intensity); and (3) experimental group 2 (EXP2), which received conventional physical therapy intervention and CPM applications for 2 consecutive hours daily (moderate intensity). Two strata were created for an equivalent distribution of subjects with and subjects without previous major surgery of the lower limbs in the 3 groups. One set of

interventions, if those were still needed.

Maximal active ROM in knee flexion. The ROM measurement was taken with a 1degree-increment goniometer. Its center of rotation was placed in line with the center of the knee, the fixed arm aligned with the greater trochanter and the mobile arm aligned with the lateral malleolus. The criterion validity and the intratester and intertester reliability of data obtained with the

prenumbered, sealed envelopes was prepared for each stratum, and subjects were assigned to the group specified in the envelope.

goniometer have been demonstrated to be high.28,31 To maximize reliability, the subjects position was standardized30,32 as follows: the subject was seated on an adjustable table, the
13

Measures For each participant, anthropometric, personal,

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foot of the affected leg was placed on a cloth, and the contralateral foot was placed on an 7.6-to 15.2-cm-high (3- to 6-in-high) bench. Subjects were asked to actively bend their knee by sliding their foot backward to the maximum ROM tolerated.

have been shown to be high for this test.33,34 WOMAC.The WOMAC questionnaire is a self-administered, activity-based, and lowerlimb specific questionnaire that contains 24 items covering pain (n = 5), stiffness (n = 2), and functional difficulty (n = 17). Excellent validity and reliability have been shown with

Maximal active ROM in knee extension.The same procedure was applied for the extension movement, except that subjects were lying supine on the adjustable table and had to actively slide their foot forward on a wooden board to the maximum ROM tolerated. Two trials were performed for both ROM measurements. If the difference between those trials was more than 5 degrees, a third trial was performed and the mean of the 2 closest ROM measurements was registered. All evaluators were required to participate in a standardization session for the entire

many populations and specifically with TKA and total hip arthroplasty populations.35,38 The visual analog scale and the French version were used. At discharge, several questions regarding functional difficulty were excluded from the original form getting in and out of the car and the bath, shopping, and managing light or heavy household work as subjects were unable to attempt these tasks at the early postoperative stage.

LOS.The real length of each subjects hospital stay wasrecorded. on This measure factors: was

procedure of ROM measurements.

dependent

other

organic

complications or disease, difficulties in the TUG.This functional test records the time required toget up from a chair with armrests, walk 3 m, turn around, walk back to the chair, and sit down. Our chair seat was 46 cm in height, and permanent painted lines on the floor delimited the 3 meter walkway. The standardized procedure included a organization of support at home, or delayed transportation to home. Therefore, a

theoretical LOS also was recorded. It was defined as the time needed to reach discharge criteria for the knee condition. Those criteria were obtaining independence and security in transferring, in walking with aids, and in managing stairs; furthermore, the subject had to demonstrate good progression in recovery of active ROM in knee flexion, which had to be approximately 75 degrees at discharge. Finally, the scar had to be healing

demonstration for the subject and 2 trials with walking aids if necessary. Good correlation with the Berg Balance Scale, walking speed, and the Barthel Index has established the validity of TUG scores.33 Intratester and intertester reliability and responsiveness also
14

appropriately.

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

applications and the reasons for disparity Interventions CPM. Subjects in both experimental groups receivedone daily CPM session, beginning on the second day after TKA until discharge or day 7 or 8. Nurses installed the CPM device, and the procedure was standardized. Teaching sessions were organized, and written and audio-video instructions were provided. Conventional intervention.At physical Shivam therapy Hospital, a between the prescribed and the actual

applications were recorded every day.

standardized clinical procedure is followed after TKA. All subjects in the 3 groups received the same daily (including weekends) conventional physiotherapy intervention,

Identical installations were performed for both groups: subjects lay supine in their bed, and the CPM device was placed under the affected leg with the knee extended. For stability, one strap surrounded the subjects thigh, another strap surrounded the subjects lower leg, and the apparatus was prevented from sliding down by the edge of the bed. In the first group (EXP1), CPM was used for 35 minutes continuously, including a 5-minute warm-up period. In the second group (EXP2), CPM was used for 2 consecutive hours, including a 5minute warm-up period. This 2-hour

which was supervised by a Physiotherapist. On the first day after surgery, respiratory and circulatory exercises were encouraged.

Isometric knee extensor muscle exercises were performed, and extension knee alignment was maintained in a splint. On the second day, the splint was removed. Active and passive knee flexion, abduction and adduction of the hip in the horizontal plane, and knee extensor muscle exercises were performed. Next, teaching for transferring and walking with the appropriate device was begun. Functional exercises with weight bearing were added on day 4. Management of stairs, if needed, was

application was performed in the evening in order to avoid interfering with all other daytime medical and rehabilitation activities. On the second day after TKA, 35 to 45 degrees of flexion was reached with CPM for all subjects in both groups. From the third day after TKA to the end of the clinical trial, increments of ROM in flexion were

performed on day 6 or 7 before discharge. All subjects had to practice exercises and walk on their own in addition to the supervised sessions. The detailed content of each

supervised session, such as the type and the number of exercises, was recorded by the physical therapist.

determined by the physical therapist on the basis of the maximal ROM in knee flexion obtained during the conventional

Co-interventions.The number and content of the occupational therapists visits and

physiotherapy intervention. All information regarding ROM and duration of CPM


15

information about daily medications were

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collected from each subjects medical chart. Details on the surgery protocol and the type of prosthesis were available for all subjects a few weeks after surgery. This information was used to verify the comparability of the groups regarding the type of surgery.

DATA ANALYSIS A first analysis was based on the intention-totreat principle. Demographic and clinical characteristics of the subjects and baseline measurements were compared between groups by use of analysis of variance (ANOVA) for continuous variables and chi-square tests for

Adherence to intervention.In EXP1 and EXP2, thenumber of CPM applications

categorical data. The nonparametric KruskalWallis test was used when data were not normally primary distributed. and At discharge, outcomes the were

planned, the number of CPM applications received, their duration, and the ROM progression were recorded. The number of conventional physiotherapy sessions planned, the number of conventional physiotherapy sessions received, and their content also were recorded in the 3 groups.

secondary

compared between groups by use of ANOVA or the Kruskal-Wallis test when necessary. Pain, stiffness, functional difficulty, and total WOMAC questionnaire scores were

transformed to a percentage of the total score available for questions answered in each

Sample Size A consensus was reached between orthopedic surgeons and physical therapists with respect to the criterion for the maintenance of CPM applications as part of the recovery program after TKA: for active ROM in knee flexion, a minimum effect size of 10 degrees was established. This value corresponds to the mean difference between the control group (CTL) and either of the experimental groups (EXP1 or EXP2). On the basis of the relevant literature and subject files reviewed over 6 months, the estimated standard deviation of the primary outcome was 10 to 12 degrees. With a two-sided (type I) error level of .05 and a statistical power of 80%, the sample size for each group was estimated to be 26 subjects.39

category. The 95% confidence interval of the group differences was calculated for each variable. Adherence to interventions in each group was analyzed by comparing their content, their frequency, and their duration. Finally, a second analysis was carried out according subjects to the per-protocol 75% principle; in

showing were

participation The

interventions

included.

SPSS

version 10 statistical program* was used for all analyses.

RESULTS From December 2011 and May 2013, 98 subjects were evaluated at baseline (Fig. 1); 82 of them were randomly assigned to 1 of 3 groups: 27 were assigned to CTL, 26 were assigned to EXP1, and 28 were assigned to
16

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

EXP2. One subject was excluded after being randomly assigned by mistake; his Primary Outcome No significant difference was found among the 3 groups in active ROM in knee flexion (P .33) (Tab. 2, Fig. 2).

preoperative diagnosis was infection, not osteoarthritis, as specified in the inclusion criteria. For the main analysis (intention-totreat principle), 81 subjects were considered. Personal characteristics, comorbid conditions, physical activity levels, and measurement outcomes at baseline were similar in the 3 groups (Tab. 1).

Secondary Outcomes No significant difference was found among the 3 groups in active ROM in knee extension in TUG duration, or in total and subscale WOMAC questionnaire scores. Both real LOS

No significant difference was found among the 3 groups for surgery characteristics, such as patella resurfacing (CTL, 85%; EXP1, 69%; and EXP2, 64%; P .19) or posterocruciate-substituting prosthesis (CTL, 22%; EXP1, 27%; and EXP2, 7%; P .15).

and theoretical LOS were similar among the 3 groups (Tab. 2). Similar results for primary and second-ary outcomes were found with analysis by the per-protocol principle when only subjects showing 75% adherence to interventions were included.

Figure 1.
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Subject enrollment, distribution, and participation in interventions. CTL control group, EXP1 experimental group 1, EXP2 experimental group 2, CPM continuous passive motion, Doppler deep vein thrombosis diagnosis test

Adherence to Interventions Adherence to the CPM applications was very high; only one subject in the EXP1 group and 3 subjects in the EXP2 group did not receive 75% of the planned interventions (Fig. 1). The mean numbers of CPM applications were similar (P .14) in both experimental groups: EXP1, 4.9 applications (SD= 0.9), and EXP2, 4.5 applications (SD = 1.4). The percentages of subjects who received CPM applications daily were comparable between the groups (Fig. 3). The mean durations of CPM applications were 35.7 minutes (SD 2.5) in EXP1 and 118.9 minutes (SD 7.6) in EXP2 (Fig. 3). Daily ROM progressions were similar in both groups. Adherence to conventional physiotherapy interventions also was very high; 3 subjects in CTL and 1 subject in EXP1 did not receive 75% of the physical therapy interventions (Fig. 1). The mean numbers of physical therapy sessions were similar among the 3 groups (P .24): CTL, 5.7 (SD = 1.0); EXP1, 6.0 (SD = 1.0); and EXP2, 6.0 (SD = 0.7). Exercises performed and percentages of subjects performing specific exercises were comparable.

groups received similar numbers of visits from the occupational therapist (P .87): CTL, 2.6 (SD = 1.8); EXP1, 2.7 (SD = 0.8); and EXP2, 2.8 (SD = 1.4).

Complications One subject in each group developed a knee hematoma; superficial vein thrombosis was present in one subject each in CTL and EXP1, and deep vein thrombosis (DVT) occurred in one subject in EXP2. Scar bleeding was seen in one subject in CTL, 2 subjects in EXP1, and no subjects in EXP2. Three subjects in CTL and 3 subjects in EXP1 had pulmonary or cardiac problems, and only 1 subject in EXP2 had these problems. No subject was required to undergo knee manipulation under

anesthesia before discharge.

DISCUSSION Our results confirm that adding CPM

applications of low or moderate intensity to conventional physiotherapy interventions has no short term effect on active ROM in knee flexion. Moreover, CPM applications did not have any additional effect on secondary outcome measurements, including active

Co-interventions In the first 36 hours after TKA, all subjects had an intravenous analgesic perfusion that they used as needed. Afterward, the analgesic medication was adjusted according to pain and discomfort requirements. Subjects in the 3
18

ROM in knee extension, TUG results, WOMAC questionnaire scores, and LOS.

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

applica-tions,9,10,16,40,41 similar ranges of knee flexion (70 82) were observed 7 days after surgery. When the mean knee flexion ROM was found to be greater (8693) at discharge, the LOS also was longer, reaching 15 to 20 days.12,13,15,18,19 In our clinical trial, the mean knee flexion ROM at discharge for the entire population of subjects (N = 81) was 80.8 degrees (SD = 11.5) for a mean LOS of 8 days (SD = 2). One of the adverse effects that could occur with CPM applications is an increased lack of active or passive ROM in knee extension. However, only a few

studies10,11,14 demonstrated a significant decrease in knee extension ROM at discharge


Figure 2. (Top) Mean and standard deviation of active range of motion in knee flexion in each group (CTL control group, EXP1 experimental group 1, EXP2 experimental group 2) at discharge. (Bottom) Ninety-five percent confidence interval for intergroup differences at discharge: 0 means no difference among groups; the dotted vertical lines illustrate the range of differences not considered clinically important.

in the experimental groups using CPM applications. In all of these studies, the duration of applications was 20 hours per day. In our study, active knee extension was not found to be decreased in groups receiving CPM applications (CTL, 8; EXP1, 7; and EXP2, 6.5). Nevertheless, in all 3 groups, there was a lack of knee extension of about 7.2 degrees (SD = 0.7). Comparable ROMs ( 4

Our results confirm those of other studies in which CPM applications did not have any additional effect on knee flexion

to 10) have been observed at discharge (5 14 days after TKA) in other studies, regardless of study duration or the protocol in

ROM.6,8,11,18,20,22,25 Agreement also was reached for the mean knee flexion ROM at discharge. In some studies,11,20,24 this ROM varied from 62.7 to 76.5 degrees 7 to 10 days after TKA, all groups taken into account. In studies supporting the efficacy of CPM

used.6,9,17,20,25,40

Difficulties

performing knee extension may be explained by extensor muscle weakness, stiffness in flexor muscles, knee swelling, pain, or a combination of these impairments, given the acute-stage condition.

Table 1. Subject Characteristics and Outcome Measurements at Baseline.a


19

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Characteristic

CTL (n=27)

EXP1 (n=26)

EXP2 (n=28) 15 (53.6) 68.4 (7.4) 80.7 (16.6) 1.6 (0.1) 11 (39.3) 11 (8.2) 12 (42.9) 14 (50.0)

Men, n (%) Age, y, X (SD) Weight, kg, X (SD) Height, m, X (SD) Live alone, n (%) Duration of symptoms, y, X (SD) Affected side, left, n (%) Physical activity, none, n (%) Comorbid conditions, n (%) Hypertension Cardiac problems Pulmonary problems Diabetes Cancer Outcomes, X (SD) Flexion, Extension, TUG duration, s WOMAC score, %, X (SD) Pain Stiffness Incapacity Total
a

13 (48.1) 67.1 (7.6) 85.8 (15.6) 1.7 (0.1) 6 (22.2) 8.6 (7.9) 15 (55.6) 12 (44.4)

10 (38.5) 69.6 (6.7) 79.3 (9.4) 1.6 (0.1) 10 (38.5) 8 (6.2) 19 (73.1) 11 (42.3)

.53 .47 .22 .42 .32 .30 .08 .84

17 (63.0) 6 (22.2) 3 (11.1) 5 (18.5) 1 (3.7)

13 (50.0) 7 (26.9) 2 (7.7) 5 (19.2) 4 (15.4)

18 (64.3) 8 (28.6) 2 (7.1) 5 (17.9) 5 (17.9)

.50 .86 .85 .99 .24

115.8 (11.5) - 7.1 (5.6) 16.4 (12.3)

117.1 (7.9) - 8.8 (4.0) 17.2 (11.3)

118.8 (9.7) - 6.9 (3.8) 16.9 (5.9)

.53 .25 .96

51.5 (20.7) 61.1 (28.0) 55.2 (21.8) 55.0 (20.7)

52.5 (17.0) 66.5 (23.7) 51.2 (18.4) 52.8 (16.5)

48.9 (17.9) 62.4 (24.7) 53.7 (20.6) 53.4 (18.9)

.77 .73 .77 .91

TUG_Timed Up & Go Test, WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index, CTL = control group, EXP1 = experimental group 1, EXP2 = experimental
20

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

group 2.

Table 2. Primary and Secondary Outcome Measurements at Discharge a Outcomes b Parameter CTL (n=27) EXP1 (n=26) EXP2 (n=28) P (Analysis of Variance) Flexion, 80.4 (11.8) 78.7 (10.6) 83.3 (11.9) .33 1.7 (5.8,9.2) .30 -1 (3.4,1.4) .33 - 8.7 (-26.8, 9.2) -2.9 (-10.3, 4.5) -1.5 (-3.9, 0.8) -10.4 (-28.0, 7.3) -4.6 (-12.1, 2.9) -0.5 (-2.9, 1.9) -1.6 (-19.6, 16.4) Intervention effects c CTLEXP1 CTLEXP2 EXP1EXP2

Extension,

- 8.0 (3.5)

- 7.0 (3.7)

- 6.5 (3.7)

TUG duration, s

41.9 (21.4)

50.7 (22.6)

52.3 (34.9)

WOMAC score, %, X (SD) Pain 39.8 (24.8) 36.8 (15.6) 27.7 (17.1) .07 3.0 (9.9,15.9) .36 -5.4 (-20.8, 10.0) Functional Difficulty 33.0 (22.7) 40.0 (20.2) 31.0 (23.9) .32 -7.0 (-21.7, 7.7) .28 -4.1 (-17.5, 12.1 (-0.6, 24.9) 3.8 (-11.5, 19.0) 1.9 (-12.6, 16.5) 4.9 (-8.4, 9.1 (-3.8, 22) 9.2 (-6.2, 24.6) 8.9 (-5.7, 23.6) 9.0 (-4.4,

Stiffness

53.8 (26.1)

59.3 (19.3)

50.1 (24.1)

Total

37.1 (22.6)

41.2 (17.6)

32.2 (20.6)

21

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9.3) LOS Real 7.8 (2.0) 8.1 (2.0) 8.0 (2.1) .83 -0.3 (-1.7, 1.0)

18.1)

22.4)

-0.2 (-1.5, 1.1) -0.2 (-1.2, 0.9)

0.2 (-1.2, 1.5) 0.2 (-0.8, 1.3)

Theoretical

7.5 (1.4)

7.9 (1.6)

7.6 (1.8)

.71

-0.4 (-1.4, 0.7)

TUG_Timed Up & Go Test, WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index, LOS = limits of agreement, CTL = control group, EXP1 = experimental group 1, EXP2 = experimental group 2. b Reported as X (SD). c Reported as mean differences between groups (95% confidence interval).

One could surmise that subjects who received additional CPM applications would have decreased functional abilities because they remained inactive during the duration of CPM interventions. To our knowledge, no study with CPM applications abilities at has measured All

EXP2, 88.9%) were using a walker for ambulating; therefore, walking speed was decreased. In a previous study not involving CPM applications, Walsh et al42 evaluated functional performance at 1 week after TKA, and their results showed that TUG duration was only twice that measured at baseline. However, the subjects in that study seemed to have greater preoperative functional abilities, as suggested by their superior performance on the TUG (12.9 seconds, SD = 0.7). In addition, the majority of their subjects used a cane (78%) instead of a walker.42 In our study, WOMAC questionnaire scores were comparable among the 3 groups. However, it is important to note that the results may have been influenced by the withdrawal of several nonrelevant items from the functional

functional

discharge.

assessments of functional abilities were performed 6 weeks to 2 years after TKA. However, at these postoperative periods, no adverse effect of CPM applications on functional abilities was found.8,10,14,20,23 In our study, functional abilities, as measured by the TUG and the WOMAC questionnaire, were comparable among the 3 groups at discharge. The mean TUG duration for all subjects in the 3 groups was 48.2 seconds (SD = 27.2), 3 times longer than that at baseline (16.8 seconds, SD = 9.8). Furthermore, 81.5% of our subjects (CTL, 85.2%; EXP1, 76%; and

difficulty subscale, because the subjects were not exposed to these during the early

22

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

postoperative

stage.

This

methodological

Therefore,

the 90

degree

knee

flexion

choice may have reduced the validity of the corresponding subscale and the total score on the WOMAC questionnaire. There is a need to develop and validate an appropriate functional outcome measure for the weeks immediately after TKA.

discharge criterion was modified to a smaller ROM, and functional ability was emphasized to accelerate discharge.46,47 In some

studies,8,20,24 the mean knee flexion ROM at discharge varied from 63 degrees to 80 degrees for an LOS between 5 and 10 days after TKA. In our study, one of our discharge

Differences in WOMAC pain component scores were close to significance at discharge (P .07). A secondary analysis of the 5 items of this pain component revealed a significant difference between CTL subjects and subjects who received moderate intensity CPM

criteria in addition to independence in functional activities was active ROM in knee flexion, which had to be approximately 75.5 degrees. Eighty-three percent of our subjects reached more than 70 degrees of knee flexion at discharge (CTL, 81%; EXP1, 81%; and EXP2, 86%). Others were allowed to return home because they had reached the functional independence goal and because they continued to be partially supervised for their exercises. All subjects were discharged with homesupervised physiotherapy interventions. In our clinical trial, when all groups were taken into account, real LOS and theoretical LOS were 8 days (SD = 2) and 7.6 days (SD = 1.6) after TKA, respectively. The slight difference between the 2 LOS measures was mostly attributable to delays in transportation for subjects living in outlying regions.

applications for the fourth item, which evaluates the intensity of pain at rest (ANOVA, P .003; Tukey honestly significant difference post hoc test, P .002; 95% confidence interval for intergroup differences 7.4%37.7%). For the other items, pain in managing stairs (item 1), in walking (item 2), at night (item 3), or in the sit-to-stand activity (item 5), no difference among groups was found, even for pain at night, when subjects were also in a resting position. One may question the validity of this finding. That is, is it the result of chance, or does it actually reflect the effect of intervention for subjects who received moderate-intensity CPM

Deep vein thrombosis can develop in 40% to 80% of subjects after TKA. This proportion decreases with prophylactic anticoagulant

applications?

In the past 10 years, preestablished discharge criteria have evolved concurrently with

therapy.48

,51

There

is

controversy

concerning the effect of CPM on DVT. Many authors did not find any difference in DVT with
23

decreasing LOS, which now varies between 5 and 10 days after TKA.8,20,24,43,46

CPM

applications,13,14,20,21,52

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whereas others found less DVT in CPM application groups, although this finding may have been attributable to the fact that their control subjects were immobilized.4,15,19,53 In our study, a majority of subjects received anticoagulant therapy, and the same very small proportions of side effects, including DVT, were observed in the 3 groups.

intervention. This second group (EXP2) received the CPM application in the evening to avoid interference with other postoperative activities routinely per-formed during the hospital stay. This 2 hour duration was chosen on the basis of a consensus among the health care professionals (orthopedic surgeons,

physiotherapists, and nurses) involved in rehabilitation after TKA. We determined that

Our choice of CPM application duration could be criticized. Indeed, many protocols with various CPM application durations have been studied, for instance, 1 hour 3 times per day,22 2 hours 3 times per day,20 comparison of moderate and intensive durations of 5 and 20 hours per day,21 mean applications between 4 and 8 hours,6 and applications as long as 20 hours per day for 1 to 6 days after TKA.8,11,23 None of these studies

CPM applications could not be any longer than 2 hours in the acute-care context after TKA because subjects had daily conventional physiotherapy interventions, occupational

therapy visits, nursing care, and radiographic and medical assessments. Furthermore,

subjects needed time to achieve all of their rehabilitation goals, in addition to knee flexion, such as independence and security in transferring and in walking with aids, before being discharged and sent home.

demonstrated any additional effect of CPM applications on knee flexion. Adherence to CPM interventions was reported in 2 studies and was less than the prescribed duration.6,20 For example, Beaupre et al20 reported an adherence of 1.7 hours 1.8 times per day, which was less than the prescribed application of 2 hours 3 times per day. In this case, 61% of subjects missed the morning session because of interference with other activities.20 In our study, the 35 minute duration in EXP1 corresponded to the usual length of the CPM application in our rehabilitation practice after TKA. The 2 hour CPM application was added to the research protocol to explore the effect of a more intense, yet still feasible, CPM
24

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

Figure 3. Adherence to continuous passive motion (CPM) interventions. (Top) Percentages of subjects in

restrictions in knee flexion are present before TKA or after knee manipulation, CPM application efficacy still needs to be tested.

experimental group 1 (EXP1) and experimental group 2 (EXP2) who received CPM applications for each day of the clinical trial. (Bottom) Mean duration (in minutes) of daily CPM applications for each experimental group.

CONCLUSION The results of this study suggest that adding CPM applications to conventional physical

Our study has many factors that contribute to the validity of the results. First, our 3 groups were comparable at baseline in terms of personal and clinical characteristics and outcome measurements. Second, there was a high degree of adherence to interventions. Only 1 subject in EXP1 (4%) and 3 subjects in EXP2 (11%) did not receive 75% of the planned CPM applications. Three subjects in CTL (11%) and 1 subject in EXP1 (4%) did not receive 75% of the conventional physical therapy interventions. Third, all subjects in the 3 groups began CPM mobilization and knee flexion exercises at the same time after TKA to avoid a delayed exposure to knee movement in CTL. Furthermore, the levels of cointerventions were comparable among the groups. Finally, in this study, considering the variability observed and the pre-established parameters ( error 5% and effect size in active knee flexion of 10 among groups), the calculated statistical power was high (86%).

therapy interventions does not favor better knee flexion ROM. Furthermore, the results indicate that CPM applications do not have any additional effect on knee extension ROM, functional ability, or LOS. Therefore, we believe that CPM should not be routinely used during in-hospital rehabilitation programs after primary TKA for people with

osteoarthritis.

This

study

has

some

limitations.

The

conclusions of this study are limited to populations and CPM application protocols similar to those described in our clinical trial. In specific situations, such as when important

25

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20 Beaupre LA, Davies DM, Jones CA, Cinats JG. Exercise combined with continuous passive motion or slider board therapy compared with exercise only: a randomized controlled trial of patients following total knee arthroplasty. Phys Ther. 2001;81:1029 1037.

21 Basso DM, Knapp L. Comparison of two continuous passive motion protocols for patients with total knee implants [published erratum appears in Phys Ther. 1987;67:979]. Phys Ther. 1987;67:360 363.

22 Gose JC. Continuous passive motion in the postoperative treatment of patients with total knee replacement: a retrospective study. Phys Ther. 1987;67:39 42.

23 Maloney WJ, Schurman DJ, Hangen D, et al. The influence of continuous passive motion on outcome in total knee arthroplasty. Clin Orthop Relat Res. July 1990:162168.

24 Montgomery F, Eliasson M. Continuous passive motion compared to active physical therapy after knee arthroplasty: similar hospitaliza-tion times in a randomized study of 68 patients. Acta Orthop Scand. 1996;67:79.

25 Nielsen PT, Rechnagel K, Nielsen SE. No effect of continuous passive motion after arthroplasty of the knee. Acta Orthop Scand. 1988;59:580 581.

26 Maloney WJ, Schurman DJ. The effects of implant design on range of motion after total knee arthroplasty: total condylar versus posterior stabilized total condylar designs. Clin Orthop Relat Res. May 1992: 147152.

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27 Godin G, Shephard RJ. A simple method to assess exercise behavior in the community. Can J Appl Sport Sci. 1985;10:141146.

28 Brosseau L, Balmer S, Tousignant M, et al. Intra- and intertester reliability and criterion validity of the parallelogram and universal goniometers for measuring maximum active knee flexion and exten-sion of patients with knee restrictions. Arch Phys Med Rehabil. 2001;82: 396 402 29 Brosseau L, Tousignant M, Budd J, et al. Intratester and intertester reliability and criterion validity of the parallelogram and universal goniometers for active knee flexion in healthy subjects. Physiother Res Int. 1997;2:150 166.

30 Bellamy N. Musculoskeletal Clinical Metrology. Boston, Mass: Kluwer Academic Publishers; 1993.

31 Mayerson NH, Milano RA. Goniometric measurement reliability in physical medicine. Arch Phys Med Rehabil. 1984;65:9294.

32 Stratford P, Agostino V, Brazeau C, Gowitzke BA. Reliability of joint angle measurement: a discussion of methodology issues. Physiother Can. 1984;36:59.

33 Podsiadlo D, Richardson S. The timed Up & Go: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39: 142148.

34 Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the get-up and go test. Arch Phys Med Rehabil. 1986;67:387389.

35 Bellamy N, Buchanan WW. Outcome measurement in osteoarthritis clinical trials: the case for standardisation. Clin Rheumatol. 1984;3: 293303.

36 Bellamy N, Buchanan WW. A preliminary evaluation of the dimen-sionality and clinical importance of pain and disability in osteoarthritis of the hip and knee. Clin Rheumatol. 1986;5:231241.

37 Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: a health status instrument for measuring clinically-important patient-relevant outcomes following total hip or knee arthroplasty in osteoarthritis. Journal of Orthopaedic Rheumatology. 1988;1:95108.

38 Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:18331840.

39 Hulley SB, Cummings SR, Browner WS, et al. Designing Clinical Research. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001.

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40 Lau SK, Chiu KY. Use of continuous passive motion after total knee arthroplasty. J Arthroplasty. 2001;16:336 339.

41 Johnson DP. The effect of continuous passive motion on wound-healing and joint mobility after knee arthroplasty. J Bone Joint Surg Am. 1990;72:421 426.

42 Walsh M, Kennedy D, Stratford PW, Woodhouse LJ. Perioperative functional performance of women and men following total knee arthroplasty. Physiother Can. 2001;53:92100, 114.

43 Oldmeadow LB, McBurney H, Robertson VJ. Hospital stay and discharge outcomes after knee arthroplasty: implications for physio-therapy practice. Aust J Physiother. 2002;48:117121.

44 Healy WL, Iorio R, Ko J, et al. Impact of cost reduction programs on short-term patient outcome and hospital cost of total knee arthro-plasty. J Bone Joint Surg Am. 2002;84:348 353.

45 Hill SP, Flynn J, Crawford EJP. Early discharge following total knee replacement: a trial of patient satisfaction and outcomes using an orthopaedic outreach team. Journal of Orthopaedic Nursing. 2000;4: 121 126.

46 Block J, Westlake S, Meredith L, Sheppard M. Total knee arthro-plasty: the effect of early discharge on outcome at 6 8 weeks postop-erative. Physiother Can. 1999;51:4551.

47 Mauerhan DR, Mokris JG, Ly A, Kiebzak GM. Relationship between length of stay and manipulation rate after total knee arthroplasty. J Arthroplasty. 1998;13:896 900. 48 Brady OH, Masri BA, Garbuz DS, Duncan CP. Rheumatology, 10: joint replacement of the hip and knee when to refer and what to expect. CMAJ. 2000;163:12851291.

49 Haas S. Recommendations for prophylaxis of venous thromboem-bolism: international consensus and the American College of Chest Physicians Fifth Consensus Conference on Antithrombotic Therapy. Curr Opin Pulm Med. 2000;6:314 320.

50 Colwell CW Jr. Low molecular weight heparin prophylaxis in total knee arthroplasty: the answer. Clin Orthop Relat Res. November 2001: 245248. 51 Huo MH, Sculo TP. Complications in primary total knee arthro-plasty. Orthop Rev. 1990;19:781788.

52 Lynch AF, Bourne RB, Rorabeck CH, et al. Deep-vein thrombosis and continuous passive motion after total knee arthroplasty. J Bone Joint Surg Am. 1988;70:1114.

53 ODriscoll SW, Kumar A, Salter RB. The effect of continuous passive motion on the clearance of a hemarthrosis from a synovial joint: an experimental investigation in the rabbit. Clin Orthop Relat Res. June 1983:305311. CORRESPONDENCE
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* Senior Physical therapist, Ahmedabad, Gujarat

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Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

EFFECTIVENESS OF SUPERVISED GRADED REPETITIVE ARM SUPPLEMENTARY PROGRAM ON ARM FUNCTION IN SUBJECTS WITH STROKE
Dr.Harsha Tummala, MPT (Neurology)*, Dr.V.Srikumari, MPT (Neuro), PhD.**, Dr. K.Madhavi, MPT (CT), PhD., ***

ABSTRACT PURPOSE: The aim of the present study is to evaluate the effect of supervised GRASP protocol in improving arm function in subjects with stroke. DESIGN: A RCT, Prospective-exp-design with pre test-post-test design. SETTING: College of physiotherapy OPD, General ward of Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati. SUBJECTS: 30 subjects divided into 2 groups, control group (n=15) & experimental group (n= 15). INTERVENTION: For experimental group: Conventional physiotherapy with Supervised GRASP protocol for upper limb (In the presence of therapist or caregiver). For control group:Conventional physiotherapy with home program exercises with printed GRASP material. DURATION: 6 weeks, 5days in a week. OUTCOME MEASURES: (1) The Chedoke Arm and Hand Activity Inventory-9 (CAHAI) was used to evaluate the performance of the paretic upper limb in the completion of activities of daily living (ADL). (2) The Box and Block test (B&BT) to measure upper limb functional performance of basic manual dexterity. (3) Isometric grip strength of the paretic hand was tested using a jammer hand grip dynamometer. RESULTS: According to the obtained values, the pre and post test values of CAHAI-9, B&BT and grip strength had an extremely significant effect with p value < 0.0001 in both control and experimental group. On comparing the results between the groups: The experimental group CAHAI-9, (p-value is 0.0001) and B&BT (p-value is

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0.0020) is considered very significant comparing to control group. The grip strength (p-value is 0.0005) is considered extremely significant than the control group. CONCLUSION: After 6 weeks of intervention program, both the supervised and unsupervised groups had a greater improvement in arm function with GRASP protocol; but, supervised group had a better improvement in ADL performance, manual dexterity and grip strength when compared to unsupervised group. Hence this study recommends the supervised GRASP protocol for improving arm functions in subjects with stroke.

KEY WORDS: Stroke, Upper limb, GRASP, CAHAI, ADL

INTRODUCTION Among all the neurological diseases of adult life, stroke or cerebrovascular accident (CVA) clearly ranks first in

limb is vital to the completion of many activities of daily living (ADL), as well as to socialization and health-related quality of life
[5, 6].

frequency and importance. It is a leading cause of disability among adults in developed countries and it may persist for lifelong and limits independence and quality of life
[1].

According to the theory learned non-use repeated disappointments in attempts to use the affected arm in acute phase can lead to negative reinforcement of using the affected arm. The individual learns not to use the affected extremity[7, 8]. This compensation has been show to hinder recovery of function in the upper limb and suppression of movement. The restraint and training techniques

Approximately 20 million people each year will suffer from stroke and of these 5 million will not survive in developing
[2].

The incidence of stroke countries will grow

approximately 30% between 2000 and 2025. In 2005 it accounts for 5.7million deaths worldwide and it is estimated that this number will climb to 6.3 million in 2015 and 7.8 million in 2030. Although most of the stroke survivors regain independent ambulation, many have

appeared to be effective because they successfully overcame the learned non-use [9]. Greater amounts of upper extremity therapy during rehabilitation can improve the ability to use ones arms and hands In the rehabilitation treatment for the paretic upper limb, it is apparent that increased treatment intensity using repetitive task oriented

difficulty in performing activities of daily living (ADL) especially their self care and house hold duties
[4]. [3].

More than 70% of

individuals experience upper-limb paresis after stroke The functional limitation in

methods improves motor and functional recovery compared to facilitative approaches [10]. Thus, a novel method which is
32

upper extremity is one of the most common disabling deficits after stroke. Use of upper

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

practical, inexpensive and well-received by the patients and clinicians are needed to deliver greater amounts of therapy with a focus on improving functional tasks of upper extremity. One of such method is Graded Repetitive Arm Supplementary Program (GRASP) GRASP is mostly used as a home based exercise program which serves as a complement to the regular physical therapy. It is a self-directed arm and hand exercise program which is supervised by a therapist, but done independent by the patient (and with their family if possible). But the effectiveness of any home based exercise regimen is not clearly studied because of the adherence to the program and patient motivation. So, this needs to supervise by the therapist or a caregiver. The need of this study is to find out the importance of therapist supervision in implementing

glasses(2), hand towel, tooth paste and tooth brush, knife, fork, thera putty, Inclusion criteria: Stroke subjects with 40 to70 years of age; both males and females; with active scapular elevation (shoulder shrug) against the gravity; voluntary control grading of 2 and 3 ;MAS score between 1 to 2 and Fugl-Meyer Upper Limb Motor Impairment Scale score between 26 and 45. Exclusion criteria: Stroke subjects with unstable cardiovascular status; MMSE below 20; Cognitive deficits; Musculo-skeletal

disorders; Receptive aphasia & Non cooperative patients. OUTCOME MEASURES: The Chedoke Arm and Hand were Activity used to Inventory-9 evaluate the

(CAHAI)

performance of the paretic upper limb in the completion of activities of daily living (ADL). 1. The Box and Block test to measure

GRASP program to stroke subjects. Material and methodology: Subjects were recruited from the college of Physiotherapy OPD & General ward of Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India. Materials: Hand gripper, ball, light rubber weight (half kg), clothe pegs, Lego-pieces, paper clips &target board, Jammer hand grip dynamometer & Box and block test kit. CAHAI materials : plastic jar & lid, telephone, scale(30 cms), pencil, water
33

upper limb functional performance of basic manual dexterity. 2. Isometric grip strength of the paretic hand was tested using a hand grip dynamometer. All the subjects were selected on the basis of inclusion criteria; were divided into 2 groups; Control group & experimental group with 15 subjects in each group. The subjects participated in this study voluntarily after signing the consent form. The

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demographic data, baseline measurements were collected from both the groups and the purpose of the study was explained to all the subjects. All the three outcome INTERVENTION Experimental Group: Conventional

measurements are measured initially before the intervention and after 6weeks of

physiotherapy + Supervised GRASP protocol for upper extremity. (In the presence of therapist or caregiver.) Control Group: Conventional physiotherapy

intervention in both the groups.

Table

1:

Demographic

&

Clinical

+ Home program exercises with printed GRASP versions) material (Telugu and English

characteristics of sample at baseline. Control Variables group (n=15) Experimental group (n=15) Sex, n Age (mean), yrs Side of paresis, n Fugl-meyer score, 9M / 6F 56.5 8R/7L 8M /7F 54.2 10R/5L 35.2 (6.2)

Conventional physiotherapy: Stretchings to spastic group of muscles of upper limb;Electrical stimulation to weaker group of muscles of upper limb;Strengthening exercises to arm and hand;Free exercises and active movements to upper limbs &Weight bearing exercises to upper limb. STATISTICAL ANALYSIS: Statistical analysis was done using Graph pad instant 3 version software. For this purpose the data was entered into

arm 34.6

max=66 (4.6)

(mean SD) CAHAI-9, max=63,(meanSD ) B&BT, (meanSD) 10.2(5.0) 10.6(4.8) Grip strength, 3.2(1.1) 3.5(0.88) 25.8(8.5) 23.4(6.9)

Microsoft Excel spread sheet, tabulated and subjected to statistical analysis. To compare the pre and post

treatment effect within the group paired sample t test was used, and to compare the pre and post test treatment effect between the groups unpaired t-test was used. RESULTS: Results of control group: (Refer table: 2) CAHAI-9 result: The p-value is < 0.0001
34

(meanSD), kg

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

which shows there is a extremely significant difference. The t-test value is 21.767 with 14 degrees of freedom. It is observed that the post intervention had shown significant impact on the subjects. B&BT result: The p-value is < 0.0001 which shows there is a extremely significant

intervention had shown significant impact on the subjects. Grip strength result: The p-value is < 0.0001 which shows there is a extremely significant difference. The t-test value is 9.727 with 14 degrees of freedom. It is observed that the post intervention had shown significant impact on the subjects.

difference. The t-test value is 9.057 with 14 degrees of freedom. It is observed that the post

Table 2: Analysis of control group with pre and post intervention: Parameter Mean SD t-value DF Pvalue Pre CAHAI-9 Post 25.866 29.666 8.676 9.005 21.767 14 <0.0001

Pre B&BT Post Pre Grip strength Post

10.866 12.933 2.967 3.9

3.523 3.674 1.274 1.339

9.057

14

<0.0001

9.727

14

<0.0001

Results of experimental group :( Refer table: 3) CAHAI-9 result: The p-value is < 0.0001 which shows there is a extremely significant difference. The t-test value is 13.266 with 14 degrees of freedom. It is observed that the post intervention had shown significant impact on the subjects. B&BT result: The p-value is < 0.0001 which shows there is a extremely significant degrees of freedom. It is observed that the post intervention had shown significant impact on the subjects. Grip strength result: The p-value is < 0.0001 which shows there is a extremely significant difference. The t-test value is 12.426 with 14 degrees of freedom. It is observed that the post intervention had shown significant impact on the subjects.
35

difference. The t-test value is 18.806 with 14

Table 3: Analysis of Experimental group with pre and post intervention Parameter Pre CAHAI-9 Post mean 23.466 37.93 SD 6.906 3.955 14 Pre B&BT Post 10.666 18.666 4.865 5.394 14 Pre Grip strength Post 3.4 5.9 1.256 1.429 14 <0.0001 12.426 <0.0001 18.806 <0.0001 t-value 13.266 DF p- value

COMPARISON BETWEEN THE GROUPS: CAHAI Results: To compare the results of between the group of control & experimental groups, the unpaired t-test was selected. The p-value is 0.0030, the difference is considered very significant. The values of CAHAI are improved in control group as well as experimental group, but the improvement is more is experimental group. B&BT Results: The p-value is 0.0020, the difference is considered very significant. The Grip strength results: The p-value is 0.0005, the difference is considered extremely values of B&BT are improved in control group as well as experimental group, but the improvement is more is experimental group.

significant. The values of B&BT are improved in control group as well as experimental group, but the improvement is more is experimental group.

Table 4: Comparison of between the groups of control and experimental group

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Para-meter Mean CAHAI-9 Experimental Control B&BT Experimental Control Grip strength Experimental Control 37.93 29.666 18.666 12.933 5.9 3.9 S.D 3.955 9.005 5.394 3.674 1.429 1.339

t-value df 28 3.255 28 3.402 28 3.955

p-value

0.0030

0.0020

0.0005

DISCUSSION: The results of the present study revealed that there is a significant difference in both control and experimental group which indicates that GRASP protocol is effective in improving arm function in stroke subjects. Our intervention techniques (GRASP) are based on the repetitive task oriented practice which contains 3 designed principles; such as, skill acquisition of functional tasks, active participation training and individualized adaptive training. All these 3 principles are helped in improving arm function with GRASP protocol. The task oriented training is emerging as the dominant and most effective approach to motor rehabilitation of upper extremity function after stroke[11]. And these task oriented exercises are based on the concrete task rather than abstract task. Subjects showed a superior motor performance when performing a concrete task

involving meaningful interaction with an object compared to an abstract task with no object involved [12]. The movement was faster in the concrete task than in the abstract task [13]. Repetitive exercise may be as critical to motor learning and it may drive brain reorganization by what appears to be as process of motor learning [14]. Time spent completing the GRASP protocol was a significant predictor of improvement in both variables (CAHAI and B&BT) in both the groups. But, the supervised exercises is very significant than unsupervised with CAHAI and B&BT, and it is extremely significant in grip strength. In the supervised group, during intervention with the subjects, therapist used the verbal cues and tactile cues to the subject to complete the task in a proper way & in a correct manner to avoid wrong synergy pattern. And, therapists used sensory input,

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verbal guidance and rewards to help the patient to learn the task or to complete the GRASP protocol. Physical guidance are also used by the therapist throughout the whole protocol/task to demonstrate what is to be done and how to do the task and it is given during the beginning, middle and in finishing the task. All these above factors help the supervised group to improve the CAHAI. In the supervised group, the therapist used the extrinsic feedback. The extrinsic feedback is provided to the subjects with knowledge of result (KR) and knowledge of performance (KP) by the therapists verbal and tactile cuing during intervention For example, to improve manual dexterity, the therapist used extrinsic

practiced the grip strength exercises such as Grip power, finger power, the twist and finger strength in the GRASP Protocol with the help of thera putty. During these thera putty exercises, the subjects are complained about the fatigueness and pain in the hands in both groups But in supervised group, proper resting time and changing of exercises are advised. But Modification of exercises are also done by the therapist when the patient is not able to perform the protocol and during these putty exercises. In unsupervised group, due to pain and fatigue, subjects less used these theraputty exercises compared to other exercises. Due to poor adherence, (participating in less than half required time), there is no therapist or family member to explore the reasons behind the problems and lack of solutions for the problems. The result of GRASP is better with the involvement of therapist of caregiver or who can assist with the exercises like track the amount of exercise, motivation to the patient, helping counting the repetitions; assist with the positioning equipment like the target board etc. Researchers noted that the motor cortex (M1) changes occurred (motor

feedback. Here, the goal is to pickup small blocks from the peg board. KR is given in the form of amount of time needed to complete the task (whole peg board). KP is given regarding information about the movement patterns in the shoulder, elbow, wrist and finger during grasping a block and during releasing a block. So, with the help of extrinsic feedback (KR and KP), the

supervised group had a statistically greater improvement in manual dexterity of hand with box and block test (B&BT). When compared to the unsupervised grip strength, the supervised grip strength is extremely significant because, the subjects
38

learning) when (a) New or novel task were used, (b) when movements were practiced together, (c) when movements were frequently

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

repeated and (d) when movements were important to the individual [15]. intervention program (GRASP Our

biomechanical basis, and practicing on real life activities. It is established well that real life practice are more beneficial for motor relearning. The present study aimed to assess whether there is any significant difference in the effectiveness of GRASP protocol between supervised and non supervised program in arm function. On the above discussed & tabulated

protocol),

meets the above same criteria which play a important role in motor learning. The

supervised group, play a major role in motor learning and neural plasticity. Hence, the use of verbal and tactile cues, proper sensory input, verbal guidance, motivation, rewards and with proper feedback by the therapist helps in process of motor learning. Hence, this motor learning enhances the neural plasticity of the brain. CONCLUSION: Task proven one oriented of program has been of

data and results after 6 weeks of intervention program, it is concluded that both the supervised and unsupervised GRASP

protocols shown greater improvement in arm function. Further, supervised Grasp protocol helps in better improvement in ADL

performance, manual dexterity and in grip strength when compared to unsupervised GRASP. Hence this study recommends that supervised GRASP protocol for improving arm functions in stroke subjects. DEDICATION: To our beloved effective methods

management for stroke related disabilities. The GRASP program is based on the concepts of task oriented program which aims to treat the motor problems on the neuro

Physiotherapy profession &God Almighty.

REFERENCES

[1]. Duncan PW, Samsa GP, Weinberger M, Goldstein L, Bonito A, Witter D,Enarson C, Matchar D. Health status of individuals with mild strokes. Stroke. 1997; 28:740745. [2]. Dalal P, Bhattacharjee M, and Vairale J, Bhat P. UN millennium development goals: can we halt the stroke epidemic in India? Ann Indian Acad Neurol 2007; 10: 130-6.

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

[3]. S Sunder, Text book of rehabilitation. 2nd edition, New Delhi, Jaypee publication, 2002, page 351. [4]. Nakayama H, Jorgensen HS, Raaschou HO, Olson TS. Recovery of upper limb function in stroke patients: the Copenhagen stroke study. Arch Phys Med Rehabil. 1994;75:394398. [5]. Dromerick AW, Lang CE, Birkenmeier R, Hahn MG, Sahrmann SA, Edwards DR. Relationship between upper-limb functional limitations and self-reported disability 3 months after stroke. J Rehabil Res Develop.2006; 43:401408. [6]. Nichols-Larsen DS, Clark PC, Zeringue A, Greenspan A, Blanton S. Factors influencing stroke survivors quality of life during subacute recovery. Stroke. 2005;36:14801484. [7]. Taub E, Berman A. Movement and learning in the absence of sensory feedback. In: Freedman S, ed. The neuropsychology of spatialy oriented behavior. Homewood: Dorsey Press; 1968, p. 173192. [8]. Taub E, Miller NE, Novack TA, Cook EW, 3rd, Fleming WC,Nepomuceno CS, et al. Technique to improve chronic motor decit after stroke. Arch Phys Med Rehabil 1993; 74: 347354. [9]. Jean-Marie Andre, Jean-Pierre Didier, and Jean Paysant. FUNCTIONAL MOTOR AMNESIA IN STROKE (1904) AND LEARNED NON-USE PHENOMENON (1966); J Rehabil Med 2004; 36: 138140. [10]. Barreca S,Wolf sl, Fasoli S,Bohannon R. Treatment interventions for the paretic upper limb of stroke survivors: A critical review. Neurorehabil Neural Repair.2003Dec;17(4):220-6. [11]. Schweighofer N, Choi Y,Winstein c. Task-oriented rehabilitation robotics. Am J Phys Med Rehbil. 2012 Nov;91(11 suppl 3):s270-9. [12]. Vander weel,FR,et al (1991). Effect of task on movement control in cerebral plasy: Implications for assessment and therapy. Dev Med child Neurol,33,419-426. [13]. Van vliet p, Kerwin DG, Sheridan M et al.(1995). The influence of goals on the kinemetics of reaching following stroke. Neurol Rep,19,11-16. [14]. A sanuma H, Kellera(1991) Neuronal mechanisms of motor learning in mammals. Neuro report,2,217-224. [15]. Byl N : The neural consequences of repetition, Neural Rep 24:60-70,2000.

CORRESPONDING AUTHOR:

*MPT (Neurology), MIAP, College of physiotherapy, SVIMS, Tirupati, India. Email :tummalaharsha@gmail.com ** MPT (Neuro), Ph.D., Assistant professor, college of physiotherapy, SVIMS, Tirupati. *** MPT (CT), Ph.D., Professor, principal, college of physiotherapy, SVIMS.

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EFFECTIVENESS OF CORE STRENGTHENING EXERCISES TO REDUCE INCIDENCE OF SIDE STRAIN INJURY IN MEDIUM PACE BOWLERS
Omkar P.Padhye*, Subin Solomen**, Pravin Aaroon***

ABSTRACT BACKGROUND: Sports injuries are injuries that happen when playing sports or exercising. Some are from accidents. A side strain refers to a tear of the internal oblique the external oblique, or the Transversalis fascia at the point where they attach to the four bottom rib. In cricket prevalence of side strain injury in bowlers is 21% in bowlers 5% and overall 9% of total injury in cricket. Management of side strain takes lengthy procedure so players may lose game so prevention is better than cure. Study done by Tymothy et al. stated that muscle strengthening program can reduce incidence of injury Hence in this study we have discussed about preseason core muscle strengthening can reduce the chances of incidence of side strain injury in medium pace bowlers. OBJECTIVES: 1) To calculate the pre-season risk of side strain injury in medium pace bowlers.2) To measure the effectiveness of core strengthening muscles to reduce incidence of side strain injury.3) To calculate changes in plank score measurement in medium pace bowlers before and after intervention.4) To assess severity of side strain injury using electrotherapeutic measurements. METHODS: Longitudinal study.30 male medium pace bowlers from Goregaon sports club, Prabodhan sports club, Payyade sports club selected for study. Pre and post plank score taken. Follow up done by phone call. INTERVENTION: Core muscle strengthening exercise will be given to players for 6 weeks. On first visit core strengthening exercise will be taught to all players, they will be observed for 6 weeks and follow up taken. RESULTS: In the study group descriptive statistical analysis is used, statistically it was found that there were significant increase in Prone hold test score(Plank test score) (pre intervention plank score 2.000.00) , ( post intervention plank score 2.930.64), P value(< .0001). Mean incidence were calculated by new injury per 1000 hrs. of participation time there were 3% of wrist injuries,10% ankle, 3% groin,14%
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hamstring 7% low back,3% shin splint, 13% shoulder,10% side strain and 37% no injuries. INTERPRETATION & CONCLUSION: As compare to other common sports injuries like incidence of Shoulder injury (33.33/1000hrs), incidence of Hamstring injury (33.33/1000hrs) incidence of side strain injury (25.00/1000hrs) is less, so it proves that core muscle strengthening exercise is effective to reduce incidence of side strain injury. Thus, Core muscle strengthening exercises can be given to medium pace bowlers to reduce incidence of side strain injury. KEYWORDS: Side strain, Prevalence of side strain injury, prone hold test, Sports injuries, Severity of side strain.

INTRODUCTION

second highest seasonal incidence and fourth Almost half of all injuries to adult cricketers occur during formal play. One third of cricket injuries to children occur during school hours reflecting the popularity of cricket as a school sport, almost 20% of injuries occur during training or practice.1, 2 To prevent injuries in cricket, the Australian cricket board SPOT program advocates the screening of young bowlers for risk factors, including postural stature,
2

highest prevalence of all body areas5. A side strain refers to a tear of the internal oblique the external oblique, or the Transversalis fascia at the point where they attach to the four bottom rib6. All side strain injuries to bowlers described within the literature affect the side opposite to the bowling arm, with all but one injury affecting internal oblique (IO) or external oblique (EO)7. In cricket the bowlers suffer the Side Strain7,8, on the nonbowling arm side as a result of a forcible contraction of the muscle on that side while they are fully stretched as the bowling arm is cocked for bowling. It has been postulated that the probable point of internal oblique rupture in side strain injuries in cricket bowlers is the sudden vigorous motion from assumed maximum eccentric contraction when the non-bowling arm is fully flexed and then suddenly extends or pulls through, allowing the
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physical

preparation, avoidance of over bowling, and use of correct bowling techniques. There are various different physical demands involved in different types of cricket, which has meant the injury profile is slightly different between five day test matches, 3 day matches, one day matches, and twenty-20 matches. There are 5 common cricket injuries hamstring strain, low back pain, side strain, shoulder pain, and sprained ankle3. Side strain is fairly common in cricket, where it typically occurs in bowlers.4 Cricket injury surveillance research in Australian first class cricket has reported that side and abdominal strains account for the

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

bowling shoulder to flex to bowl the ball. The fast bowling technique is

more active rehabilitation can be started under the supervision of

physiotherapist, once the immediate pain resolves. So if the strength of the muscle is less then muscle is more prone for strain injury10. Hence be classified into four distinct styles: (son)side-on, (sop)semi-open,

(fo)front-on or mixed, according to their relationship between the planes of the hips and shoulders, and shoulder counter-rotation during the bowling action8. Investigations of side strain in cricket bowlers using MRI found that the injury consistently occurred on the non-bowling side and tended to affect abdominal muscles internal oblique muscle rather than the external oblique muscle, this could suggest that the asymmetrical muscular demands of the repetitive bowling action creates

strengthening

exercises

can

incorporated to prevent sports injuries like side strain injury. Core

strengthening exercises can be done on an exercise mat using swiss ball and resistance band which includes core activation exercises, mat exercises, simple exercise and the Pilates10. Compare to other sports injuries side strain injuries are not recurrent if treated11. Timothy et al did study to examine whether players classified as at risk participate in an intervention program could reduce the incidence of adductor muscle strain. The author concluded

hypertrophy in the torque producing muscles of trunk rotation and side flexion.2 Side strain injury is very common in cricket players and javelin throwers8, in cricket prevalence of side strain injury in bowlers is 21% in bowlers 5% and overall 9% of total injury in cricket8. All side strain injuries

that a preseason strengthening exercise to adductor muscle group appears to be an effective method for preventing adductor strain in professional Ice Hockey players, similarly it is not known that whether a preseason core strengthening exercises can reduce the risk of incidence of side strain injury in medium pace bowlers who are at risk12. Management of side strain takes lengthy procedure so players may lose
43

required some kind of treatment which is aimed at pain relief and restore mobility and strength9. Management of side strain is ice application for twenty minutes every two hours, application of cohesive compression bandage to help to limit bleeding in the tissue,

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game so prevention is better than cure.9Hence, if the strength of muscle is increased, it can increase performance of the individual.12So greater the performance more the chance of winning the game and increase in ranking level. METHODOLOGY Study design: Descriptive longitudinal study Setting and Participants: 30 male medium pace bowlers from prabodhan sports club, payyade sports club, cricket clubs.Medium pace bowlers with core muscle strength average (i.e. Grade 2) on plank score, Age group of 18 to 24, with bowling action front on were included.Previous history of lateral trunk pain or low back pain or side trunk injuries, previous history of chest pain due to cardio, respiratory disorders were excluded. Intervention Procedure: The plank test was described as follows. The player lied in prone position on mat or couch. Watch was being positioned on the ground where the player and therapist can easily see it. Player assumed the basic press up position (elbow on the ground) and holded that position for 60 seconds. Player lifted his right arm off the ground and holded that position for 15 seconds and take it return to the ground after 15 seconds. Player lifted his left arm off the ground and holded that position for 15 seconds and take it return to the ground after

15 seconds. Player lifted his right leg off the ground and holded that position for 15 seconds and take it return to ground after 15 seconds. Player lifted his left leg off the ground and holded that position for 15 seconds. Player lifted his left leg & right arm off the ground and holded that position for 15 seconds and take it return to the ground after 15 seconds. Player lifted his right leg & left arm off the ground and holded that position for 15 seconds and take it return to basic up position (elbows on the ground) and hold that position for 30 second. Grading was done according to scoring as mentioned in table below. Grades: Time Under 20 seconds 21-45 seconds 46-70 seconds 71+seconds Grades Poor Average Good Scores 1 2 3

Excellent 4

Core muscle strengthening exercise22 was given to players for 6 weeks. On first visit core strengthening exercise was taught to all players, they were observed for 6 weeks. During exercise sessions, coaches or

physiotherapist were educated about side strain injury, which includes concept of side strain injury, its symptoms, diagnostic tests and its management. After one season (20
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Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

matches) matches, number of incidence of side strain injury was collected from coaches or physiotherapist then severity of side strain injury was assessed by Sonography or Magnetic resonance imaging and was

OUTCOME MEASURES Number and percentage of incidence of side strain injury among medium pace bowlers after one season. Number and percentage of players who are at risk of side strain injury Plank scores in all players before and after one season. DATA ANALYSIS Data analysis was performed by SPSS (version 17). Alpha value was set as 0.05. Effectiveness of core strengthening exercise was assessed by number and percentage of incidence of side strain injury. Injury

confirmed by Orthopaedic. Data was collected in form of number and percentage of incidence of side strain injury after one season.

incidence was calculated by new injury per 1000 hrs. of participation time. Wilcoxon signed rank sum test was used to find out pre post difference within the group for plank score (ordinal scale) for assessing core muscle strength. RESULTS Study Design: A study was undertaken to measure effectiveness of core strengthening muscle exercise to reduce incidence of side strain injury.

Table 1: Descriptive statistics for demographic & outcome variables


45

Variables Age Height Weight BMI Pre Plank Score

Range 6.00 19.0 34.00 14.30 3.00

Minimum 18.0 165.00 59.00 19.90 1.00

Maximum 24.00 184.00 93.00 34.20 4.00

Mean 20.73 171.68 70.03 23.79 2.70

Std. Deviation 2.04 4.66 7.22 2.64 0.74

In the study group the range of age is 6, minimum 18.00yrs. and maximum 24.00yrs. with mean 20.73yrs and std. deviation of 2.04. In the study group the range of height is 19 with minimum height 165cm and maximum height 184cm with the mean of 171.68cm and std. deviation of 4.66. In the study group range of weight is 34.00 with minimum weight of 59.00kg and maximum weight of 93.00kg with mean of 70.03kg and std. deviation 7.22. In the study group the range of BMI is 14.30 with minimum BMI 19.90 and maximum BMI 34.20 with mean of 23.79 and std. deviation of 2.74 In the study group the range of Plank score is 3 with minimum plank score as 1and maximum as 4 with mean of 2.70 and std. deviation 0.74. Graph: Preseason risk of injury in bowlers This graph explains about preseason risk medium pace bowlers. In the study group 88% of medium pace bowlers are considered as at risk of injury before season and 12% were having no preseason risk of injury. Graph : Side strain injury in 30 medium pace bowlers

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Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

This graph explains about presence of side strain injury in medium pace bowlers. In the study group 90% of medium pace bowlers have not shown side strain injury after one season but 10% of medium pace bowlers have shown side strain injury after one season(one season = 20 matches). Graph: Percentage of injuries in medium pace bowlers

This graph explains about percentage of total injuries in the study group it was 1( 3%) of wrist injuries,3 (10%) ankle,1(3)% 7%) low 4(13%)

groin,4(14%) back,1(3%)

hamstring,2( shin splint,

shoulder,3(10%) side strain and11( 37%) no injuries. Table 2: Pre- post data within groups Variable Plank score Pre 2.000.00 post 2.930.64 value < .0001

Data are mean SD in study Plank score is improved from pre mean score of 2.00with Sd. of 0.00 to post mean score 2.93 with Sd.of 0.64 and which was statistically significant.( p < 0.0001 ). DISCUSSION Objective of the present study was to calculate the pre-season risk of side strain injury in medium pace bowlers. Second objective was to measure the effectiveness of core muscle strengthening to reduce the incidence of side
47

strain injury. Third objective was to calculate changes in plank score measurement in medium pace bowlers before and after intervention. & fourth objective was to assess the severity of side strain injury using electrotherapeutic measurements.

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30 male medium pace bowlers were chosen for present study. Demographic variables included were age, weight, height, BMI. In the present study players with age group 18-24 who were highly susceptible for side strain injury was taken. This was in accordance with study done by HaronObaid et al. Author did a study on sonographic appearance of side strain injury and author stated that there were nine men, one woman who showed side strain injury of mean age, 22 years; range, 1630 years it concludes that this age group is highly susceptible for side strain injury. In the present study 21 right arm medium pace bowlers and 9 Left arm medium pace bowlers who fulfilled inclusion criteria and who were having plank score Grade-2 (poor core muscle strength) who were at risk of side strain injury because of muscle weakness were chosen. This was in accordance with study done by HaronObaid et al. Author did a study on sonographic appearance of side strain injury and author stated that 8 bowlers have got strain side injury out of which 7 were right arm bowlers and one was left arm bowler, so it concludes that incidence of side strain injury was more to right arm bowlers than left arm. In this study there were 88% out of 30 medium pace bowlers showed risk of injury. This was in accordance with study done by R. A. Stretch et al. Author stated that injuries tend to occur during specific stages of the season, with the many preseason matches and the concentration of matches toward the end of
48

the season tending to result in an increase in injuries at those times Fast bowlers are at the greatest risk of injury for a variety of reasons, including the demands that fast bowling places on the musculoskeletal system, incorrect technique, poor preparation and training, and overuse. In this study there were 3 side strain injury (10%) observed after one season( 20 matches) out of which one was left arm medium pace bowler 33% and two were right arm medium pace bowlers 67%. Number of games missed by injured bowlers is 7, 6 & 5 respectively. This was in accordance with study done by HaronObaid et al. Author stated in the study of sonographic appearance of side strain injury that 8 bowlers have got side strain injury out of which 7 were right arm bowlers and one was left arm bowler. So present study concludes incidence of side strain injury were more in right arm bowlers than left am medium pace bowlers. In the present study, 3 (10%) out of 30 medium pace bowlers have got side strain injury after one season (20 matches), and 23 (90%) showed other injuries or no injury. As bowlers perform high velocity combination of sudden eccentric contraction when they bowl, there are high chances of getting Side stain injury. This was in accordance with study done by Haronobaid et al. Author stated that Side strain is thought to occur as a consequence of a combination of sudden eccentric contraction of the internal oblique

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

muscle that results in muscle tear. Also side strain injury can occur due to Side due to (plank score Grade-2) poor muscle strength which is one of the causative factor for injury. This was in accordance with study done by Timothy et al. Author stated in preseason risk study that poor muscle strength may cause stain of abductor muscles. In the present study, there were 3% of wrist injuries,10% ankle, 3% groin,14% hamstring, 7% low back,3% shin splint, 13%

Mean incidence was calculated by new injury per 1000 hrs. of participation time.

Calculations were given by Foundation in sports marketing. Out of 30 medium pace bowlers there were 4 hamstring injury (33.33 mean incidence value) 1 wrist and forearm injury (8.33 mean incidence), 3 side strain injuries (25.00 incidence), 4 shoulder injuries (33.33 mean incidence), 3 ankle injuries (25.00 mean incidence), 1 groin injury (8.33 mean incidence), 2 low back injuries (16.66 mean incidence), and 1 shin injury (8.33

shoulder,10% side strain and 37% no injuries. This was in accordance with study published by National Institute of Arthritis and

mean incidence). 11 players did not show any injury after one season (20 matches). Total numbers of hours played by 30 medium pace bowlers were 3276 hours. Total numbers of hours were calculated by the product of number of matches played by individual player and number of hours played by individual. (e.g. 17 matches * 6 hours = 102 hours) and sum of all hours were calculated.

Musculoskeletal and Skin Diseases. NIAMS updated that there are some most common sports injuries are: Sprains and strains Knee injuries swollen muscles Achilles tendon injuries Pain along the shin bone Fractures Dislocations. In the present study, Plank test was used to measure strength of core muscles. This was in accordance with study done by Janine Gray and Rene Naylor. Author have used plank test for musculoskeletal assessment for to test strength of core muscles. The test is used to determine the relative strength of the global stabilizers of the body namely the transverses abdominus, internal and external obliques, and scapula stabilizers. When compared with in group it was found that there were significant increase in plank score from a pre mean plank score of 2.00 to post mean plank score 2.93 which was statistically significant.
49

Total numbers of games played by 30 players were 546and total games missed by 30 players were 54. In the present study it was considered one season = 20 matches so total number of games played were calculated by product of total number games played by 30 players and 20 matches (one season) and total number of games missed by player were calculated by subtracting total number of games missed by 30 players from the total number of games played which was considered for 20 matches i.e. one season.

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In the present study, MRI technique is used to measure severity of side strain injury. This was in accordance with study done by Kathleen shorter et al. Author stated that a high percentage of type II or fast twitch fibers may also be a predisposing factor to tearing. MRI appears to be a sensitive test for evaluating side strain injury, showing an abnormality in all patients who had a clinical suspicion of a muscular tear and also to assess the severity of injury. It is postulated that the mechanism of injury for internal oblique muscle strain is sudden eccentric contracture with rupture of muscle fibers. Movements associated with medium pace bowling, which is then subjected to superimposed eccentric contraction, making it vulnerable to rupture. Present study describes an effective strategy for injury prevention, by core muscle strengthening exercises program before season in medium pace bowlers to reduce incidence of side strain injury. LIMITATIONS Inability to monitor players exercise

Involvement of side in terms of dominance is not considered which might have influenced the study. Lack of control group.

RECOMMENDATIONS Further studies can be done by comparing core muscle strengthening exercise with other pre-season

prevention protocols. Study can be done to see how much incidence of side train injury is reduced when compared to a preseason when there is no intervention given Further studies can be done to find its effectiveness in fast bowler, batsmen & other sports like javelin throw hockey, tennis, badminton etc.

CONCLUSION

Objective of present study was to calculate the pre-season risk of side strain injury in medium pace bowlers. Second objective was to measure the effectiveness of core

compliance(daily

strengthening muscles to reduce incidence of side strain injury. Third objective was to calculate changes in plank score measurement in medium pace bowlers before and after intervention. & fourth objective was to assess severity of side strain injury using

performance) with the home exercise program which might have influenced the study. The study was done with small sample size. Long term effects of the treatment were not assessed.

electrotherapeutic measurements. As there was a significant improvement in pre and post plank score (prone hold test) with in group. And significant improvement in core muscle
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Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

strength. Incidence of side strain injury as compare to other common cricket injuries were less. Hence null hypothesis was rejected. The study concludes exercises as are Core muscle in

reducing the incidence of side stain injury in medium pace bowlers. Thus, Core muscle strengthening exercises can be given to medium pace bowlers to reduce incidence of side strain injury.

strengthening

effective

REFERENCES
1. U.S. Department of health and human sciences public health service. Sports injuries National Institute of Arthritis and Musculoskeletal and Skin Diseases June 2009; 1-6. 2. McGrath A, Finch C. Bowling cricket injuries over: A review of the literature, Monash University Accident Research Centre. Report No 105 November 1996; 9-18. 3. Laura and Stuart. Sports Injury(prevention in sports) Research Journals available from URL http://www.physioroom.com/research/journals.php 2011;1-3 4. Shorter K, Nealon A, Smith N and Lauder M. Cricket side strain Injuries, A description of trunk muscle activity and the potential influence of bowling technique Portuguese Journal of Sport Sciences 2011 ;11 (Suppl. 2):1-3. 5. 6. Orchard J, James T.Cricket Australia Injury Report October 2003 Official Report, Version 3.2:15-17. David A. Connell, Jhamb A, James T.Side Strain A Tear of Internal Oblique Musculature.AJR June2003; 181:15111517. 7. Krishna A. Cricket injury report. Barkisland cricket club Jameka West indies 2005 available on URL http://www.ckcricketheritage.org; 1:1-7. 8. James T, Orchard J. Summary and analysis of injuries occurring in Australian cricket board (ACB Injury Report). Australian journal of sports medicine October 10 2002; Version 4.0:12-18. 9. Humphries M, Jamison J.Clinical and magnetic resonance imaging features of cricket bowlers side strain. bjsportmed 2004;38.21: 1-3. 10. Orchard, T James, Alcott E, Carter S, Farhart P. Injuries in Australian cricket at first class level1995/1996 to 2000/2001. Br J Sports Med 2002;36:270275 11. Orchard J, James T.Cricket Australia Injury Report, Australian journal of sports medicine October 2003; Version 3:2-7. 12. Timothy F. Tyler, Stephen J. Nicolas, Richard J.Campbel. The effectiveness of preseason exercise program to prevent adductor muscle strain in professional ice hockey players.American journal of sports medicine 2002, 30. 5:681-83. 13. Mcdonald Da, DelgadilloJq, Fredericson M, Mcconnell J, Hodgins M, BesierTf. Reliability And Accuracy Of A Video Analysis Protocol To Assess Core Ability. Howard Hughes Medical Institue Science Education March 2011; Volume 3, Issue 3: 204-211 14. Shorter K, Nealon A, Smith N, Lauder M. Cricket side strain Injuries, A description of trunk muscle activity and the potential influence of bowling technique Portuguese Journal of Sport Sciences 2011 ;11 (Suppl. 2):1-3. 15. Dendas A M. The relationship between core stability and athletic performance. Humboldt State University August 2010;1:30-56

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16. Obaid H, Nealon A, Connell D. Sonographic Appearance of Side Strain Injury.AJR December 2008; 191:264 267. 17. Jerrold S. Petrofsky, Eric G. Johnson, Hanson A, Cuneo M, Dial R, Somers R, et al. Abdominal and Lower Back Training for People with Disabilities Using a 6 Second Abs Machine, Effect on Core Muscle Stability.The Journal of Applied Research 2005; 5. 2: 345-351. 18. David A. Connell, JhambA , James T. Side Strain A Tear of Internal Oblique Musculature.AJR June2003; 181:15111517. 19. Stretch R A. Cricket injuries: a longitudinal study of the nature of injuries to South African cricketers. British Journal of sports medicine 2003; 37:250-253. 20. Orchard J, Marsden J, Lord S. Preseason hamstring weakness associated with hamstring muscle injury in Australian footballers Am J Sports Med Jan1997;25:81-85 21. Hagen JS, Nemeth G, Eriksson E. Hamstring injuries in sprinters: the role of concentric and eccentric hamstring muscle strength and flexibility. A J Sports Med. March1994;22:262-265. 22. Howell J, DC Strengthening the Core Muscles core training and athletic performances. Available from URL. www.johnhowelldc.com;1:1-7. 23. Dr. Rebecca Denniss Evidence-based injury prevention for repetitive microtrauma injuries: The cricket example. School of Human Movement and Sport Sciences University of Ballarat. Available from URL www.rdemmispfarhrt.com 24. Janine Gray, Rene Naylor MUSCULOSKELETAL ASSESSMENT FORM. 2009. Available from URL. www.booksmart.com ;1: 26 25. Anderson M.K. Foundations of Athletic Training: Prevention, Assessment, and Management. 4th Ed. Chapter 6 Foundations in sports therapy. 26. Rebecca J Dennis, Caroline F Finch, Andrew S McIntosh, Bruce C Elliott. Using field-based tests to identify risk factors for injury to fast bowlers in cricket. Br J Sports Med2008 ;10: 3, 7, 9, 16.

CORRESPONDING AUTHOR: Email: padhye_omkar@rediffmail.com

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A COMPARATIVE STUDY OF STANDING BALANCEPERFORMANCE BETWEEN OA KNEE PATIENTS COMPARED WITH NORMAL AGE MATCHED CONTROLS
Alagappan Thiyagarajan.T MPT (Sports)*, DY, PGDFWM; Prem Karthik .GS MPT (Ortho)

ABSTRACT OBJECTIVE: To find out the standing balance performance among osteoarthritis of knee patients compared with normal age matched controls STUDY DESIGN: Descriptive study. SAMPLING TECHNIQUE: Non Probability convenient sampling. SETTING: Department of physiotherapy, Pallava Hospital, Chennai. SUBJECT: 20 osteoarthritis patients and 20 normal were taken for this study. METHOD: To assess the balance performance functional research test were administered to both osteoarthritis patients and control groups. RESULTS: Functional reach test score value, which is higher for control group compared with osteoarthritis patients. CONCLUSION: The results suggests that osteoarthritis of knee patients having significant loss of (proprioception) balance performance compared with normal age matched controls

INTRODUCTION

apophyseal joints. It is characterized by the is a heterogeneous focal areas of damage to the cartilage surfaces of the synovial joints and is associated with remodelling of the underlying bone and mild synovitis1.
Osteoarthritis is one of the most

Osteoarthritis

condition for which the prevalence, risk factors, clinical manifestation, and prognosis vary according to the joints affected. It most commonly affects knee, hips, hand and spinal

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prevalent

musculoskeletal

complaints

knee patients compared with normal age matched controls OSTEOARTHRITIS AN OVERVIEW CAUSES OF OSTEOARTHRITIS Over weight in the main cause Harmful stress upon the knee CLINICAL FEATURES Pain Muscle spasm Stiffness Loss of movement Muscle wasting and weakness Joint enlargement Deformity Crepitus Loss of function DURING ACTIVE INFLAMMATION Heat. Redness. Swelling. Pain. PAIN The onset is of low intensity and can be described as three types. 1. Pain on weight bearing, severe aching, due to stress on the synovial

worldwide. It is a major cause of impairment and disabling among the elderly. Individual with osteoarthritis of knee suffer progressive loss of function, displaying increasing dependency in

walking, stair climbing and other lower extremity tasks2.

Balance involving

is

complex

function

numerous

neuromuscular

mechanisms. Control of balance is dependent upon sensory input from the vestibular, visual, and somatosensory systems. Central

processing of this information results in coordinated neuromuscular response that

ensures the center of mass remains within the base of the support in situation when balance is disturbed3. Effective control of balance thus relives not only on account sensory input but also on timely response of strong muscles. Balance is an integral component of activities of daily living. Balance impairments are associated with an increased risk of falls and poorer mobility in the elderly population3. Most of our clinical practice while treating osteoarthritis patients we use to concentrated to relieve pain and swelling and increase the muscle power and so on. But nobody performance. concentrated The
4,5,6,7

membrane and later due to the bone surfaces, which are rich in nerve endings, coming into contact. 2. During and after exercise there is pain described as being around the joint. 3. AT night especially after a very active day there is severe aching. NATURE OF PAIN 1. Aching is dominant, at first

on

balance are

recent

literatures

suggests that osteoarthritis patients having significance loss of proprioception that leads to imbalance. So, this study helps to find out balance performance among osteoarthritis of
54

fleeting and then becoming more constant.

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

2.

Referred pain is described as passing down a limb distally from the affected joint.

eburnated

bone

ends

grate

with

characteristic sound on movement. LOSS OF FUNCTION Pain, muscle,

3.

Sharp stabbing pain is associated with a loose body becoming impacted in the joint.

weakness, giving way lead to inability to use the limb normally and can be severely disabling. CLINICAL FEATURES RELATING TO KNEE JOINTPain is described as round and through the joint. And may be referred up the anterior aspect of the tight or down to the ankle. Muscle spasm may be present in the hamstring muscles. Deformity from prolonged hamstring spasm is flexion and there is deformation of the tibia with valgus

MUSCLE SPASM This occurs over one aspect of the joint and is initially protective but where it remains beyond the acute episode it must be treated to prevent contractures. STIFFNESS This is present after rest and takes a little time to wear off with movement. It may be due to loss of joint lubrication, chronic oedema in the periarticular structures or swelling of the articular cartilage. LOSS OF JOINT MOVEMENTThis is different from stiffness because it does not wear off. It may be permanent where there is articular cartilage destruction but will respond to physiotherapy where it is due to muscle spasm or soft-tissue contracture. MUSCLE WASTING AND WEAKNESS Muscle become weak often on the aspect of the joint which is opposite to contracures. (E.g. his extensors). JOINT ENLARGEMENT Chronic oedema of the synovial membrane and capsule together with muscle wasting makes the joint appear large. DEFORMITY Each joint tends to adopt a characteristic deformity. CREPITUS The flaked cartilage and

deformity. The joint is enlarged and there is quadriceps atrophy especially vastus medialis. There is a limp due to pain and a tendency for the joint to give way especially during stepping down. PATHOLOGY This will be considered in relation to each joint structure as follows: 1. 2. 3. 4. 5. 6. Articular Cartilage Bone Synovial membrane Capsule Ligaments Muscles

1. ARTICULAR CARTILAGE Erosion occurs, often central and frequently in the weight- bearing areas. Cartilage is usually the first structure to be affected. Fibrillation which cause softening, splitting and fragmentation of the cartilage occurs in both weight bearing and non weight bearing areas.

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Collagen fibres split and there is disorganization of the proteoglycan- collagen relationship such that water is attracted into the cartilage which causes further softening and flaking flakes of cartilage break off and may be impacted between the join surfaces causing locking and inflammation.

aspect of the joint become contracted or elongated. 5. CAPSULE This undergoes fibrous

degeneration and there are low grade chronic inflammatory changes. 6. MUSCLE These undergo atrophy which may be related to disuse because pain limits movement and function. Without adequate exercise the muscles may undergo fibrous

Proliferation occurs at the periphery of the cartilage. 2. BONEEburnation the bone

surfaces become hard and polished as there is loss of protection from the cartilage

atrophy.

METHODOLOGY Cystic cavities form in the subcondalar bone because eburnated bone is brittle and microfractures occur allowing the passage of synovial fluid into the bone tissue. There can also be venour congestion in the subchondral bone. Osteophytes form of the margin of articular surfaces where they may project in to the joint or into the capsule and ligaments. Bone of the weight bearing joints alters in shape- the femoral head becomes flat and mushroom shaped. The tibial condyles INCLUSION CRITERIA Age between (45-65years) Patient Body mass index (BMI) value between (25-30) Kg/m2 3. SYNOVIAL MEMBRANE and is This The patient who has diagnosed undergoes oedematour. hypertrophy Later there becomes fibrour SETTING - Department of Physiotherapy, A.C.S General Hospital, Chennai SAMPLE - 20 osteoarthritis Patients20 control Subjects SAMPLING TECHNIQUES Non STUDY DESIGN - The design of the study is Descriptive study.

probability convenient sampling

become flattened.

osteoarthritis of knee from orthopedic department of A.C.S. General

degeneration. Reduction of synovial fluid secretion results in loss of nutrition and lubrication of the articular cartilage. 4. LIGAMENTS This undergo the same changes as the capsule and according to the
56

Hospital, Chennai. EXCLUSION CRITERIA H/o injuries and multiple falls Uncorrected visual impairments

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

H/o stroke and cerebellar disorder H/o hospitalization in last two months EQUIPMENTS AND MATERIALS Inch tape Weight machine Wooden Scale METHOD: The functional reach test is developed as a quick screen for balance problems in older adults. For performing this test subjects stand with feet shoulder distance apart and with the arm raised to 90flexion without moving their feet, subjects reach as for forward as they can, while still maintaining their balance. The distance reached is measured and compared to age-related norms3. Twenty osteoarthritis knee patients and twenty normal subjects were participated in this study. To assess the balance performance the functional reach test is administered to both the groups. Before applying the test, the procedure was clearly explained to the patient. To perform the functional reach test subjects stand with feet shoulder distance apart and with the arm raised to 900 flexion without moving their feet, subjects reach as for forward as they can, while still Functional Reach Test By Patient

maintaining their balance. The measuring scale is placed on the wall. SAMPLE The sample consists of 20 Osteoarthritis, patients and 20 control subjects.
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TABLE -1 FUNCTIONAL REACH SCORES OF

MALE SUBJECTS (45-65 YRS)


OA KNEE 11.2 10.5 9.5 10.4 11 8.9 9.3 10.6 8.5 9.2 CONTROL 16.3 15.6 15.2 16 17 14.8 15.6 16.8 16.5 16.7

TABLE 2 (MALES) BETWEEN GROUP ANALYSIS USING PAIRED T-TEST FOR MALES

OA KNEE Mean 9.91

CONTROL Mean 16.05

SIGNIFICANT

(p <0.001) SD 0.9409 S.D 0.7337

Functional Reach Test By Patient

RESULTS:

Table 2 shows the value of mean and S.D functional reach test score between OA knee patients and control subjects. For OA patients mean value is 9.91 and standard deviation
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(S.D) 0.9409. For control subjects mean value 16.05 and S.D 0.7337. In order to find out the level of significance. I used paired T- test. The

results shows that level of significance p value <0.001.

BAR DIAGRAM

BETWEEN GROUP ANALYSIS USING PAIRED TTEST FOR MALES

20 15 10 5 0 OA (MALE)
TABLE 3 FUNCTIONAL REACH SCORES OF FEMALE SUBJECTS (45-65YRS) OA KNEE 9.3 8.5 9.4 10.5 CONTROL 14.6 13.3 12.6 14.5

CONTROL(MALE)

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8.9 9.2 10.1 9.5 8.5 10.2

13.3 14 14.2 12.5 13.9 14.5

FUNCTIONAL REACH TEST SCORES OF FEMALES(45 TO 65 YRS)


16 14 FRT SCORES 12 10 8 6 4 2 0 SUBJECTS OA CONTROL

TABLE 4 (FEMALES) BETWEEN GROUP ANALYSIS OF FEMALE USING PAIRED T-TEST

OA KNEE

CONTROL

SIGNIFICANT

Mean

9.4

Mean

13.74 (p <0.005)

SD

0.688

S.D

0.7763

RESULTS: Table 4 shows the value of mean and standard


60

deviation of functional reach test score between OA patients and control subjects. For

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

OA patients mean value 9.4 and SD 0.688. For control subjects mean value 13.74 and SD 0.7763. In order to find out the level of

significance I used paired t-test. The results shows that the level of significance p-value < 0.005.

BAR DIAGRAM
BETWEEN GROUP ANALYSIS OF FEMALE USING PAIRED T-TEST

15

10

0 OA KNEE CONTROL

DISCUSSION The aim of this study is to identify the standing balance performance between OA knee patients and age matched normal controls. Table -1 Shows that value of functional reach test score for male. The value of functional reach score which is high for control subjects compared with AO patients. Table 2 shows the value of mean and S.D functional reach test score between OA knee patients and control subjects. For OA patients mean value is 9.91 and standard deviation (S.D) 0.9409. For control subjects mean value

16.05 and S.D 0.7337. In order to find out the level of significance. I used paired T- test. The results shows that level of significance p value <0.001. Table 3 Shows that the value of functional reach test score for female. The value of functional reach test score which is high for control subjects compared with OA patients. Table 4 shows the value of mean and standard deviation of functional reach test score between OA patients and control subjects. for OA patients mean value 9.4 and SD 0.688. For control subjects mean value 13.74 and SD 0.7763. In order to find out the level of significance I used paired t-test. The results

61

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shows that the level of significance p-value < 0.005. KORALEWICZ12et-all 2000 concludes knee proprioception in middle aged and elderly persons with advanced knee arthritis are reduced in comparison with that in middle aged and elderly persons without arthritis. HASSON11et-all 2001 June concluded

Based on the results it is suggests that OA knee patients having significant loss of (Proprioception) compared with balance normal performance controls. While

comparing the functional reach test score value between male and female, male

obtaining more value than female. It suggests that female having more risk of imbalance than man. CONCLUSION To conclude from the results of this study osteoarthritis knee patients having significant loss of (Proprioception) balance performance compared with normal age match controls. RECOMMENDATION This study can be carried out large sample size. This study can be carried out different BM.

compared with age sex mateched controls, subjects with symptomatic knee osteoarthritis have quadriceps weakness reduced knee proprioception and increased postural way. PAI Y.C.6et-all 2005 concludes

proprioception declines with age and is further impaired in elderly patients with knee osteoarthritis contribute to poor proprioception impairment may in

functional

osteoarthritis.

REFRENCES
1. 2. 3. Tidys physiotherapy 4th Edition Page No. 107-109 Author TIDYS and THOMSON. Orthopaedics and Traumatology 6th Edition Author - NATARAJAN Motor control theory and practical applications Page No.208-209 Author ANNE SHUMWAY, MARJORIE WOOILACOTT 4. 5. 6. 7. Effects of kinaesthesia and balance exercises in knee osteoarthritis 2005 Dec., DIRACOGLU .D, AYDIN. R Effects of age and osteoarthritis on knee proprioception 12th Dec., 2005 PAI.Y.C Impaired proprioception and osteoarthritis 1997 May SHARMA .L, PAI.Y.C Is knee joint proprioception worse in the arthritic knee versus the unaffected knee in unilateral knee osteoarthritis 1997 August- HOLT KAMP .K, 8. RYMER WZ

Relationship of knee joint proprioception to pain and disability in individuals with knee osteoarthritis 2000KIM.L, BENNELL, RANA.S.

9.

Static postural sway, proprioception and maximal voluntary quadriceps contraction in patterns with knee osteoarthritis and normal control subjects, January 2001, HASSAN B.S. , MOCKETT.S

10. Effect of pain reduction on postural sway. Proprioception and quadriceps strength in subjects with knee osteoarthritis 2002 May- HASSAN B.S., DOHERTHY. S.A.
62

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

11. Influence of elastic bandage on knee pain. Proprioception and postural sway in subjects with knee osteoarthritis 2002- B. HASSAN, S. MOCKETT 12. Comparison of proprioception in arthritic and age matched normal knees 2000- KORALEWICZ L.M. ENGH. G.A. 13. The incidence and neutral history of knee osteoarthritis in the elderly- 1995, OCT., FILSON D.T. , ZHANQ.Y 14. Incidence and progression of osteoarthritis in women with unilateral knee disease in the general population the effect of obesity Sept., 1994- D.V. DOYLE, D.J. HART 15. Incidence and risk factor for radiographic knee osteoarthritis in middle aged women 22 May 2001- KIM.D. DEBORAH, J. HART. 16. The influence of pathology pain balance and self-efficacy on function in women with osteoarthritis of the knee Sept., 2004 A.L. HARRISON.

17. Strategies for enhancing proprioception and neuromuscular control of the knee 2002 Sep., - WILLIAMS AND
WILKINS.

CORRESPONDING AUTHOR:

* Department of physiotherapy Pallava hospitals

63

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THE EFFECTS OF BIT VERSUS MCIMT ON FUNCTIONAL PERFORMANCE OF UPPER EXTREMITY IN CHRONIC HEMIPARESIS
Dr. Bhatri Pratim Dowarah, MPT(Neurology)*

ABSTRACT Aim of the study was to evaluate the effectiveness of Bilateral Isokinematic training versus Modified Constraint Induced Movement therapy in improving the functional performance of the upper extremity in chronic hemiparetic subjects. METHOD: In mCIMT group, training was administered intensively for 2 hours per day for 6 days per week for 12 weeks with restraining of the unaffected upper extremity in sling and splint. In BIT group, 2 hour session containing 5 exercise each with minimum 5 trails of every task and maximum the patient can perform with BIT. SUBJECTS: The population of 30 patients was included in the study which was divided by random allocation into two groups. The features of each group was as mentioned under 15 minutes of therapy was spent on stretching and weight bearing exercises for normalization of muscle tone of the affected limb as needed in both the group. RESULTS: Subjects in mCIMT group Confirmed that they were largely using their affected limb for ADL following intervention with significant changes in MAL and ARAT score suggesting increased use of the affected limb, whereas subjects in the BIT group showed nominal MAL and ARAT changes and reported the pattern of use similar to those that they reported before intervention. KEY WORDS: Modified CIMT, BIT, MAL scale, ARAT scale

64

INTRODUCTION

Most patients who survive a stroke survivors experience experience persistent impairment of arm movement
10,11 .

Many

stroke

impairments such as hemiparesis, spasticity, sensory/perceptual disorders, hemianopia,


8.

It has been suggested that

constraint- induced movement therapy or less intensive variants of constraint-induced

dysphasia or cognitive impairments

Most

patients regain their walking ability, but between 30 and 60% are no longer able to use their more affected hand after 3-6 months
4,7,19

movement therapy (i.e. modified) may be used to overcome the learned non-use phenomenon and improve functional

. Only 11% to 18% of those sustaining a


7.

performance of the affected arm of stroke patients in the acute, subacute and chronic phases 13,17,18,25. Bilateral Isokinematic Training (BIT) is used for upper limb rehabilitation in stroke patients and is based on the theory that therapy for stroke patients needs to be directed at the central nervous system because it is the brain that is damaged by a stroke, not the muscles. Quite simply, BIT trains the stroke patient to use both hands in the same way, simultaneously but separately (bilateral = both sides, iso = equal/same, kinematic = same movement of both upper limbs simultaneously) 23. Need and Significance of the study: Functional recovery of the paretic upper extremity post stroke continues to be one of the greatest challenges faced by rehabilitation professionals. Although most patients regain

severe post stroke upper extremity paresis achieve full upper extremity function The

inability to reach, to grasp and to manipulate objects limits activities and causes particular difficulties to perform daily personal care. Perceived loss of arm function has been reported as a major problem in approximately 65% of patients with stroke Thus, there is a strong need to develop effective arm-hand treatment methods in stroke rehabilitation 4. Constraint-induced movement therapy

(CIMT), also known as forced use movement therapy, is a therapeutic approach to

rehabilitation of movement after stroke. The principal therapy involves constraining

movements of the less-affected arm with a sling for 90% of waking hours for the duration of therapy, while intensively training use of the more-affected arm. 3 Chronic lack of use of the upper extremity induced in monkey by unilateral sectioning of the dorsal cervical and upper thoracic spinal nerve roots could be reversed several months to years later with a physical restraint applied to the contralateral unaffected arm 21.
65

walking

ability,

30%66%

of

stroke

survivors fail to regain functional use of their arm and hand 10. The incorporation of bimanual movements into upper limb rehabilitation protocols, also

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it is considered that the BIT approach is in direct contrast to constraint- induced therapy as long as the implementation of the technique is considered 6.

week for 12 weeks with restraining of the unaffected upper extremity in sling and splint. 15 minutes of therapy was be spent on normalization of muscle tone of the affected

Hypothesis Experimental Hypothesis: There may be significant difference in the effectiveness between Movement Isokinematic Modified therapy Training Constraint and in Induced Bilateral improving

limb as needed by stretching and weight bearing exercises, patients unaffected hand and wrist was restrain with sling and splint every week days for 6 hours identified as a time of frequent arm use. 6 In BIT group, 2 hour session(training period matching to mCIMT group in duration) containing 5 exercise each with minimum 5 trails of every task and maximum the patient can perform with BIT (spatiotemporally identical movement performed bilaterally but with each limb independently).

functional performance of upper extremity in chronic hemiparesis. Null Hypothesis: There may not be any significant difference in the effectiveness between Movement Isokinematic Modified therapy Training constraint and in Induced Bilateral improving

functional performance of upper extremity in chronic hemiparesis.

Taub and Colleagues et al showed that chronic lack of use of the upper extremity induced in monkey by unilateral sectioning of the dorsal cervical and upper thoracic

Materials & Methodology: For the present comparative study a pre test and post test design was used. Population included chronic hemiparetic subjects.

spinal nerve roots could be reversed several months to years later with a physical restraint applied to the contralateral unaffected arm
2,21,22.

Subjects were assigned to two groups, Group A for mCIMT with 15 subjects and Group B for BIT with 15 subjects with equal probability In mCIMT group, training was administered intensively for 2 hours per day for 6 days per
66

Wolf and Colleagues et al conducted studies on chronically brain hemiparetic injury stroke and which

traumatic

patients

involved forced use, that is, restraint of the less affected arm with sling for 2 weeks while requiring the more affected arm to conduct routine daily living activities found

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

that speed of the task execution improved for most functional task for up to a year following intervention 20. CIMT and mCIMT involve restraint of the unaffected limb for an extended period and repeated task-specific training of the affected limb. Numerous studies in stroke patients have shown that CIMT/mCIMT can enhance performance of the affected UE during unilateral and bimanual functional tasks (e.g., flipping a light switch, putting on socks) assessed, for example, using the Motor Activity Log (MAL). During the unilateral task mCIMT produce a greater increase in the amount of preplanned control of reaching movement than did TR 6. Inter-rater and retest reliability have been shown to be high (ICC > 0.98) in studies involving patients with stroke 25 Concurrent validity has been confirmed by comparison with the upper limb component of the Fugl- Meyer Assessment and the In recent years the development of new rehabilitation therapies has demonstrated that significant progressions in movement ability are achievable in chronic stroke patients many months or even years after the initial event 6,9. Motor Activity Log scale is a structured interview during which subjects used a six point scale to rate how much and how well they use their hemiparetic limb to perform common functional activities 22. It appears to captureboth how well and how much patients use their more-impairedarm to accomplish ADL, and, therefore, might simply be namedthe Arm Use scale 14.
67

Action Research Arm Test (ARAT) is the valid and consistent scale for measuring recovery of arm-hand function in stroke patient. ARAT may reflect not only arm function but also upper extremity motor impairmrnt that represents the exteriorization of neurophysiological state due to

cerebrovascular diseases. The score of ARAT may also represent the degree of upper extremity impairment.

Motor Assessment Scale (MAS) 12,25.

Study settings All the patients were referred by consultant neurologist from the above mentioned

hospitals and clinics.

Research Design: It was a comparative study design, a sample of 30 subjects were included in the

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study with a pretest and post test study design. The subjects were selected by convenient sampling method based on an initial baseline assessment and diagnosis of their condition as per neurologist.

Patient with any congenital deformity of upper extremity like heterotrophic

ossification. Patients with any other neurological disability like any head trauma, dementia, learning disorder, schizophrenia, major depression before the stroke, epilepsy

Inclusion Criteria: Hemiparesis Age 45-75 years 19. Duration more than 1 year and less than 2 years Patient who can perform some active finger and wrist extension 6,11. Patient on MMSE( Mini Mental Scale Examination) more than 23/30 . Spasticity grading less than or equal to 2/5 on modified Ashworth Scale . Both gender to be included Both dominant and nondominant hemisphere lesion involvement patient will be equally included Considerable nonuse of the more affected limb (Amount of Use<2.5 on Motor activity log scale 20. Patients consent for participation. 30

brain tumor . Patients with visual impairment. Patient who had stroke more than once in the ipsilateral hemisphere or stroke in the contralateral hemisphere on imaging studies.

Population: The population of 30 patients was included in the study which was divided by random allocation into two groups. The features of each group was as mentioned under Sample Design: subjects with chronic hemiparesis

duration between 1-2 years and age group between 40-60 years were taken. The

definition of 'chronic' for the purposes of this study was defined as onset of stroke at least one year prior to the commencement of the treatment phase of this study 13,20,26. Time and Duration of the study:

Exclusion Criteria Duration of the study was 6 months & Data Patient who has any orthopaedic were collected within the period of 3 months. Protocol:
68

condition like post fracture stiffness or contractures of wrist and fingers.

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

The subjects underwent the standardized assessment technique based on an initial baseline assessment which also included patients cognitive assessment by MMSE scale and assessment of the tone of the upper limb by Modified Ashworth Scale and diagnosis neurologist. In mCIMT group, training was administered intensively for 2 hours per day for 6 days per week for 12 weeks with restraining of the unaffected upper extremity with sling and splint. In mCIMT, we concentrated on use of the affected limb during functional task chosen by patients and the treating therapist. It consisted of shaping which involved 1. Selecting functional tasks tailored to address the motor deficits of the affected hand. 2. Increasing the task difficulty in small steps when performance was improved. 15 minutes of therapy was spent on normalization of muscle tone of the affected limb as needed by stretching and weight bearing exercises, patients unaffected hand and wrist was placed in restrain every week days for 6 hours identified as frequent arm use 6. In BIT group, 2 hour session(training period matching to mCIMT group in duration) containing 5 exercise each with minimum 5 trails of every task and maximum the patient
69

can perform with BIT (spatiotemporally identical movement performed bilaterally but with each limb independently). Procedure: 15 minutes of therapy was spent on stretching and weight bearing exercises for normalization of muscle tone of the affected limb as needed in both the group. All the 15 patients of Group A were given restraint using sling and splint on the unaffected extremity for 6 hours identified as a time of frequent arm use. Training had taken place during regularly scheduled physical therapy session, and all other routine interdisciplinary stroke rehabilitation was as usual. Group program was given to the patients (with 3-4 patients in a group), for 2 hours per day
6

of

their

condition

as

per

Patients were seated on the

chair with harness tied around the trunk to prevent the trunk rotation and forward flexion (only if required) and a table in front of the patient 2cm below the elbow the level or standing with support provided by the assistant as necessary6. Training in Group B had also taken place during regularly scheduled physical therapy session, and all other routine interdisciplinary stroke rehabilitation was as usual. All 15 patients were seated on the chair with harness tied around the trunk to prevent the trunk rotation and forward flexion(only if required) and a table in front of the patient 2cm below the elbow the level or standing with support

time of

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provided by the assistant as necessary. Exercise in BIT included activities with both hands doing same task separately, but at the same time and same speed. Analysis and Interpretation The data obtained using ARAT, MAL(AOU) Within Table: Group analysis within Group A and Group B of ARAT scale
ARAT
45 40 35 30 25 20 15 10 5 0 Day 0 Day 45 Day 90

scale of this study are ordinal and not interval or ratio. Since this does not adequately fulfill the conditions for parametric tests; nonparametric test is applied here. The result shows a significant improvement in both the group getting both mCIMT and BIT. group
Outcome measures Day 0 Mean SD Day 45 Mean SD Day 90 Mean SD

analysis
Repetitive measures Z P

ARAT

Group A Group B

30.60 8.34 27.67 7.32

37.73 7.76 31.07 7.22

42.47 8.14 33.20 6.12

-2.90

.000

-3.86

.000

Within group analysis

MAL (AOU)
4 3.5 3 2.5 2 1.5 1 0.5 0 Day 0 Day 45 Day 90

Outcome measures

Day 0 Mean SD

Day 45 Mea n SD 2.40 .54 1 1.73 .56 3

Day 90 Mea n SD 3.37 .51 6 2.40 .47 1

Repetitive measures Z P

MAL (AOU)

Group A

1.47. 516

-2.90

.000

Group B

1.27. 594

-3.86

.000

Table: RESULT The

Group

analysis

within

Group

and

Group

of

MAL(AOU)

scale

on the functional performance of the upper extremity of hemiparetic stroke patient. study was undertaken to Data collected through the study showed more improvement in the hand function and
70

present

determine the effect of the mCIMT and BIT

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

functional

activities

in

patients

with

The study is done on an immediate basis i.e. the MAL scale was measured immediately on the use of mCIMT and BIT and no follow up was done. The lack of follow up has the drawback that sustained of this improvement and further progression value is not revealed. It is known that right sided hemiparesis usually have some perceptual disorder also which is not considered in the study, but

hemiparesis in the group A. Thus, it can be concluded that mCIMT is more beneficial in improving hand function for hemiparetic patients post stroke. There results showed that patients treated with mCIMT had their functional performance of affected upper extremity improved significantly more DISSCUSSION It has been recorded from the study that use of mCIMT and BIT produces significant

nevertheless can affect the outcome. CONCLUSION The present study showed a lasting effect of forced use therapy on the functional

improvement in functional performance of the upper extremity in patients with hemiparesis due to stroke. A positive effect was found on the subjective Amount of Use of the affected arm in ADL (measured by the MAL(AOU) scale)

performance of the affected arm, as measured by the ARA test in comparison to the Bilateral Isokinematic training. A positive effect was found on the subjective Amount of Use of the affected arm in ADL (measured by the MAL(AOU) scale)

especially in the patients with the learned nonuse.

especially in the patients with the learned nonuse. LIMITATIONS


REFERENCES
1. 2. 3. 4. Anna Tuke, Constraint Induced Movement Therapy: A Narrative Review; Physiotherapy 94 (2008) 105-114 Anne Shumway, M.H. Woollacott, Motor Control Theory and Practical Application, Page 521-523. Atena, Clinical policy BulletinNo.0665 Brogardh C and Sjlund BH (2006). Constraint induced movement therapy in patients with stroke: a pilot study on effects of small group training and of extended mitt use. Clin Rehabil (20) 218-227. 5. Ching-Lin Hsieh, I-Ping Hsueh, Fu-Mei Chiang, Po-HsinIN Lin: Interrater reliability and validity of the ARAT in stroke patients. Age and aging 1998; 27: 107-113. 6. Ching yi Wu, Keh Chung Lin, We-hsein Hong, Hsieh-ching Chen and I-hsuen Chen et al. Constraint Induced movement therapy on movement Kinematics and daily function in patient with stroke: Neurorehabilitation and neural repair 2(5);2007- Pg 460-465 7. Darcy Umpherd, Neurological Rehabilitation,Fourth Edition; page 797-798.
71

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

8.

Gresham GE, Duncan PW and Stason WB (1995). Post-stroke rehabilitation; Clinical practise guidline. Vol. 16 AHCPR.

9.

Gwyn Lewis N, Wiston D Byblow, Neurophysiological and behaviour adaptations to a bilateral training intervention following stroke. Clin rehab 2004;18,48.

10. Janet Carr, Roberta Shephard; Neurological Rehabilitation- Optimizing motor performance 143-144. 11. K-C Lin, Effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional performance after chronic stroke: a randomized controlled study; Clinical Rehabilitation 2007; 21: 10751086 12. Michelle McDonnell Action Research Arm Test; Australian Journal of Physiotherapy,2008, Vol.54 13. Miltner W, Bander H, Sommer M,et al. Effects of Constraint induced movement therapy on patient with chronic motor deficits ater stroke : A replication stroke. 1999; 30; 586-592 14. Mudie MH and Matyas T.A. (1996) Upper extremity retraining following stroke: Effects of bilateral practice. Journal of Neurologic Rehabilitation 10(3): 167-184. 15. Nadir Bharucha,Epidemiology of stroke in India; Neurol.J.Southeast Asia 1998,3:5-8 16. Nakayama H, Jorgensen HS, Raaschou HO and Olsen TS (1994). Recovery of upper extremity function in stroke patients: the Copenhagen strokestudy. Arch Phys Med Rehabil (75) 394-398. 17. Page SJ, Sisto S, Johnston MV, et al. Modified CIMT after subacute stroke: a preliminary study. Neurorehabil neural repair 2002; 16: 290-295. 18. Page Stefen J, Levin Peter, Modified CIMT in chronic stroke: result of a single blinded randomized controlled trial: Phy Therapy 2008; 88: 333-340. 19. Physical Rehabilitation, Edition 5, Susan B OSullivan. Thomas J Schmitz, 2007, page 706. 20. Taub E, Miller NE, Novack TA et al. Technique to improve motor deficits after stroke. Arch Phy Med. Rehab. 1993; 74: 347-59 21. Taub E. Some anatomical observation following chronic dorsal rhizotomy in monkeys Neuroscience 1980; 5:389-401. 22. Taub E. Technique to improve chronic motor deficit after stroke. Arch Phys Med rehaib 1993; 74: 347-354.

23. The Star Sunday May 15, 2005 Using your hands in a BIT 24. Uswatte G, Taub E, Morris D, Vignolo M, Mc Culloch K : Reliability and Validity of Upper Extremity motor activity log-14 for measuring real world arm use. Stroke 2005; 36 : 2493-6 25. Van Der Lee JH, Wagenaar RC, Lankhorsst GJ, et al. Forced use of upper extremity in chronic stroke patients. Stroke. 1999; 30: 2369-2375.

26. Wolf St, Lecrew DE, Barton LA, Jann BB. Forced use of hemiplegic upper extremities to reverse the effect of
learned nonuse among chronic stroke and head injured patients. Exp neurol 1989b; 104(2):

CORRESPONDING AUTHOR:

* PhD Scholar, Srimanta Sankardeva University of Health Sciences, Guwahati, Assam

72

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

RARE PRESENTATION OF TYPE 1 DIABETES MELLITUS AS DIABETIC KETOACIDOSIS COMPLICATING INTO ACUTE PANCREATITIS: A CASE REPORT
Srinivas Madoori, Kapil C, Mangath Bhukya, Sandeep Chilumoju

ABSTRACT Patients diagnosed to have Type 1 Diabetes Mellitus (T1DM) initially present with diabetic ketoacidosis (DKA) in 10-15% cases. Acute Pancreatitis (AP) as a complication is rare. AP is more likely associated with severe episode of DKA with marked acidosis and hypertriglycerdemia. We report a case of a 12 year old female child brought to the Emergency Department with features of DKA with severe hypertriglycerdemia and AP with no previous history of T1DM. Case was managed successfully with insulin therapy and adequate hydration. KEYWORDS: Type 1 Diabetes Mellitus, diabetic ketoacidosis, hypertriglyceridemia, acute pancreatitis.

INTRODUCTION

from adipose tissue and muscle respectively and increased counter regulatory hormones cause increased gluconeogenesis and glycogenolysis in the liver(5,6). Elevated FFA taken up by the liver leads to increased production of very low density lipoprotein

Acute pancreatitis coexisting with diabetic ketoacidosis (DKA) as a cause or result has been reported previously
(1-4)

. During severe

episodes of DKA, insulin deficiency increases free fatty acid (FFA) and amino acids release
73

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(VLDL)

cholesterol,

which

causes
(7-9)

vomiting and loose motions. Her development is appropriate for age. She was immunized according to national immunization schedule. She did not attain menarche till date. There were no similar complaints in the family. On admission child was determined to be 129 cms height (<3rd percentile, WHO growth charts), 20 kgs weight (<3rd percentile, WHO growth charts) with body mass index 20 with sexual maturity score 1. Child was drowsy with kussumaul acidotic breathing,

hypertriglyceridemia

Hypertriglyceridemia is an uncommon cause of acute pancreatitis accounting for 1 to 4% of cases, especially when the serum triglycerides (TG) levels exceed 1000 mg/dl. These transiently elevated levels of serum
(10)

triglycerides cause acute pancreatitis

Diabetic ketoacidosis is known to mask the clinical features of acute pancreatitis, with acute pancreatitis reported in 10 to 15% of patients
(9)

We report a case of Type 1

Diabetes mellitus first presenting with diabetic ketoacidosis and acute pancreatitis as a complication. CASE REPORT A 12 year old girl was brought to the emergency department with complaints of fever, pain abdomen for 1 day. Fever was high

Respiratory rate 44/min, pulse rate 126/min, blood pressure was 100/60 101
0

mm F. On

Hg

and

temperature

physical

examination she had sunken eyes, dry tongue and decreased skin turger without evidence of xanthoma, xanthelesma and eruptive

xanthomas. On abdomen examination, soft tender epigastrium with normal bowel sounds without any mass or skin discoloration. Lungs with equal air entry on both sides without any adventitious sounds. Pupils were equal in size and reacting to light on both sides without any focal neurological deficit. Blood sample collected for the laboratory workup had milky white appearance (Figure:1). Figure: Lipaemic sample Initial laboratory findings are hemoglobin 16.5 gm/dl, total leukocyte count 16000 cells / cumm, random blood sugar 398 mg/dl, Urinary ketone bodies 8 mmol/dl, total

grade, intermittent, without chills and rigors. Pain was in the epigastric region, squeezing type, non-radiating, not associated with
74

cholesterol 775 mg/dl, triglycerides 3000 mg/dl, LDL 148 mg/dl, HDL 27 mg/dl, serum sodium 141 meq/L, potassium 4.1 meq/L,

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

chloride 121 meq/L, Arterial blood gas (PH 6.985,pco2- 10.3 mm hg,Hco3-2.5 meq/liter and Sao2 98.4 %)), total serum proteins 5.3 gm/dL, serum albumin 3gm/dl, total serum bilirubin 0.8 mg/dl, alkalinephosphatase levels 60 IU/L, blood urea nitrogen 33mg/dL, serum creatinine 0.8 mg/dl, ,HBA1C levels are 10%,C-peptide(premeal) (normal 0.3 ng/ml 1.1

was given adequate hydration and started on intravenous soluble insulin.On the 2nd day of hospitalization, her sensorium improved,

respiratory rate came down to 22/min, random blood glucose was within normal limits, her epigastric pain persisted. Clinically there was tenderness, serum suspecting acute pancreatitis were

amylase and

lipase levels

estimated and CT imaging of abdomen was done. Laboratory analysis of serum amylase and lipase levels were elevated (Table 1).

4.4ng/ml,T32.015ng/ml,T4125.16ng/ml,TSH2 .08microlit/ml. With a provisional diagnosis of T1DM with DKA and hypertriglyceridemia with AP child

CT abdomen showed bulky pancreas which confirmed acute pancreatitis.

Table 1.Laboratory findings Parameters Total cholesterol (TC) Triglycerides (TG) High density lipoproteins (HDL) Lowdensity lipoproteins (LDL) Very low density lipo proteins Blood glucose Urinary ketone K+ Na+ ClHCO3PH Initial 775 3000 27 Day3 644 1800 29 Day4 ---------------------Day8 -----------------Day9 260 160 40

148

255

172

600

360

30

398 8 mmol 4.1 141 121 2.5 6.985

301 4 mmol 3.2 136 111 3.1 7.1


75

246 nil 3.9 134 96 16 7.35

180 ----4.2 138 105 ---------

178 ----4.3 142 109 -------

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Serum amylase Serum lipase Blood urea nitrogen Serum creatinine

482 750 19 0.6

------------------

------------25 0.9

-----------------

69 250 -------

On 3rd day of hospitalization TG levels were decreased to 1800 mg/dl (Table1) epigatric pain had diminished; patient commenced oral intake and multiple subcutaneous insulin. On 4
th

hypertriglyceridemia, which is defined as a TG level >2,000 mg/dL, is rare. Although morbidity is <1%, clinicians should be aware that devastating consequences such as acute pancreatitis or lipidemia retinalis are possible
(11)

day of hospitalization, all her symptoms subsided. repeat On 9th day of

completely

hospitalization,

laboratory

workup

In severe hypertriglyceridemia, there is an increased risk of developing acute pancreatitis. The mechanism is related to high plasma chylomicrons or TGs, which are hydrolyzed by lipase in the pancreatic capillaries and subsequently trigger FFA(12) release that, in turn, causes activation of trypsinogen and commences pancreatic capillary damage by free radical damage(13,14). The common

showed normal serum levels of triglycerides blood glucose, serum amylase and lipase (Table1). The child was discharged on 12th day of hospitalization. She was followed for two months for every 20 days with lipid profile, blood sugar levels and clinical examination. No similar episodes were noted and she maintained her blood glucose levels within normal limits with approximately 1U/Kg of insulin per day. DISCUSSION In DKA, the deficiency of insulin activates lipolysis in adipose tissue releasing increased FFA, which accelerates formation of VLDL in the liver. In addition, reduced activity of lipoprotein lipase in peripheral tissue

clinical scenario of hypertriglyceridemiainduced acute pancreatitis involves poorlycontrolled diabetes mellitus. In the two case reports by Sunil et al
(15)

, Suk Jae Hahn et

al(16), there was previous history of diabetes in cases presenting with diabetic ketoacidosis with hypertriglyceridemia and acute

pancreatitis. In our case report, the case presenting with diabetic ketoacidosis with hypertriglyceridemia and acute pancreatitis did not have previous history of diabetes mellitus. Moderate hyperlipidemia (usually <400 mg/dL) can be observed secondary to
76

decreases removal of VLDL from the plasma, resulting in hypertriglyceridemia. Moderate hypertriglyceridemia episodes of is common However, during severe DKA(10).

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

acute pancreatitis and should not be confused with the marked hypertriglyceridemia that causes acute pancreatitis(17) as in the present case. Serum levels of triglycerides 3000 mg/dl in present case report in a 12 yr old child causing acute pancreatitis is less as compared with the case report by Suk Jae Hahn et al(16) where triglyceride levels of 15240 mg/dl were seen in a 20 yr old female and more compared to serum levels of trigycerides of 1020 mg/dl of case report by Sunil et al(15). This shows increase in serum triglycerides level in diabetic ketoacidosis corelates with age. Nonspecific elevations of amylase and lipase without clinical evidence of pancreatitis have been reported in 24.7-79.0% of DKA cases
(18)

abdomen. In case reports by(1-4),diagnosis of acute pancreatitis was based solely in clinical features and associated elevations in serum pancreatic enzymes without any confirmatory imaging findings .In present case there was confirmatory CT findings in addition to clinical features and elevated serum pancreatic enzymes. In our case CT abdomen showing bulky pancreas indicative of acute pancreatitis. CONCLUSION Diabetic ketoacidosis can be the first

presentation of Type 1 diabetes mellitus. In every case of type 1 diabetes mellitus presenting as DKA, particularly if the

epigastric pain is not subsiding and vomiting continue, acute pancreatitis should be

suspected. In case of acute pancreatitis with hypertriglyceredemia line of management is conservatively with insulin and hydration therapy.

At least in those patients with continuous abdominal pain, it is prudent to seek further laboratory evaluation or a CT scan of the

REFERENCES
1. 2. 3. 4. Tully GT, Lowenthal JJ. The diabetic coma of acute pancreatitis. Ann InternMed 1958; 48: 310 9. Hughes PD. Diabetic acidosis with acute pancreatitis. Br J Surg. 1961; 49: 901. Davidson AJ. Diabetic coma without ketoacidosis in a patient with acutepancreatitis. Br Med J 1964; 1: 356. Maclean D, Murinson J, Griffiths PD. Acute pancreatitis and diabeticketoacidosis in accidental hypothermia, and hypothermic myxoedema. Br MedJ 1973; 4: 757 61. 5. Exton JH. Mechanisms of hormonal regulation of hepatic glucose metabolism.Diabetes Metab Rev 1987; 3: 163-83 6. Fortson MR, Freedman SN, Webster PD 3rd. Clinical assessment of hyperlipidemic Pancreatitis. Am J Gastroenterol 1995; 90: 2134-9. 7. Chiasson JL, Aris-Jilwan N, Belanger R, Bertrand S, Beauregard H, Ekoe JM, Fournier H, Havrankova 1. Kitabchi AE, Nyenwe EA. Hyperglycemic crises in diabetes mellitus: diabeticJ. Diagnosis and treatment of diabetic ketoacidosisand the hyperglycemic hyperosmolar state. CMAJ 2003; 168:859-66. 8. Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, MaloneJI, Wall BM. Hyperglycemic crises in diabetes. Diabetes Care 2004; 27Suppl 1: S94-102
77

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9.

Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis & acutepancreatitis: observations in 100 consecutive episodes of DKA. Am J Gastroenterol 2000; 95:2795 800.

10. Fulop M, Eder H. Severe hypertriglyceridemia in diabetic ketosis. Am JMed Sci 1990; 300: 361-5. 11. Fulop M, Eder HA. Plasma triglycerides and cholesterol in diabetic ketosis.Arch Intern Med 1989; 149: 1997-2002. 12. Havel RJ. Pathogenesis, differentiation and management of hypertriglyceridemia.Adv Intern Med 1969; 15: 117-54. 13. Havel RJ. Approach to the patient with hyperlipidemia. Med Clin NorthAm 1982; 66: 319-33. 14. Tsuang W, Navaneethan U, Ruiz L, Palascak JB, Gelrud A. Hypertriglyceridemicpancreatitis: presentation and management. Am J Gastroenterol2009; 104: 984-91. 15. Acute Pancreatitis in Association with Diabetic Ketoacidosis in a Newly Diagnosed Type 1 Diabetes Mellitus Patient; Case Based Review.International Journal of Clinical Cases and Investigations 2012. Volume 4 (Issue 1), 54:60, 1st April, 2012. 16. Severe Hypertriglyceridemia in Diabetic Ketoacidosis Accompanied by Acute Pancreatitis: Case Report DOI: 10.3346/jkms.2010.25.9.1375 J Korean Med Sci 2010; 25: 1375-1378. 17. Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA. Am J Gastroenterol 2000; 95: 2795- 800. 18. Yadav D, Nair S, Norkus EP, Pitchumoni CS. Nonspecific hyperamylasemiaand hyperlipasemia in diabetic ketoacidosis: incidence and correlationwith biochemical abnormalities. Am J Gastroenterol 2000; 95: 31238.

CORRESPONDING AUTHOR: Srinivas Madoori, MD (Pediatrics)Professor of Pediatrics, Department of Pediatrics, Chelmeda Anand Rao Institute of Medical Sciences,Bommakol, Karimnagar - 505001 9866535700, Email: madoorisrinivas@gmail.com Andra Pradesh, India.Mobile: 91

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Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

CASE REPORT VERY LARGE SUPPURATIVE PERICARDIAL EFFUSION CAUSED BY GROUP A HEMOLYTIC STREPTOCOCCUS: IN THE ANTIBIOTIC ERA.
Dr. J. Rajendra Kumar*, Dr. Mamta B. Kumbhare**, Dr. P. Shanmuga Raju***, Dr. M. Manjusha****, Dr. M. Sumanth*****, Dr.Ch. Rachna******

ABSTRACT

Suppurative or Purulent bacterial pericarditis is a rare disease. In most cases; pericardial infection does not produce a purulent effusion. Viral infection, which together with idiopathic pericarditis account for 90% of pericarditis cases 1, rarely produces purulent pericardial effusion and is typically self limited. In contrast, bacterial infections of the pericardium are relatively uncommon but are much more likely to produce purulent effusion and to proceed to cardiac tamponade and pericardial constriction. We report a 17 year-old male patient who presented with fever with progressive dyspnea. Large pericardial effusion with cardiac tamponade was detected by the transthoracic-two-dimensional echocardiography. KEYWORDS: Purulent Pericarditis, Cardiac tamponade, Streptococcus viridans , group A streptococcus pericarditis.

79

INTRODUCTION Purulent (or Suppurative) pericarditis is defined as an infection of the pericardial space that produces pus that is found on gross examination of the pericardial sac, on tissue microscopy and characteristic appearance on transthoracic two-dimensional

Sciences Karimnagar, A.P.), for evaluation of fever and progressive dyspnea. His illness begun 2 weeks before with daily fever, and cough with expectoration. Fever was

associated with chills. Expectoration was yellow in color, non foul smelling and not blood tinged. He consulted a private

practitioner and has taken antibiotic (I/V, Cefotaxime 1 gm X 8 hourly), antipyretic (Oral Paracetamol) for 6 days, but his symptoms did not subside. He also had history of progressive dyspnea, fatigue and

echocardiography. It is usually a severe acute illness with high mortality, especially if diagnosis and treatment both are delayed. Pericarditis is more common in adults than children, and of the infectious causes of pericarditis, bacterial pericarditis is seen in a minority of cases 2. Several bacterial agents have been reported to cause purulent

substernal chest discomfort, 8 days prior to admission .Chest discomfort was described as my heart is floating in my chest. There was no history of sore throat in the weeks preceding his presentation, dysphagia,

pericarditis. These include Staphylococcus aureus, Haemophilus Streptococcus influenzae, and pneumoniae, anaerobic

hiccups, dysphonia and no evidence of sinusitis, septic arthritis and meningitis. On physical examination patient was, thin built, moderately nourished and conscious (Figure no. 9). Vital signs included a body temperature of 36.8 0 C, heart rate of 125beats per minute, respiratory rate 22 per minute and blood pressure of 90/60 mmHg in supine position , and the arterial oxygen saturation was 91% which was measured by non invasive

bacteria .The clinical course of purulent pericarditis is usually fulminant, manifesting with shock syndrome due to cardiovascular collapse and /or septic phenomena leading to catastrophic outcome. However, it can also be insidious. Here, we describe a febrile male patient presenting with purulent pericarditis caused by Group leading A to -hemolytic very large

Streptococcus,

monitoring technique ( pulse oximetry) on room air . Pulsus paradoxus was present. His Jugular venous pressure was elevated (6cm above the sternal angle).Precordium was quite. His heart sounds were distant but regular, with no significant murmur. Trachea was central in

pericardial effusion, which was successfully treated by an emergency pericadiocentesis and adequate antibiotic treatment. Case report: A 17 year- old-male patient was referred to our department (Department of medicine, Chalmeda Anand Rao Institue of Medical
80

position. Chest percussion note were impaired in right basal, right infra mammary, right

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

lower axillary and right infra scapular region. Lung auscultation revealed bilateral basal crackles and tubular bronchial breathing in right lower lobe of lung. Ewarts sign was present (dull percussion note over left subscapular area.) The reminder of physical and systemic examination was unremarkable. His laboratory studies revealed a white blood-cell count of 22,000/L, with

1.10cm

visceral

pericardium)

and

early

diastolic collapse of free walls of the right atrium and right ventricle but without

evidence of oscillating vegetation or valve regurgitation ,consistent with cardiac

tamponade ( Figure no.5 and 6). Consistency of pericardial fluid appeared thickened on an echocardiography examination.(Figure no. 6). Left atrial collapse was absent (Figure no. 5 & 6).An emergency subxiphoid percutaneous pericardiocentesis was performed and around 800 ml of purulent pericardial fluid was drained form pericardial cavity. Initial few milliliters of pericardial fluid was slightly blood tinged but after that it was yellow in color. A pigtail catheter was placed in the pericardial sac for continuous drainage (Figure no. 2 & 9). Immediate (Primary) irrigation of pericardial cavity was done with the use of streptokinase (STK) fibrinolytic agent in dose of 250,000 IU, dissolve in 20 ml of normal saline and catheter was clamped for 4 hours. Intrapericardial instillation of STK was

64%segmented cells , 21% bands, 14% lymphocyte, 12.8g/dL hemoglobin and a platelet count of 310,000/L. Erythrocyte

sedimentation rate was 36mm/hr.The Creactive protein level was 12.6mg/L.His liver function and kidney function test were with in normal limit. His prothrombin time was 12sec; international normalized ratio 1.1; thromboplastin 3.2ng/ml and time 32sec ; partial CPK-MB T was surface

Troponinlead

32ng/ml.Twelve

electrocardiogram revealed sinus tachycardia with rate of 125 beats per minute, T wave

inversion in V5, V6 chest leads, and diffuse low voltage QRS complex (Figure no. 4). Chest radiograph showed cardiomegaly

continued for 7 days in dose of 250,000IU, at 12 hour interval and catheter was clamped for 4 hours after irrigation of pericardial cavity. Laboratory analysis of the pericardial fluid showed 384,000 nucleated cells/L, with 76% segmented cells, 15%bands, 12%

(water-bottle-shaped heart) and radio opaque shadow in right lobe of lung due to pneumonic consolidation emergency (Figure no. 1 &2). An

trans-thoracic-2 revealed

dimensional very large

echocardiography

lymphocytes and 4% monocytes,340 red blood cells/L, lactate dehydrogenase of 3700 U/L, triglycerides of 24mg/dl, glucose of

pericardial effusion (3.1.cm posterior, 2.90cm lateral, 3.00cm apical, 2.50cm around right ventricle, 2.40cm around right atrium,1.10cm around great arteries origin), thickened

15mg/dl,protein of 5.2gm/dl, , and negative activity of adenosine deaminase. The acid-fast stain was negative. A
81

pericardium ( 1.15cm parietal pericardium and

Gram stain of the

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pericardial fluid revealed Gram-Positive cocci in chains and within 12 hours, routine bacterial cultures grew Group A -hemolytic streptococcus. The organism was susceptible to Penicillin, Clindamycin, and

At the time of discharge his trans-thoracic-2 dimensional echocardiography was repeated which revealed minimal pericardial effusion and normal biventricular function. We advised regular follow up at time of discharge and during 12 months follow up patient had recovered uneventfully (Figure no. 8). Discussion: Purulent pericarditis is a rare entity in highly developed antibiotic era. In most cases, pericardial infection does not produce a purulent effusion. It generally presents with acute cardiovascular decompensation and a sepsis-like appearance. Cardiac tamponade is a medical emergency, which should be diagnosed carefully and treated thoroughly. Common causes of cardiac tamponade include inflammation, disorder, infection, immunological renal

Erythomycin,Ceftriaxone,Tetracycline

Vancomycin. Intravenous antibiotic treatment was started according to pericardial fluid culture and sensitivity report. In our case we started intravenous, 3 million U of Penicillin G every fourth hourly and 1 gram Ceftriaxone at twelve hour interval. A subsequent culture of pericardial fluid was negative for bacteria, mycobacterium and fungi. All culture reports, including blood culture, sputum culture, and urine culture, showed no bacterial growth. Further laboratory studies including thyroid function test, a polymerase chain reaction for tuberculosis bacilli in pericardial fluid,

autoimmune disease test and tumor marker were within normal limits. Percutaneous pigtail catheter aspiration was done at 6 hours interval and continued until the volume of effusion decreased to less than 25 ml per day. We also repeated Trans thoracic-2 X-ray

neoplasm,

myxedema,

insufficiency, pregnancy, aortic or cardiac rupture, trauma to the chest, nephrotic syndrome, hepatic cirrhosis and chronic heart failure 4. Bacterial purulent pericarditis is not typically a primary infection but is almost exclusively a complication from an underlying infection. In our case the predisposing factor was pneumonic consolidation of right lob of lung. In the pre-antibiotic era, patients most frequently developed bacterial pericarditis due to pneumonia with empyema, and most common pneumoniae organism
7

dimensional echocardiography and

chest PA view, at regular interval which revealed gradual decrease in pericardial effusion, no evidence of adhesion or loculated pericardial effusion (Figure no. 7 & 8) and pneumonic consolidation disappeared in right lower lobe of lung (Figure no. 3). Intravenous antibiotics Penicillin G antibiotic and

was

Streptococcus

.In the antibiotic era the

Ceftriaxone were continued for total 4 weeks and the patient recovered well after 4 weeks.
82

common organism is Staphylococcus aureus 6. Recent studies have noted a trend towards

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

involvement of more diverse microbes, and anaerobes have been reported as a common cause of purulent pericarditis
8

chest pain (often with dyspnea), tachypnea, cough, generalized weakness and tachycardia out of proportion to fever. Our patient had these entire clinical features. Classic

retrospective study found primary anaerobic infection in 40% of cases and mixed infection (aerobic / anaerobic) in 13%; however, there were no clinical or diagnostic differences between these types of infection 8. The current etiologies of bacterial purulent pericarditis include seeding from circulating bacteremia, contiguous intrathoracic source (Empyema, Pneumonia), penetrating trauma, surgical

symptoms of pericarditis, including substernal chest pain and pericardial friction rub; occur in only 50% of patients1-3. Tachycardia is often due to the febrile response, but it may be an effort to compensate for decreased cardiac output from reduced ventricular filling due to cardiac tamponade. In our patient febrile

response and cardiac tamponade both are cause of tachycardia .Features of the

wounds (sternal osteomyelitis), intracardiac source, and esophageal rupture with fistula formation, retropharyngeal abscess, and hepatic/sub diaphragmatic abscess9 .(Table no.3). The recognized risk factors for bacterial pericarditis include advance age, diabetes mellitus, untreated infection (eg. Pneumonia ,Empyema ),extensive burns, an

underlying infection also may be present, such as cough with purulent sputum and findings of lung consolidation if pneumonia is the source (like in our patient) or skin findings of

injection drug use and a cardiac murmur if bacterial endocarditis is the source. Our

patient did not have any cardiac murmur, features of infective endocarditis and skin finding of injection drug use 10. Arsura et al
11

immunosuppressed

state, cardiac surgery,

thoracic trauma and a preexisting aseptic pericardial effusion (renal failure, congestive cardiac failure)
5,6,7

found purulent pericarditis conformed by pericardial fluid analysis or at autopsy in 13% of patients admitted in intensive care unit with a diagnosis of sepsis. Thus, it is important to maintain a high index of suspicion for pericardial involvement in patients with a septic presentation (Fever and hypotension). The presence of Cardiomegaly on chest radiograph and elevated ST segments on electrocardiography suggest pericarditis and raise the possibility of pericardial effusion, which can be confirmed by echocardiography (Table no. 1 & 4). If untreated this condition
83

. Our patient had only one

recognized risk factor ( Pneumonia of right lobe of lung) out of all of these risk factors .Comorbidities associated with bacterial

pericarditis include renal failure, AIDS, immunosuppression (due to chemotherapy or intrinsic disease), alcoholism, diabetes,

preexisting pericardial effusion and indwelling venous access, particularly if the patient is receiving total parenteral nutrition
5,6,79

Bacterial pericarditis typically presents with fever at regular intervals and chills, substernal

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has a mortality rate up to 100%.

Early

thrombolytic agents enhances the complete drainage of pericardial fluid by dissolving its fibrinous minimizing components the risk and of therefore constrictive

diagnosis, along with combination therapy using systemic antibiotics and surgical

drainage, has reduced the mortality rate to < 10% in some reports and between 10 % to 20 % in others
12, 13.

pericarditis. Complications of fibrinolytic agents infusion in to the pericardial cavity are allergy, major hemorrhage, and cardiac

. Thus effective management

of purulent pericarditis requires a combined medical and surgical approach. It is important to use a regimen that includes an

tamponade. Our patient did not develop any complication of STK infusion. Most patients with bacterial purulent pericarditis respond well with subxiphoid tube drainage except H.influenzae, because of its tendency to cause thick, loculated pus (that is described as scrambled eggs and very difficult to drainage with catheter and likely to require partial pericardiectomy)
1213.

antistaphylococcal agent until information about the causative organism is available. No guidelines exist regarding the duration of antibiotic therapy; however, most patients in the literature have been treated successfully with 2 to 4 weeks of intravenous antibiotic therapy. The antibiotic regimens most often reported in the literature have used lactum agents such as penicillin and ampicillin, either alone or in combination with an

and

constrictive

pericarditis

Our patient very well

responded to subxiphoid Percutaneous, pigtail catheter drainage, intra-pericardial STK

aminoglycoside. Although pericardiocentesis is a crucial life saving intervention, complete drainage of the pericardial collection using a definitive surgical procedure is important in preventing further complications such as constrictive pericarditis. Several methods of surgical drainage have been reported 13. (Table no. 5). There are no definitive data on the

infusion and intra venous antibiotic. There is a paucity of reported cases of purulent

pericarditis caused by GAS. This organism has, however, been implicated in a self resolving, nonprogressive syndrome of

streptococcal tonsillitis associated with acute nonrheumatic myopericarditis without

effusion. Dissemination of bacteria to the pericardium contiguous can focus occur in either lung from or a by

appropriate dose of these fibrinolytic agents like STK and Urokinase in purulent

the

pericarditis. Fibrinolytic agent (STK) should be dissolve in 20 ml of normal saline, to ensure adequate diffusion into pericardial space. Fibrinolytic agents must be retained in the pericardial space by clamping the drain for 2 to 4 hours. Intra - pericardial infusion of
84

hematogenous spread. Manifestations of GAS disease can be classified into the following: (1) Invasive (2) Noninvasive (3)

Nonsuppurative. Invasive diseases include, among others, bacteremia, pneumonia, septic arthritis, necrotizing fasciitis, puerperal sepsis

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

and streptococcal toxic shock syndrome 14.It is possible that the antibiotic era has seen very few cases of GAS-purulent pericarditis due to widespread use of antibiotics for common infection such as tonsillitis and pharyngitis. During the past 10 to 15 years, severe invasive infections caused by GAS have been reported with increase frequency 15. Pericarditis should be suspected in the context of acute respiratory decompensation, shock and a sepsis like presentation, especially when supported by findings of distant heart sounds and an enlarged cardiac silhouette (Table no.2). Although this case provides an example of a disease that remains extremely rare, it does occur periodically, and the clinician must maintain a high index of suspicion for this particular organism in the setting of purulent pericarditis. Conclusion: Purulent pericarditis is typically an acute and often catastrophic illness. Both early detection and effective management of purulent

pericarditis require much effort and skill to achieve correct diagnosis. Therefore,

clinicians should be very alert to the type of disease setting. Diagnostic pericardiocentesis should be performed early, followed by a percutaneously placed catheter via a

subxiphoid route along with appropriate antibiotic treatment Evacuation of the

pericardial fluid is essential to minimize the risk of subsequent development of constrictive pericarditis. We conclude that an

Echocardiography plays a major role in the diagnosis of purulent pericardial effusion, detection of severity (Grading) of pericardial effusion, detection of complications (pre and post operative), response to medical and surgical treatment, future treatment plan,

assessment of ventricular function, oscillating vegetations and valvular regurgitation.

Percutaneous catheter drainage of pericardial fluid is an easy, safe and effective technique and should be considered as first choice of treatment in purulent pericarditis.

REFERENCES
1. Lange RA, Hills LD. Clinical practice. Acute pericarditis [Published erratum appears in N Engl J Med 2005;352:1163]. N. Engl Med 2004; 351:2195-202. 2. Gould K, Barnett JA, Sanford JP. Purulent pericarditis in the antibiotic era. Arch Intern Med 1974; 134:923-927. 3. 4. 5. 6. Trougton RW, Asher CR, Klein AL. Pericarditis. Lancet 2004; 363:717-727. Spodiac DH. Acute cardiac temponade. N Engl J Med 2003;349:648-690. Spodick DH. Acute pericarditis current concepts and practice. JAMA 2003;289:1150-1153. Rubin RH, Moellering RC Jr. Clinical microbiologic and therapeutic aspects of purulent pericarditis. American Journal of Medicine 1975; 59:68-78.

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

7.

Klacsmann PG, Bulkley BH, Hutchins GM. The changed spectrum of purulent pericarditis: an 86 year autopsy experience in 200 patients.. Am J of Med. 1977; 63:666-673.

8.

Brook I, Frazier EH. Microbiology of acute purulent pericarditis. A 12 - year experience in a military hospital. Arch Intern Med. 1996; 156:1857-60.

9.

Little WC, Freeman GL. Pericardial disease [published erratum appears in Circulation 2007; 115:e406]. Circulation 2006; 113; 1622-1632.

10. Pankuweit S, Ristic AD, Seferovic PM, Maisch B. Bacterial pericarditis diagnosis and management. Am J cardiovasc Drugs 2005;5:103-12. 11. Arsura EL, Kilgore WB, Strategos E. Purulent pericarditis misdiagnosed as a septic shock. South Med J 1999;92:285-8. 12. Roodpeyma S, Sadeghian N. Acute pericarditis in childhood: a 10-year experience. Pediatr Cardiol 2000;21:363 367. 13. Cakir O. Gurkan F, Balci AE, Eren N, Dikici B. purulent pericarditis in childhood: ten years of experience. J.Pediatr Surg 2002;37:1404-1408. 14. Stevens DL. Invasive groups A streptococcus infections. Clin infect Dis 1992; 14:2-11. 15. Davies HD, McGeer A, Schwartz B, Green K, Cann D, Simor AE, Low DE. Invasive group A streptococcal infection in Ontario, Canada. Ontario Group A streptococcal study group. N Engl J med 1996:335:547554.

Figure

1.

X-Ray

chest

PA

view,

before

Figure-2.

X-Ray

chest

PA

view,

after

pericardiocentesis, shows, cardiomegaly (water-bottleshaped) and radio-opaque shadow in right lower lobe (consolidation of lower lobe of right lung).

pericardiocentesis, shows, cardiomegaly, and radioopaque shadow in right lower lobe and a pigtail catheter in pericardial sac for continuous drainage.

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Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

in Subcostal- four- chamber view , shows an echofree space surrounding the entire heart (Large or massive pericardial effusion ), swinging heart in

pericardial fluid and thickened pericardium.

Figure-3.

Normal X-Ray chest PA view in our

patient after 45 days of treatment.

Figure -6. TTE before pericardiocentesis; in Apical 4 chamber view, shows an echo-free space

surrounding the entire heart (Large pericardial effusion), swinging heart in purulent pericardial fluid, consistency of fluid appeared thick and thickened pericardium. Figure -4. Twelve leads surface electrocardiogram shows, sinus tachycardia, diffuse low voltage QRS complex and T wave inversion in V6 andV6 chest lead.

Figure -7. TTE 5 days after of an emergency pericardiocentesis, shows mild pericardial effusion (Right diastolic and Left systolic frame in apical 4 chamber view) Figure -5. Trans-Thoracic 2 Dimensional
87

Echocardiography (TTE) before pericardiocentesis;

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Figure -8. TTE - One year after treatment, shows no pericardial effusion, normal thickness of pericardium and no complication (like - Pericardial constriction). [Right frame - Parasternal long axis in diastolic and Left frame - parasternal short axis view in diastole].

Figure -9. Photograph of our patient shows, thin built, moderately nourished and a pigtail catheter (right side, blue in color).

Table 1. Electrocardiography findings in pericarditis Stage I II Early II Late III IV ST Segment Elevated Isoelectric Isoelectric Isoelectric Isoelectric T- Waves Upright Upright Low to flat to inverted Inverted Upright PR- Segment Depressed or Isoelectric Isoelectric or depressed Isoelectric or depressed Isoelectric Isoelectric

Table 2. Different type of paradoxus in large (massive) pericardial or cardiac tamponade. 1. Arterial Paradoxus ( Pulsus Paradoxus) A drop in systolic blood pressure > 10 mmHg, during inspiration, whereas diastolic blood pressure remains unchanged. An inspiratory increase in Jugular venous pressure

2.

Venous Paradoxus

(Kussmauls sign). Prominent xdescent and absent or diminished diastolic y descent.

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Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

3.

Radiological paradoxus

Cardiomegaly seen in X-ray chest PA view due to pericardial effusion but actually the heart size is normal.

Table 3. Classification of purulent pericarditis according to source of infecting organism. 1. 2. 3. 4. 5. Infection by contiguous spread from a pleura, mediastinum or pulmonary focus. Infection by contiguous spread of intracardiac infection. Infection following systemic bacteremia. Infection with contiguous spread from a postoperative infection. Infection following a sub diaphragmatic Suppurative infection.

Table

4. Grading of pericardial effusion by Trans- Thoracic - 2 Dimensional

Echocardiography. Small Moderate Large Very Large An Echo-free space <10 mm in diastole. An Echo-free space between 10 to 20 mm in diastole An Echo-free space 20 mm in diastole An Echo-free space >20 mm in diastole and compression of the heart.

Table 5. Different surgical modalities for pericardial effusion evacuation or drainage. 1. Subxiphoid Percutaneous catheter. 2. Subxiphoid tube drainage. 3. Subxiphoid tube drainage or Percutaneous catheter and fibrinolysis.

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4. Pericardial window and pleural drain. 5. Partial pericardiectomy with pericardial tube drainage. 6. Anterior interphrenic pericardiectomy. 7. Total pericardiectomy.

CORRESPONDING AUTHOR: *Associate Professor, **Senior Specialist Anesthesia, Dhanvanthari Hospital, NTPC, RSTPS, Jyothi Nagar District Karimnagar (AP) India 505 215 ) ***Assistant Professor , Department of Physical Medicine and Rehabilitation, CAIMS, Bommakal, Karimnagar (A.P.) India 505 001) ****PG student, Department of Medicine, CAIMS, Bommakal, Karimnagar (A.P.) India 505 001) *****PG student, Department of Medicine, CAIMS, Bommakal, Karimnagar (A.P.) India 505 001) ******PG student, Department of Medicine, CAIMS, Bommakal, Karimnagar (A.P.) India 505 001)

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Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

TECHNICAL SOFTWARE PROJECT MANAGER VS NON TECHNICAL SOFTWARE PROJECT MANAGER


Zunera Jalil*, Nazia Tabbasum**

ABSTRACT In software industry many projects exceed from budget and time and acquire low customer satisfaction due to managerial problems. These managerial and technical problems lead to the shipment of an unsuccessful project, setting the reputation of the whole software organization on stake. Such failures not only damage the economical condition of the software market, they also create an air of uncertainty to win future projects. Keeping in view the managerial and technical problems being faced by the Pakistani software industry at present, we thought of conducting a survey on project managers soft and hard skills. In this paper we highlight those technical and non-technical skills that need further consideration or improvement. In addition to this, it is to give the software houses an overall picture of those practices that are common in our software industry and help them move towards the ideal direction so that they could effectively improve their skills.

KEYWORDS: Software project management; project manager; technical skills; non technical skills

I. INTRODUCTION In the 1970s and early 1980s, achieving


91

effective

software

project

management

became recognized as a significant issue.

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Projects were often delivered late and over budget and didnt meet requirements and expectations. As we approached the 1980s and our knowledge and sophistication with software development grew, the number of complex systems began to increase

management attack: standardize the process, standardize the product, standardize the support environment, and professionalize the workforce companies [1]. Many organization project and

arrange

management

training for their employees, but did not get the desired results. According to the Standish Group CHAOS report, 2009 [2] as illustrate in Figure 1.1-1:

dramatically, and the problems associated with ineffective project management became more acute. Collectively, these initiatives embodied a four-pronged technical and 32% completed on time, within budget and fully functional. 44% exceed budget and schedule. 24% failed or canceled.

Figure 0-1: Standish Group Chaos Report 2009 [3] Project manager can improve/enhance his/her abilities through training to contribute skills. TECHNICAL SOFTWARE PROJECT MANAGERS Technical skills are also called hard skills, considered a science and processes, tools and techniques to plan and execute PROJECT MANAGEMENT Managementin all organizational and business activities is the act of getting people together to accomplish required goals and objectives using available resources projects on time and on budget. Technical experts create project schedule, identify risks and conflicting issues, control changes, track the budget and schedule [4, 5].Some project managers prefer to have little technical knowledge about the projects to manage and leave the technical management to other junior managers, such as programming managers or network managers. Some have detailed technical skills of computer

technically, but it is unlikely to improve their management skills. Some basic terminology is define as

efficiently and effectively. Management is composing of planning, organizing, staffing, leading or directing and controlling an organization. Project management requires a deep knowledge of human behavior and the ability to skillfully apply right interpersonal

languages, software, and networks. On larger

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

complex projects, such as systems integration projects or multiple-year projects, there are normally too many multifaceted technologies for the project manager to handle. Project manager is eventually responsible for the entire management of the project, technical or otherwise, require solutions to the technical issues that will occur [6,7]. A technical software project manager should know how to apply project

teambuilding; leadership style; responsibility; self directed learning; ethical and

professional moral; planning; negotiation; oral and written communication;

interpersonal ability to apply knowledge in the workspace; creativity and capacity to learn new skills; critical thinking and problem solving ability [1-12]. Software project manager should have technical skills but not necessity as: Many IT project managers lose control of a project because their technical leads provided

management

tools,

techniques,

methodologies and process. For example, he should know how to prepare requirements specification document, construct a network diagram, and work breakdown structure. Without these skills, software project

erroneous information, such as unrealistic estimates, flawed reasons for falling behind schedule, requests for unnecessary software, etc. This is because the project manager does not have the experience to know the difference [13]. Normally software projects fail not because of lack of adequate technology but because the soft science portions of the project have not been addressed adequately. Responsibilities of project managers are to develop strategies and and

manager cannot coordinate and facilitate the creation of a high-quality project plan and maintain control during project execution. NON-TECHNICAL PROJECT MANAGERS Soft skills can be termed as how we use it. Non-technical skills are soft skills that are normally neglected during software project management. Soft skills are an art which concerned with managing and working with people, ensuring customer satisfaction. These skills also help in creating conducive environment for the project team exceeding stakeholder expectations, improve cost SOFTWARE

implement

management

communication plans of their respective stakeholders and are also responsible for cocoordinating the scope of work packages and applicable terms and conditions [14]. Outsourcing is another successful way to build new software quickly and

performance and high quality product [8, 9, 10]. With reference from various studies, following soft skills are considered essential:

inexpensively. However, when companies outsource solely, they fail due to

misunderstanding,

inadequate

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communication and time zone. Software development in outsourcing requiring right mix of hard skills, such as software programming, architecture designing, and engineering, and soft skills, such as

project management association. This also helps software project managers to

understand how they can perform better in project management area by considering the soft skills of their working. This paper identifies and analyzes problem that help us understand the barriers to management of project management area within the

communication, collaboration, and project management. For more complex projects software project managers require a mix of programming skills, technical proficiency, cultural compatibility and communications Unfortunately in most of the software organizations; management management disciplines are and project

organizations. The survey conducted on the basis of the above Since the field of software project management is new to Pakistani software industry, we are interested in assessing the abilities of the software project managers working in different software companies; analyze their qualification, experience, skills, and success rate of their software projects. The survey will be intended to determine project managers abilities by investigating the following: Technical skills to measure project managers ability of implementing basic project management tools and techniques throughout a project life cycle. Skills such as teamwork, leadership and communication to manage realworld problems. A survey of 59 software project managers was conducted from all over Pakistan. For this research, survey is conducted focusing mainly on level of project manager (PM) skills and also include the problems which have been involved in software project

considered

redundant, futile and most importantly not the main focus of work. Like traditional mindsets, many believe that the best way to get work completed is through technical skills mainly. People, employees and team members or team heads within the projects consider technical work as the central focal point of the project and therefore pay no attention to project management. Due to these reasons, an improvement in the technical essentially improvement and non-technical for the skills is

required and

overall

organizational

sustainability, maturity and development. The objective of this research is to help the software organizations in Pakistan analyze the technical vs. non-technical skills of project managers and evaluate them with respect to the ideal project management practices as defined by the Project

Management Institute (PMI), the leading

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

implementation. It has been found that there are more or less twenty five software project managers in Pakistan who have management skills very strong. It is made sure that all organizations and software project managers are approached for their response. And for this purpose questionnaires have been

Graduate (Management/Others) Basic Others Education

Degree

(Diploma

in

(Management/Other)

Project Management Training level Certifications Training courses Technical Skills Experience development Experience in Project Management Strong understanding of domain Planning and control Non technical Skills Communication skills Team building skills Conflict resolution skills Planning and Control skills Leadership skills Problem solving skills Management skills Time management skills Experience Number of years in project in Software

designed which are then floated via web, emails, face to face interviews and personal contacts. The methodology and process adopted for conducting this research is further elaborated in this chapter. A. SURVEY FORM The survey form was made to get the following information about software project managers: Technical PM Education Post Graduate Degree(Comp.

Science/Software Engineering/IT) Graduate Basic Degree (Comp.

Science/Software Engineering/IT) Education (Diploma in

(Comp. Engineering/IT)

Science/Software

Non-Technical PM Education Post Graduate

management Number of years in other disciplines

Degree(Management/Others)

B. OBSERVATIONS AND ANALYSIS

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Technical PMs: Focus on Technical and Time management skills The results show us that about half of the technical project managers having In addition to this, 40-50% percent nontechnical project managers have sociocultural skills such as leadership and problem solving.

moderate technical skills (follow standard method, experience and domain knowledge).

Non-technical PMs focus on Team development, communication, leadership and management skills. Most of project managers are fortunately able to meet the deadlines, probably because of putting in extra hours, making the resources sit late till night in the offices and in some cases, making the weekends on (time management: 82% ). Therefore, we conclude that the project managers of our software industry put too much stress on the team members regarding the completion of work in little time allocated to the project activities. This could

be because of pressure from the client end, but the project managers should devise methods to avoid making their team members work in a crunch mode.

FREQUENCY

OF

RESPONSES

ACCORDING TO COMPANY SIZE As can be seen in the graph below that the only type of enterprise that has minimal responses is Micro-Enterprise. Therefore, it is evident from the fact that the sample of this survey mainly contains the Small,

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

Medium and Large Enterprises.

Figure 0-2: Percentage responses according to company size Our statistics have confirmed that Companies involved in offshore development are higher in rate than the rest of the companies. In hybrid development, project managers always motivate, consult with team members before taking any decision and timely decision and we observe in relation to team involvement and motivation are about 53 percent in in-house development. 50-60% of the technical software project managers sometime follows standard method and has domain knowledge. Many project managers cannot handle resources and appropriate decision.

Figure 3: Responses according to Type of Business In off-shore development, non-technical PM seem to realize the importance of effective communication skills and because of this, 58% non-technical PM motivate team

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members to complete the work assigned to them. In In-house development, most of the project managers almost focus to define clear goal, monitor the performance and motivate their team to promote cooperation. The analysis confirmed that following soft/hard categories are at the High, Medium and Low severity levels according to Company Types.

In

the world of software technology,

experience is a particularly powerful and effective teacher. Statistics have confirmed that majority of the PM population in this survey is of the software practitioners having experience more than two years and less than 6 years.

The results show that 90 of the project managers we targeted in our survey had some prior Having software some development software experience. development

world of software technology, certification is a particularly effective trainer. From our survey, we observed that the project

managers in the market fall in the following range of PM experience: 54 percent Non-Technical PMs on the average have PMP Certification. 42 percent Non-Technical PMs on the average have No Certification. The rest have 4 percent CMMI Certification 33 percent Technical PMs on the average have PMP Certification. 56 percent Technical PMs on the average have No Certification. The rest have 11 percent CMMI Certification

experience indeed is an added quality of a successful project manager who can well understand and comprehend the technicalities of the project. But the emphasis should be on managing projects without getting too much involved in the technical details of the project and taking into consideration the business aspect of the project as describe by PMI [1718]. Statistics have confirmed that majority of the PM population in this survey is of the software practitioners having certification almost fifty percent of total population. In the

Scientific Research Journal of India Volume: 2, Issue: 4, Year: 2013

Figure 4: Percentage responses according to Respondents Certification CONCLUSION In this thesis, the level of software project manager (PM) skills is conducted, by gathering inputs from Pakistan software industry. There are a total of 45 software project managers who have participated in this research. It has revealed more of the soft skills were missing in past articles. The survey has a significant importance among past studies related to soft and hard skills because of (i) technical vs. non-technical as users learn and mature with time and the difficulties in incorporating multiple,

diversified and contradictory vision and views. We can reduce technical and

management risks with proper practices. Some of the experience software project managers when interviewed on the

enhancement and improvement strategies for technical and non-technical skills, responded that these soft skills must be promote and tackle with the professionalism and training on the importance of leadership, they also mentioned that top management should now forget about the past experiences and should have the courage to meet the challenges of coping up with the standardization of their software, if they want to be recognized as a reliable software industry in the world. They have also stated that new opportunities must now be created for the true professions in the Industry by giving them job security and seeking new ideas to improve or evolve their processes as this could be the only way to introduce CMMI in their organizations and pacing it up to the ultimate capability level just like some of the top-notch companies

skills are specific to Project Management Body of Knowledge(PMBOK), (ii) Survey is conducted on Pakistan Software Industry which has its own uniqueness in a way that it is a Industry of an under-developed country and having a different culture in terms of both political instability and economic

situation, and (iii) It has revealed that software industry currently has more lessexperienced project managers than the

experienced ones. The complexity of recent software systems also causes difficulties for software project managers. The potential challenge is the ever-changing requirement of customers

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have already done in recent years of Pakistan. FUTURE WORK From our observation, it can be concluded that the software industry currently has more less-experienced project managers than the experienced ones. Emphasis should lie on making the more experienced project

managers as well. Furthermore, educational programs in the institutes could also prove to be helpful in producing good project

managers by equipping them with the desired soft and hard skill sets so that they can stand out to be better project managers and help the software industry using their managerial skills. The training of project managers should focus on those identified skills required to deal with the Typical Problems encountered.

managers help the inexperienced ones by giving them valuable guidance and direction so that they could turn out to be good project

REFERENCE
1. A Guide to the Project Management Body of Knowledge (PMBOK Guide), Fourth Edition ed.: Project Management Institute, 2008. 2. "The Standish Groups CHAOS Report 2009," CHAOS University, http://www.standishgroup.com/chaos 2009. 3. S. El-Sabaa, "The skills and career path of an effective project manager," International journal of project management, vol. 19, no. 1, pp. 1-7, 2001. 4. J.R. Mller and R.Turner, "Communication and Co-operation on Projects Between the Project Owner As Principal and the ProjectManager as Agent," European Management Journal, vol. 22, no. 3, pp. 327336, June 2004. 5. D.H. Stevenson and J.A. Starkweather, "PM critical competency index: IT execs prefer soft skills," International Journal of Project Management, vol. 28, no. 7, pp. 663671, 2010. 6. T.A. Carbone and S. Gholston, "Project Manager Skill Development: A Survey of Programs and Practitioners," Engineering Management Journal, vol. 6, no. 3, September 2004. 7. J.M. Conrad and Y. Sireli, "Learning Project Management Skills in Senior Design Courses," in Frontiers in Education, 2005. FIE '05. Proceedings 35th Annual Conference, 2005, p. F4D. 8. E. Hemmatnia. (2005) A Project Manager:Specialist in Management or Specialist in a Topic Area? [Online].http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.84.7106&rep=rep1&type=pdf. 9. J. R. Turner and R. Muller , "The project manager's leadership style as a success factor on projects: A literature review," Project management journal, vol. 36, no. 1, pp. 49-61, 2005. A. Aitken and L. Crawford, "Coping with stress: Dispositional coping strategies of project managers," International Journal of Project Management, vol. 30, no. 7, pp. 1-4, 2007. 10. V.Vadlamuri. (2007, March) How techie does a project manager need to be, to be successful in 21st century. [Online]. Http://blogs.ittoolbox.com/pm/vadlamuri/archives/howtechie-does-a-project-manager-need-to-be-

to-be-successfulin-21st-century-1499

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11. Z. Jalil and A. A. Shahid, "Is Non Technical Person A Better Software Project Manager?," in 2008 International Conference on Computer Science and Software Engineering, vol. 2, 2008, pp. 1-5. 12. S.A. Slaughter and T. Mukhopadhyay N. Langer, "Project Managers' Skills and Project Success in IT Outsourcing," in ICIS 2008 Proceedings, 2008, p. 147. 13. S. Gillard, "Soft skills and technical expertise of effective project managers," Issues In Informing Science and Information Technology, vol. 6, 2009. 14. S. Milladi. (2007) What it Takes to be a Better Project Manager Going Beyond Project Management. [Online]. http://www.pmworldtoday.net/ 15. D. G. Morales, L. M. de Antonio, and J. LR. Garcia, "Teaching Soft Skills in Software Engineering," in Global Engineering Education Conference (EDUCON), 2011, pp. 630 - 637. 16. M. Pinkowska, B. Lent, and S. Keretho, "Process Based Identification of Software Project Manager Soft Skills," in Computer Science and Software Engineering (JCSSE), 2011 Eighth International Joint Conference on, 2011, pp. 343 - 348. 17. S. Dillon, H. Taylor, and G. Rodriguez-Jolly. (2010) The identification of IT project manager competencies: a grounded theory approach. [Online]. http://www.pacis-net.org/file/2011/PACIS2011-044.pdf

CORRESPONDING AUTHOR:

*Department of Computer Science, International Islamic University, Islamabad, Pakistan. **Department of Computer Science, International Islamic University, Islamabad, Pakistan.

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