Scientific Research Journal of India (Multidisciplinary, Peer Reviewed, Open Access, Journal of science) ISSN: 2277-1700 Vol: 2, Issue: 2, Year: 2013
Editor in Chief Dr. Krishna N. Sharma (PT) Editors Dr. Popiha Bordoloi Dr. Kuki Bordoloi Dr. Sudeep Kale Dr. Waqar Naqvi Junior Editor Mrityunjay Sharma
Office Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403 Website http://www.srji.info.ms URL Forwarded to http://sites.google.com/site/scientificrji Email editor.srji@gmail.com Contact +91-9320699167, 9839973156
Copyright Š 2013 Scientific Research Journal of India All rights reserved.
CONTENTS
Title
Author/s
Editorial
Dr. Krishna N. Sharma
The Sustained Effect of Short Durations of Warm Up and Stretching Exercises on Shoulder Joint Proprioception
Department
Page i
Bala Jyoti, Pacheri Bari, Gupta Manish, Shaina
Physiotherapy
1
Physiotherapy
9
Physiotherapy
17
Physiotherapy
24
Physiotherapy
39
Computer Science
44
Industrial Management
54
-
63
Sandeep, Kumar Satish
Impact of Ageing on Depression and Activities of Daily Livings in
Vanshika Sethi,
Normal Elderly Subjects Living in
Vijeylaxmi Verma,
Old Age Homes and Communities
Udhbhav Singh
of Kanpur, U.P. To
Assess
between
the
Relationship
Temporomandibular
Joint Dysfunction and Cervical Spine Dysfunction
Khyati Harish Sanghvi, Amrit Kaur, Ganesh Subbiah
Effectiveness of Neuromotor Task Training
Combined
with
Kinaesthetic Training in Children with
Developmental
Ordination
Disorder
Co-
A
Sundaresan Chockalingam, Agnel Kevin Gomes
Randomised Trial Cognitive Rehabilitation in MS
Krishna N. Sharma
Network Border Patrol Eradicates the Over Loading of Data Packets and Prevents Congestion Collapse thereby Promoting Fairness Over
Lakshminarayanan T., Dr. Umarani R.
TCP Protocol in LAN /WAN
Use of Fuzzy TOPSIS Model for Evaluating Cooling Towers
Correction Notice
Dr. Ali Kheradmand, Mahdi Naqdi Bahar, Ali Ghani Abadi -
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iv
EDITORIAL
Dear Readers! I am very pleased to present this issue of the Scientific Research Journal of India (SRJI). With this issue. This issue of the multidisciplinary and open access Journal of science contains total 5 papers in Physiotherapy, 1 paper in Computer Science, and 1 paper in Industrial Management. Hopefully you’ll find these papers informative. Here I would like to bring one more thing to your notice that our URLs are hacked so from now our permanent URL will be http://sites.google.com/site/scientificrji . Do drop a mail to us (editor.srji@gmail.com) if you have any comment and suggestion.
Happy Reading.
Regards,
Dr. Krishna N. Sharma Editor in Chief
i
THE SUSTAINED EFFECT OF SHORT DURATIONS OF WARM UP AND STRETCHING EXERCISES ON SHOULDER JOINT PROPRIOCEPTION Bala Jyoti*, Pacheri Bari, Gupta Manish**, Shaina Sandeep, Kumar Satish
ABSTRACT
OBJECTIVE: To study the sustained effect of Short Durations of Warm up and Stretching Exercises on Shoulder joint Proprioception. DESIGN: Pre-test and Post test control group design. SETTING: Inpatient and rehabilitation hospital. PARTICIPANTS: A total number of 75 subjects free from pain and discomfort and any pathology in and around shoulder joint are allocated randomly into 1 of 5 groups.
INTERVENTION: Group A received 1 min. of warm up and stretching(n=15),Group B received 2 min. of warm up and stretching (n=15), Group C received 3 min. of warm up and stretching (n=15), Group D received 4 min. of warm up and stretching (n=15) and Group E control group received no warm and stretching (n=15)). All groups received intervention. MAIN OUTCOME MEASURES: A CPM Machine was used to move a desired joint continuously through controlled ROM without the subject’s active effort. To measure the JPS, passive CPM was used.
Outcomes were measured before and immediately after
intervention and 5 min. after 2nd data. All JPS scores were measured on same day. RESULTS: Outcome measures for all groups showed the effect of warm up and stretching still persisted after 5 min of 2nd data collection, except at 150 degrees of shoulder flexion in Group A. At 2 min, 3 min and 4 min of warm up and stretching, the improvement in joint position sense appreciation were significant at all ranges/target positions checked and this improvement sustained even after 5 min of 2nd data collection. Also group C i.e. 3 minutes warm up had the maximum gains, Group A had the minimum gains and Group D had the fewer gains due to the effects of muscular fatigue as reported by the subjects after performing this warm up.The control group
1
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showed the minimum non-significance across all the groups. CONCLUSION: This study concludes that warm up and stretching exercises improve shoulder joint position sense appreciation and this improvement sustained even after 5 min of 2nd data collection.
KEYWORDS: Contract-Relax Stretch, Performance, Proprioception, Sports, Injury Prevention
depending on the joint tested.
INTRODUCTION Proprioception is defined as the cumulative
The exact mechanism of proprioceptive
input to central nervous system from specialized
control remains unclear, particularly in the
nerve endings called mechanoreceptors. They are
shoulder.
located in the joint capsules, ligaments, muscles,
indispensable because the glenohumeral joint
1
Shoulder
proprioception
is
tendon and skin . It is currently acknowledged
relics primarily on dynamic restraint of rotator cuff
that
entity
to maintain stability. Proprioception may also
encompassing several different components such
affect injury predisposition and rehabilitation.
as sense of position, velocity, movement detection,
Several
and force and that the afferent signals that give rise
proprioception is impaired after fatigue, injury and
to them may well have origins in different types of
in overhand athletes.
proprioception
receptors2.
is
a
complex
Proprioception is the ability to
that
shoulder
exercise during rehabilitation of shoulder because
kinesthesia is the ability to detect movement. Joint
the rotator cuff is vital for glenohumeral joint
position sense is mediated by joint and muscle
stability4. In the present study our focus is on
receptors as well as visual, vestibular and
position sense here in defined as the awareness of
cutaneous input3.
actual position of the limb.
Early research suggested that the joint had
suggest
Clinicians commonly use proprioception
determine the location of a joint in space where as
receptor
studies
the
predominant
proprioception and kinesthesia.
role
Many researchers have used joint position
in
sense appreciation tests to evaluate knee joint
Joint receptors
performance after the administration of warm up
have been identified in joint capsules, ligaments,
exercises and stretching of different duration and
menisci, labrum and fat pads3. Recent research has
intensities.
identified ruffini−like ending in the glenohumeral
physical
joint capsules, found pacinian corpuscles in
fitness
.Stretching is used as a part of and
rehabilitation
programs
because it is thought to positively influence
glenohumeral ligaments, and free nerve endings in the glenoid labrum of human cadavers3.
5,6,7,8,9,10
performance and injury prevention 11.
Most Many
proprioception research has examined the elbow,
researchers
have
used
different
Some authors have
durations and intensities of stretching for different
attempted to generalize their findings to other
purposes viz. soft tissue extensibility modulation,
joints. However, proprioceptive control may differ
prevention of injury during sporting activity and
wrist, knee, and ankle.
2
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
also to increase proprioception in human joints.
interviewed
12,13,14,15,16
to
physiotherapist of Sir Ganga Ram Hospital who
investigate whether varying intensities of warm up
was unaware of their group. By using random
and stretching exercises helps in improving
sampling method, the subjects were assigned to 1
shoulder joint position sense appreciation
of 5 treatment groups. Group A received 1 min. of
.Therefore
this
study
is
aimed
and
examined
by
a
clinical
warm up and stretching(n=15),Group B received 2 min. of warm up and stretching (n=15), Group C
METHODOLOGY A total number of 75 subjects(N-15 X 5
received 3 min. of warm up and stretching (n=15),
groups) were included in the study, were recruited
Group D received 4 min. of warm up and
from the physiotherapy department of Sir Ganga
stretching (n=15) and Group E control group
Ram Hospital, NewDelhi, India.Subjects (N-15 X
received no warm and stretching (n=15)). The joint
5 groups) were included in the study.
position sense score was measured before warm up and stretching, after warm up and stretching and 5 min. after 2nd data with the help of CPM Machine.
Inclusion criteria were: 1. Mean Age of subject is 20-30 years,
CPM machine was considered most appropriate
2. Right Hand Dominant
and yield reliable and valid data. The subjects
3. Free from pain and discomfort in and
were instructed to remove their shirt and vest to allow for acclimatization to room temperature for
around shoulder joint 4. No
pathological
musculo-skeletal
conditions and
10 minutes.
affecting
The rig of CPM machine and chair was
neuromuscular
adjusted so that the rotation axis of the rig was
system. 5. Only Males are included.
congruent with centre of glenohumeral joint. The rotation axis of shoulder was adjusted by laser
Exclusion criteria were:
detection ray, which was present in machine.
1. Patients with previous shoulder surgery
Subjects were seated in chair and blind folded and
2. Patients who have signs and symptoms of
cotton gauge was put in the ear.
gross shoulder instability
All movements were performed on right shoulder
3. Patients who had red flags suggesting
joint.
serious shoulder pathology
Subjects were required to match a
4. Patients with cardio –pulmonary diseases
previously presented angle from starting position
5. Patients with tumor, infection and fracture
to target position by machine respectively i.e.
6. Patients with History of soft tissue injury
Flexion 30-90°, flexion 60-120° and flexion 90-
within one last year
150°.
7. Patients pathological conditions affecting musculo-skeletal
and
The shoulder joint (arm) was passively
moved at 2 degree/sec to predetermined target
neuromuscular
position. The arm remained at target position for 5
system
sec. (Same duration for all trials) and returned at a speed
Subjects who are willing to participate were
2°/sec
to
starting
position.
Three
familiarizing trails were given before data was 3
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collected.
Stop switch was given to subjects.
When the button was pressed by the subject, it indicated recognition of target position.
Each
movement
times
data
was
collected
two
measurements of JPS difference between the perceived angle and angle of flexion was recorded with the +ve sign of error. After recording data, warm-up and stretching were performed by the subjects for 1 min (Group A), 2 min (Group B), 3 min (Group C), 4 min (Group D) and no exercises for control group (Group E). Again data was collected immediately after warm up and also 5 min. after 2nd data . RESULTS
Similarly, at 2 min, 3 min and 4 min of warm
Since the data did not follow normal
up and stretching, the improvement in joint
distribution, therefore, repeated measure Anova
position sense appreciation were significant at all
was not used, instead Non-parametric tests were
ranges/target
used.
Wilcoxon-signed ranks test was used to
improvement sustained even after 5 min of 2nd
compare the pre-intervention, post-intervention
data collection.The control group result indicated
data collection errors among themselves (between
no improvements at all target positions checked.
group comparison) for all the 5 groups.
positions
checked
and
this
Examining the results (through master chart)
One way Anova was used to calculate the
from a clinical perspective, we observe that the
significance value of pre-intervention and post-
third group i.e. 3 minutes warm up had the
intervention data collection of all the 5 groups for
maximum gains, 1 minute warm up had the
both between-group comparison and within group
minimum gains and 4 minute warm up had the
comparison. Post-HOC and Mann-Whitney tests
fewer gains due to the effects of muscular fatigue
were used to compare significance values among
as reported by the subjects after performing this
all the groups (multiple comparisons).
warm up.
The gains in joint position sense appreciation
Examining Mann Whitney multiple group
were significant after 1 min of warm up at all the
comparison test results the 3 minute warm up
target positions checked. The effect of warm up
group showed maximum significance across all the
and stretching still persisted after 5 min of 2nd
groups.
data collection, except at 150 degrees of shoulder
minimum non-significance across all the groups.
flexion.
findings of this study indicate that warm up and stretching
Table 1: Wilcoxon Signed Ranks Test.
And the control group showed the
exercises
improve
shoulder
joint
position sense appreciation. This improvement in shoulder 4
joint
position
sense
appreciation
Scientific Research Journal of India â—? Volume: 2, Issue: 2, Year: 2013
enhances with increase in duration and intensity of warm up upto 4 minutes. At 4 minutes there are lesser gains in joint position sense because muscular fatigue starts setting in.
Table 2: Mann Whitney Tests (Multiple Group Comparison)
Graph 2: Mann Whitney Tests (Multiple Comparison 60-120)
Graph 1: Mann Whitney Tests (Multiple Comparison 30-90) Table 4: Mann Whitney Tests (Multiple Group Comparison)
Table 3: Mann Whitney Tests (Multiple Group Comparison)
Graph 3: Mann Whitney Tests (Multiple Comparison 60-120)
5
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warm up upto 4 minutes. At 4 minutes there are lesser gains in joint position sense because muscular fatigue starts setting in. In this study, the gains in joint position sense appreciation were significant after 1 min of warm up at all the target positions checked. The effect of warm up and stretching still persisted after 5 min of 2nd data collection, except at 150 degrees of shoulder flexion. that
Similarly, at 2 min, 3 min and 4 min of warm
Wilcoxon-signed ranks test was used to compare
up and stretching, the improvement in joint
the
position sense appreciation were significant at all
Interpretation:
The
pre-intervention
Table-1
and
showed
post-intervention
(between group comparison) for all the 5 groups.
ranges/target
positions
checked
and
this
the gains in joint position sense appreciation were
improvement sustained even after 5 min of 2nd
significant after 1 min, 2 min, 3 min and 4 min of
data collection. The control group result indicated no
warm up and stretching, The table-2,3,4 showed that three Examining
improvements at all target positions checked.
Mann Whitney multiple group comparison test
Examining the results (through master chart) from
results the 3 minute warm up group showed
a clinical perspective, we observe that the third
maximum significance across all the groups. And
group i.e. 3 minutes warm up had the maximum
the control group showed the minimum non-
gains, 1 minute warm up had the minimum gains
significance across all the groups.
and 4 minute warm up had the fewer gains due to the effects of muscular fatigue as reported by the
The improvement in joint position sense appreciation still persisted after 5 min of 2nd data
subjects after performing this warm up. Examining Mann Whitney multiple group
collection, except at 150 degrees of shoulder
comparison test results the 3 minute warm up
flexion in Group A.
group showed maximum significance across all the
At 2 min, 3 min and 4 min of warm up and stretching, the improvement in joint position sense
groups.
And the control group showed the
appreciation were significant at all ranges/target
minimum non-significance across all the groups. The results of this study match with the
positions checked and this improvement sustained even after 5 min of 2nd data collection.
results of previous studies done on same subject indicating that warming up exercises improve joint position sense appreciation5,20.
DISCUSSION The findings of this study indicate that warm up and stretching exercises improve shoulder joint
CONCLUSION
position sense appreciation. This improvement in shoulder
joint
position
sense
The findings of this study support that the
appreciation
larger amount or duration of warm up and
enhances with increase in duration and intensity of
stretching will give more accuracy of joint position
6
Scientific Research Journal of India â—? Volume: 2, Issue: 2, Year: 2013
sense before the occurrence of muscular fatigue.
position sense alter across the ROM with
Also the effect of warm up and stretching still
potentially greater position sense acuity in the
persisted after 5 min of 2nd data collection,
outer range of shoulder flexion where there is more tension upon the restraints of motion.
Clinicians should be aware of this information in making decisions during rehabilitation of
Muscular fatigue should not be allowed to set
shoulder injuries or proprioceptive training of
in during warm up period so as to prevent the loss
athletes. The results suggest that shoulder joint
of proprioceptive acuity.
REFERENCES
1.
Voight L.M., Allen J., Turner A,Tippett S. and Gary C., The effect of muscle fatigue and relationship of arm dominance to shoulder proprioception, J.O.S.P.T., 2(6), 348-352(1996)
2.
Lonn J., Albert M.S. and Pederson., Position sense testing: influence of starting position and type of displacement, APMR., 81, 592-593(2000)
3.
Marnic A., M Scott S.L., J.I.and F.H., Shoulder kinesthesia in healthy unilateral athletes participating in upper extremity sports, J.O.S.P.T., 21(4), 220-226( 1995)
4.
Drover G., M.S., C.A.T., A.T.C and Powers M.E.,Cryotherapy does not impair shoulder joint position sense, APMR., 85, 1241-1246(2004)
5.
Br. J. SP., Effect of warm up exercises on knee proprioception before sporting activity, Med.,36,132-134(2002)
6.
Effects of static stretch and warm up exercises on hamstring length over the course of 24 hours, J.O.S.P.T., 33(12), 727-33(2003)
7.
In sports & exercise:- A randomized trail of pre-exercise stretching for prevention of lower limb injury, Med. & Sc.
8.
After effects of resisted muscle contraction on accuracy of joint position sense in elite male athletes, A.P.M.R.,79,1250-1254(1998)
9.
Effects of age and activity on knee joint proprioception, Am.J.Phys.Med. Rehab., 9,235241(1997)
10.
Knee proprioception: A review of mechanism, measurements, and implications of muscular fatigue, Orthopedics., 21(4),463-471 (1998)
11.
Effect of superficial heat, deep heat, active exercises warm up on extensibility of plantar flexors, Phys. Ther., 81, 1206-1214(2001)
12.
The effect of time on static stretch on flexibility of hamstring muscles, PHY. THER.,74(9),845850(1994)
13.
The effect of duration of stretching of hamstrings for increasing ROM in people aged 65 years or older, PHY. THER., 81(5),1110-1117(2001)
14.
Duration of stretching effect on ROM in lower limb, A.P.M.R., 66,171-173(1985)
15.
Effects of static stretch versus static stretch and U.S. combined on triceps surae muscle extensibility in healthy women, PHY. THER.,67(5), 674-679 (1987) 7
ISSN: 2277-1700 â—? Website: http://www.srji.info.ms â—? URL Forwarded to: http://sites.google.com/site/scientificrji
16.
SWD and prolonged stretching increase hamstring flexibility more than prolonged stretching alone, J.O.S.P.T.,34( 1), (2004)
CORRESPONDENCE
*Research Scholar, Singhania University. Rajasthan, India **Consultant Orthopaedics, Kapoor Medical Center
8
IMPACT OF AGEING ON DEPRESSION AND ACTIVITIES OF DAILY LIVINGS IN NORMAL ELDERLY SUBJECTS LIVING IN OLD AGE HOMES AND COMMUNITIES OF KANPUR, U.P. Vanshika Sethi*, Vijeylaxmi Verma**, Udhbhav Singh***
ABSTRACT INTRODUCTION: Ageing is a progressive generalized impairment of functions resulting in loss of adaptive response to stress and increasing the risk of age related disease. METHODOLOGY: A sample of 200 elderly subjects i.e. 100 from the community (group A) and 100 from Old age home (group B) of sixty & above years of age were taken by the convenience sampling method. The subjects were collected through various old age homes and community which includes Vaikunth Dham Old Age Home, Ishwar Prem Ashram, Swaraj Ashram, Ramkrishna Mission old age home and nearby community located in the Kanpur and Varanasi. The subjects were assigned a number to maintain the confidentiality of the subjects and then the scales were used to assess the scores i.e., Geriatric Depression Scale (GDS) and Barthel index of daily livings were used to check the level of depression & ADL’s and then the scores were compared. THE RESULTS: The mean GDS scores for group A were 11.32 and for group B were 16.42 with a value of -6.981 with a p value of 0.00* and mean ADL’s scores on the Barthel index for group A were16. 54 and 17.98 for group B within value of -2.898 with a p value of 0.004* which shows there is a significant difference. Conclusion: Elderly subjects living in Old age home are more affected in terms of depression and ADL’s as compared to community dwelling elder subjects as old people living in their own homes were most able to cope in their homes. They received more support from relatives and friends than from health and social services16
9
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KEY WORDS: Elderly, ADLs, Depression, Community, Old age home
INTRODUCTION
However elderly are not preparing themselves for long life, nor are we receiving any information
Age classification varied between countries
about the aging process at home, school,
and over time, reflecting in many instances the
community in general. Society tends to exclude the
social class differences or functional ability related
elderly. They are considered incompetent and are
to the workforce, but more often than not was a
denied any responsibilities. This is far removed
reflection of the current political and economic
from previous societies in which, given their
situation. Many times the definition is linked to the
experience, the eldest members enjoyed a much
retirement age, which in some instances, was
higher status. They considered wise, the teachers,
lower for women than men. This transition in
and traditions. A great number of people in this
livelihood became the basis for the definition of
sector are slightly depressed and tend to consider
old age which occurred between the ages of 45 and
themselves less productive than they really are5
55 years for women and between the ages of 55
Between the year 2000 to 2050, the
and 75 years for men1.
worldwide proportion of persons over 65 years of
Elderly people are classified into: - 1) 60 yrs
age is expected to more than double, from the
to 70yrs- Young old 2) 70 yrs to 80yrs- Middle old
current 6.9% to 16.4%. As healthcare facilities
3) 80yrs &above- Old old 2
improve in countries, the proportion of the elderly
The risk factors for reduced physical function
in the population & the life expectancy after birth
in elderly people, as identified in longitudinal
increase accordingly. This is the trend which has
studies, relate to comorbidities, physical and
been in both developed & developing countries. It
psychosocial health, environmental conditions,
is commonly believed that the majority of the
social circumstances, nutrition, and lifestyle3
elderly population resides in developed countries.
As the western population is increasingly
However, this is a myth, as about 60% of the 580
ageing, problems connected with old age will
million older people in the world live in
dominate healthcare. Depression, one of the most
developing countries, and by 2020, this value will
prevalent psychiatric disorders, is expected to take
increase to 70% of the total older population 6
an even more prominent position than presently, as
Depression is common in medically ill elderly
the risk for developing depression increases with
and
old age. Depressive symptoms are present in
associated
with
greater
morbidity
and
mortality, increased health service use and medical
almost one third of the elderly populations and
costs. Studies have shown that antidepressant and
major depression may be present up to 4%
structured psychotherapy, alone or combined, are
Furthermore, once present, the prognosis for
effective in reducing depressive symptoms among
elderly with depression is poor4
older adults7
There have always been elderly people, but
Depression and anxiety lead to a serious
what is new today that they now form the largest
impairment of daily functioning and quality of life.
sector of the population in industrialized societies. 10
Scientific Research Journal of India â—? Volume: 2, Issue: 2, Year: 2013
In frail elderly, the effects of depression and
The model of the International Classification
anxiety are especially deep encroaching .The
of Functioning, Disability and Health can describe
number of elderly is rapidly growing. Almost a
the consequences of dementia that eventually lead
third of elderly subjects in the community with sub
to deterioration in BADL and loss of autonomy. In
threshold depression or anxiety will develop a
the context of this review, dementia (health
major depressive or anxiety disorder in three years
condition) has a negative influence on mobility,
8
endurance, lower-extremity strength and balance The prevalence of major depressive disorder
(body functions and body structures). Those body
at any given time in community samples of adults
functions are important for BADL functioning
aged 65-67 older ranges from 1-5% in larger scale
(activity). Depending on the quality of the BADL
epidemiological investigations in the United States
performance, patients are less or more restricted in
and internationally, with the majority of studies
their participation (participation). By training
reporting prevalence at the lower end of the range.
physical components underlying ADL, or by a
Clinically significant depressive symptoms are
direct influence of exercise on ADL, healthy
present in approximately 15% of the community-
elderly subjects can stabilize or improve their
dwelling older adults 9
ADL score12
Major depressive disorder is one of the most
The mechanisms by which depression has an
common forms of psychopathology, one that will
effect on physical disability are not completely
affect approximately one in six men and one in
understood. Both behavioral (depressed patients
four women in their lifetimes. It is also usually
may have poor lifestyle, such as nonadherence to
highly recurrent, with at least 50% of those who
medication and self-care regiments) and biological
recover from a first episode of depression having
mechanisms (depression may worsen medical
one or more additional episodes in their lifetime,
diseases
and approximately 80% of those with a history of
pituitary-adrenal axis and the sympathetic nervous
two episodes having another recurrence. Once a
and immunological system) have been proposed.
first episode has occurred, recurrent episodes will
Each could lead to more disability13
through
changes
in
hypothalamic-
One might expect that elevated body mass
usually begin within five years of the initial episode, and, on average, individuals with a
index
history of depression will have five to nine
impairments in ADL through other mechanisms
10
that include associations with diabetes and
separate depressive episodes in their lifetime Disability in Activities of
(throughout life) could also promote
Daily Living
possibly knee joint injuries in
later life or
(ADL) , which are the essential activities that a
difficulties in walking around the house (more
person needs to perform to be able to live
common in Hawaii but unrelated to body mass
independently , is an adverse outcome of frailty
index in the current sample). It may be that
that places a high burden on frail individuals,
impairments in the ADL are more frequent in the
health care professionals and health care systems .
presence of subclinical frailty where weight loss is
Frail elderly people have a higher risk of ADL
a problem. Long-term follow-up of the effects of
11
body mass in middle adulthood on the risk of late-
disability compared to non-frail elderly people
11
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Ashram, Ramkrishna Mission old age home and
life ADL impairment might reveal a clearer 14
nearby
association
community
located
in
the
Kanpur
&Varanasi.
In a study of patients with and without depression during the immediate period after
All subjects signed consent forms & were
stroke but with similar impairments in ADL
ready to take part in the study .The subjects were
scores, we found, 2 years later, that the depressed
given the instructions regarding the procedure &
patients had significantly less recovery in their
the subjects who fulfilled the inclusion criteria &
ADL functions than the no depressed patients. The
were ready to actively participate, were selected.
recovery curves for ADL function were not
Inclusion criteria
significantly different between patients with major
1. Normal elderly male & female with age of ≥ 60 years.
depression versus those with minor depression, suggesting that both moderate and severe forms of
2. Able to understand verbal instructions &
depression lead to impaired recovery in ADL
completed 8-10 years of formal education.
functions. Morris et al who used an abbreviated
3. Subjects with stable medications Exclusion criteria
version of the Barthel index, also reported that at 15 months after stroke, patients with major
1. Any neurological problems such as
depression and those with minor depression had a
Parkinsonism, stroke, cerebellar disorders,
significantly greater physical disability than no
balance disorders, myopathy, myelopathy
depressed patients15
which can influence the psychological
As in elderly people living in community &
status of the subjects.
old age home depression and impairment in
2. Any cardiovascular or orthopedic problems
performing activities of daily livings are major
which affects their day to day routine
problem therefore assessing the prevalence of
activity & further may become the cause
depression and impairment in ADL’s forms the
of depression. 3. Significant hearing & vision impairment.
basis of the study.
4. Uncontrolled hypertension. 5. Any speech deficit interfering the survey.
MATERIALS & METHODS:
6. Unstable seizure / disorder affecting the
This study is a survey type of study which
psychological status of subjects.
intends to find changes in levels of depression and
7. Smoking or alcohol intake.
activities of daily livings scores in elderly subjects living in the community and in old age home. A sample of 200 elderly subjects i.e. 100 from
Procedure
the community and 100 from Old age home of sixty & above years of age were taken by the convenience sampling method. The subjects were collected through various
Group
Mean
Community
11.32
(gp A)
old age homes & which includes Vaikunth Dham
Home
Old Age Home, Ishwar Prem Ashram, Swaraj
(gp B) 12
Standard Deviation
T
0.000*
4.29 -6.981
16.42
5.90
P
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
Subjects were introduced to the study
The mean value of the Barthel index for the old
followed by the signing of consent forms ,general
age home was 16.54 with standard deviation
assessment regarding of socio-demographic data (
4.001and mean value for subjects living in the
name, gender, age), education level, past medical
community was 17.98 with SD 2.947 and p value
history, personal history, family history were
was 0.004 which shows there is a significant
gathered from the participants assessment forms.
difference in the scores hence Activities of daily
The subjects were collected from community &
livings are more affected in elderly people living
various old age homes & were divided into two
in an old age home town community.
groups a (community) and b (old age home) for comparison. Total 200 numbers of subject’s data
Table 2: Analysis of Activity Of Daily Living
was collected, 100 for Group A(community) and
by Barthel index between group ‘A’ & group
group B (old age home).The subjects were
‘B’
assigned a number to maintain the confidentiality of the subjects and then the scale was used to
Group
Mean
assess the scores i.e., Geriatric Depression Scale (GDS) and Barthel Index (BI) was used to check
Community
the level of depression and impairment in ADL’s
(gp A)
and then the scores were entered in the data
Home
collection form.
16.54
17.98
(gp B)
Standard Deviation
T
P
-2.898
0.004*
4.001
2.947
*Significant difference RESULTS Reading on GDS and BI were taken during
DISCUSSION
first interview contact with the subject and were
As results of the study shows that depression
tabulated as data.
level is more in elderly living in an old age home
The mean value of GDS for the old age
than in community. It is supported by a study
home (group B) was 16.42 with standard deviation
which
5.90 and mean value for subjects living in
suggests
that
urbanization
promotes
nucleation of the family system and a decrease in
community (group A) was 11.3 with SD 4.29 and
care and support for the elderly. Depression and
p value was 0.000 which shows there is a
physical illness often coexist in the elderly as they
significant difference in the score hence level of
both occur commonly in old age. There is a close
depression is more in elderly people living in an
relation between depression and physical illness.
old age home town community.
Depression may be caused by a specific physical disorder possibly as a direct consequence of the
Table 1: Analysis of GDS score in group A and
cerebral organic effect of these conditions.
group B
Therefore strategies to decrease depression should be utilized for persons living in an old age home.
*Significant difference
The
literature
shows
the
institutionalized
participants were more likely to report depressed 13
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mood, crime, wishing to be dead, future looking
4. Group involvement and interaction with
bleak and staying away from others. Therefore the
society may be suggested for subjects
persons living in an old age home should be
living in an old age home as loneliness
encouraged to intact with the society and family
may be the factor affecting ADLs and
members to cope up depression.
depression.
Literature shows that older people living in their own homes were most able to cope in their homes. They received more support from relatives and
friends
than
from
health
and
social
3
services .Result of the present study also shows that elderly people living in an Old age home were more affected in terms of ADLs than elderly people living in the community.
Relevance to clinical practice: This research study may serve as a basis for development and implementation of a new rehabilitation program to cope up depression and to improve daily living skills for subjects living in an old age home and in community by which further their level of dependency and depression can be reduced.
Future research: 1. This study is a survey type study in which no training was given to the improvement of ADLs and to decrease the depression hence in a future training program can be administered and its after effects may be noted down. 2. As sample size was small hence large sample size may be taken to generalize the results. 3. Task
oriented
goals/activities/training/may be used to improve the efficiency of subjects living in an old age home and community.
14
REFERENCES
1.
Definition
of
an
older
or
elderly
person
.
www.int/healthinfo/survey/agingdefinolder/en/index.html. 2.
Mascarenhas Steffi ,Yardi Sujata . Retrospective study on limitation of activity of daily living in geriartric women. Indian Journal Of Physiotherapy And Occupational Therapy .2012 ; 6(1)
3.
Beswick DA , Rees K , Dieppe P, Ayis Salma , Hill Gooberman R , Horwood J And Shah E. Complex study to improve physical function and maintain independent living in elderly people : a systemic review and meta analysis . Lancet.2008 ; 371(9614): 725-735
4.
Most IS Els, Scheltens Philip, Someren Van JW Eus. Prevention of depression and sleep disturbances in elderly with memory-problems by activation of the biological clock with light- a randomized clinical trial. Most et al. Trials. 2010:11-19
5.
Hernandezequena Carmen, Gonzalez Zubiaur Marta .Effects of Intergenerational Interaction on Aging. Educational Gerontology.2008;34:292-305
6.
Taqui Ather M, Itrat Ahmed, Qidwai Waris, Zeeshan Qadri. Depression in the elderly: Does family system play a role? A cross-sectional study.BMC Psychiatry.2007;7: 57
7.
Ell Kathleen , Unutzer jurgen, Aranda Maria, Gibbs E.Nancy, Lee Jiuan ,Xie Bin .Managing Depression in the Home Health Care: A Randomized Clinical Trial. Home Health Care servQ.2007;26(3):81-104
8.
Veer-Tazelaar, Marwick Harm van, Oppen Van Patricia, Ninpels Giel, Hout Van Hein, Cuijpers Pim, Stalman Wim, Beekma Aartjan. Prevention of anxiety and depression in the age group of 75 years and over: a randomized controlled trial testing the feasibility and effectiveness of a generic stepped care programme among elderly community residents at high risk of developing anxiety and depression versus usual care. BMC Public Health .2006; 6:186
9.
Fiske Amy, Wetherell Loebach Julie, Gatz Marget.Depression In Older Adults.Annu Rev Clin Psycho. 2009: 363-389
10.
Burcusa L. Stephanie, Locono G.William.Risk for Recurrence in Depression. Clin Psychol. 2007 ; 27(8):959-985
11.
Vermeulen Joan , Neyens Jacques Cl , Rossum Van Erik , Spreewenberg Marieke D and Witte De P Luc.Predicting Adl Disability In Community –Dwelling Elderly People Using Physical Frailty Indicators : Systemic Review . Bmc Geriatrics .2011;11:33
12.
Canhota Da Nogueira Manuel Carlos. Depressive disorders in elderly chienese patients in macau: a comparison of general practitioners consultations with a depression screening scale.Australian and New Zealand Journal of Psychiatry .2001;35:336-344
13.
Li W. Lydia, Conwell Yeates. Effects of changes in depressive symptoms and cognitive functioning on physical disability in home care elders. J Geronetol A Boil Sci Med Sci .2009; 64 (2):230-236 15
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14.
Abbott Robert D. , Kadota Aya , Miura Katsuyuki , Hayakawa Takehito, Kadowaki Takashi , Okamura Tomonori , Okayama Akira , Masaki H. Kamal , Ueshima Hirotsugu . Impairment in activity of daily living in older japanese men in hawaii and japan .Journal Of Aging Research .2011 ;Article Id 324592
15.
Chemerinski Eran, Robinson G. Robert, Kosier T. James. Improved recovery in activity of daily living associated with remission of post stroke depression. Journal of the American heart Association Stroke. 2001; 32:113-117.
16.
Rogers C. Joan, Holm Margo B., Raina Ketki D., Dew Amanda Mary, Shih Min-Mei, Begley Amy, Houck R. Patricia , Majumdar Sati , Reynolds F. Charles.Disability in late life major depression : patterns of self-reported task ability, task habits and task performance . Psychiatry Res . 2010 ; 178(3): 475-479
CORRESPONDENCE
* Assistant Professor, Physiotherapy Dept., Saaii College of Medical Science and Technology, Kanpur, U.P. ** B.P.T. Student, Saaii College of Medical Science and Technology, Kanpur, U.P. *** B.P.T. Student, Saaii College of Medical Science and Technology, Kanpur, U.P.
16
TO ASSESS THE RELATIONSHIP BETWEEN TEMPOROMANDIBULAR JOINT DYSFUNCTION AND CERVICAL SPINE DYSFUNCTION Khyati Harish Sanghvi (BPT)*, Amrit Kaur (MPT)**, Ganesh Subbiah (MPT)***
ABSTRACT The temporomandibular joint is directly related to the cervical and scapular region. AIM- To assess any possible relationship between temporomandibular dysfunction (TMD) and cervical spine dysfunction (CSD) METHODS- Total 30 volunteers,15 volunteers that were presenting clinical signs and symptoms of TMD and 15 volunteers that were presenting CSD according to Temporomandibular Dysfunction Assessment Questionnaire and Neck disability Index respectively were selected for this study. Individuals having TMD were assessed for any signs and symptoms of CSD using Neck disability Index, Index of Cervical Mobility and VAS score. Individuals having CSD were assessed for TMD using Temporomandibular Dysfunction Assessment Questionnaire, Mandibular Mobility Index and VAS score RESULT-Correlation test (p ≤ 0.05) was performed to verify the relationship between CSD & TMD. The increase in TMD signs and symptoms was accompanied by increase in CSD severity. CONCLUSION- The result of this study concluded that TMD is accompanied with CSD and vice-a-versa.
KEYWORDS: Cervical pain, cervical spine dysfunction, Temporomandibular Joint; Temporomandibular joint dysfunction.
INTRODUCTION
conditions affecting the cervical region and related
Cervical spine dysfunctions are common
structures, with or without radiating pain towards 17
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the Shoulder, Arms, Inter scapular region and Head
considered a predisposing factor for cervical spine
1, 2, 3
. There are estimates that 67% of the
dysfunction, and supposing that the referred neck
population will suffer from neck pain at some
pain is of orofacial origin7, there should be direct
stage of life 3. Neck pain is often the major
relationship between the increase of cervical spine
symptom in cervical spine dysfunction related to
dysfunction
post-traumatic or to chronic micro-traumatic
previously
lesions of the joints and periarticular structures1.
dysfunction severity.
Temporomandibular dysfunctions are defined as
Mara
4
signs
and
symptoms
existing
Ines
the
temporomandibular
Baptistella
evaluated
Temporomandibular dysfunction is collective term
dysfunction in patients undergoing physiotherapy
applied
to
treatment for cervical pain. They concluded that
associated
90% of patients with cervical pain were found to
all
temporomandibular
problem joint
related
and
of
Ferao (2008)
common non-dental cause of orofacial pain .
to
prevalance
and
temporomandibular
have temporomandibular dysfunction16.
musculoskeletal structures. Temporomandibular dysfunction characterizes a cluster of disorders
However study done by BEVILAQUA-
marked by pain in the pre-auricular area,
GROSSI (2007) concluded that, cervical signs and
temporomandibular joint and masticatory muscles,
symptoms
as well as limitations or deviations during the
dysfunction but the inverse was not true, the
mandible range of motion, and temporomandibular
temporomandibular
joint sounds during function 5.
symptoms did not increase with cervical spine
accompanied
temporomandibular
dysfunction
sign
and
dysfunction severity in female community cases17.
Anatomically, the mandible and the base of skull presents the muscular and ligamentous
It is known that the balance of the body, as
connections with the cervical region, forming a
well as the movements of the head, originated
functional
from the positioning of the skull over the cervical
system
known
as
cranio-cervico-
mandibular system6.
and scapular region; determine the posture of the
If cervical spine dysfunction is considered
individual. Therefore, it is supposed that any
a predisposing factor for temporomandibular
alteration in these structures can bring about
dysfunction, and supposing that the related
postural imbalance, not only in these locations, but
Orofacial pain is of cervical origin 7, there should
also in other muscle groups of the body11. In this
be a direct relationship between the increase of
way,
temporomandibular
and
represent a constant concern for Medicine,
symptoms and the previously existing cervical
Dentistry, Physiotherapy and Public Health who
spine dysfunction severity. Thus, cervical spine
wish to understand the behavior of the joint in its
dysfunction
signs
8
Lesions caused by repetitive movements , head and cervical posture alterations
9, 10
temporomandibular
dysfunction
may
biomechanical activities.
likely lead to
The present study was done to determine
cervical spine dysfunctions and, subsequently, to
any possible relationship between cervical spine
the
dysfunction and temporomandibular dysfunction
manifestation
of
temporomandibular
dysfunction signs and symptoms. If
temporomandibular
in individuals aging from 18 to 40years. The dysfunction
is
findings of this study can be used to frame
18
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
assessment and management goals in patients with cervical
spine
dysfunction
Total between 70 and 100 points
and/or
Severe TMD
The mean of the patient’s age with
temporomandibular dysfunction.
primary temporomandibular dysfunction was 25 years (SD=7). Temporomandibular Joint ROM and
METHODS
VAS were recorded. Then they were assessed for
30 patients were selected to participate in the study
any signs and symptoms of cervical spine
on basis of inclusion criteria;
dysfunction using Neck disability Index13, index of cervical mobility (ICM)14 and VAS score.
Individuals aging from 18 to 40 years.
Other 15 volunteers that were primarily
15 Individuals having temporomandibular joint dysfunction (Group 1).
presenting cervical spine Dysfunction according to
15 Individuals having cervical spine dysfunction
Neck disability Index13 were selected as Group 2
(Group 2).
for this study. They were screened for any
Exclusion criteria was General Joint Disorder
exclusion criteria and then divided into severity
involving Head and Neck (e.g. Rheumatoid
i.e., mild, moderate or severe Cervical spine
Arthritis); History of Jaw Fracture; Individuals
dysfunction on basis of their scoring in Neck
suffering through Facial Palsy; History of Cervical
disability Index13. The Neck Disability Index is
vertebra fracture; Patients having Trigeminal
divided into 10 set of multiple choice questions
Neuralgia and Patients having braces applied for
which have 6 options for each and each 5 options
proper alignment of teeth.
are scored from 0 to 5 on basis of severity. Maximum score can be 50 and minimum 0.
15 volunteers that were primarily presenting clinical
signs
temporomandibular Temporomandibular 12
Questionnaire
and
symptoms
dysfunction Dysfunction
according
Table 2: NDI scoring Total between 0 and 4 Total between 5 and 14 Total between 25 and 34 Total between 35 and 50
of to
Assessment
No CSD Mild CSD Moderate CSD Severe CSD
were selected as Group 1 to
participate in the study. They were screened for
The mean of the patient’s age with
any exclusion criteria and then divided into
primary cervical spine dysfunction was 24.1 years
severity i.e., mild, moderate or severe of Temporo-
(SD=6.65). Cervical Spine ROM and VAS were
mandibular dysfunction on basis of their scoring in
recorded.
temporomandibular
temporomandibular
dysfunction
assessment
12
Then
they
were
assessed
dysfunction
for using
questionnaire . The questionnaire is set of 10
Temporomandibular
questions
Questionnaire, Index of Mandibular mobility
regarding
Temporo-mandibular
Dysfunction
Assessment
(IMM)15 and VAS score.
dysfunction and the symptoms. Answers were collected in terms of “YES”, “SOMETIMES” or
The
“NO” and were scored 10, 5 or 0 respectively.
movements
Maximum score can be 100 and minimum 0.
opening (MMO), maximal lateral deviation to
Table 1: TMDQ Scoring Total between 0 and 15 points Total between 20 and 40 points Total between 45 and 65 points
right and left (MLDR and MLDE) and maximal No TMD Mild TMD Moderate TMD
following were
Temporomandibular
recorded:
maximal
mouth
protrusion (MP). The cervical movements of flexion, extension, right and left rotations and right 19
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and left lateral flexions were recorded. To measure
correlation
Temporomandibular and Cervical range of motion,
p>0.05. As coefficient of correlation value is
a ruler (mm) and a universal Goniometer (°) were
between 0 and +1, we can say that the two sets of
used respectively.
data show weak, positive correlation. But as P
This
study
was
approved
by
coefficient
(SRCC) =
0.223214,
the
value is more than 0.05, the result is not
Committee for Ethics and Research of the
significant, i.e., there is no correlation between
NDMVP medical college and the patients signed a
scores of IMM and CMI scores.
term of free and informed consent confirming their
The correlation test was applied to check
agreement to participate in the study. Spearman’s
rank
correlation
prevalence of cervical spine dysfunction in test
was
patients with temporomandibular dysfunction. The
performed to verify the relationship between
result was, spearman’s rank correlation coefficient
cervical spine dysfunction & temporomandibular
(SRCC) = 0.62857, p<0.05. As coefficient of
dysfunction.
correlation value is between 0 and +1, we can say that
the
two
sets
of
data
show good,
RESULT
positive correlation. As P value is less than 0.05,
Descriptive data is given in table 3.
the result is significant, i.e., there is prevalence of cervical spine dysfunction in patients with temporomandibular dysfunction. Group 2 Total 15 individuals were selected under the category of cervical spine dysfunction after performing screening test (NDI). The mean of the
Table 3: Descriptive Data
patient’s age was 24.1 years (SD=6.65). On
Group 1
analysis it was found that, 40% had mild, 33% had
Total 15 individuals were selected under the
moderate
category of temporomandibular dysfunction after
and
26.67%
had
severe
temporomandibular dysfunction.
performing screening test (TMDQ). The mean of
The mean VAS of two groups was;
the patient’s age was 25 years (SD=7). On analysis
Cervical pain: 4.66
it was found that 26.67% patient had no cervical
Temporomandibular Joint pain: 1.6
spine dysfunction, 60% had mild, 6.67% had
The correlation test was applied to check
moderate and 6.67% had severe cervical spine
the association between the scores of index of
dysfunction.
mandibular mobility and index of cervical
The mean VAS of two groups was;
mobility. The Result was, spearman’s rank
Cervical pain: 2.64
correlation
Temporomandibular Joint pain: 4.25
coefficient
(SRCC) =
0.076786,
p>0.05. As coefficient of correlation value is
The correlation test was applied to check
between 0 and +1, we can say that the two sets of
the association between the scores of index of
data show very weak, positive correlation. But as P
mandibular mobility and index of cervical
value is more than 0.05, the result is not
mobility. The Result was, spearman’s rank 20
Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 2, Year: 2013
significant, i.e., there is no correlation between
neck
scores of IMM and CMI scores.
posteriorly the levator scapula. The mandible is
are
anteriorly
sternocleidomastoid
and
The correlation test was applied to check
controlled by the muscle of mastication and it is
prevalence of temporomandibular dysfunction in
connected to cranium through its articulation of
patients with cervical spine dysfunction. The result
the teeth and the temporomandibular joint. This
was, spearmanâ&#x20AC;&#x2122;s rank correlation coefficient
complex relationship is important since mandible
(SRCC) = 0.657143, p<0.05. As coefficient of
is attached to both cranium and cervical spine and
correlation value is between 0 and +1, we can say
any positional changes of either will produce
that
postural
the
two
sets
of
data
show good,
changes
of
mandible
and
hence
positive correlation. As P value is less than 0.05,
disturbances in its articulation. The inverce is also
the result is significant, i.e., there is a prevalence
true
of temporomandibular dysfunction in patients with
temporomandibular joint articulation, it can alter
cervical spine dysfunction.
the position of mandible and in turn cervical spine
that
if
there
is
disturbances
in
and shoulder girdle. DISCUSSION
Thus there is relationship between the
The result of this study demonstrated that
mandible,
is
temporomandibular
suprahyoid and infrahyoid structures, shoulder
dysfunction in patients with cervical spine
girdle, the thoracic spine and ultimately the
dysfunction or cervical spine dysfunction is one of
lumbosacral spine. These structures function as
the predisposing factors for temporomandibular
inter related biomechanical unit. Dysfunction in
dysfunction and vice-a-versa. However, significant
any one part of this unit may often lead to
differences in the values of Mandibular range of
dysfunction of unit as a whole. However in
motion among temporomandibular dysfunction
reviewed literature, there were no studies that
severity groups and in values of cervical range of
varified the time required for development of of
motion among cervical spine dysfunction severity
orofacial pain signs and symptoms caused by head
groups were not verified.
postuer alteration and vice-versa.
there
prevalence
of
the
cranium,
the
cervical
spine,
The ideal posture of head places the center
The result of this study suggest that almost
of gravity slightly anterior to the cervical spine.
all the individual with cervical spine dysfunction
For this reason, when sitting or standing the head
had temporomandibular dysfunction and about
falls anteriorly if the muscles of the head and neck
73% of individuals with temporomandibular
are totaly relaxed. To maintain this postural
dysfunction had cervical spine dysfunction.
position, strong posterior cervical muscles are needed. The anterior cervical muscles are small
CONCLUSION
and thin muscles which come from the clavicle, The
sternum and rib cage to the hyoid bone (infrahyoid
result
of
this
study
concluded
that
temporomandibular dysfunction is accompanied
muscles) and from the hyoid to the mandible
with cervical spine dysfunction and vice-a-versa.
(suprahyoid muscles). Two other important muscle
Almost all the individual with cervical spine
which controls position and stability of head and
dysfunction had temporomandibular dysfunction 21
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and
about
73%
of
individuals
with
dysfunction.
temporomandibular dysfunction had cervical spine
REFERENCES
1. Ciancaglini R, Testa M and Radaelli G (1999). Association of neck pain with symptoms of temporomandibular disorders in the general adult population. Scand J Rehabil Med.;31(1):17-22. 2. De Wijer A, Steenks MH, Bosman F, Helders PJ and Faber J (1996). Symptoms of the stomatognathic system in temporomandibular and cervical spine disorders. J Oral Rehabil; 23(11):733-741. 3. Visscher CM, Lobbezoo F, Boer W, van der Zaag J, Verheij JG and Naeije M (2000). Clinical tests in distinguishing between persons with or without craniomandibular or cervical spinal pain complaints. Eur J Oral Sci; 108(6):475-483. 4. Mcneill C (1997). Management of temporomandibular disorders: concepts and controversies. J Prosthet Dent; 77(5):510-522. 5. Dworkin SF, Huggins KH, Leresche L, Von Korff M, Howard J, Truelove E, et al (1990). Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in cases and controls. J Am Dent Assoc; 120:273-281. 6. Arrelano JCV (2002). Relações entre postura corporal e sistema estomatognático. JBA; 2: 155-164. 7. Browne PA, Clark GT, Kuboki T and Adachi NY (1998). Concurrent cervical and craniofacial pain: a review of empiric and basic science evidence. Oral Surg Oral Med Oral Pathol Oral Radiol Endod; 86(6):633-640. 8. Kirveskari P, Alanen P, Karskela V, Kaitaniemi P, Holtari M, Virtanen T, et al (1988). Association of functional state of stomatognathic system with mobility of cervical spine and neck muscle tenderness. Acta Odontol Scand; 46(5):281-286. 9. Gonzalez HE and Manns A (1996). Forward head posture: its structural and functional influence on the stomatognathic system, a conceptual study. Cranio; 14(1):71-80. 10. Mannheimer JS and Rosenthal R (1991). Acute and chronic postural abnormalities as related to craniofacial pain and temporomandibular disorders. Dent Clin North Am; 35:185-208. 11. Amantéa DV, Novaes AP, Campolongo GD and Barros TP(2004). A importância da avaliação postural no paciente com disfunção temporomandibular. Acta Ortop Brás; 12:1-8. 12. Kariny Nomura, Mathias Vitti, Anamaria Siriani de Oliveria, Thaís Cristina Chaves, Marisa Semprini, Selma Siessere, Jaime Eduardo Cecilio Hallak and Simone Cecilio Hallak Regalo (2007). Use of the Fonseca’s Questionnaire to assess the prevalence and Severity of Temporomandibular Disorders in Brazilian Dental Undergraduates. Braz Dent J; 18(2): 163-167. 13. Joy C. Macdermid, David M. Walton, Sarah Avery, Alanna Blanchard, Evelyn Etruw, Cheryl Mcalpine and Charlie H. Goldsmith (2009). Measurement Properties of the Neck Disability Index: A Systematic Review. Journal of orthopaedic & sports physical therapy; 39, 5:400-417.
22
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
14. Wallace C and Klineberg IJ (1993). Management of craniomandibular disorders. Part 1. A craniocervical dysfunction index. J Orofac Pain; 7(1):83-88. 15. Helkimo M (1974). Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state. Swed Dent J; 67(2):101-21. 16. Mara Ines Baptistella Ferao and Jefferson Traebert (2008). Prevalence of temporomandibular dysfunction in patients with cervical pain under physiotherapy treatment. Fisioter; 21(4):63-70. 17. Débora Bevilaqua-Grossi, Thaís Cristina Chaves and Anamaria Siriani de Oliveira (2007). Cervical spine signs and symptoms: perpetuating rather than predisposing factors for temporomandibular disorders in women. J Appl Oral Sci; 15(4):259-64.
CORRESPONDING AUTHOR: * N.D.M.V.P College of Physiotherapy, Email: drkhyati_26@yahoo.co.in ** Assistant Professor, Department Of Community Based Rehabilitation, N.D.M.V.P College of Physiotherapy, Email: dr_amritkaur@yahoo.co.in *** Associate Professor, Department of Musculoskeletal Sciences, N.D.M.V.P College of Physiotherapy, Email: ganeshmpt2006@yahoo.co.in
23
EFFECTIVENESS OF NEUROMOTOR TASK TRAINING COMBINED WITH KINAESTHETIC TRAINING IN CHILDREN WITH DEVELOPMENTAL CO-ORDINATION DISORDER - A RANDOMISED TRIAL Sundaresan Chockalingam* Agnel Kevin Gomes**
ABSTRACT The aim and objectives of this study was to find out the prevalence of Developmental coordination disorder (DCD, a chronic motor impairment affecting child’s ADL) in school children from 5 to 10 years of age and to analyse the effectiveness of Neuromotor Task Training when combined with Kinaesthetic training in managing them. Using Pretest-Posttest Quasi Experimental study design, 56 samples of children with indication or suspect for DCD in DCDQ’07 who also obtained total scores below the 15th percentile on the TGMD-2 were randomly assigned for two interventions, Neuromotor Task Training (NTT) combined with Kinaesthetic training (Intervention Group 1) and NTT alone (Intervention Group 2) for a period of 7 weeks in small groups. The outcome was assessed with Gross Motor Quotient of TGMD-2. The data were analysed with Student’t’ tests comparing values within the groups and between the groups. Results showed that the prevalence of DCD in the local population is 6.82% and there is no significance difference between the improvements made in the two intervention groups but the differences in the mean value support the combined therapy group to have some better effects.
KEYWORDS: Developmental Coordination Disorder (DCD), Developmental Coordination Disorder Questionaire’07(DCDQ’07), Test of Gross Motor Development-2 (TGMD-2), Neuromotor Task Training, Kinaesthetic Training. 24
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
there is extensive evidence that motor difficulties
INTRODUCTION disorder
have a pervasive effect on children’s lives. The
of children between 5 and 11
difficulties affect the child both in school and at
. Prevalence of movement
home, and in contrast with similar aged children
difficulties in children has been reported as high
who acquire skills with little effort such as
as 19%. However, two studies undertaken in the
dressing, playing ball games and handwriting,
UK reported a prevalence of 5% and 8.5%
these children take longer to learn and automate
Developmental affects about 6% years of age
respectively
1
coordination
2
motor skills. Increasing interest in these children,
. DCD is defined, using the
Diagnostic and Statistical Manual of Mental
in
academic
research
and
in
clinical
and
Disorders, Fourth Edition (DSM-IV), as a
educational practice, has focused on the need not
condition marked by a significant impairment in
only for early identification but also to consider
the development of motor coordination, which
the presentation in adolescence and adulthood, as
interferes with academic achievement and/or
around 70% of children continue to have
activities of daily living (ADL). These difficulties
difficulties when grown up5.
are not due to a general medical condition (e.g.,
Over the past forty years, various
cerebral palsy) and are in excess of any learning
treatment programs have been developed for
difficulties if present
1
children
. The symptoms of
with
Developmental
Coordination
developmental coordination disorder may include
Disorder (DCD). These treatment programs can
marked delays in achieving milestones of motor
roughly be divided into two categories: the
development, dropping things, clumsiness, and
process-oriented approaches and the task-oriented
poor performance in sports or poor handwriting. If
approaches 6. The process-oriented approaches
any of these symptoms interferes with a child’s
concentrate on the treatment of deficits in
performance of daily activities, a diagnosis is
processes assumed to underlie poor motor
warranted 1. Observations of school-age children
coordination. Task-oriented approaches, on the
with Developmental coordination disorder during
other hand, focus directly at the functional skills
organized and free play show that these children
with
spend less time in formal and informal team play
Examples of process-oriented approaches are
than children without the disorder3.
kinesthetic training developed by Laszlo et al.
which
a
child
experiences
problems.
DCD is defined on the basis of a failure
(1988) and Sensory Integration Therapy developed
of the acquisition of both fine and gross motor
by Ayres (1972). Neuromotor Task Training
skills, which is not explicable on the basis of
(NTT) was recently developed for treating children
impaired general learning and similar exposure to
with DCD by pediatric physical therapists 7. The
opportunity to gain motor skills as their peers.
training concerns a task-oriented program based
DCD is often seen as the ‘Cinderella’ of
upon recent insights about motor control and
developmental
always
motor learning. The developmental coordination
considered routinely by clinicians 4. However,
disorder questionnaire 2007 (DCDQ’07) was
disorders
and
not
25
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motor difficulties, while others have difficulties
developed to screen for the presence of motor 8
with both fine and gross motor tasks 18.
problems and as an adjunct to standardized tests . Over the past 10 years, it has also proven to be a valid measure of everyday
Use of the DCDQ’07 by occupational
functioning, as
and physical therapists, as well as researchers, to
academic achievements or activities of daily
both screen for DCD and to confirm the functional
living. It is recommended that The Movement
consequences of a motor deficit, will support the
Assessment Battery for Children (M-ABC) and
identification of children in need of services. The
The Test of Gross Motor Development (TGMD-2)
DCDQ’07
should be considered for assessing the gross motor
collaboration and application of research results
performance of children with DCD in the first
across cultures 15.
will
also
allow
international
instance. Both these tests give standardized scores
Neuromotor Task Training (NTT) was
that are easily explained to the patient/parent, and
developed for treating children with DCD by
both have items that children would find
pediatric physical therapists. Within this approach,
9
acceptable and relevant .
physical therapists start with the assessment of the strengths and weaknesses of a child’s functional
BACKGROUND
performance. Next, therapists will analyze which
Developmental coordination disorders
cognitive or motor control processes might be
may first become apparent in early childhood, but
involved in deficient motor skill performance. A
they are difficult to assess reliably before the age
child can fail to learn a specific motor skill
of 5 years. Children with DCD are usually first
because of attention problems, fear of failure, lack
noted in primary school when the condition clearly
of motivation, or lack of understanding how to
interferes with school performance or activities of
execute a particular skill. In addition, motor-
daily living. Most of these children are therefore
control
diagnosed between 6 and 12 years of age. Some
performance, such as timing of the components of
may even go unnoticed
17
processes
might
hamper
successful
. The teachers may
a motor skill pattern, motor planning, or parameter
initially notice children on the basis of difficulties
setting (the execution of a motor act with the
and poor handwriting is now one of the major
required speed and force).
reasons for the clinical referral of children with
In NTT, the functional exercises are
18
DCD . The DCD population is considered to be
designed in such a way that the therapist can
at risk for a range of associated psychosocial
analyze which motor control processes are
difficulties,
expected
deficient. Another important characteristic of NTT
educational achievement and low self-esteem.
is that teaching principles derived from motor
Children with DCD may show functional deficits
learning research are applied. The ultimate goal of
over a range of motor tasks. Some are impaired in
treatment is not only to improve functional task
whole body tasks such as running and jumping,
performance during treatment but also to transfer
ball skills, and tasks involving balance, such as
learned skills to daily life performance.
such
as
poorer
than
riding a bicycle. Some children may have fine
Kinesthesia is integral to the acquisition of motor skills in process-oriented treatment
26
Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 2, Year: 2013
approaches. Therapeutic intervention with process-
manner to which children respond to intervention.
oriented treatment is based on specifically
They also have stated that some children may
designed
As
require varying amounts of exposure to activities
described by Laszlo and Bairstow, this approach
with the amount being the influential factor,
has an inherent reward system built into it through
whereas with others, most notably the ones who
its use of positive reinforcement, presentation of
did not improve following intervention and
desirable activities within the capabilities of the
concluded that a qualitatively different type of
child, and judicious progression of the level of
approach may be required in dealing with children
difficulty. The usefulness of the process-oriented
with DCD 10.
kinesthetic
training
activities.
treatment approach has been the subject of
To date, combined approaches are
considerable study. Sims and colleagues suggested
largely untested, research has provided limited
that much of the success of this approach can be
evidence to support combined approaches as they
attributed to a strong motivation effect, fostered by
made smaller effects than pure approaches. It will
positive feedback and a sense of self-competence
be important for us to develop a systematic,
19
. Children with DCD benefit from using vision in
evidence-based approach to the treatment of these
combination with touch information for standing
children 13. To date there is no studies that have
control possibly due to their less well developed
clearly focused on finding out the incidence of
internal models of body orientation and self-
DCD in South Indian population. Considering
motion. Internal model deficits, combined with
these statement, it is very clear that there is a need
other known deficits such as postural muscles
for a good experimental trail on finding the
activation timing deficits, may exacerbate the
effectiveness of combined approaches (top down
12
balance impairment in children with DCD .
and bottom up approaches) in children with DCD.
Group-based motor skill training may have its own advantages. First, the group setting
METHODOLOGY
provides opportunities for social interaction.
Participants for this study included
Secondly, children are competitive, and this
children, both boys and girls, aged 5 to10 years
motivates them to perform better. Furthermore, a
from Bharathidasan Matric Higher Secondary
stronger sense of competence may be developed if
School, Kanchipuram, Tamil Nadu, India. In two
a child can successfully demonstrate the acquired
stage selection process, sequential sampling was
motor skills in front of his or her peers in the
used to screen 1407 students (boys and girls).
group. This perceived competence may further
Among the subjects screened by staged procedure,
encourage the childrenâ&#x20AC;&#x2122;s participation in the
54 were selected and assigned randomly into two
training and in other physical activities affecting
groups and considered for intervention. All
14
their motor competence .
children with indication or suspect for DCD aged
Children with DCD do not form a
from 5 to 10 years in DCDQâ&#x20AC;&#x2122;07, Obtained total
homogeneous group. It is possible that, just as
scores on the TGMD-2 below the 15th percentile
characteristics are showing differences across
and their motor problems could not be attributed to
clusters of children, differences are evident in the
evident pathological neurological signs were
27
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are under indication, or suspect for DCD.
included. Only children attending schools for
In the second stage of selection process,
general education were considered which implies
the children under indication or suspect for DCD
an IQ-score in the normal range. The children those who had received or
underwent TGMD-2. The TGMD-2 was conducted
were undergoing physical therapy or occupational
in the outdoor play area. 2 Physical Education
therapy and those who have any profound visual or
Teachers and 1 special skill training staff were
hearing deficiencies that could not be corrected by
involved in this selection process, assisting the
external devices were excluded.
procedure. On the first testing day, the procedure
In the first stage selection process, 2
was explained to the participants in details. Then,
Physical Education Teachers 1 special skill
their names were asked and a name tag was
training staff and 63 Class Teachers from the
provided for each of them for identification. The
School, handling children from 5 to 10 years of
TGMD-2 was operated with the following
age forming standard I to standard V in State
sequences: run, gallop, hop, leap, horizontal jump,
Board of Education were called for a meeting for
slide, striking a stationary ball, stationary dribble,
about 2 hrs in school conference hall for two
catch, kick, overhand throw and underhand roll.
consecutive days. On the first day of meeting, A
The participants were queued behind the first line
talk
coordination
and performed the skill within 50 feet of clear
disorder, including the prevalence, nature of the
space, which was marked with tape and cones
disorder, diagnostic criteria, complications, role of
were placed.
about
the
Developmental
health care professional, teachers and parents in
The assessment was preceded with an
dealing with these children, and management of
accurate demonstration and verbal description of
the condition were given. On the second day, the
the skill, i.e., run. Then, a practice trial was
selection of children based on the DCDQ’07 was
provided for the child who queued at the front, to
demonstrated and the teachers were trained
assure the child understands what to do. After that,
individually to fill the questionnaire. The teachers
two test trials were given to the subjects and the
were instructed to observe their class students for 3
raw skill score was given for each item ranged
days on play ground activities like ball handling,
from 0-2. When the first subject was done, the
running, jumping and on class room activities like
second one at the queue was instructed to start the
writing and learning. With the knowledge and
test
practice obtained from the meeting, observation on
demonstration was also been when he or she did
child’s activities, teachers were asked to fill
not appear to understand the two test trials. The
questionnaire for the average of 30 students they
procedures were repeated until the last participant
handle in the class room. Under supervision the
was completed. The test was then followed by
process of filling up the questionnaire was made
second skill task, i.e., gallop and the process was
and doubts in marking the questionnaire were
as same as before. However, the sequence of the
clarified then and there during the process. With
queue was alternate so that one child did not
the total scores obtained from the questionnaire,
always go first or last. Scoring was made with
screening was done to find out the children who
observation of all participants’ performance. The
28
with
the
practice
trial;
an
additional
Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 2, Year: 2013
assessment protocols were also standardized for all
performance criteria for hop were as follows:
participants according to the test manual of
nonsupport leg swings forward in pendular fashion
TGMD-2 (Ulrich, 2000) (38).
to produce force; foot of nonsupport leg remains
Locomotor Subtest-Run
behind body; arms flexed and swing forward to
50 feet of running space and 8 feet of
produce
force;
takes
off
and
lands
three
safe stopping distance were made for this test
consecutive times on preferred foot; takes off and
(Ulrich, 2000). The child ran as fast as he or she
lands three consecutive times on non-preferred
can from the green cone to the red cone when the
foot.
examiner said â&#x20AC;&#x153;Goâ&#x20AC;?. For the second trial, the child
Locomotor Subtest-Leap
ran from the red cone back to the green cone and
A minimum of 20 feet of clear space was
then waited at the end of the queue. According to
made and a 10 inch plastic ball was used (Ulrich,
Ulrich (2000), the performance criteria for run
2000). First, the ball was placed 10 feet away from
were as follows: arms move in opposition to legs,
the green cone. The child stood behind the line of
elbows bent; brief period where both feet are off
the green cone and ran and leaped over the ball. A
the ground; narrow foot placement landing on heel
second trial was made by leaping back to the line
or toe (i.e., not flat footed); and nonsupport leg
of green cone. According to Ulrich (2000), the
bent approximately 90 degrees (i.e., close to
performance criteria for leap were as follows: take
buttocks).
off on one foot and land on the opposite foot; a
Locomotor Subtest-Gallop
period where both feet are off the ground longer
25 feet distance was made for this test
than running; forward reach with the arm opposite
(Ulrich, 2000). From the green cone, the child
the lead foot.
galloped to the line in middle between the green
Locomotor Subtest-Horizontal Jump
and red cones and repeated a second trial by
10 feet of clear space was made (Ulrich,
galloping back to the green cone. According to
2000). The child started behind the starting line of
Ulrich (2000), the performance criteria for gallop
green cone and jumped as far as he or she can. A
were as follows: arms bent and lifted to waist level
second trial was from the starting line again.
at takeoff; a step forward with the lead foot
According to Ulrich (2000), the performance
followed by a step with the trailing foot to a
criteria for horizontal jump were as follows:
position adjacent to or behind the lead foot; brief
preparatory movement includes flexion of both
period when both feet are off the floor; maintains a
knees with arms extended behind body; arms
rhythmic pattern for four consecutive gallops.
extend forcefully forward and upward reaching
Locomotor Subtest-Hop
full extension above the head; take off and land on
15 feet of clear space was made (Ulrich,
both
feet
simultaneously;
2000). The child was told to hop three times on his
downward during landing.
or her preferred foot and then three times on the
Locomotor Subtest-Slide
arms
are
thrust
other foot towards the line next to the green cone.
25 feet of clear space was made during
The trial was repeated by hopping back to the
the test (Ulrich, 2000). The child was told to stand
green cone. According to Ulrich (2000), the
sideway to the performing space, i.e., left foot
29
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parallel to the starting (green cone) line. The first
with one hand at about belt level; pushes ball with
trial began by sliding from the starting line to the
fingertips (not a slap); ball contacts surface in front
middle line between the green and red cone, i.e.,
of or to the outside of foot on the preferred side;
slide to the left. Then, repeated a second trial by
maintains control of ball for four consecutive
sliding back to the starting (green cone) line, i.e.,
bounces without having to move the feet to
slide to the right. According to Ulrich (2000), the
retrieve it.
performance criteria for slide were as follows:
Object Control Subtest-Catch
body turned sideways so shoulders are aligned
The 8- to 10-inch playground ball was
with the line on the floor; a step sideways with
used as mentioned by Ulrich (2000) in the manual.
lead foot followed by a slide of the trailing foot to
15 feet of clear space was also made (Ulrich,
a point next to the lead foot; a minimum of four
2000). The child and the tosser stood 15 feet away
continuous step-slide cycles to the right; a
of each other and the latter tossed the ball
minimum of four continuous step-slide cycles to
underhand directly to the child with a slight arc
the left.
aiming for his or her chest. The child was told to
Object Control Subtest-Striking a Stationary Ball
catch the ball with both hands for two times.
A plastic bat, a batting tee and two 4-
According to Ulrich (2000), the performance
inch lightweight balls were used in this test
criteria for catch were as follows: preparation
(Ulrich, 2000). The batting tee was adjusted to the
phase where hands are in front of the body and
child’s waist level. In the performing area, the
elbows are flexed; arms extend while reaching for
child was told to hold the bat with both hand and
the ball as it arrives; ball is caught by hands only.
hit the ball hard. For time saving, a second trial
Object Control Subtest-Kick
was done by using another ball. According to
Two 8- to 10-inch playground balls, a
Ulrich (2000), the performance criteria for striking
plastic ring instead of a bean bag to place the ball
a stationary ball were as follows: dominant hand
were used and 30 feet of clear space was made for
grips bat above non-dominant hand; non-preferred
this test (Ulrich, 2000). The ball was placed on the
side of body faces the imaginary tosser with feet
top of the ring between the green and red cones,
parallel; hip and shoulder rotation during swing;
i.e., 10 feet away from the starting line. The child
transfers body weight to front foot; bat contacts
waited behind the starting line and then ran up and
ball.
kicked the ball hard. A second trial was repeated
Object Control Subtest-Stationary Dribble
by using another ball. According to Ulrich (2000),
An 8- to 10-inch playground ball was
the performance criteria for kick were as follows:
used in this test (Ulrich, 2000). The test was held
rapid continuous approach to the ball; an elongated
in the performing area. The child was told to
stride or leap immediately prior to ball contact;
dribble the ball four times without moving his or
non-kicking foot placed even with or slightly in
her feet, using one hand, and then stop by catching
back of the ball; kicks ball with instep of preferred
the ball. A second trial was done. According to
foot (shoelaces) or toe.
Ulrich (2000), the performance criteria for
Object Control Subtest-Overhand Throw Two tennis balls were used and 20 feet
stationary dribble were as follows: contacts ball
30
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
of clear space was made this test (Ulrich, 2000).
descriptive rating of below average, poor and very
The child was told to stand behind the starting line
poor were considered for intervention.
and threw the ball hard. A second trial was done
Parental consent forms were sent out to
by using another ball. According to Ulrich (2000),
parents of those ninety-six children, and a total of
the performance criteria for overhand throw were
fifty-four signed forms were returned on time.
as follows: windup is initiated with downward
After obtaining informed consent from parents,
movement of hand/arm; rotates hip and shoulders
clinical observations were made to assess the
to a point where the non-throwing side faces the
child’s musculoskeletal flexibility and movement
wall; weight is transferred by stepping with the
patterns. This ensured that the child met DSM IV
foot opposite the throwing hand; follow-through
criteria. TGMD-2 scores of the selected subjects
beyond ball release diagonally across the body
were recorded as Pre test values. These children
toward the non-preferred side.
were randomly assigned to one of the two
Object Control Subtest-Underhand Roll
intervention groups. All underwent 20 minutes of
Two tennis balls, a cone were used and
intervention for 5 days a week for 7 consecutive
25 feet of clear space was made for this test
weeks. The intervention includes NTT, based on
(Ulrich, 2000). The cone was placed between the
the assessment of child’s motor performance on
starting and ending line, i.e., 20 feet away from the
the range of tasks then the kinaesthetic training
starting line. The child was told to stand behind the
based on Laszlo’s kinaesthetic approach. At the
starting line and rolled the ball hard towards the
end of 7 weeks of intervention TGMD-2 post test
bean bag. A second trial was repeated by using
values were taken for statistical analysis.
another tennis ball. According to Ulrich (2000), the performance criteria for underhand roll were as
INTERVENTION
follows: preferred hand swings down and back,
There were two intervention groups,
reaching behind the trunk while chest faces cones;
NTT
strides forward with foot opposite the preferred
(intervention
hand toward the cones; bends knees to lower body;
(intervention group 2). Fifty- four children from
releases ball close to the floor so ball does not
different class sections of standard I to standard V,
bounce more than 4 inches high.
by
combined
simple
with
group
kinaesthetic 1)
randomization
and
training
NTT
using
alone
computer
In the TGMD-2, individual performance
generated random numbers from statistical website
was scored with 1 or 0 to show the presence or
were assigned to either intervention group 1 or
absence of that particular skill while each skill
intervention group 2. Intervention groups had 27
ranged from 6 to 10 points. Raw scores were
participants each and both the groups were
added up across skills to form a sub-set of
subdivided into 5 instructional subgroups for the
locomotor or object control, with ranged from 0 to
purposes of instruction.
48 points. The two sub-set total raw score were
Intervention group 1
converted into standard scores so to achieve a
The group was the NTT combined with
Gross Motor Development Quotient (GMDQ) by
KT group consisted of 27 children including 7
summing them. Ninety-six children showing
females and 20 males. NTT was given in group
31
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intervention, in the school play ground, for 20 minutes of 3 sessions per week for 7 weeks
(11)
successful
performance
such
as
timing
of
. KT
components of a motor skill pattern, motor
was also given as group training for 20 minutes
planning, or parameter setting (the execution of a
sessions 2 times per week for 5 weeks (39). These
motor act with the required speed and force) were
two interventions were administered on basis of
also taken consideration (40).
one intervention a day in alternate days.
Each session started with general warm up program for 10 minutes which was followed by intervention of task training (considering all the principles of ntt) over the range of tasks which the child failed to perform in tgmd2 (locomotor and object control subsets) during the pre test. The progression was made by combining two or more tasks into a game in groups (e.g., tasks like hitting, over head throw, under arm roll and catch combined into a game activity of cricket). Each children were given time to comment on their as well as others performance. As the children were trained in group of five, everyone was made to perform their role as a leader once during the week. Kinaesthetic Training Developed by Laszlo (1985). Training
Intervention group 2 This was the NTT only group. It consisted of
was based on kinesthetic awareness â&#x20AC;&#x201C; class room
27 participants with 9 females and 18 males. NTT
and individual practice Performa from Therapy
was given as group intervention, in school, for 20
skill builders
minutes of 5 sessions per week for 7 weeks.
training were, 1. Recognizing and Reproducing
Neuromotor task training.
line direction and length. 2. Awareness activities
(41)
. The activities included in the
During the training, the therapist noted
for fingers and hands. 3. Controlling direction of
the extent to which motor tasks are performed
movements- Dot to dot designs. 4. Recognizing
below the expected level, such as handwriting or
and controlling grip position 5.Recognizing and
ball skill tasks. Second, they were analyzed for the
reproducing Size, Shapes- Glue drawing, Template
cognitive or motor control processes that were
activities.
involved in the deficient motor performance. The RESULTS
reason for the failure to learn a specific motor skill were found out , for e.g., attention problems, fear
The results of prevalence of DCD in
of failure, lack of motivation, or lack of
children in age group between 5 and 10 years in
understanding of how to execute a skill. In
the school population considered shows that the
addition, motor control processes might hamper
rate of prevalence is 6.82. The pre test and post
32
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
test values of Group 1 (Neuromotor Task Training
Kinaesthetic training against Neuromotor task
Combined
was
training alone in children with DCD. The results of
analysed using paired‘t’ test. For 24 degrees of
the post test values comparing two groups shows
freedom and at 5% level of significance, the
COHEN’S d = 0.362229. The results suggest that
table‘t’ value is 2.064 and the calculated ‘t’ value
there was a Medium Effect size.
with
Kinaesthetic
Training)
was 11.586 . As the calculated‘t’ value was greater than the table ‘t’ value and P value < 0.05, there was a significant effectiveness of Neuromotor Task
Training
Training
in
combined children
with
with
Kinaesthetic
Developmental
Coordination Disorder. The pre test and post test values of Group 2 (Neuromotor Task Training Only) was analysed using paired‘t’ test. For 25 degrees
of
freedom
and
at
5%
level
of
significance, the table‘t’ value is 2.060 and the calculated
‘t’
value
was
11.588.
As
the
calculated‘t’ value was greater than the table ‘t’ value and P value < 0.05, there was a significant effectiveness of Neuromotor Task Training alone in children with Developmental Coordination Disorder. The pre test values of both the groups were analysed using independent‘t’ test. For 49 degrees of freedom and 5% level of significance, the
DISCUSSION
table‘t’ value 1.960 and the calculated ‘t’ value is
Out of 121 children suspected for DCD
0.207. As the calculated‘t’ value was lesser than
with initial screening by DCDQ’07, One child was
the table‘t’ value and P value > 0.05, there was no
diagnosed of having congenital hemiplegia, One
significant difference between the pre test values
with ADHD and 5 dropped out as they were absent
of both groups. Hence there was homogenicity
during the sessions of screening. Thus 114
between both the groups before the experiment.
children underwent secondary screening with
The post test values of both the groups were
TGMD-2. Out of 96 children identified with DCD,
analysed using independent‘t’ test. For 49 degrees
only 54 who consented on time (before the start of
of freedom and 5% level of significance, the
intervention) were included, as the study duration
table‘t’ value 1.960 and the calculated ‘t’ value is
is
1.292. As the calculated‘t’ value was lesser than
training
combined
randomized
groups
for
of the study, 2 subjects from the intervention
significant difference between the effectiveness of task
Two
intervention had 27 subjects each on the initiation
the table‘t’ value and P value > 0.05, there was no
Neuromotor
limited.
group 1 and 1 subject from the intervention group
with
2 were excluded from the results reported as they 33
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missed out many of the sessions during the
et al., (2009), found that 18 of 1000 7-year-olds
intervention period due to illness.
have DCD according to strict DSM-IV criteria and that 49 of 1000 7-yearolds have DCD or probable
The result from our study on local school
(16)
population of Kanchipuram, South India on age
DCD
group between 5 and 10 years shows that DCD is
1000 (5 to 10 years old children) have DCD and
prevailing in 6.82 % of children. The result is
approximately 86 of 1000 have probable or
correlating
suspect for DCD. The problem predominantly
with
the
previous
statement
of
. In our study the approximate of 68 of
(24)
‘Approximately 6% of children in mainstream
affects boys in a ratio of 3–4: 1
primary schools demonstrate motor competence
McKinley, 1980). In our study the boys to girls’
below normal range, although they appear both
ratio is 3.36: 1. Thus our results add support to the
physically and intellectually normal’
1
(Gordon &
previous studies.
(American
Psychiatric Association, 1994). But in contrast to
Angela D. Mandich et al., (2001), have
the study done on the local population group in
stated that, 1. To date, combined approaches are
kattankulathur of South India
by Ganapathy
largely untested and research has provided limited
Sankar U and Saritha S (2011) have shown that
evidence to support combined approaches. 2.
there is prevailing (Prevalence rate=1.37%) of
Combined approaches have demonstrated smaller
Developmental Coordination Disorder among the
effects than pure approaches. 3. The evidence for
(13)
. As this study was done
bottom up approaches would suggest that no one
only with DCDQ’07 screening, the prevalence rate
approach, or combination of approaches, is
is only the suspect and the methodology of survey
superior to another in improving motor skill. 4. No
was also not clearly explained, so this is
bottom up approach has been shown to be reliably
incomparable with our results.
better than no treatment at all
age group of 5–10 years
these
statements,
Top
(11)
. Considering
down
approach
of
Neuromotor Task Training was combined with Bottom up approach of Kinaesthetic Training. With the hypothesis to prove the effectiveness of Neuromotor
Task
Training
combined
with
Kinaesthetic Training in children with DCD, our study compared the groups with interventions combined (NTT with KT) on one group and NTT alone on another group. The results are statistically insignificant
to
prove
the
effectiveness
of
combined group over group with NTT alone, but there is a considerable difference in the mean values and the medium effect size shown by Cohen’s d effect size measure shows its beneficial effect. The effectiveness of Neuromotor Task Training in DCD is promising in this study, The UK population based study by Raghu Lingam 34
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
because there is a significant improvement seen in
secondary screening with TGMD-2 administered
both the subsets of TGMD-2 in the two
by the principle investigator. The diagnosis was
intervention groups. Kinaesthetic training in
made with the children falling below 15th
combined therapy group has added some benefits
percentile in the test. The intervention were given
by producing difference in mean value between
in two groups , one with combined therapy and the
the groups.
other with Neuromotor Task Training alone for a
The reason for the effectiveness of
period of 7 weeks in small groups. The outcome
intervention may be due to the physical activity as
was assessed with Gross Motor Quotient of
running, jumping and aerobic game playing which
TGMD-2. The data were analysed with Student’t’
has a definite impact on children’s frontal lobe, the
tests comparing values within the groups and
primary brain area for mental concentration,
between the groups. Results showed that the
planning and decision making(25). It is also
prevalence of DCD in the local population is
commonly believed that children automatically
6.82% and there is no significance difference
acquire motor skills as their bodies develop but
between the improvements made in the two
scientists now believe that the opportunities for
intervention groups.
practice, encouragement and instruction are crucial
Thus
to the development of mature patterns of fundamental motor skills
(26)
it
is
concluded
that
the
prevalence of DCD in the locality, Kanchipuram
. The benefits made
of South India is 6.82%. The conclusions drawn
would have been due to the group training in both
from our results are, 1. There is a significant
the groups as this has provided opportunity for
effectiveness of Combined therapy of Neuromotor
social
Task Training with Kinaesthetic Training in
interaction
competence
(14)
and
stronger
sense
of
.
children with DCD. 2. There is a significant
The added benefits of Kinaesthetic training
effectiveness of Neuromotor Task Training in
may be due to the processing of visual information
children with DCD. 3. There are no statistical
about
environment,
significant differences between the effectiveness of
proprioceptive information about limb and body
combined therapy Group against Neuromotor Task
position, and then the initiation of an appropriate
Training alone in children with DCD. The
corrective response. The integration or mapping of
differences in the mean value support the
these two sources of sensory information is also a
combined therapy group to have some better
the
body
and
external
critical ingredient in balance control
(27)
.
effects.
CONCLUSION The effectiveness
LIMITATIONS AND SUGGESTIONS
study of
was
to
find
out
the
This study was done with limited number of
Neuromotor
Task
Training
samples from a single school of a locality in South
combined with kinaesthetic training in children
India.
with Developmental coordination disorder. With
produce long term effects and the stability of the
the DCDQ’07 questionnaire filled by the school
effects produced cannot be determined. This
teachers the initial screening was done followed by
simple measure of gross motor development alone
35
Intervention duration is not enough to
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is not enough to measure all the characteristics of
participation in assessing and managing these
children
Assessment
children to be considered. Stability of the effects
Battery for Children 2 (MABC-2) which was
produced with the intervention to be studied. Other
proven to be a valid measurement tool for children
combinations of approaches can be tried.
with
with
DCD
DCD.
should
Movement
be
considered.
Parental
REFERENCES: 1. Disorders Usually First Diagnosed In Infancy, Childhood Or Adolescence. Diagnostical and Statistical Manual Of Mental Disorders: DSM-IV-TR: 4th Edition Text Revision. American Psychiatry Association. Pg. No. 56-58. 2. Developmental Co-Ordination Disorder: A Review Of Evidence And Models Of Practice Employed By Allied Health Professionals In Scotland. Specification/PDU/AHP/2006/001. 3. Smyth, M. M., & Anderson, H. I. Coping with Clumsiness In The School Playground: Social And Physical Play In Children With Coordination Impairments. British Journal of Developmental Psychology, 2000, 18, 389-413. 4. Kirby, A. & Davies, R. Developmental Coordination Disorder and Joint Hypermobility Syndrome - Overlapping Disorders? Implications for Research and Clinical Practice. Child Care Health and Development, 2007, 33(5), 513-9. 5. Kirby, A., Sugden, D., Beveridge, S. & Edwards, L. Developmental Co-Ordination Disorder (DCD) In Adults and Adolescents. Journal of Research In Special Education Needs, 2008, 8,12031. 6. Sugden, D. A., &Wright, H. C. Motor Coordination Disorders In Children. Thousand Oaks, CA: Sage. 1998. 7. M.M. Schoemaker, A.S. Niemeijer, K. Reynders, B.C.M. Smits-Engelsman Effectiveness Of Neuromotor Task Training For Children With Developmental Coordination Disorder: A Pilot Study. Neural Plasticity Volume 10, No. 1-2, 2003 8. Wilson, BN, Kaplan, BJ, Crawford, SG, And Roberts, G., The Developmental Coordination Disorder Questionnaire 2007 (DCDQ’07) October 2007 ©B.N. Wilson 2007 9. Leanne M. Slater, Susan L. Hillier, Lauren R. Civetta. The Clinimetric Properties Of Performance-Based Gross Motor Tests Used For Children With Developmental Coordination Disorder: A Systematic Review Pediatric Physical Therapy: Summer 2010 - Volume 22 - Issue 2 - Pp 170-179 10. David A. Sugden and Mary E. Chambers., Intervention In Children With Developmental Coordination Disorder: The Role Of Parents And Teachers. British Journal Of Educational Psychology (2003), 73, 545–561.
36
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
11. Angela D. Mandich, Helene J. Polatajko, Jennifer J. Macnab, Linda T. Miller. Treatment Of Children With Developmental Coordination Disorder: What Is The Evidence? Physical & Occupational Therapy In Pediatrics, Vol. 20, No. 2/3, 2001 51-68. 12. Woei-Nan Bair. Children With Developmental Coordination Disorder Benefit From Using Vision In Combination With Touch Information For Quiet Standing. Gait & Posture. June 2011. Volume 34, Issue 2 , Pages 183-190. 13. Sankar U and Saritha S. A Study Of Prevalence Of Developmental Coordination Disorder (DCD) At Kattankulathur, Chennai. Indian Journal Of Physiotherapy And Occupational Therapy. Year: 2011, Volume: 5, Issue: 1 :( 63-65) 14. Winnie W. Y. Hung And Marco Y. C. Pang.Effects Of Group-Based Versus Individual-Based Exercise Training On Motor Performance In Children With Developmental Coordination Disorder: A Randomized Controlled Pilot Study. J Rehabil Med 2010; 42: 122–128 15. Brenda N. Wilson, Susan G. Crawford, Dido Green, Gwen Roberts, Alice Aylott, Bonnie J. Kaplan. Psychometric Properties of The Revised Developmental Coordination Disorder Questionnaire. Journal Of Physical And Occupational Therapy In Pediatrics.2009. 29(2): 182202. 16. Raghu Lingam, Linda Hunt, Jean Golding, Marian Jongmans And Alan Emond., Prevalence Of Developmental Coordination Disorder Using The DSM-IV At 7 Years Of Age: A UK Population_Based Study. Pediatrics 2009; 123; E693-E700. 17. Reint H. Geuze., Static Balance and Developmental Coordination Disorder. Human Movement Science. 22 (2003)527–548. 18. Margaret Cousins, Mary M. Smyth., Developmental Coordination Impairments in Adulthood. Human Movement Science 22 (2003) 433–459. 19. Barnhart RC, Davenport MJ, Epps SB, Nordquist VM. Developmental Coordination Disorder. Phys Ther. 2003; 83: 722–731. 20. Dale A Ulrich. Test Of Gross Motor Development. Examiner’s Manual - Second Edition. Pro-Ed, 2000. 21. Polatajko H, McNab J, Anstett B, Malloy-Miller T, Murphy K, Noh S. A Clinical Trial Of The Process Oriented Treatment approach For Children With Developmental Coordination Disorder. Developmental Medicine And Child Neurology. 1995. 37. 310-319. 22. Anuschka S. Niemeijer et al., Developmental Medicine & Child Neurology. 2007; 49: 406-411. 23. Kinesthetic Awareness – Class Room And Individual Practice Performa From Therapy Skill Builders. A Division of Communication Skill Builders/ 602-323-7500 (1991). 24. Gordon N, McKinley I Helping clumsy children. Churchill Livingstone, Edinburgh.1980 25. http://www.ivyacademy.cn/MI/BodilyKinesthetic%20Intelligence.pdf. The Multiple Intelligences Preschool - IVY Academy.
37
ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji
26. Wafaa Abd Elzafez Abd Elmaksoud Ghaly. The Effect of Movement Education Program by Using Movement Pattern to Develop Fundamental Motor Skills For Children Pre School. World Journal of Sport Sciences. 2010; 3 (S); 461-491. 27. Sharon A. et al. Developmental coordination disorder. Cengage learning.2001.
CORRESPONDING AUTHOR: *M.P.T. (Neurology)., F.N.R., P.G.C.D.E. Health Care Consultant, Bharathidasan Matric Hr Sec School, Kanchipuram, Tamilnadu, India. & Consultant Physical Therapist, Star Health Care Center, Kanchipuram, Tamilnadu, India. **Bachelors in Physiotherapy (India), PG Dip Sci - Exercise Rehabilitation (Clinical Exercise Physiology), University of Auckland, New Zealand.
38
COGNITIVE REHABILITATION IN MS Krishna N. Sharma. MPT (Neuro)*
INTRODUCTION
that connect with primary sensory, motor, speech, and integration areas of the cerebrum. It may result
Cognition
refers
to
the ‘higher’
brain
in poor recognition of deficits as well as an
functions e.g. memory and reasoning. Sometimes the
MS
patients
associate
the
inability to store and retrieve new information. The
cognitive
combination of these two issues becomes a major
dysfunction to severity of physical symptoms or to
obstacle in the way to rehabilitation.10
duration of the disease which is actually a misbelief.1,2 Cognitive problems are one of the
Testing Cognitive Dysfunctions:
most frequent symptoms of MS, which is evident
Neuropsychological testing can assist in
in about 50% of the patients.3,4 Approximately
determining the degree of cognitive impairment in
10% to 20% patients show significant cognitive
patients with MS. Wallin et al (2006) et al.
dysfunction. Symptoms may be exaggerated by
categorized the tests for cognitive dysfunctions
underlying depression.5 The most often affected
associated with MS in three main schools of
cognitive functions are - memory, attention, speed
thought:11
of processing, abstract reasoning, verbal fluency, and
executive
functions.6,7,8
Widespread
1. Short screening with traditional measures
deterioration of intellectual function in MS is rare.9
in a neurologist’s office i.e. BRB-N (Brief Repeatable Battery of Neuropsychological
Why do they occur?
Tests). It is composed of the Buschke
The Cognitive problems in MS are actually
Selective Reminding Test, the 7/24 Spatial
the result of demyelination in the cerebral tracts
Recall Test, the Paced Auditory Serial 39
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Addition
Test
(PASAT),
and
Designing Interventions:
the
Designing intervention is the second step of
Controlled Oral Word Association Test (COWAT).12
the cognitive rehabilitation. It is intended to improve the patient's ability to function in all
2. Testing by a neuropsychologist with a minimal
(but
aspects - personal, family, social, and vocation
comprehensive)
neurocognitive battery i.e. MACFIMS
life.
(Minimal
Cognitive
progressive, and fluctuating in nature and there is a
Function in Multiple Sclerosis). It is
complex interaction of motor, sensory, cognitive,
composed of PASAT, COWAT, SDMT
functional, and affective impairments, it requires
etc.
Assessment
of
13
Since
periodic
3. Testing with automated, computerized
the
disease
reassessment,
rehabilitative
is
unpredictable,
monitoring,
interventions.
The
and
therapist
measures in a neurologist’s office or as
recognizes the deficit and includes the functionally
part of a clinical trial i.e. ANAM
oriented therapeutic tasks accordingly.
(Automated
Neuropsychological
There are two approaches - Restorative
Assessment Metrics). It is composed of
Strategies and Compensatory Strategies, which are
Procedural
believed
Reaction
Time,
Code
Substitution, Sternberg Memory Search etc.
to
be
dysfunctions.
14
helpful
Since
the
in
the
cognitive
effectiveness
of
Restorative Strategies to cognitive rehabilitation is largely inconclusive15, Compensatory strategies
Such an evaluation could be helpful in the
(i.e. teaching to use intact skills with/without
following ways:
external aids) are widely used and are suggested
•
by most authors.
It can identify impaired and intact functions.
•
The MS patient as well as the family
Compensatory Strategies-
members may have a better understanding •
of the nature and extent of the illness. •
Cognitive
Structuring-
The
therapist
The evaluation may help the person
applies suitable learning theory and make
develop realistic vocational and other life
the patient practice the cognitive task to
goals.
turn it in a routine behaviors. •
The results can suggest compensatory techniques.
Substitution
Strategies-
The
therapist
teaches to use the intact cognitive abilities to circumvent the impaired abilities. For example- Using intact visual memory in place of impaired verbal memory function. •
Scheduling and Timelines- The patients are encouraged to use schedulers and alarms.
40
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
•
Using the recording devices- It helps the patients remember and store the important details.
•
Memory strategies- The patients are taught and encouraged to use mnemonics, lists, clustering, and visualization techniques etc. to remember things.
•
Assistive Technology- The patients are advised to use handheld computers,
•
electronic calendars, and memory logs etc.
An MS Patient using COGNIsoft-I for Cognitive
Creating structured environment- It helps
Rehabilitation
the patients find their things on certain
Tips:
fixed places to avoid the hassle in
•
forgetting and searching things.
places to avoid distractions. •
Restorative Strategies-
games/ activities are available for restoring or improving cognition, there is lack of evidence-
•
The activity should be demonstrated first.
•
The instructions should be simple and short.
based-practice of the restorative strategies for the
•
cognitive deficits associated with MS. There are
mind. Application of the principles of
improvement by the cognitive games.16,17 many
toy
games
for
Spaced
cognitive
•
of computer and technology few application
etc. would enhance
Instructions may be given in the forms of
would
Games etc; and online cognitive rehabilitation
help
them
remembering
the
activities even when they are at home.
multiplesclerosis.com18,
BICBrainInjuryCentre.co.uk19,
Story
Audio/ video tape, printed material also. It
softwares e.g.- COGNIsoft-I, BrainTrain, MSTY
on
24
the outcome.
Quoridor, Tenzi, Fiddlesticks etc. But in this age
available
Learning,23
Retrieval
Memory Technique,
rehabilitation e.g.- Peg Board, Puzzle-cubes,
games
The activities should be carried out with the concept of Errorless Learning22 in
very less researches which confirm significant
are
The sessions should be well-designed and engaging.
Though so many verities of therapeutic tasks/
There
The activities should be conducted in quiet
•
Peartrees.com20,
The exercises should be done for the
Mind360.com21 etc. are proving to be effective and
shorter periods of time to avoid cognitive
easily administrable.
fatigue. New skills should not be taught before the previous skill has been strongly established.
41
REFRENCES 1. Peyser JM. Edwanb KR, Poser CM, et al: Cognitive function in patients with multiple sclerosis. Arch Neurol 37:577-579, 1980 2. Beatty WW, Goodkin DE. (1990) Screening for cognitive impairment in multiple sclerosis: An evaluation of the Mini Mental State Examination. Arch Neurol, 47, 297–301. 3. Aronson K, G. E.; Socio-demographic characteristics and health status of persons with multiple sclerosis and their care givers. MS Management 3(1), 5-15. 1996. 4. Lublin F, Reingold S; Defining the course of multiple sclerosis. Neurology 46(4):907-911, 1996. 5. Debra I. Frankel; Multiple Sclerosis. DA Umphred (Ed.), Neurological Rehabilitation, The CV Mosby Company, St. Louis, pp. 714. 1995 6. Debra I. Frankel; Multiple Sclerosis. DA Umphred (Ed.), Neurological Rehabilitation, The CV Mosby Company, St. Louis, pp. 714. 1995 7. Rao SM, Leo GL, Bernardin L, et al: Congnitive dysfunction in multiple sclerosis. I. Grequency, patterns, and prediction, Neurology 41(5):685-691, 1991 8. Peyser JM. Edwanb KR, Poser CM, et al: Cognitive function in patients with multiple sclerosis. Arch Neurol 37:577-579, 1980 9. Lublin F, Reingold S: Defining the course of multiple sclerosis. Neurology 46(4) :907-911, 1996. 10. Debra I. Frankel; Multiple Sclerosis. DA Umphred (Ed.), Neurological Rehabilitation, The CV Mosby Company, St. Louis, pp. 728. 1995 11. Wallin et al. Cognitive dysfunction in multiple sclerosis. JRRD, Volume 43, Number 1, 63-71. 2006 12. Rao SM, Leo GJ, Bernardin L, Unverzagt F. Cognitive dysfunction in multiple sclerosis. I. Frequency, patterns, and prediction. Neurology. 1991;41(5):685–91. 13. Benedict RH, Fischer JS, Archibald CJ, Arnett PA, Beatty WW, Bobholz J, Chelune GJ, Fisk JD, Langdon DW, Caruso L, Foley F, LaRocca NG, Vowels L, Weinstein A, DeLuca J, Rao SM, Munschauer F. Minimal neuropsychological assessment of MS patients: a consensus approach. Clin Neuropsychol. 2002;16(3):381–97. 14. Wilken JA, Kane R, Sullivan CL, Wallin M, Usiskin JB, Quig ME, Simsarian J, Saunders C, Crayton H, Mandler R, Kerr D, Reeves D, Fuchs K, Manning C, Keller M. The utility of computerized neuropsychological assessment of cognitive dysfunction in patients with relapsing-remitting multiple sclerosis. Mult Scler. 2003;9(2):119–27. 15. O’Brien AR, Chiaravalloti N, Goverover Y, Deluca J. Evidenced-based cognitive rehabilitation for persons with multiple sclerosis: a review of the literature. Arch Phys Med Rehabil 2008;89(4):761–9. 16. Chooi, Weng-Tink; Thompson, Lee A. (2012). "Working memory training does not improve intelligence in healthy young adults". Intelligence 40 (6): 531–42.
42
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
17. Redick, T. S.; Shipstead, Z.; Harrison, T. L.; Hicks, K. L.; Fried, D. E.; Hambrick, D. Z.; Kane, M. J.; Engle, R. W. (2012). "No Evidence of Intelligence Improvement After Working Memory Training: A Randomized, Placebo-Controlled Study". General J Exp Psychol Gen. 2012 Jun 18. 18. http://www.multiplesclerosis.com/us/index.php 19. http://www.bicbraininjurycentre.co.uk 20. http://www.pearltrees.com/#/N-play=0&N-s=1_4127047&N-u=1_487865&N-p=44503368&Nf=1_4127047&N-fa=4055621 21. http://www.mind360.com/games 22. Wilson BA, Baddeley A, Evans J, et al. Errorless learning in the rehabilitation of memory impaired people. Neurospsychol Rehabil 1994; 4(3): 307–26. 23. Heesen C, Kasper J, Segal J, et al. Decisional role preferences, risk knowledge and information
interests in patients with multiple sclerosis. Mult Scler 2004; 10: 1–8. 24. Camp CJ, Foss JW, O’Hanlon AM, et al. Memory interventions for persons with dementia. Appl Cog
Psychol 1996; 10: 193–210.
CORRESPONDING AUTHOR: * Senior Physiotherapist. Multiple Sclerosis Society of India (Mumbai Chapter), Mumbai, India. Cont: +91-9320699167. Email: dr.krisharma@gmail.com
43
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NETWORK BORDER PATROL ERADICATES THE OVER LOADING OF DATA PACKETS AND PREVENTS CONGESTION COLLAPSE THEREBY PROMOTING FAIRNESS OVER TCP PROTOCOL IN LAN /WAN Lakshminarayanan T.*, Dr. Umarani R.**
ABSTRACT The Project flow chart algorithm is multicast service. It is very simple being LAN/WAN broadcasting tool. The LAN/WAN links are often private Lines, unlike submarine and over network. A private network has the advantage of being managed and by few people so to avoid many problems about the property and origin of LAN/ WAN has been investigated in the literature for some use. The fundamental philosophy behind the internet is expressed by scalability argument No protocol, mechanism or service should be introduced in to the internet if it does not scale well. A key corollary to the scalability argument is the end to end argument to maintain scalability algorithmic complexity should be pushed to the edges of the network to whenever possible Perhaps the best example of the internet philosophy the TCP congestion control which is implemented primarily to algorithms operating at end systems unfortunately TCP congestion control also illustrates some of the shortcomings the end to end argument As a result of its strict adherence to end and congestion control. KEYWORDS: LAN/WAN, TCP Congestion Control
RELATED WORKS
undelivered packets and of unfair bandwidth allocations have not gone unrecognized. Some
The maladies of congestion collapse from 44
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
have argued that there are social incentives for
On the second bottleneck link (R2-S4),
multimedia applications to be friendly to the
much of the traffic from flow B is discarded. Due
network, since an application would not want to be
to the link’s limited capacity (128 kbps). Hence,
held responsible for throughput degradation in the
flow A achieves a throughput of 750 kbps and
Internet. However, malicious denial-of-service
flow B achieves a throughput of 128 kbps. Clearly,
attacks using unresponsive UDP flows are
congestion collapse has occurred, because flow B
becoming disturbingly frequent in the Internet and
packets, which are ultimately discarded on the
they are an example that the Internet cannot rely
second bottleneck link, unnecessarily limit the
solely on social incentives to control congestion or
throughput of flow A across the first bottleneck
to operate fairly. Some have argued that these
link. Furthermore, while both flows receive equal
maladies may be mitigated through the use of
bandwidth allocations on the first bottleneck link,
improved
packet
scheduling1
or
queue
their allocations are not globally max-min fair. An
2
management mechanisms in network routers.
allocation of bandwidth is said to be globally max-
For instance, per-flow packet scheduling
min fair if, at every link, all active flows not
mechanisms like Weighted Fair Queuing (WFQ)3,4
bottlenecked at another link are allocated a
attempt to offer fair allocations of bandwidth to
maximum, equal share of the link’s remaining
flows Contending for the same link. So do Core-
bandwidth9.
Stateless Fair Queueing (CSFQ)5, Rainbow Fair Queueing6 and Choke7, which are approximations of WFQ that do not require, core routers to maintain per-flow state. Active queue management mechanisms like Fair Random Early Detection (FRED)8 also attempt to limit malicious or unresponsive flows by preferentially discarding packets from flows that are using more than their
Fig: 1, Example of a Network Which Experiences
fair share of a link’s bandwidth.
Congestion Collapse
All of these mechanisms are more
A globally max-min fair allocation of
complex and expensive to implement than simple
bandwidth would have been 1.372 Mbps for flow
FIFO queuing, but they reduce the causes of
A and 128 kbps for flow B. This example, which is
unfairness and congestion collapse in the Internet.
a variant of an example presented by Floyd and
Nevertheless, they do not eradicate them. For
fall10, illustrates the inability of local scheduling
illustration of this fact, consider the example
mechanisms,
shown in Figure 1. Two unresponsive flows
congestion collapse and achieve global max-min
compete for bandwidth in a network containing
fairness without the assistance of additional
two bottleneck links arbitrated by a fair queuing
network mechanisms. Jain et al. have proposed
mechanism. At the first bottleneck link (R1-R2),
several rate control algorithms that are able to
fair queuing ensures that each flow receives half of
prevent congestion collapse and provide global
the link’s available bandwidth (750 kbps).
max-min fairness to competing flows11.
45
such
as
WFQ,
to
eliminate
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These algorithms (e.g., ERICA, ERICA+) are designed for the ATM Available Bit Rate (ABR) service and require all network switches to compute fair allocations of bandwidth among competing connections. However, these algorithms are not easily tailor able to the current Internet, because they violate the Internet design philosophy of keeping router implementations simple and pushing complexity to the edges of the network. Fig: 2, The Core-Stateless Internet Architecture
Rangarajan and Acharya proposed a network
Assumed By NBP
border-based approach, which aims to prevent
1.1 TCP congestion control has mainly two
congestion collapse through early regulation of
phases:
unresponsive flows (ERUF)12. ERUF border
Slow Start and Congestion avoidance. A
routers rate control the input traffic, while core
new connection begins in Slow-start, setting its
routers generate source quenches on packet drops
initial cwnd to 1 packet, and increasing it by 1 for
to advise sources and border routers to reduce their
every received Acknowledgement (ACK). After
sending rates. While
this
approach
may
cwnd reaches ssthresh, the connection switches to
prevent
congestion-avoidance where cwnd grows linearly.
congestion collapse, it does so after packets have
A variety of methods have been suggested in the
been dropped and the network is congested. It also
literature recently aiming to avoid multiple losses
lacks mechanisms to provide fair bandwidth
and achieve higher utilization during the startup
allocations to flows. That is responsive and
phase. A larger initial cwnd, roughly 4K bytes, is
unresponsive to congestion. Floyd and fall have
proposed in.
approached the problem of congestion collapse by
This could greatly speed up transfers with
proposing low-complexity router mechanisms that
only a few packets. However, the improvement is
promote the use of adaptive or “TCP-friendly”
still inadequate when BDP is very large and the
end-to-end congestion control10. Their suggested
file to transfer is bigger than just a few packets.
approach requires selected gateway routers to monitor determine
high-bandwidth whether
they
flows are
in
order
to
responsive
to
Fast start uses cached cwnd and ssthresh in recent connections to reduce the transfer latency. The cached parameters may be too aggressive or too
congestion. Flows determined to be unresponsive
conservative when network conditions change
to congestion are penalized by a higher packet
Smooth start has been proposed to slow down
discarding rate at the gateway router. A limitation
cwnd increase when it is close to ssthresh. The
of this approach is that the procedures currently
assumption here is that default value of ssthresh is
available to identify unresponsive flows are not
often larger than the BDP, which is no longer true
always successful5.
in large bandwidth delay networks. Proposes to set the initial ssthresh to the BDP estimated (Packet Network Discovery) has been proposed to derive 46
Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 2, Year: 2013
optimal TCP initial parameters. SPAND needs
System Flow diagram are directed graphs
leaky bucket pacing for outgoing packets, which
in which nodes specify processing activities and
can be costly and Problematic in practice.
arc
TCP
Vegas
detects
congestion
specify
data
item
transmitted
between
processing nodes .Data Flow diagrams represent
by
the system between individual items in fig: 5.a,
comparing the achieved throughput over a cycle of length equal to RTT, to the expected throughput implied by cwnd and base RTT (minimum RTT) at the beginning of a cycle. This method is applied in both Slow-start and Congestion-avoidance phases. During Slow-start phase, a Vegas sender doubles
Fig: 5.A, Backward Feed Back
its cwnd only every other RTT, in contrast with
2.1 System implementation
Renoâ&#x20AC;&#x2122;s doubling every RTT. A Vegas connection
Egress module- Input parameters: (I) Data packets
exits slow-start when the difference between
from router. (II)Forward feedback from the router.
achieved and expected throughput exceeds a
Egress module- Output parameters: (I) Data
certain threshold. However, Vegas are not able to
packets. (II)Backward feedback.
achieve high utilization in large Band width delay networks as we will, due to its over-estimation of
Destination module: (I) Message received from the
RTT.
egress router will be stored in the corresponding We believe that estimating the eligible
folder as a text file depends upon the source
sending rate and properly using such estimate are
machine name.
critical to improving bandwidth utilization during Slow-start.TCP Westwood and Eligible Rate
2. Network border patrol
Estimation Overview in TCP Westwood (TCPW),
Network Border Patrol is a network layer
the sender continuously monitors ACKs from the
congestion avoidance protocol that is aligned with
receiver and computes its current Eligible Rate
the core-stateless approach. The core-stateless
Estimate (ERE). ERE relies on an adaptive
approach, which has recently received a great deal
estimation technique applied to ACK stream. The
of research attention [13], [5], allows routers on
goal of ERE is to estimate the connection eligible
the borders (or edges) of a network to perform
sending rate with the goal of achieving high
flow classification and maintain per-flow state but
utilization, without starving other connections. We
does not allow routers at the core of the network to
emphasize that what a connection is eligible for is
do so. Figure 2 illustrates this architecture. As in
not the residual bandwidth on the path. The
other work on core-stateless approaches, we draw
connection is often eligible more than that. For
a further distinction between two types of edge
example, if a connection joins two similar
routers. Depending on which flow it is operating
connections, already in progress and fully utilizing
on, an edge router may be viewed as ingress or an
the path capacity, then the new connection is
egress router. An edge router operating on a flow
eligible for a third of the capacity.
passing into a network is called an ingress router, whereas an edge router operating on a flow
1. Problem Methodology 47
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passing out of a network is called an egress router.
Fig: 3- An Input Port of an NBP Egress Router.
Note that a flow may pass through more than one egress (or ingress) router if the end-to-end path crosses
prevents
The only components of the network that
congestion collapse through a combination of per-
require modification by NBP are edge routers; the
flow rate monitoring at egress routers and Per-flow
input ports of egress routers must be modified to
rate control at ingress routers. Rate monitoring
perform per-flow monitoring of bit rates, and the
allows an egress router to determine how rapidly
output ports of ingress routers must be modified to
each flow’s packets are leaving the network,
perform per-flow rate control. In addition, both the
whereas rate control allows an ingress router to
ingress and the egress routers must be modified to
police the rate at which each flow’s packets enter
exchange
the network. Linking these two functions together
illustrates the architecture of an egress router’s
are the feedback packets exchanged between
input port. Data packets sent by ingress routers
ingress and egress routers; ingress routers send
arrive at the input port of the egress router and are
egress routers forward feedback packets to inform
first classified by flow. In the case of IPv6, this is
them about the flows that are being rate controlled,
done by examining the packet header’s flow label,
and egress routers send ingress routers backward
whereas in the case of IPv4, it is done by
feedback packets to inform them about the rates at
examining the packets Source and destination
which each flow’s packets are leaving the network.
addresses and port numbers. Each flow’s bit rate is
This section describes three important
then rate monitored using a rate estimation
aspects
multiple
of
the
networks.
NBP
NBP
3.1 Architectural Components
mechanism:
(a)
the
and
handle
feedback.
Figure:
3,
algorithm such as the Time Sliding Window
architectural components, namely the modified
(TSW) [14].
edge routers, which must be present in the
These rates are collected by a feedback
network, (b) the feedback control algorithm, which
controller, which returns them in backward
determines
is
feedback packets to an ingress router whenever a
exchanged between edge routers, and (c) the rate
forward feedback packet arrives from that ingress
control algorithm, which uses the information
router. The output ports of ingress routers are also
carried in feedback packets to regulate flow
enhanced. Each contains a flow classifier, per-flow
transmission rates and thereby prevent congestion
traffic shapers (e.g., leaky buckets), a feedback
collapse in the network.
controller, and a rate controller. See Figure 4. The
how
and
when
information
flow classifier classifies packets into flows, and the traffic shapers limit the rates at which packets from individual flows enter the network. The feedback controller receives backward feedback packets returning from egress routers and passes their contents to the rate controller. It also generates forward feedback packets, which it occasionally transmits to the network’s egress
48
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
routers. The rate controller adjusts traffic shaper
is the combination of source address, destination
parameters according to a TCP-like rate control
address, source port number, and destination port
algorithm, which is described later in this section.
number. An edge router adds a flow to its list of active flows
Fig: 4, an Output Port of an NBP Ingress
Fig: 5, Forward and Backward Feedback Packets
Router.
Exchanged By Edge Routers.
3.2 The Feedback Control Algorithm
Whenever a packet from a new flow arrives; it removes a flow when the flow becomes
The
feedback
control
algorithm
inactive. In the event that the network’s maximum
determines how and when feedback packets are exchanged
between
edge
routers.
transmission unit size is not sufficient to hold an
Feedback
entire list of flow specifications, multiple forward
packets take the form of ICMP packets and are
feedback packets are used. When an egress router
necessary in NBP for three reasons. First, they
receives a forward feedback packet, it immediately
allow egress routers to discover which ingress
generates a backward feedback packet and returns
routers are acting as sources for each of the flows
it to the ingress router. Contained within the
they are monitoring. Second, they allow egress
backward feedback packet are the forward
routers to communicate per-flow bit rates to
feedback packet’s original time stamp, a router
ingress routers. Third, they allow ingress routers to
hop count, and a list of observed bit rates, called
detect incipient network congestion by monitoring
egress rates, collected by the egress router for each
edge-to-edge round trip times. The contents of
flow listed in the forward feedback packet.
feedback packets are shown in Figure 5. Contained
The router hop count, which is used by the
within the forward feedback packet are a Time
ingress router’s rate control algorithm, indicates
stamp and a list of flow specifications for flows
how many routers are in the path between the
originating at the ingress router. The time stamp is
ingress and the egress router. The egress router
used to calculate the round trip time between two
determines the hop count by examining the time to
edge routers, and the list of flow specifications
live (TTL) field of arriving forward feedback
indicates to an egress router the identities of active
packets. When the backward feedback packet
flows originating at the ingress router. A flow
arrives at the ingress router, its contents are passed
specification is a value uniquely identifying a
to the ingress router’s rate controller, which uses
flow. In IPv6 it is the flow’s flow label; in IPv4, it
them to adjust the parameters of each flow’s traffic 49
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else
shaper. In order to determine how often to generate forward feedback packets, an ingress
f.phase = CONGESTION_AVOIDANCE;
router keeps a byte transmission counter for each
if (f.phase == CONGESTION_AVOIDANCE)
flow it processes. Whenever a flow’s byte counter
if (deltaRTT × f.ingressRate < MSS × e.hopcount)
exceeds a threshold, denoted TX, the ingress
f.ingressRate = f.ingressRate + rateQuantum ×
router generates and transmits a forward feedback
RTTsElapsed;
packet to the flow’s egress router. The forward feedback
packet
includes
a
list
of
else
flow
f.ingressRate = f.egressRate - rateQuantum;
specifications for all flows going to the same egress router, and the counters for all flows
Fig: 6, Pseudo Code for Ingress Router Rate
described in the feedback packet are reset.
Control Algorithm.
Using a byte counter for each flow ensures that
feedback
packets
are
generated
more
3. The Rate Control Algorithm
frequently when flows transmit at high rates,
The NBP rate control algorithm regulates
thereby allowing ingress routers to respond more
the rate at which each flow enters the network. Its
quickly to impending congestion collapse. To
primary goal is to converge on a set of per-flow
maintain a frequent flow of feedback between edge
transmission rates (hereinafter called ingress rates)
routers even when data transmission rates are low,
that prevents congestion collapse from undelivered
ingress routers also generate forward feedback
packets. It also attempts to lead the network to a
packets whenever a time-out interval, denoted tf, is
state of maximum link utilization and low router
exceeded.
buffer occupancies, and it does this in a manner that is similar to TCP. In the NBP rate control algorithm, shown in Figure 6, a flow may be in
On arrival of Backward Feedback packet p from
one of two phases, slow start or congestion
egress router e
avoidance, which is similar to the phases of TCP
Current RTT = current Time - p.time stamp;
congestion control. New flows enter the network
if (currentRTT < e.base RTT)
in the slow start phase and proceed to the
e.base RTT = currentRTT;
congestion avoidance phase only after the flow has
delta RTT = currentRTT - e.base RTT;
experienced congestion.
RTTsElapsed = (current Time -
The rate control algorithm is invoked
e.lastFeedbackTime) / currentRTT;
whenever a backward feedback packet arrives at
e.lastFeedbackTime = current Time;
an ingress router. Recall that BF packets contain a
for each flow f listed in p
list of flows arriving at the egress router from the
rateQuantum = min (MSS / currentRTT,
ingress router as well as the monitored egress rates
f.egressRate / QF);
for each flow. Upon the arrival of a backward
if (f.phase == SLOW_START)
feedback packet, the algorithm calculates the
if (deltaRTT × f.ingressRate < MSS × e.hopcount)
current round trip time between the edge routers
f.ingressRate = f.ingressRate × 2 ^ RTTsElapsed;
and updates the base round trip time, if necessary.
50
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
The base round trip time reflects the best observed
since the last backward feedback packet arrived.
round trip time between the two edge routers. The
The estimated number of round trip times since the
algorithm then calculates delta RTT, which is the
last feedback packet arrived is denoted as
difference between the current round trip time
RTTsElapsed.
(currentRTT) and the base round trip time (e.base
Doubling the ingress rate during slow start
RTT). A delta RTT value greater than zero
allows a new flow to rapidly capture available
indicates that packets are requiring a longer time to
bandwidth when the network is underutilized. If,
traverse the network than they once did, and this
on the other hand, the flow is in the congestion
can only be due to the buffering of packets within
avoidance
the network. NBP’s rate control algorithm decides
conservatively incremented by one rateQuantum
that a flow is experiencing congestion whenever it
value for each round trip that has elapsed since the
estimates that the network has buffered the
last backward feedback packet arrived. This is
equivalent of more than one of the flow’s packets
done to avoid the creation of congestion. The rate
at each router hop. To do this, the algorithm first
quantum is computed as the maximum segment
computes the product of the flow’s ingress rate and
size divided by the current round trip time between
deltaRTT.
the edges routers. This results in rate growth
phase,
then
its
ingress
rate
is
This value provides an estimate of the
behavior that is similar to TCP in its congestion
amount of the flow’s data that is buffered
avoidance phase. Furthermore, the rate quantum is
somewhere in the network. If the amount is greater
not allowed to exceed the flow’s current egress
than the number of router hops between the ingress
rate divided by a constant quantum factor (QF).
and the egress router multiplied by the size of the
This guarantees that rate increments are
largest possible packet, then the flow is considered
not excessively large when the round trip time is
to be experiencing congestion. The rationale for
small. When the rate control algorithm determines
determining congestion in this manner is to
that a flow is experiencing congestion, it reduces
maintain both high link utilization and low
the flow’s ingress rate. If a flow is in the slow start
queuing delay. Ensuring there is always at least
phase, it enters the congestion avoidance phase. If
one packet buffered for transmission on a network
a flow is already in the congestion avoidance
link is the simplest way to achieve full utilization
phase, its ingress rate is reduced to the flow’s
of the link, and deciding that congestion exists
egress rate decremented by MRC. In other words,
when more than one packet is buffered at the link
an observation of congestion forces the ingress
keeps queuing delays low. A similar approach is
router to send the flow’s packets into the network
used in the DEC bit congestion avoidance
at a rate slightly lower than the rate at which they
mechanism [15].
are leaving the network.
When
the
rate
control
algorithm
determines that a flow is not experiencing
RESULT
congestion, it increases the flow’s ingress rate. If
In this paper, we have presented a novel
the flow is in the slow start phase, its ingress rate
congestion avoidance mechanism for the Internet
is doubled for each round trip time that has elapsed
called network border patrol. Unlike existing
51
ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji
internet congestion control approaches, which rely
that they can perform the requisite per-flow
solely on end-to-end control, NBP is able to
monitoring, per-flow rate control and feedback
prevent congestion collapse from undelivered
exchange operations.
packets. It does this by ensuring at the border of
Extensive simulation results provided in
the network that each flows packets do not enter
this paper show that NBP successfully prevents
the network faster than they are to leave it NBP
congestion collapse from undelivered packets.
requires no modification to core routers or to end
They also show that, while NBP is unable to
systems. Only edge routers are enhanced so that
eliminate unfairness on its own, it is able to
they can perform the requisite per – flow
achieve approximate global max-min fairness for
monitoring, per-flow rate control and feedback
competing network flows when combined with
exchange operations.
WFQ, Furthermore, NBP, when combined with CSFQ, approximate global max-min fairness in a
CONCLUSION
completely core-stateless fashion.
In this paper, we have presented a novel
As
in
any
feedback-
based
traffic
congestion avoidance mechanism for the Internet
mechanism, stability is an important performance
called Network Border Patrol.
Unlike existing
concern in NBP. Using techniques described in
Internet congestion control approaches, which rely
(16), a plan as part of my future works to perform
solely on end-to-end control, NBP is able to
an analytical study of NBP’s stability and
prevent congestion collapse from undelivered
convergence
packets. It does this by ensuring at the border of
Preliminary results already suggest that NBP
the network that each flow’s packets do not enter
Benefits greatly from its use of explicit rate
the network faster than they are able to leave it.
feedback, which prevents rate over-corrections in
NBP requires no modifications to core routers or
response to indications to indications of network
to end systems. Only edge routers are enhanced so
congestion.
toward
max
–
min
fairness.
REFERENCES 1. B. Suter, T.V. Lakshman, D. Stiliadis, and A. Choudhury, “Design Considerations for Supporting TCP with Per-Flow Queueing,” in Proc. Of IEEE Infocom ’98, March 1998, pp. 299–305. 2. B. Braden et al., “Recommendations on Queue Management and Congestion Avoidance in the Internet,” RFC 2309, IETF, April 1998. 3. A. Demers, S. Keshav, and S. Shenker, “Analysis and Simulation of a Fair Queueing Algorithm,” in Proc. of ACM SIGCOMM, September 1989,pp. 1–12. 4. A. Parekh and R. Gallager, “A Generalized Processor Sharing Approach to Flow Control – the Single Node Case,” IEEE/ACM Transactions on Networking, vol. 1, no. 3, pp. 344–357, June 1993. 5. I. Stoica, S. Shenker, and H. Zhang, “Core-Stateless Fair Queueing: Achieving Approximately Fair Bandwidth Allocations in High Speed Networks,” in Proc. of ACM SIGCOMM, September 1998, pp. 118–130.28
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Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
6. Z. Cao, Z. Wang, and E. Zegura, “Rainbow Fair Queuing: Fair Bandwidth Sharing Without Per-Flow State,” in Proc. of IEEE Infocom ’2000, March 2000. 7. R. Pan, B. Prabhakar, and K. Psounis, “CHOKe - A stateless active queue management scheme for approximating fair bandwidth allocation,” in Proc. of IEEE Infocom ’2000, March 2000. 8. D. Lin and R. Morris, “Dynamics of Random Early Detection,” in Proc. of ACM SIGCOMM, September 1997, pp. 127–137. 9. D. Bertsekas and R. Gallager, Data Networks,
second edition, Prentice Hall, 1987.
10. S. Floyd and K. Fall, “Promoting the Use of End-to-End Congestion Control in the Internet,” IEEE/ACM Transactions on Networking, August 1999, to appear. 11. R. Jain, S. Kalyanaraman, R. Goyal, S. Fahmy, and R. Viswanathan, “ERICA Switch Algorithm: A Complete Description,” ATM Forum Document 96-1172, Traffic Management WG, August 1996. 12. A. Rangarajan and A. Acharya, “ERUF: Early Regulation of Unresponsive Best-Effort Traffic,” International Conference on Networks and Protocols, October 1999. 13. S. Blake, D. Black, M. Carlson, E. Davies, Z. Wang, and W. Weiss, “An Architecture for Differentiated Services,” Request for Comments 2475, Internet Engineering Task Force, December 1998. 14. D. Clark and W. Fang, “Explicit Allocation of Best-Effort Packet Delivery Service,” IEEE/ACM Transactions on Networking, vol. 6, no. 4, pp. 362–373, August 1998. 15. K.K. Ramakrishna and R. Jain, “A Binary Feedback Scheme for Congestion Avoidance in Computer Networks with a Connectionless Network Layer,” ACM Transactions on Computing Systems, vol. 8, no. 2, pp. 158–181, May 1990.
CORRESPONDING AUTHOR: * Research Scholar , Department of Computer Science , Periyar University College of Arts and Science, Mettur Dam-636401. Email- lakshmitvr@rediffmail.com ** Associate Professor, Department of Computer Science, Sri Sarada College for Women, Salem -07
53
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USE OF FUZZY TOPSIS MODEL FOR EVALUATING COOLING TOWERS Dr. Ali Kheradmand*, Mahdi Naqdi Bahar**, Ali Ghani Abadi***
ABSTRACT Present paper applies Fuzzy TOPSIS Model for identification of indicators regarding to cooling towers and assigning weight to indicators and prioritizing Cooling Towers distributed questionnaires among 37 expert and specialist in Besat Electricity Production Company in Tehran – Iran. The current research concluded to this result that in most of the existing studies on decision making issue , the issue is supposed in an environment of definitive data but in some cases it seen that determination of exact values for the criteria is difficult and the value should be considered as Fuzzy Values. KEY WORDS: Fuzzy TOPSIS (Technique for Order Preference by Similarity to Ideal Situation) Model, Cooling Tower, Technology Selection, Decision Making
INTRODUCTION
involves ‘gathering information from various sources about the alternatives, and the evaluation
Technology selection is concerned with
of alternatives against each other or some set of
choosing the best technology from a number of
criteria’.(Lamb and Gregory,1997) Technology
available options. The criteria for a ‘best’
selection
technology may differ depending on the specific
technology
selection
process
which
master’.(Garegory,1995)
the
firm
technology
seeks
involve
decision
growth of a company in the increasing competitive
as
global scenario.(Chan et al, 2000) One of the
‘identification and selection of new or additional technologies
justification
makings that are critical to the profitability and
requirements of a company. (Shehabuddeen et al, 2006)
and
technologies regarding the industry is cooling
to
tower which has many applications in industries.
selection
Role of cooling towers for chemicals producing 54
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
units is like role of radiator in an automobile. As
assessing
cutting off flow of cooling water in automobile
technologies. To select the best technologies in the
and radiator break down causes irreparable
existence of both cardinal and ordinal data
damages to engine and other parts of automobile,
Faerzipoor Saen(2006) proposed an innovative
in industry too, cutting off cooling water even for a
approach, which is based on Imprecise date
short time involves huge damages as consequence
envelopment analysis (IDEA). Lee and Hwang
so that operators in case of cooling water cut-off
(2010) proposed to use AHP as a tool for
for any reason often consider it a saving action to
prioritizing the strategically promising nuclear
put the system out of service in spite heavy costs
technologies for commercial export from Korea.
of production halt. This strong dependence of
Jaganathan et al (2007) proposed an integrated
production on cooling towers function indicates
Fuzzy AHP based approach to facilitate the
their special economic importance. On the other
selection and evaluation of new manufacturing
side, limitation of water sources and necessity of
technologies
their use make the towers’ economic role more
attributes and uncertainty. However, AHP as two
obvious and on the other side, incorrect selection
main weaknesses First subjectivity of AHP is a
of this technology may in addition to loss of water
weakness.
sources, bring irremediable damages to the
interrelationship within the criteria in the model
country’s industry. Hence, selection of this
this paper, using Fuzzy TOPSIS Model tries to
technology is of very high importance. This paper,
evaluate and prioritize cooling towers.
the
in
prior
the
Second
order
of
presence
AHP
could
regenerative
of
intangible
not
include
using Fuzzy TOPSIS Model tries to evaluate and prioritize cooling towers.
FUZZY TOPSIS METHOD The TOPSIS is widely used for tackling
LITERATURE REVIEW Some
mathematical
ranking problems in real situations. This method is programming
often criticized for its inability to adequately
approaches have been used for technology
handle the inherent uncertainty and imprecision
selection in the past. Hsu et al. (2010) provided a
associated with the mapping of the decision-
systematic approach towards the technology
makers perception to crisp values. In the
selection in which two phase procedures were
traditional formulation of the TOPSIS, personal
proposed. The first stage utilized fuzzy Delphi
judgments are represented with crisp values.
method to obtain two the critical factors of the
However, in many practical cases the human
regenerative technologies by interviewing the
preference model is uncertain and decision makers
experts. In the second stage, fuzzy AHP was
might be reluctant or unable to assign crisp values
applied to find the importance degree of each
to the comparison judgments (Chan & Kumar,
criterion as the measurable indices of the
2007; Shyur & Shih, 2006). Having to use crisp
regenerative technologies. They considered eight
values is one of the problematic points in the crisp
kinds of regenerative technologies which have
evaluation process. One reason is that decision-
already been widely used, and established a
makers usually feel more confident to give interval
ranking model that provides decision markers to
judgments rather than expressing their judgments
55
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in the form of single numeric values. As some
competitive and to sustain growth (McNamara and
criteria are difficult to measure by crisp values,
Baden-Fuller, 1999). These firms engage in
they are usually neglected during the evaluation.
various technology management practices, and
Another reason is mathematical models that are
deploy technology strategies and planning in order
based on crisp value. These methods cannot deal
to meet these needs. This is becoming more
with decision-makers’ ambiguities, uncertainties
difficult
and vagueness which cannot be handled by crisp
technologies,
values. The use of Fuzzy set theory (Zadeh, 1965)
abundance of technological options, higher cost of
allows
incorporate
technological development, and rapid diffusion of
incomplete
technologies (see Lei, 2000; Steensma and
the
decision-makers
unquantifiable information;
to
information, non-obtainable
information
and
due
to
increasing
convergence
complexity of
of
technologies,
Fairbank, 1999; Berry and Taggart, 1994). The
partially ignorant facts into decision model (Kulak,
dispersion
Durmusoglu, & Kahraman, 2005). As a result,
organizations,
Fuzzy TOPSIS and its extensions are developed to
countries, and the resulting obscurity, makes the
solve
problems
task of accessing suitable technologies and
(Büyükzkan, Feyzioglu, & Nebol, 2008; Chen &
selection of the most suitable option more difficult
Tsao, 2007; Kahraman, Büyükzkan, & Ates, 2007;
(Cantwell, 1992). Greenberg and Cazoneri (1995)
Onüt & Soner, 2007; Wang & Elhag, 2006; Yong,
and Hackett and Gregory (1990), report that
2006). This study uses triangular Fuzzy number
projects to incorporate new technology, in a
for Fuzzy TOPSIS. The reason for using a
majority of companies, are failing or are not
triangular Fuzzy number is that it is intuitively
fulfilling expectations. Nabseth and Ray (1974) in
easy for the decision-makers to use and calculate.
their study of the European and USA machine tool
In addition, modeling using triangular Fuzzy
companies found that similar problems still remain
numbers has proven to be an effective way for
although
formulating
the
undertaken to study these issues. As Huang and
information available is subjective and imprecise
Mak (1999) explain in their study of 100 British
(Chang, Chung, & Wang, 2007; Chang & Yeh,
manufacturing companies, the failure of a chosen
2002; Kahraman, Beskese, & Ruan, 2004;
technology often results from poor management
Zimmerman, 1996). In practical applications, the
and preparation of the change process. Some of the
triangular form of the membership function is used
causes have been attributed to the inability to
most often for representing Fuzzy numbers (Xu &
consider the wider relationship of technology to
Chen, 2007).
the business and organizational context and
ranking
and
decision
justification
problems
where
of
technology geographical
several
sources locations
investigations
have
across and
been
include these issues in the technology investment NEED FOR A TECHNOLOGY SELECTION
considerations (Schroder and Sohal, 1999). This
METHOD
finding is echoed by Efstathiades et al. (2000) who
Technology based businesses rely on
assert the need for careful assessment of potential
renewal of existing technological resources and
problems before introducing a technology into an
exploitation of new technologies to remain
organization.
56
Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
RESEARCH PURPOSES
various models existing in the area of decision
I.
making with multi-indices, TOPSIS method due to
Identification of indicators regarding cooling
its advantages relative to other method has been
towers II.
Assigning
weight
to
indicators
selected for weight assignment and prioritization.
and
Step 1: formation of Fuzzy Decision Making
prioritizing cooling towers
Matrix in which m alternatives by n indices are assessed. A Fuzzy multi-indicator decision making
RESEARCH METHODOLOGY
matrix is defined as follows.
This research in terms of purpose is of applied type and the research execution method is of descriptive and survey type. The research’s
C1
statistical society includes two parts: the first part
1)
is for identification of cooling towers’ indicators including experts and specialists of cooling towers of Besat Electricity Production Company. Given
~ A1 X11 ~ ~ A X D = 2 21 M M ~ Am Xm1
C2
L Cn
~ ~ X12 L X1n ~ ~ X22 L X2n , i =1,2,...,m, j =1,2,...,n M M M ~ ~ Xm2 L Xmn
In which, A , A ,..., A represent alternatives, 1 2 m
that the statistical society was a limited society, 32 specialists were selected and the questionnaire was
C , C ,..., C represent 1 2 n
distributed among them. The second part regards weight assignment and prioritization of cooling
indices,
denotes Fuzzy value of the option
towers’ various options in which 5 connoisseurs
and
~ x ij
i in terms
of the index j . Verbal variables and Fuzzy
were questioned.
numbers equivalent to each verbal variable used in this study are presented in table (1).
DATA COLLECTING TOOL In this paper, to collect information with
Table(1)
regard to the research’s theoretical bases and literature, index cards and tables have been used. To gather the data from the 3 used questionnaires (first questionnaire for identification of indices, the two other questionnaires for weight assignment to the indices and prioritization of cooling towers) the validity of which has been confirmed by professors and its stability using Cronbach Alpha was found to be 75% and hence confirmed.
Step 2: Make normalize matrix decision making
DATA ANALYSIS METHOD the
matrix as relation (2) which takes place by means
alternatives, given the determined indicators, it
of relations (3) and (4). Relation (3) is used for
was found that this issue in the field of decision
scale less making of indices with positive aspect
making with multi indices and from among
and relation (4) for scale less making indices with
After
data
collection
for
all
negative aspect. 57
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[ ]
~ (2) R = ~ rij
m× n
v~ ~ (8) v
, i = 1,2,..., m, j = 1,2,..., n
(7)
aij bij cij (3) ~ rij = + , + , + , c +j = max cij c c c j j j
v~
a _j a _j a _j (4) ~ rij = , , , a _j = min aij cij bij aij
m× n
− j
{( v~ ~ = {(min v
= max
And
ij
ij
v~
) } j ∈ J )i = 1,...., m } j ∈ J i = 1,...., m
−
ij
takes place in three stages and
using the following relations. Obviously, if at both stages the greatest and smallest Fuzzy numbers are found, there will be no need for other stages.
matrix as relation (5) using relation (6).
[ ]
j
+
ij
Step 3: calculation and make harmonic normalize
~ (5) V = v~ij
+
, i = 1,2,..., m, j = 1,2,...n
Stage 4.1: at this stage, using relation (9) we rank Fuzzy numbers in order to find its greatest and
~ (6) v~ij = ~ rij ⊗ w j
smallest quantity. At this stage, we need to evaluate indices’ weights.
(~ )
(9) S A,0 =
To calculate indices’ weight in this research the suggested method by Wang and Chang (1995) has
a + 2b + c 4
Stage 4.2: if at stage one there are numbers which
been used. For this purpose, five connoisseurs
are placed in one group, or in other words, using
have been asked to determine indices’ importance
relation (9) we cannot determine their smallness or
with verbal variables. To determine importance of
greatness relative to each other, we take their tide
the constituents and the respective weights, the
into consideration and using Fuzzy numbers’ tide
respective verbal variables and Fuzzy numbers
we rank them.
(~ )
suggested by Wang and Chang (1995) have been
(10) mod e A
used. Table 2 shows verbal variables and Fuzzy
Stage 4.3: at third stage, if there are still numbers
numbers. This method has been used by Wang and
which are placed in one group, for their ranking
Chang (1995) and Chen (2000), Wang and Elhag
we consider Fuzzy numbers’ Domain.
(2007) to determine the indices’ weights.
(~ )
(11) A
Table(2)
Stage 5: distance of each alternative is found through positive and negative ideal solution. This is done using relations (12) and (13). (12)
(~
~
)
(13) In which
by taking
and into account as two
triangular Fuzzy numbers it calculated as relation (14). Source: (Wang & Chang, 1995; 2007)
(14)
Step 4: determining positive and negative ideal for
Step 6: calculation of relative closeness of each
each index using relations (7) and (8).
alternative to ideal solution which is done using 58
Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 2, Year: 2013
Table 2: Closeness of Alternative to the Ideal
relation (15).
Solution
_
(15) cci =
di , i = 1,2,..., m + d i + d i_
Step 7: alternatives ranking; at which the existing alternatives from the hypothetic problem are ranked in ascending order starting from the most important.
RESULT: The questionnaire which had been provided to the statistical society (32 persons) was analyzed
RANKING OF ALTERNATIVES:
and 8 indicators were selected for cooling towers evaluation. Next, 5 connoisseurs were asked to
Table 3: Ranking Based on the Preferred
assign weight to the indices the results of which
Alternatives
are presented in the table below:
Table 1: Weights Indices
Check rank the cooling tower can be seen Tower with a suction fan(A4) rated first and Tower with a blower fan(A3), Tower with normal tension(A5), Tower with a Traction stokehole(A6), Tower with normal tension(A2), Tower with mechanical tension(A1) were next to the stars.
CONCLUSION: Given identification of the identified indices
In this paper, evaluation of level and prioritization
and weigh of each index, now using Fuzzy
of cooling towers technology based on the
TOPSIS method which has been explained in data
specified indices by experts using ranking method
analysis method we prioritize the options. The
based on similarity with ideal answer Fuzzy
following results indicate relative closeness of
TOPSIS was investigated. In most of the existing
each option to the ideal solution.
studies on decision making issue, the issue is supposed in an environment of definitive data but in some cases, it is seen that determination of exact 59
ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji
values for the criteria is difficult and the values
Fuzzy Sets and then based on TOPSIS method
should be considered as Fuzzy values. In this
approach which is a simple method and quickly
paper, we have investigated the existing options in
specifies the required answer, we calculated the
Fuzzy environment and based on the Theory of
closest option to the ideal solution.
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CORRESPONDING AUTHOR: * Department of Accounting, Zahedshahr Branch, Islamic Azad University (IAU), Zahedshar , Iran. ** Corresponding Author: Research Scholar, Thiruvananthapuram, Kerala, India, E mail: mahdinaqdibahar@yahoo.com, Mobile phone: +919623566206 *** Ali Ghani Abadi, Master of Industrial Management
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Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013
CORRECTION NOTICE It is hereby informed to all the readers of Scientific Research Journal of India that the main author of the article entitled “Effect of McConnell Taping on Pain, ROM & Grip Strength in Patients with Triangular Fibrocartilage Complex Injury” published in the Year: 2013, Vol:2, Issue:1 was Babloo Sharma. So kindly read the authors as- Babloo Sharma, Dr. Shahid Mohd. Dar and Dr. R Arunmozhi instead of Dr. Shahid Mohd. Dar, Dr. R Arunmozhi, Babloo Sharma. Thanks for your kind cooperation.
Editor-in-Chief
63
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