Scientific Research Journal of India (SRJI), Vol 2, Issue 1, Year 2013 by Dr. Krishna N. Sharma

Scientific Research Journal of India (Multidisciplinary, Peer Reviewed, Open Access, Journal of science) ISSN: 2277-1700 Vol: 2, Issue: 1, Year: 2013

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, 9305835734

CONTENTS

Title

Author/s

Editorial

Dr. Krishna N. Sharma

Effect Of McConnell Taping on Pain, ROM & Grip Strength in Patients

with

Triangular

Fibrocartilage Complex Injury

Evaluation of Knee Joint Effusion with

Osteoarthritis

Physiotherapy: A Pilot Study on Musculoskeletal Ultrasonography

Department

Page i

Dr. Shahid Mohd. Dar, Dr. R. Arunmozhi,

Physiotherapy

Chemistry

Babloo Sharma

Shanmuga Raju P., Suryanarayana Reddy V., Madurwar AU, Sridhar EB, Harsha Vardhan NS.

Physical Therapy Management of Tuberculous

Arthritis

the

Amit Murli Patel

Elbow Effect of Sensory Cueing on Gait and Balance during both “On” and

“Off”

Drug

Phase

Sinha Siddharth, Bhatt Sunil

Parkinson’s Disease Congenital Talipes Equinovarus (CTEV) Analysis of Water Quality of Halena Block in Bharatpur Area

Mayank Pushkar

Sunil Kumar Tank, R. C. Chippa

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EDITORIAL

Greetings of the New Year!!! I am very pleased to present this issue of the Scientific Research Journal of India (SRJI). With this issue, we have entered in the 2nd year of our publication. This multidisciplinary and open access Journal of science published total 22 papers (13 papers in Physiotherapy, 1 paper in Surgery, 1 paper in Microbiology, 3 papers in Computer Technology, 1 paper in Chemical Engineering, 1 paper in Metallurgical Engineering, 1 paper in Agriculture, and 1 paper in Anthropology) last year. This year, we are hopeful to bring more researches in light. In the current issue we have covered two disciplines of science Physiotherapy, and Chemistry. Hopefully youâ&#x20AC;&#x2122;ll find these papers informative. Your comments and suggestions are very valuable for us.

Happy Reading.

Regards,

Dr. Krishna N. Sharma Editor in Chief

EFFECT OF MCCONNELL TAPING ON PAIN, ROM & GRIP STRENGTH IN PATIENTS WITH TRIANGULAR FIBROCARTILAGE COMPLEX INJURY Dr. Shahid Mohd. Dar* MPT (Orthopaedic & Sports), Dr. R. Arunmozhi** MPT (Sports & Rehabilitation), Babloo Sharma*** MPT (Sports)

ABSTRACT STUDY OBJECTIVES: To find out the efficacy of McConnell Taping on Pain, Range of Motion and Grip strength in subjects with Triangular Fibrocartilage Complex (TFCC) injury. DESIGN: An Experimental Study. SETTING: All the Subjects were selected from various sports center from Dehradun and SAI Guwahati. Methods: A total of 28 subjects were recruited for the study on the basis of inclusion and exclusion criteria after signing the informed consent form. The subjects were divided into two Groups (A= Taping & B= Conventional Therapy). OUTCOME MEASURE: Grip Strength, Range of Motion for Wrist and Forearm & Numerical Pain Rating Scale. RESULTS: The result of the study shows that both McConnell Taping and Conventional Therapy are effective in improving the Range of Motion, Grip Strength and reducing the Pain level. Both groups showed significant improvement when comparison was made within the group. However, there is significant reduction in pain level between the groups for Group A (p=0.000). CONCLUSION: The present study demonstrates that both McConnell Taping and Conventional Treatment are effective in improving the Grip Strength, Range of Motion and reducing the Pain level in subjects with TFCC injury. However, it can be concluded that McConnell Taping is the better form of treatment in improving the Grip Strength, Range of Motion and reducing the Pain level in subjects with TFCC injury.

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KEY WORDS: TFCC, Taping, Grip Strength, Range of Motion, Numerical Pain Rating Scale, Conventional Therapy.

The problem that arises from soft tissue

INTRODUCTION

injury of this important structure is distal radio ulnar The triangular fibrocartilage complex (TFCC)

joint (DRUJ) instability. The DRUJ is a diarthroidal

is a special structure at the ulno-carpal articulation.8 It

composed

semicircular

trochoid articulation, which is an incongruent

biconcave

articulation; only around 20% of its stability is

fibrocartilage or articular disc called the TFC, the

produced by osseous articular contact. Soft-tissue

palmar and dorsal distal radioulnar ligaments, a

structures of the TFCC play a critical role in intrinsic

meniscus homolog, ulnolunate and ulnotriquetral

joint stability.7

ligaments and the extensor carpi ulnaris tendon subsheath.7,17

TFCC

Wrist injuries are often complex and their

extends the radio-carpal articulation, permitting

management will vary greatly; as such it is vital that

(ECU)

Functionally, 8

the

the correct diagnosis is made. If we look specifically

cartilaginous and ligamentous structure, important in

at the athletic population TFCC tears are more

the stabilization of the distal radial ulnar joint and in

frequently

the absorption of load between the distal ulna and

racquet/batting sports, boxing, and pole vaulting.

the volar carpus.7,17 The articular disc of the TFCC

This is due to the repetitive high forces on the wrist

separates the ulna and the proximal carpal row, and

that will often be in extension or ulnar deviation, or

carries about 20% of the axial load from wrist to

both (Parmelee-Peters & Eathorne, 2005).30 The

forearm.17

most common mechanism of injury to the TFCC

pronation

and

supination.

The TFCC

seen

gymnastics,

hockey,

occurs with axial loading, ulnar deviation, and Injuries to the TFCC occur with repetitive ulnar

forced extremes of forearm rotation. Injury may also

loading (e.g., bench press, racquet sports) or acute

be associated with localized swelling, crepitus, grip

traumatic axial load with rotational stress (e.g., FOOSH).

weakness and sense of instability.7

Most injuries to the TFCC have a

component of hyperextension of the wrist and

The initial treatment for TFCC injury may

rotational load. Injury to the TFCC is the most

include

splinting,

rest,

anti-inflammatory

common cause of ulnar-sided wrist pain. Ulnar-

medications, cryotherapy, electrotherapy modalities

sided wrist pain made worse with ulnar deviation,

and physiotherapy techniques like manual and

wrist extension, or heavy use is the common

exercise therapies.23 Biomechanical adjustments may

complaint of an athlete who has a TFCC injury.

be required to comprehensively manage the injury

TFCC injuries are more commonly seen in such

and reduce the incidence of recurrence.23 These

sports as gymnastics, hockey, racquet sports, boxing,

include on court stroke analysis and if necessary,

and pole vaulting.

modifications to the athlete’s stroke mechanics, or their equipment, such as adjustments of the grip size, 2

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

the over grip, the strings and string tension, the

METHODS

weight balance of the racket, or the grip placement An experimental study design was conducted

(continental, eastern, semi-western, and western).23

on total of 28 subjects who were recruited from Physiotherapists and Athletic Trainers often

various sports center in and around Dehradun and

use athletic tape methods to support and prevent

SAI Guwahati based on the inclusion and exclusion

sport related injuries. Athletic tape is effective due to

criteria. The subjects were divided into two groups

its reported ability to provide stability, maintain

after the informed consent was signed. Subjects with

proper structural alignment, facilitate proprioception

prediagnosed cases of TFCC injury were included in

and also its neuromuscular effects. The aim of taping

the study. Group A (Taping + Conventional

is to reduce healing time, to protect and support the

Therapy, n=14) and Group B (Conventional

wrist, and prevent future injury.23

Therapy, n=14). Pre intervention measurements of pain, range of motion and grip strength were taken

In response to the limited effective taping

out using Numerical Pain Rating Scale, Universal

options for wrist injuries involving the TFCC and/or

Goniometer and Hand Dynamometer. Both the

ECU tendon, Kathleen Stroia and Kathy Martin

groups were received intervention for total of 8 days

applied the McConnell principles of “unloading” to

with a rest period on the 4th day. Subjects were

the wrist.23 Stroia and Martin experimented with

excluded from the participation if they present with

various tape applications and created a clinically

any neurological deficit of the reference extremity,

effective tape technique, consisting of 1) an unload,

ay other reason of wrist and hand pain of the

2) a block, and 3) a re-direction tape for players who

reference extremity, history of fracture or any other

sustained wrist injuries involving the TFCC and/or

musculoskeletal surgery of wrist, pain or movement

ECU tendon.23 This tape technique is effective for

restriction more than 6 weeks and subjects with h/o

injuries involving both the TFCC and ECU as they

TFCC injury less than 48 hours.

are in close proximity to each other, and due to the co-morbid nature of ECU tenosynovitis and TFCC

Grip strength (pound)11,18, Range of Motion

pathologies.23 This tennis-specific wrist taping

(degree)15 for Wrist and Forearm and Numerical

technique

injured

Pain Rating Scale13,28 was taken as outcome measure

structures; however it restricts only the desired

before and after the total session of treatment. All

motions (supination, ulnar deviation, and extension).

the subjects were assessed for outcome on 1st day

The technique meets the desired goal of allowing a

(before the intervention), 4th day and the final data

player to play with more support which improves

was collected on 8th day.

protects

and

supports

the

function, while restricting extreme range of motion. Protocol for Group A (Taping): Tennis Specific

It is designed to consider the anatomy and patho-

Unload, Block and Redirection Tape Technique

physiology of the injury and the biomechanics of the

were

two-handed backhand.23

applied

according to the

principle

McConnell taping. This tennis-specific wrist taping 3

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technique

protects

and

supports

the

injured

structures; however it restricts only the desired motions

(supination,

ulnar

deviation,

and

extension).23 The technique meets the desired goal of allowing a player to play with more support which improves function, while restricting extreme range of motion. It is designed to consider the anatomy and patho-physiology of the injury and the biomechanics of the two-handed backhand.23 Fig. 1.3: Tape with redirectional technique for supination

1 subjects was dropout before the 4th day assessment.

Fig. 1.4: Tape with supination end range block Fig. 1.1: Fixomull Stretch with Gutter

Protocol for Group B (Conventional Therapy): Conventional treatment of TFCC was given, which include rest to the part, Ultrasound Therapy and Home Exercise Program.23,2 The parameter for Ultrasound was Frequency: 3 MHz, Intensity: 1.4W/cm2, Time: 6 minutes, Mode: Continuous.6 2 subjects were dropout, 1 before the 4th day and other after the 4th day assessment. DATA ANALYSIS Fig. 1.2: Tape with directional force

Data was analyzed by using SPSS software (version 16). Paired t-test was applied to compare the data within the groups whereas Independent t-

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

test was applied to compare the data between the groups. The p value was set at (≤0.05) with 95% confidence interval. RESULTS Table 1.1: Comparison of Pre and Post Grip Strength score for Group A and B MEAN

SD t

PRE

POST

PRE

POST

24.674

24.55889

GROU PA

64.102

78.308

18.6662 9

GROU PB

52.5

69.306

20.7864 4

Fig. 1.6: Comparison of Pre and Post Wrist Extension ROM for Group A and Group B -6.697

.000

-7.824

.000

Table 1.3: Comparison of Pre and Post Pain Score for Group A and Group B MEAN

PRE

POST

PRE

POST

GROUP A

5.3077

0.6154

0.63043

0.50637

GROUP B

5.8333

1.3333

1.19342

0.65134

26.836

.000

12.539

.000

Fig. 1.5: Comparison of Pre and Post Grip Strength score for Group A and B Fig. 1.7: Comparison of Pre and Post Pain Score for Group A and Group B

Table 1.2: Comparison of Pre and Post Wrist Extension ROM for Group A and Group B MEAN

PRE

POST

PRE

POST

GROUP A

67.692

71.692

4.38529

2.35884

GROUP B

68.75

71.667

3.76889

3.25669

-3.399

.005

Table 1.4: Comparison of Grip Strength between Group A and Group B MEAN

-2.244

GROUP B

GROUP A

GROUP B

PRE

64.102

52.5

18.66629

20.78644

POST

78.308

69.306

24.674

24.55889

.046

GROUP A

1.464

.157

.913

.371

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Fig. 1.8: Comparison of Grip Strength between Group A and Group B

Fig. 1.10: Comparison of NPRS between Group A and Group B

Table 1.5: Comparison for Wrist Extension ROM between Group A and Group B MEAN

GROUP A

GROUP B

GROUP A

GROUP B

PRE

67.692

68.75

4.38529

3.76889

POS T

71.692

71.667

2.35884

3.25669

-.648

.523

.023

.982

Results of the study showed that there is significant reduction in pain and improvement in grip strength and range of motion in both the groups after the intervention. However, Group A (Taping) showed more reduction in pain score when compared to Group B and this was found to be statistically significant p=.005 post intervention. Other variables also showed improvement but it was statistically non-significant. DISCUSSION Hand and wrist trauma accounts for 3-9% of all athletic injuries.12 An injury to the TFCC is very

Fig. 1.9: Comparison for Wrist Extension ROM between Group A and Group B

important as it is the most common cause of ulnar side wrist pain and limited wrist function in work or in sports.29 According to Kathleen Stroia et al., when

Table 1.6: Comparison of NPRS between Group A and Group B MEAN

the wrist is loaded into supination, ulnar deviation and extension, the TFCC, ECU tendon and sheath are loaded with significant stress. This is the typical

SD t

GROUP A

GROUP B

GROUP A

GROUP B

PRE

5.3077

5.8333

0.63043

1.19342

-1.393

.177

handed backhand stroke, it also occurs during a

POST

0.6154

1.3333

0.50637

0.65134

-3.091

.005

forehand stroke.23

position of the non-dominant wrist during the two-

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 1, Year: 2013

The present study was done to find out the

neurophysiological model the tape may exert an

efficacy of Taping in terms of grip strength, range of

effect on grip strength by primarily altering pain

motion and pain score in subjects with Triangular

perception, either locally at the wrist by inhibiting

Fibrocartilage Complex Injury.

nociceptors, facilitating large afferent fiber input into the spinal cord and/or possibly by stimulating

The most probable reason for the reduction in

endogenous processes of pain inhibition thereby

pain after the application of tape could be due to

increasing the grip strength and reducing the pain

reduction of strain on the injured structure in both

level as according to the Alireza Shamsoddini et al

the acute phase and also during the ongoing repair

in his study.22

and rehabilitation phase. Supporting an injured joint with tape is widely believed to be helpful in

Limitations of the study are small sample size

reducing pain, preventing exacerbation of the injury

and different grades of the TFCC injury was not

and promoting tissue healing. This technique met

taken

the desired goal of allowing the players to play with

recommendation for future studies need to be done

full support and improved function as said by the

with broader dimension, on the workers who are

Kathleen Stroia in his study.

into

consideration.

the

further

mainly involved with hand and wrist work, and its effectiveness can also be checked with other taping

Another possible effect of tape could be due to

technique.

a direct mechanical effect on the TFCC, presumably by somehow improving the internal mechanics or by

CONCLUSION

protecting the damage tissues from excess forces and The present study demonstrates that both the

as a result, decrease in pain and improving grip

technique is effective in improving the grip strength,

strength.26

range of motion and reducing the pain in subjects Along with it, this method of taping technique

with TFCC injury. However, Taping technique used

also disperses the stress generated by the muscle

in this study proves to be effective in reducing the

during contraction which results in decreasing the

pain in subjects with TFCC injury. So, it can be

pain level by reducing the painful inhibition. The

concluded that Taping is the better choice of

possible mechanism behind the reduction in pain is

treatment in subjects with TFCC injury along with

due to its neurophysiologic effects on the nervous

other therapeutic modalities.

system, particularly the nociceptive system. In this

REFERENCES

Adams BD, Holley KA. Strains in the articular disk of the triangular fibrocartilage complex: a biomechanical study. J Hand Surg Am. 1993 Sep;18(5):919-25.

Brukner P, Khan K. Clinical Sports Medicine 3rd Edition. India: Tata McGraw-Hill; 2008.

ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji

Busconi B, Stevenson J H. Sports Medicine Consult. USA: Lippincott Williams and Wilkins, Wolters Kluwer; 2009.

Constantinou M, Brown M. Therapeutic Taping For Musculoskeletal Conditions. Australia: Churchill Livingstone; 2010.

Cornwall R. The Painful wrist in Pediatric Athlete. J Pediatr Orthop 2010 March;30(2).

David O. Draper. Ultrasound and Joint Mobilizations for Achieving Normal Wrist Range of Motion After Injury or Surgery: A Case Series. Journal of Athletic Training 2010;45(5):486–491

Dr. Wai L H. Management of triangular fibrocartilage complex injury, a cause of ulnar wrist pain. HKMA CME Bulletin 2011 May.

Gerbino Peter G. Wrist Disorders In The Young Athlete. Operative Techniques in Sports Medicine 1998 October;6(4):197-205.

Hyde T E, Gengenbach M S. Conservative Management Of Sports Injuries 2nd Edition. United Kingdom: Jones & Bartlett; 2007.

10.

Joshi S. S, Joshi S. D, et al. Triangular Fibrocartilage Complex (TFCC) of Wrist: Some Anatomico-clinical Correlations. J Anat Soc India 2007;56(2):8-13.

11.

Mathiowetz V, Kashman N, et al. Grip and Pinch Strength: Normative Data for Adults. Arch Phys Med Rehabil 1985;66:69-72.

12.

Maffulli N, Lango U G, et al. Sports Injuries: a review of outcomes. British Medical Bulletin 2010; 1–34.

13.

Moore J, Ali D. Rehab Measures: Numeric Pain Rating Scale. Rehabilitation Measures Database; 12/15/2010.

14.

Nakamura T, Yabe Y, et al. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg Br. 1996 Oct;21(5):581-6.

15.

Norkin Cynthia C, White D. Joyce. Measurement Of Joint Motion- A Guide to Goniometry 3rd Edition. India: Jaypee Brothers Medical Publishers (P) Ltd; 2004.

16.

Palmer AK. Triangular Fibrocartilage Complex Lesion; A classification. Jour of Hand Surgery 1989;14(A):594-605.

17.

Parmeelee-Peters K, Eathorne Scott W. The Wrist: Common Injuries and Management. Primary Care: Clinics In Office Practice 2005;32:35–70.

18.

Peolsson A, Hedlund R, et al. Intra- and Inter- Tester Reliability and Reference Values For Hand Strength. J Rehab Med 2001;33:36–41.

19.

Perkins R H, Davis D. Musculoskeletal Injuries in Tennis. Phys Med Rehabil Clin N Am 2006;17:609-631.

20.

Reid David C. Sports Injury Assessment & Rehabilitation. USA: Churchill Livingstone: 1992.

21.

Retting Arthur C. Athletic Injuries of the Wrist and Hand. Am J Sports Med 2004; 32: 262.

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

22.

Shamsoddini Alireza, Mohammad Taghi Hollisaz, et al. Initial effect of taping technique on wrist extension and grip strength and pain of Individuals with lateral epicondylitis. Iranian Rehabilitation Journal 2010;8(11).

23.

Stroia K, Baudo M, et al. Taping Techniques for TFCC and ECU injuries on the Sony Ericsson WTA Tour. Med Sci Tennis 2009;14(1):15-19.

24.

Tang JB, Ryu J, et al. The triangular fibrocartilage complex: an important component of the pulley for the ulnar wrist extensor. J Hand Surg Am 1998 Nov;23(6):986-91.

25.

Vezeridis Peter S, Yoshioka Hiroshi, et al. Ulnar-sided wrist pain. Part I: anatomy and physical examination. Skeletal Radiol 2010; 39:733-745.

26.

Vicenzino B, Brooksbank J, et al. Initial Effects of Elbow Taping on Pain-Free Grip Strength and Pressure Pain Threshold. J Orthop Sports Phys Ther 2003;33:400–407.

27.

Wadsworth C T, Nielsen D H, et al. lnter-rater Reliability of Hand-Held Dynamometry: Effects of Rater Gender, Body Weight, and Grip Strength. J Orthop Sports Phys Ther 1992 August;16(2):74-81.

28.

Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. Journal of Clinical Nursing 2005;14;798-804.

29.

Yao-Tung Hou, Jui-Tien Shih, et al. Chronic triangular fibrocartilage complex tears with distal radioulna joint instability: A new method of triangular fibrocartilage complex reconstruction. Journal of Orthopaedic Surgery 2000;8(1):1–8.

30.

The Sports Physiotherapist Blog. Triangular Fibrocartilage Complex Tears: Evidence Based Assessment and Management. 2012 May 06.

CORRESPONDENCE

* Asst. Prof. Department of Physiotherapy, Dolphin (PG) Institute, Dehradun (UK) ** Associate Prof. Department of Physiotherapy, SBS PGI Biomedical and Research, Dehradun (UK) *** Student Researcher, Dolphin (PG) Institute, Dehradun (UK). Email: babloo83_sharma@yahoo.com

EVALUATION OF KNEE JOINT EFFUSION WITH OSTEOARTHRITIS BY PHYSIOTHERAPY: A PILOT STUDY ON MUSCULOSKELETAL ULTRASONOGRAPHY Shanmuga Raju P. MPT*, Suryanarayana Reddy V. MS, Madurwar AU. MD, Sridhar EB. MD, Harsha Vardhan NS. MD

ABSTRACT AIM: The aim of study is to investigate the changes of knee joint effusion before and after osteoarthritis of knee, using by musculoskeletal Ultrasonograpy. DESIGN: Prospective, follow-up study. SETTING: Department of Physiotherapy, Chalmeda Anand Rao Institute of Medical sciences, Karimnagar. METHODS AND MATERIALS: 20 cases of unilateral knee osteoarthritis were assessed by PHILPS EnviSor CH D Ultrasonographic examination of knee effusion. Subjects were prospectively assigned to the follow-up treatment of Interferential stimulation and Non-thrust Manual exercise (including Knee, Hip and and Leg muscles. A 15 session treatment program, 30 minute per day was performed for KOA. OUTCOME MEASURES: Before and after intervention, we assessed knee joint effusion through ordinal scale. T â&#x20AC;&#x201C;test was used for comparison between pre and post treatment results in respectively. RESULTS: 12 cases (women 7, men 5) were identified and a total 20 subjects of knee OA. The mean score of effusion (2.75); T-value (2.20%) in the nonthrust manual exercise and interferential current. CONCLUSION: Significantly reduction in knee effusion in patients with knee osteoarthritis. KEYWORDS: Knee osteoarthritis, Musculoskeletal ultrasonography, Knee effusion, Interferential current, 10

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

nonthrust manual exercise.

INTRODUCTION In 1743, Willams Hunter first described

•

Knee pain with independence walking.

•

Aged between 40-75 years (Both female and

Osteoarthritis. Osteoarthrtis is a condition that

male). •

primarily affect the articular cartilage, but involve the entire joint, including the subcondral bone,

PHILPS EnVisor C HD Musculoskeletal Ultrasonography.

and

•

Ultrasonic Gel.

periarticular muscles (Brandt.KD. et.al 2009). The

•

L12- 3 MHZ probe/ Transducer.

basic aim of physiotherapy is to prevent disability,

•

Universal Goniometry

improve joint range of motion, reduce pain, stiffness,

•

Interferential stimulation (IFS) modality.

and improve muscular strength, fitness and Quality

•

Nonthrust manual exercise

of life. The purpose of study is to investigate

•

Knee effusion Imaging Record

whether changes of knee joint effusion in patients

•

Digital Camera.

ligaments,

capsule,

synovial

membrane

with osteoarthritis before and after Physiotherapy treatment using musculoskeletal Ultrasonography.

Exclusion Criteria were

Musculoskeletal Ultrasonography is a non-

•

invasive, lowcost, bedside procedure that may be

surgery

used and to assess osteoarthrtic joints (Iagnocco.A. 2008). Ultrasound detects changes of intra articular knee

effusion

and

(Coopenberg.PL.et.al Et.al,1982).

inflammatory 1978

arthritis

Kanfman

RA.

The purpose of this study is to

investigate the changes of knee joint effusion before and

after

osteoarthritis

knee,

using

A history of knee and Hip Replacement

•

Psoratric Arthritis

•

Unable to walk without assistance

•

Non-steroid anti-inflammatory Drugs.

•

Corticosteroid injections

•

Radicular pain below knee and

•

A History of malignancy.

musculoskeletal ultrasonograpy Musculoskeletal Ultrasonography Imaging PHILPS EnVisor CH D M2540 A Ultrasound

METHODS AND MATERIALS

System (L12-3 MHZ, Bothell, WA, USA 98041).

The study was conducted in the Department of

Linear transducer was used to determine the

Physiotherapy and association with Department of

presence of joint effusion (Meenagh.G. et.al 2006).

Radio- Diagnosis and Imaging, Chalmeda Anand

Therefore a total 20 subjects with osteoarthritis of

Rao Institute of Medical Sciences, Karimnagar. The

knee were investigated in this study.

prospective, Follow-up study was done from first August 2008 to December 2009.

Inclusion Criteria were as follows 11

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power/Voltage 230 V. The pairs of rubber electrodes were placed over the trigger points of the knee joint. The intensity of the current was set a comfortable level as determined by subjects and ranged from 10 – 50 mA. The patient position was supine lying with comfortable support and 20 degree flexed knee. Non thrust manual exercise as repetitive passive

Figure: 1 Musculoskeletal Ultrasonography

movement of varying amplitudes and of low velocity, applied at different points through the range of motion, depending on the effect desired (Cameron. WM, 2006). The number of repetitions time 5-10 per session of program. Duration of treatment time KOA was 15 sessions. The patients recorded in a dairy their use of base, spectrum, intensity, treatment time of therapeutic modality and Figure: 2 Demonstration of long axis of

exercise.

transducer, to measure AP diameter of the supra STATISTICAL ANALYSIS

patellar recess

Before and after intervention, we assessed knee Examination of knee effusion was obtained by

joint effusion through ordinal knee effusion scale. t –

measuring the anterior posterior scan along the main

test analysis was used for comparison between the

axis of the bursa. The probe was placed just above

pre and post treatment results in respectively. The

the superior border of the patella with knee in 30

value were expressed in mean, +_ standard deviation

degree flexion. The AP diameter was scored (Grade)

and median with statistical significance considered

as 0/Absent, 1/mild < 5mm, 2/moderate (5-10mm),

when P < 0.05.

3/severe (>10mm) (Kakati .P.et.al 2008). RESULTS TREATMENT PROTOCOL Initially, 20 subjects were enrolled in this study. Interferential current modality (LIFEMED V

However, 8 patients did not undergo the evaluations

744 04 04, Chennai, India). Alternating current

due to lack of regularity and were automatically

frequency 50, 4000-4100HZ was used for this study.

excluded;

The treatment duration was applied to 20 minutes.

participants in this study. All patients imaging were

The stimulation parameters of machines beat

saved in consent forms before the evaluations.

frequency 30HZ, sweep frequency 80 m second, wave 4 PV (6/6), Carbonized rubber electrodes,

therefore,

total

patients

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

circulation, reducing spasm of muscles, pain, relaxation and changes in knee effusion. Kakati P.et.al (2008) observed that knee effusion and synovial thickening could be detected using ultrasonography in patients with Rheumatoid arthritis. Our study sample consisted of 12 cases OA Figure: 3 Sonographic view of Pre -evaluation of

Knee followed -up Pre treatment and post treatment

knee joint effusion in a patient with OA Knee.

results showed Table 5 and 6. The results of this study demonstrated, the total knee effusion only was examined.

Significantly

changes between 10-15 sessions of interferential stimulation and

non thrust

manual

exercise.

However, in this study, pharmacological therapy, injections and replacement of surgery of knee/Hip were

Figure 4 Ultrasonographic view of Post evaluation

excluded.

Following

sessions

Interferential current and Nonthrust manual exercise,

for knee effusion results with OA Knee.

although reduction of the knee joint effusion was The initial total knee effusion was not

significant (12 Subjects of Knee OA).

statistically different (P<.05), indicating that the LIMITATIONS OF THE STUDY

initial effusion status of all participants in this study. Change

of total effusion for

KOA,

the

There are few limitations in the study.

measurements were taken in figure 4. After 15 sessions of treatment, decreased

•

to effusion

Large

sample

size

may

give

better

understanding of reduction in knee effusion

approximately (t-2.20) of the observation.

with osteoarthritis. •

For analysis of the data showed that the

This study was needed to explore the

decrease in knee effusion was significantly changed

difference

after 15 sessions of IFS/ Non-thrust manual knee

ultrasonographic image and Hematological

exercise (T=37.77 and 20.2) respectively.

findings of effusion. •

DISCUSSION

musculoskeletal

Future studies are needed to evaluation of the

This is first controlled study to evaluate

between

cost

effectiveness

musculoskeletal

ultrasonography

using for

musculoskeletal ultrasonography detected changes in

assessing the condition progress compared

the effusion of knee with osteoarthritis of knee after

with other techniques and the effect of the

interferential stimulation and non -thrust manual

interferential stimulation and nonthrust

exercise. It is specifically used to increased arterial

manual exercise on control of knee effusion. 13

ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji

reduction in knee joint effusion with Osteoarthritis

CONCLUSION

of knee. So, it is a low cost, short term relief, and Our

study

results

shows

that,

Interferential

promotion of health in senior citizens.

stimulation and Non-thrust manual exercise with musculoskeletal ultrasonography a significantly

Conflict of Interest: None

References 1. Banwell,BF, Gall.V- Physical therapy management of Arthritis, Newyork, Churchill Livingstone , 1988; 77-106. 2. Braunwald, Fauci (2006)- Harrison’s Principles of internal medicine, 15th ed, Vol:2, PP:1979-1987. 3. Chaveez, Lopez,MA, Naredo, F, Acebes cachafeiro, JC et.al – Diagnostic accuracy of Physical examination of the knee in Rheumatoid Arthritis; Clinical and Ultrasonographic sytudy of jont effusion and Baker’s Cyst, Rheumatol Clin, 2007; 3(3); 98-100. 4. F.Gogus, J.Kitchan, R, Collins, D.Kane: Reliability of physical Knee Examination for Effusion: Verification by Musculoskeletal Ultrasound, Annual ACR Meeting, san Francisco, 2008. 5. Guermazi Ali – Imaging of Osteoarthritis, Radiological Clinic of North America, vol: 47; July 2009. 6. Hill CL, Gale DG, Chaisson, CL, et.al – Knee effusions, popliteal cysts and synovial thickening; Association with knee pain in osteoarthritis, J Rheumatol 2001; 1330-1337. 7. Hatemi,G. Tascilar,K. Melikoglu, M, et.al – Ultrasonographic and Physical Examination of the inflamed knee: Intra and Inter Rater Reliabiliy of the sonographers and Clinical Examiners, 20 Oct, 2009. 8. Jamt, Vedt.G. Dahm KT, Christie, A. et.al – Physical Therapy Interventions for patients with Osteoarthrtis of the Knee: An overview of systemic Reviews, Phy The 2008, Vol. 88; PP 123-136. 9. Jan MH, Lai JS: The effect of Physiotherapy on Osteoarthrtic Knee of Females, J Formosan Med Assoc 1991; 90; 1008- 1013 (Medline). 10. Keen HI, Browa AK, Wakefield RJ, Conaghan, PG – Update on Musculoskeletal Ultrsonography, J R Coll Physician Edin B; 2005; 35; 345-349. 11. Kellgren JH, Lawrence JS- Radiological Assessment of Osteoarthritis, ANN Rheum Dis 19576; 16; 494502. 12. Meenagyu G, Iagnocco E, Filppucci E, et.al – Ultrasound imaging for the Rheumatologist IV, Ultrasonography of the knee, Clin Exp Rheumatol 2006; 24; 357-360. 13. Pratab K, Kushaljit SS, Manavijit SS, et.al – Correlation between Ultrasonographic findings and the response to corticosteroid Injections in PesAnserinus Tendoino Bursitis syndrome in Knee Osteoarthritis patients, J Korean Med.Sci 2005; 20;109-12. 14. Robertson D-An introduction to Musculoskeletal Ultrasound, Sports Medicine 2007; July; 22-26.

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 1, Year: 2013

15. Rubaltelli I, Fiocco U, Cozzi L, et.al- Prospective Sonographic and Arthroscopic Evaluation of proliferative knee joint synovitis.J Ultrsound Me 1994; 13; 855-862. 16. Smit j, Jonathan T, Finnoff DO- Clinical Reviwe; Current concepts Diagnostic and Interventional Muscculoskeletal Ultrsound Part 1 Fundamentals. 17. Scheel Ak, Matteson EL, et.al â&#x20AC;&#x201C; Clinical study: Reliability Exercise for the Polymyalgia Rheumatica Classification criteria study;: The oranjewound Ultrasound sub study, International journal of Rheumatology, vol 2009, article ID 738931, 5 Pages, Hindawi Publishing corporation. 18. Theodore P, Joel AB- Pain and Radiographic damage in Osteoarthritis 2009, BMJ, Vol 339; PP: 469. 19. Tuhimna N, David F., Jingbo N, et.al- Association between Radiographic features of knee Osteoarthrtis and Pain: results from two cohort studies 2009; BMJ, vol: 339; PP: 498-501. 20. Tsai LY, Jan MH, Tseng SC, et.al- Interrator and interrater reliability of the knee joint synovitis in patients with Knee Osteoarthritis: The use of Sonographic evaluation, Formoson journal of Physiotherapy 2003; 28; 19-26. 21. Van Holsbeeck MT and Intracaso JH- Musculoskeletal Ultrasound, 2nd ed Mosby, 1991 ISBN: 0815189753. 22. Wakamuke E, Kawooya M,et.al- Experience with Ultrasound of the knee joint at Mulago Hospital, Uganda , East cent, Afri.J. Surg, vol: 14; No: 2: July/August 2009.

ACKNOWLEDGMENT This research study was supported by Arihant Educational Society, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Andhra Pradesh, India. We would like to thank sri. C. Anand Rao, Ex.Minister of Law and Social worker, Sri.C.Lakshmi Narasimha Rao, BE, MBA Chairman, Dr.V. SurayaNarayana Reddy, MS, Director for grateful support of our study. We would like to acknowledge Prof. Dr. V. Aruna, MD, Dr.(Mrs.). Ezhilarasi Ravindran, MD, Prof. SA. Aasim,MD, Medical Superintendent CAIMS, Karimnagar, for useful discussions and support for preparing this study.

CORRESPONDING AUTHOR: * ShanmugaRaju P, Asst. Professor &I/C Head, Physiotherapy, Department of Physical Medicine & Rehabilitation, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar- 505001, Andhra Pradesh, INDIA. E-mail: shanmugampt@rediffmail.com

PHYSICAL THERAPY MANAGEMENT OF TUBERCULOUS ARTHRITIS OF THE ELBOW Amit Murli Patel BPT, MPT-Orthopaedics*

ABSTRACT BACKGROUND AND PURPOSE: Tuberculous arthritis is not commonly seen by physical therapists in India. The purpose of this case report is to describe a case of tuberculous arthritis of the elbow.

CASE

DESCRIPTION: The patient was a 35-year-old man referred for physical therapy evaluation and intervention for chronic elbow pain. After an evaluation and a trial of physical therapy, the patient was referred back to a primary care provider for additional tests to rule out systemic pathology. An open debridement of the synovium and a biopsy of the capitellum and radial head was positive for acid-fast bacilli, which was later identified as Mycobacterium tuberculosis. OUTCOMES: The patient was placed on a 4-drug antituberculosis regimen that resolved all patient complaints and restored full elbow function. DISCUSSION: Tuberculous arthritis has characteristic findings during examination and in diagnostic tests. Although tuberculous arthritis is uncommon, it should be considered when patients have chronic or vague musculoskeletal complaints. KEYWORDS: Tuberculous arthritis, Elbow arthritis, Knee effusion, Physical therapy managemet.

of the bones or joints of the body but is usually

INTRODUCTION Tuberculous arthritis occurs in approximately

confined to one location, with 10% of tuberculous

arthritis in the upper extremity6 and up to 8% in the

1% to 5% of all patients with TB. It can involve any 16

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

elbow.7 The sites most frequently affected are the

and

spine, sacroiliac, hip, and knee.8 Because weight-

granulomatous process eventually imparts a “boggy”

bearing joints are the most frequently involved,

or “doughy” feeling to the joint and periarticular

some authors5 suspect that trauma plays a role in the

structures.9 Localized pain may precede other

pathogenesis of bone and joint TB.

symptoms of inflammation or radiograph changes by

joint

deformities

may

develop.8

The

Tuberculous arthritis is usually secondary to

weeks or even months.9 Other symptoms include

hematogenous dissemination of tubercle bacilli from

joint stiffness, reduced range of motion, fever, night

Less commonly, it

sweats, or weight loss.8,11 Because of the rarity of

can occur by spreading through the lymphatic

tubercular infections of joints and because the usual

a primary pulmonary lesion.

1,8

system or into adjacent tissue. Joints can become

signs of inflammation (eg, erythema, heat) do not

infected by activation of dormant lymphatic or blood

occur, diagnosis of tuberculous arthritis affecting

stream areas of morbidity.9 In the long bones, TB

peripheral joints is often delayed.8,11 When diagnosis

originates

is not timely, joint contractures and limited

mycobacteria and causes tubercle formation in the

functional improvement after treatment are more

marrow, with secondary infection of the trabeculae.8

likely to occur, especially if bone and articular

the

epiphysis

response

the

cartilage are destroyed.12 Authors have reported

inflammatory

diagnoses of olecranon bursitis,13,14 tennis elbow,15

reaction, followed by formation of granulation

and pyogenic arthritis, osteomyelitis, neopathic

tissue. The pannus of granulation tissue formed then

articular disease, and neoplasm before an eventual

begins to erode and destroy cartilage and eventually

diagnosis of tuberculous arthritis.

The

joint

mycobacteria

synovium

by developing

responds an

bone, leading to demineralization. Because TB is

The purpose of this case report is to describe a

not a pyogenic infection, proteolytic enzymes, which

case of tuberculous arthritis of the elbow. The

destroy peripheral cartilage, are not produced. The

patient described in this report had numerous

joint space, therefore, is preserved for a considerable

previous diagnoses for chronic elbow pain and was

time. If allowed to progress without treatment,

ultimately referred for physical therapy evaluation

however, abscesses may develop in the surrounding

and intervention.

tissue.

Asaka et al10 described an abscess around the

CASE DESCRIPTION

elbow joint and between the biceps brachii and

Patient: The patient was a 35-year-old, Athlete,

brachioradialis muscles in a patient with tuberculous

right-hand–dominant

man

who

reported

arthritis.

experiencing intermittent sharp pain with insidious

In India, the most common early symptoms of

onset and swelling in his left elbow 10 months

tuberculous arthritis are insidious onset of local pain

previously. He reported that his symptoms were

and swelling around the joint. In advanced cases,

aggravated with movements of the elbow and eased

which occur primarily in countries where TB is more

with rest. There was no known history of left elbow

common and often is allowed to progress, sinuses

or arm injury. The patient did not report any recent 17

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fever or weight loss, and he said that he was healthy except for the elbow pain. He stated that he had been an intravenous (IV) drug user for 5 years, during which he used his left arm for injections, but he said he had not used any IV drugs for 2 years prior to the physical therapist examination and evaluation. The patient was not working at the time of the examination His goal was to play Tennis pain-free. The patient had a 10-month history of evaluations for left elbow pain, swelling, and decreased range of motion. The patient had been diagnosed with lateral epicondylitis, degenerative joint disease, synovitis, and tenosynovitis by 3 different physicians at 3

Figure 1. Anteroposterior radiograph of elbow showing cyst-like structures (arrows).

different facilities, and he had been treated with nonsteroidal anti-inflammatory drugs. After 10 months, an orthopedic surgeon examined the patient. The physician referred the patient to the physical therapist

for

examination,

evaluation,

and

intervention for chronic elbow pain and ordered electromyography (EMG) and nerve conduction studies (NCS). Three series of elbow radiographs were taken prior to the physical therapy evaluation. Each of the Figure 2. Lateral radiograph of elbow showing a posterior fat-pad sign (arrows)

3 series of elbow radiographs was taken at a different facility

The third radiographic series 4 months before

The first series, taken 10 months previously,

the physical therapy evaluation revealed a posterior

showed no noticeable abnormalities. Two months

fat-pad sign, which the radiologist suggested may

later, a second series was negative for fracture, but

have been created by joint effusion or an occult

there were cyst-like structures and mild exostotic

fracture (Fig. 2). Normally, the posterior fat pad,

bone formation in the region of the lateral

which lies deep in the olecranon fossa, is not visible

epicondyle, and there was another cyst-like structure

on the lateral view. It can be displaced out of the

in the proximal shaft of the ulna (Fig. 1). The lateral

fossa by blood or synovial fluid within the joint, thus

view showed exostotic bone formation at the

becoming visible.17 The radiologist who interpreted

anterior distal humerus, which the radiologist stated

the third series recommended further evaluation if

may have been indicative of an old injury.

the patient’s complaints continued. 18

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

Nerve conduction studies of motor and sensory

stopped. The wrist was cleared when overpressure

components of the left median, ulnar, and radial

was performed during active flexion and extension.

nerves completed just prior to the physical therapy

Because both procedures failed to reproduce the

evaluation

limits.

patient’s elbow pain, the therapist considered the

Electromyograms of the middle deltoid, biceps

shoulder and wrist cleared as the source of his

brachii, brachioradialis, pronator teres, abductor

pathology. The therapist tested light touch sensation

pollicis brevis, and first dorsal interosseus muscles

by moving the index fingers along the patient’s C4-

also were within normal limits. The patient had

T2 dermatomes and upper-extremity nerve fields

positive purified protein derivative (PPD) tests since

bilaterally. Sensation was recorded as intact and

the previous year. A standard posteroanterior chest

symmetrical. Muscle stretch reflexes were not tested.

radiograph for patients with a positive PPD test was

Manual

normal. A normal chest radiograph shows no

musculature were performed during the examination

pleurisy with effusion.

as described by Kendall and McCreary.19 The

were

within

normal

Pleurisy with effusion results when the pleural

muscle

tests

the

upper-extremity

trapezius, middle deltoid, wrist flexor, dorsal and

space is seeded with Mycobacterium tuberculosis.18

palmar interosseus, and extensor pollicis longus muscles were painless and rated normal bilaterally. The patient said that he was unable to hold the left

EXAMINATION The patient held his left elbow in a flexed

biceps brachii, triceps brachii, and wrist extensor

position and apparently was guarding the elbow

muscles in the test position against resistance

against his body. He had diffuse left elbow effusion,

because he said that it reproduced his pain. Because

with the left elbow joint girth 1.5 cm greater than the

pain limited the patient’s effort during these muscle

right elbow joint girth measured at the elbow flexion

tests, grading was not done.

crease. There was no ecchymosis at the time of

Palpation revealed a mild increase in warmth

examination, but wasting of the biceps and triceps

around the left elbow compared with the right

muscles was noticeable. The patient had elbow

elbow. Palpation at the olecranon and both lateral

active and passive range of motion of 30 to 110

and medial epicondyles caused a sharp pain that did

degrees, with pain at both flexion and extension end

not radiate. Palpation of the patient’s entire anterior

ranges. Wrist range of motion was normal, but the

forearm also reproduced his elbow pain.

patient did have a sharp pain at the lateral and medial condyles during end ranges of pronation and

EVALUATION

supination, respectively. The shoulder was cleared

A posterior fat-pad sign has been reported to be

for pathology using overpressure during active

a possible sign of interarticular fracture or

flexion, abduction, and while the patient was

swelling.17 Due to local tenderness, swelling, and a

reaching behind his back. The therapist performed

documented

overpressure by applying a force to the patient’s end

radiographic report, the therapist chose to rule out

range at the point where his active range of motion

systemic pathology or a fracture before initiating 19

fat-pad

sign

this

patient’s

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aggressive

stretching

immobilization

During the week 4 follow-up evaluation, the

intervention. The patient began a light physical

patient reported increased pain in the area of the

therapy regimen of active range of motion exercises

medial and lateral epicondyles. Examination of

for 10 to 15 minutes 3 times a week on an upper-

elbow girth, active and passive ranges of motion,

body cycle to maintain his present range of motion,

and palpation revealed no other changes. Based on

followed by ice massage for 10 minutes. The patient

the patient’s continued pain and swelling, the

was instructed to use ice bags for 10 to 15 minutes

physician and Therapist agreed that a magnetic

on his own throughout the day. He was also

resonance image (MRI) could be informational. At

instructed to stop playing tennis. The therapist

the same time, the physician referred the patient

discussed

back to the orthopedic surgeon for re-evaluation

the

subsequently

case ordered

with

joint

physician,

follow-up

including an oblique view to

who

radiographs, rule out

following

the

discontinued

MRI.

until

the

Physical MRI

therapy and

was

orthopedic

interarticular fracture as was originally advised in

evaluations were completed. The MRI showed a

the most recent radiologist’s report.

large joint effusion and increased marrow signal within the radial neck (Fig. 3).

RE-EVALUATION AND INTERVENTION The new radiographs showed a smaller posterior fat-pad sign but no fractures or evidence of other pathologies in osseous structures. Therefore, the patient continued his physical therapy program and was re-evaluated 2 weeks after the initial evaluation. During the week 2 follow-up, the patient reported that the pain had lessened and that his elbow was tender to palpation only at the olecranon. Both active and passive ranges of motion were unchanged, as was the elbow flexion crease girth. Resistive exercises were added because the patient expressed concern about the atrophy in his biceps Figure 3. T2 weighted sagittal view of the elbow. Note the increased marrow signal within the radial neck (arrows).

and triceps muscles. Because he was reporting less elbow pain with palpation and range of motion end ranges, the therapist decided to allow the patient to

Signal intensity refers to the strength of the

perform seated biceps muscle curls and supine

radiowave that a tissue emits following excitation.

triceps muscle extension exercises in a pain-free

The strength of the radio wave determines the degree

range. The patient performed 3 sets of 10 repetitions,

of brightness of the imaged structures. A bright

3 times a week, in the clinic under the therapist’s

(white) area in any image is said to demonstrate a

supervision. 20

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

high signal intensity, and a dark (black) area

patient had recovered normal elbow range of motion,

demonstrates a decreased intensity.17 Hematopoietic

and manual muscle tests of the biceps brachii,

marrow normally displays a low to intermediate

triceps brachii, and wrist extensor muscles were

signal intensity, whereas fluid displays a higher

normal and painless.19 He said that he was working

signal intensity on T2 weighted MRI.17 The

and playing Tennis without pain. The patient

radiologist suspected infection and recommended

performed janitorial work, which consisted of Room

aspiration of synovial fluid and a biopsy. During the

cleaning, walls, and bathroom fixtures.

second orthopedic evaluation, 2 months after the MRI, the surgeon aspirated the elbow and ordered a

DISCUSSION

bone scan. A culture of the aspirated fluid was

Tuberculous arthritis usually occurs in an

negative for growth, but the bone scan image was

insidious manner, with pain and swelling of the

consistent

affected joint. It is rare among people born in the

with

possible

septic

arthritis

and

osteomyelitis.

India and is more often found in people born in other countries or those with a compromised immune

At the orthopedic follow-up 3 months later, the

system. The patient in this case report had chronic

surgeon ordered an open debridement and biopsy

elbow pain and swelling without signs of infection.

based on the bone scan reports and performed an

Lack of signs of infections is consistent with other

arthrotomy of the left elbow with open debridement

cases of tuberculous arthritis described.15,16 He also

of synovium and biopsy of the capitellum and radial

reported a history of IV drug use, which, along with

head the next day. The culture was positive for acidfast

bacilli,

which

was

later

identified

direct joint trauma, interarticular steroid injections,

and systemic illness, has been found to be a

Mycobacteria tuberculosis. Following identification

predisposing factor for tuberculous arthritis.16 These

of TB, a physician specializing in infectious diseases

factors and this patient’s history suggest an onset of

evaluated the patient. The bacterium was sensitive to

TB that is consistent with reports of other patients

ethambutol, pyrazinamide, isoniazid, and rifampin,

who developed tuberculous arthritis.

and the patient began a 4-drug anti-TB regimen for

Joint effusion, such as that seen in this patient,

no less than 1 year.

often occurs with tuberculous arthritis and has been shown to affect muscles and nerves around the

OUTCOMES

elbow.20,21 Chen and Eng20 noted compression of the

Four months after initiating the drug regimen,

posterior interosseous nerve at the region of the

the patient reported that he was pain-free, and he

arcade of Frohse. Prem et al21 noted wasting of

was discharged from the orthopedic surgeon’s care.

muscles around the upper limbs and shoulder girdle

The therapist attended a weekly orthopedic clinic

along with obliteration of bony landmarks due to

during which patient was evaluated by an orthopedic

swelling around an elbow infected with tuberculous

surgeon.

arthritis. Yao and Sartoris1 also stated that weakness

At 12 months after the diagnosis of TB, the

and muscle wasting could be present around 21

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involved joints. The patient in this case report did

appearance in the involved bone is not uncommon.

not have sensory deficits, but he did have noticeable

The third set of radiographs revealed no

wasting of his biceps and triceps muscles. Persistent

abnormalities in bone or joint space, with the

effusion in the knee affects afferent activity of

exception of a positive fat-pad sign. Greenspan17

intracapsular

reported that a positive fat-pad sign could be

receptors

and

can

cause reflex 22–24

indicative of interarticular swelling or a fracture. The

similar mechanism may have occurred in this

fourth set of radiographs eliminated the possibility

patient, causing wasting of the biceps and triceps

of a fracture that had not been diagnosed, but they

muscles due to capsular distention and intracapsular

revealed a smaller fat-pad sign, which most likely

pressures. An alternative hypothesis might also

appeared because of interarticular swelling. When

attribute the muscle wasting to disuse secondary to

radiographs are normal, an MRI may be beneficial

pain during elbow motion.

by revealing early changes such as edema that are

inhibition of the quadriceps femoris muscle.

Radiographs can be powerful diagnostic tools,

not visible on radiographs.27 The patient’s MRI

but they are not always beneficial during evaluation

identified the complex effusion in his elbow, but a

of a patient with tuberculous arthritis. Some authors

biopsy that was needed for the definitive diagnosis.

have described normal chest radiographs in patients

the

most

with tuberculous arthritis20,25 and old or active

tuberculous arthritis.

6,9,13,15

pulmonary disease evident in only 50% of chest

reported that synovial fluid or tissue cultures

8,16

establish a diagnosis in 90% of the cases of

Elbow radiographs can also be negative, even when

tuberculous arthritis.11 Material for the culture may

the disease is present.15 Unlike pyogenic organisms

be obtained from aspiration of joint fluid, but this

that produce rapid destruction of bone, TB has a

may be inconclusive, as it was in this patient’s case.

radiographs in patients with tuberculous arthritis.

gradual progression of symptoms.

Biopsy

definitive

test

for

Some authors have

It has been

Laboratory tests such as sedimentation rate,

reported to begin in the distal end of the humerus,

granulocyte count, and lymphocyte count are not

olecranon, or synovium of the elbow joint.13,25 The

thought to be helpful.7 This patient’s prior tuberculin

first radiograph report of the patient’s elbow was

skin tests were positive, which is consistent with

normal.

researchers’ findings for patients with tuberculous

The second series of radiographs identified a

arthritis.6,10,20,25 However, as was described in cases

cyst-like structure and mild exostotic bone formation

involving a 66-year-old woman15 and a 76-year-old

that was not identified on the first and final

man16 with tuberculous arthritis of the elbow, a

radiographs. Munk and Lee26 contended that a

negative TB skin test does not exclude diagnosis of

normal appearance on imaging is the rule with TB

tuberculous arthritis. Repeated negative tuberculin

infections because the underlying bone reacts (by

tests, however, practically eliminate TB as a possible

forming cysts and producing sclerotic borders at the

etiology.7

margins of the infected lesion) in an attempt to wall

chemotherapy, the classic treatment in adults

off the infectious process. Thus, a cyst-like

consisted of excision or arthrodesis of the elbow 22

Before

the

advent

anti-TB

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

joint.28 The disadvantage of arthrodesis was loss of

patient’s elbow to being pain-free with full range of

motion, and the risk of excision was an unstable

motion. Chen et al12 reported that a continuous

elbow.28 Anti-TB agents are effective in halting the

passive

destructive process and treating the infection.

functional results after synovectomy and intra-

However, they cannot repair the anatomical defects

articular debridement. Following surgery, the arc of

movement

(CPM)

device

improved

that can occur in later stages. During these stages,

movement was set at 30 to 90 degrees and then

fibrous tissue can result in ankylosis of the joint.

increased to a level that the patients were able to

Similarly, the untreated cases can evolve to bony

tolerate. Patients used the CPM device for 2 to 4

ankylosis.16 The literature provides few specifics for

weeks until movement exceeded 120 degrees. The

the

TB.

average flexion deformity in a group of 8 patients

reported using prolonged

who used the CPM device was 24 degrees versus 34

immobilization for an average of 18 months. With

degrees in a group of 8 patients who were treated

the introduction of TB drugs, this is no longer

with active and passive movement. Active and

physical

Investigators

necessary.

therapist have

Some

management

authors

6,28

passive movement was not defined.

advocated

immobilizing the elbow for 1 to 2 months at 90

The patient in this report responded well to

degrees to relieve pain and, in the event of fusion, to

antibiotics and regained full elbow function without

achieve a functional position. After removing the

immobilization or surgery. This improvement could

cast, rehabilitation proceeded daily for 3 to 6

have been due, in part, to the location of the disease

months, with a back splint used between therapy

in the joint. Vohra and Kang25 stated that prognosis

sessions to prevent extension deformity and help the

is excellent in synovial and extra-articular lesions,

elbow

flexors

regain

power.

specific

whereas involvement of articular cartilage reduces

descriptions of the splint or interventions were

the chances of maintaining good range of motion. In

reported.

addition, this patient’s improvement could have been

Surgery may be necessary in certain cases when

due to diagnosing tuberculous arthritis early and

the disease does not respond to drugs or to correct

administering anti-TB treatment before severe

deformities or improve joint function. Vohra and

destruction occurred. Chen et al12 noted that joints

Kang25 treated 6 cases of elbow TB, ranging from

with severe intra- and extra-articular destruction

the disease being restricted to within the synovial

usually become stiff with fibrosis and adhesions.

membrane

cartilage

Martini and Gottesman28 hypothesized that, unlike

involvement. Patients were treated with 3 to 6 weeks

the lower-limb joints, the elbow is non–weight

of immobilization after surgery followed by

bearing and therefore more able to recover a normal,

encouraging active movements and using night

painless range of motion, as this patient was able to

splints for 2 to 5 months. No other intervention

do.

extensive

articular

specifics were given. Other authors

reported that

using a hinged long arm brace for a month after

CONCLUSION

surgically removing granulation tissue returned the

Patients with tuberculous arthritis are not often 23

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examined or treated by physical therapists in India

physical therapist and other health care providers.

due to the relative rarity of TB infections of joints.

Physical therapists and other health care providers

progression,

can learn from this case to consider tuberculous

tuberculous arthritis is a frequently misdiagnosed

arthritis in the differential diagnosis of unexplained

condition, which delays treatment and can lead

musculoskeletal complaints, especially in patients

deformities and functional deficits.

with compromised immunity or from an area where

Because

its

often

slow

This patient’s disease was identified as a result

TB is endemic.

of diagnostic tests and communication between a

REFERENCES 1. Yao DC, Sartoris DJ. Musculoskeletal tuberculosis. Radiol Clin North Am. 1995;33:679–689. 2. Centers for Disease Control and Prevention. Tuberculosis morbidity—United States, 1997. MMWR Morb Mortal Wkly Rep. 1998;47: 253–275. 3. Centers for Disease Control and Prevention. Progress toward the elimination of tuberculosis—United States, 1998. MMWR Morb Mortal Wkly Rep. 1999;48:732–736. 4. Zuber PL, McKenna MT, Binkin NJ, et al. Long-term risk of tuberculosis among foreign-born persons in the United States. JAMA. 2007;278:304 –307. 5. Davidson PT, Horowitz I. Skeletal tuberculosis: a review with patient presentations and discussion. Am J Med. 1970;48:77– 84. 6. Martini M, Benkeddache Y, Medjani Y, Gottesman H. Tuberculosis of the upper limb joints. Int Orthop. 2006;10:17–23. 7. Martini M, Ouahes M. Bone and joint tuberculosis: a review of 652 cases. Orthopedics. 2005;11:861– 866. 8. Wright T, Sundaram M, McDonald D. Radiologic case study: tuberculous osteomyelitis and arthritis. Orthopedics. 1996;19:699 –702. 9. Rotrosen D. Infectious arthritis. In: Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of Internal Medicine. 12th ed. New York, NY: McGraw-Hill; 1991:544–548. 10. Asaka T, Takizawa Y, Kariya T, et al. Tuberculous tenosynovitis in the elbow joint. Intern Med. 1996; 35:162–165. 11. Naides SJ. Infectious arthritis: viral and less common agents. In: Schumacher HR, Klippel JH, Koopman WJ, et al, eds. Primer on the Rheumatic Diseases. 10th ed. Atlanta, Ga: Arthritis Foundation; 2003: 199– 200. 12. Chen WS, Wang CJ, Eng HL. Tuberculous arthritis of the elbow. Int Orthop. 2007;21:367–370. 13. Parkinson RW, Hodgson SP, Noble J. Tuberculosis of the elbow: a report of five cases. J Bone Joint Surg Br. 1990;72:523–524. 14. Holder SF, Hopson CN, Vonkuster LC. Tuberculous arthritis of the elbow presenting as chronic bursitis 24

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

of the olecranon. J Bone Joint Surg Am. 1985;67:1127–1129. 15. Patel S, Collins DA, Bourke BE. Don’t forget tuberculosis. Ann Rheum Dis. 1995;54:174 –175. 16. George JC, Buckwalter KA, Braunstein EM. Case report 824: tuberculosis presenting as a soft tissue forearm mass in a patient with a negative tuberculin skin test. Skeletal Radiol. 2004;23:79–81. 17. Greenspan A. Orthopedic Radiology: A Practical Approach. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 2007. 18. Daniel TM. Tuberculosis. In: Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of Internal Medicine. 12th ed. New York, NY: McGraw-Hill; 1991:637–645. 19. Kendall FP, McCreary EK. Muscles: Testing and Function. 3rd ed. Baltimore, Md: William & Wilkins; 1983:18–293. 20. Chen WS, Eng HL. Posterior interosseous neuropathy associated with tuberculous arthritis of the elbow joint: report of two cases. J Hand Surg [Am]. 1994;19:611– 613. 21. Prem H, Babu NV, Chittaranjan BS, et al. Tuberculosis of the elbow: an unusual presentation. Tuber Lung Dis. 2004;75:157–158. 22. Fahrer H, Rentsch HU, Gerber NJ, et al. Knee effusion and reflex inhibition of the quadriceps: a bar to effective retraining. J Bone Joint Surg Br. 2008;70:635– 638. 23. Spencer JD, Hayes KC, Alexander IJ. Knee joint effusion and quadriceps reflex inhibition in man. Arch Phys Med Rehabil. 2004;65: 171–177. 24. Stratford P. Electromyography of the quadriceps femoris muscles in subjects with normal knees and acutely effused knees. Phys Ther. 2002;62:279 –283. 25. Vohra R, Kang HS. Tuberculosis of the elbow: a report of 10 cases. Acta Orthop Scand. 1995;66:57–58. 26. Munk PL, Lee MJ. Musculoskeletal case 3: musculoskeletal tuberculosis. Can J Surg. 2009;42:120 –121. 27. Gordon AC, Friedman L, White PG. Pictorial review: magnetic resonance imaging of the paediatric elbow. Clin Radiol. 1997;52: 582–588. 28. Martini M, Gottesman H. Results of conservative treatment in tuberculosis of the elbow. Int Orthop. 1980;4:83– 86. 29. Wilson JN. Tuberculosis of the elbow: a study of thirty-one cases. J Bone Joint Surg Br. 1953;35:551– 560. 30. Yip KH, Lin J, Leung PC. Cystic tuberculosis of the bone mimicking osteogenic sarcoma. Tuber Lung Dis. 2006;77:566 –568.

CORRESPONDING AUTHOR: * Amit Murli Patel BPT, MPT-Orthopaedics, Assistant Professor & Vice Principal, College Of Physiotherapy, Ahmedabad E-Mail : patelmpt@Yahoo.Com

EFFECT OF SENSORY CUEING ON GAIT AND BALANCE DURING BOTH “ON” AND “OFF” DRUG PHASE OF PARKINSON’S DISEASE Sinha Siddharth M.P.T. (Neurology)*, Bhatt Sunil M.P.T. (Neuro-science)**

ABSTRACT AIM: The effect of cueing has been well proved in PD but almost all of the studies are done in “on” drug phase of the disease. So in this study we tried to investigate the efficacy of a supervised cueing training in “on” drug as well as “off” drug phase of Parkinson patients. METHODOLOGY: Experimental study sample 8 individuals with idiopathic PD are selected on basis of inclusion criteria- Idiopathic Parkinson’s , in stage 2-3 on hoer and yahr staging, excluded those MMSE < 24, any known Cardio respiratory complication that hinders the exercise program, any other known neurological condition ,any fracture or surgery of lower limb in last one year . Group A is “OFF” drug phase and group B “ON” drug phase. Both groups were assessed in both “ON” drug phase and “OFF” drug phase. Intervention consisted of a sensory cuing visual (floor markers) and auditory (beep) cues. The data analyzed within group and between groups for any improvements in both the phases. RESULTS AND CONCLUSION: cueing techniques is helpful in improving gait and balance in PD. But we suggest that treatment given in “OFF” drug phase is more beneficial. KEYWORDS: “ON” drug phase, “OFF” drug phase, PD, sensory cueing.

common neurological disorders in elderly people.

INTRODUCTION

Between the age of 55 and 85 years, 4.2% of all Parkinson’s disease (PD) is one of the most

women and 6.1% of all men develop PD. The major 26

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

motor symptoms in PD are tremor, rigidity,

limited. Although there is evidence to support the

bradykinesia, and postural instability, resulting in

use of sensory cues to improve gait, balance and

problems with gait, balance, transfers, and posture.

other impairments in PD but almost all of the

These problems can lead to reduced mobility and

literature available is using this technique in “ON”

decreased levels of physical activity, which in turn

drug phase of disease i.e. when the PD patient is

can cause increased dependency and social isolation

under the effect of antiparkinson’s medicine.

and thereby reduce quality of life.19 it is therefore

Secondary the definitive effect of sensory cueing in

important to encourage patients to maintain their

“ON” and “OFF” drug phase of the disease has not

mobility and to stay active, for example, by referring

been compared.

them to physical training programs. These physical exercise programs include use of rhythmic cues.

BACKGROUND

Cueing can be defined as using external temporal or

Sean Ledger, Rose Galvin et al. in their

spatial stimuli to facilitate movement (gait) initiation

randomized controlled trial evaluated the effect of an

and continuation. Cueing can be defined as using

individual auditory cueing device on freezing and

external temporal or spatial stimuli to facilitate

gait speed in people with Parkinson's disease. In this

movement

continuation.

study they used an Apple iPod-Shuffle™ and similar

Unfortunately, evidence-based knowledge about

devices provide a cost effective and an innovative

effects of cueing in PD is limited. Best-evidence

platform for integration of individual auditory

synthesis of 24 studies, up to 2002, showed only 1

cueing devices into clinical, social and home

high- quality study. Specifically focused on the

environments and are shown to have immediate

effects of auditory rhythmical cueing. Studies claim

effect on gait, with improvements in walking speed,

positive effects of cueing on gait speed of patients

stride length and freezing. Visual, auditory and

with PD; however, it was unclear whether positive

somatosensory cueing devices have also been used

effects identified can be generalized to improved

in conjunction with walking aids, to improve gait in

activities of daily living in patients’ own home

individuals with Parkinson’s disease. Given the

setting and reduced frequency of falls in the

challenge that this clinical population may have with

community. In addition, the sustainability of a

initiating motor movements during gait (i.e. freezing

cueing training program remains uncertain.19

gait).37 The freezing phenomena are difficult to treat.

(gait)

initiation

and

A recent review on cueing suggests that cueing

Pharmacological treatment is usually disappointing.

can have an immediate and powerful effect on gait

Rehabilitation in particular the efficacy of auditory

in PD. Vision-to facilitate locomotors activity was

and visual cues, is a new rehabilitation strategy

first described by Martin over 25 years ago. In a

based on treadmill training associated with auditory

later study, Forsberg et a reported beneficial effects

and visual cues. Giuseppe Frazzitta, MD, Roberto

of visual guidance on gait movements in patients

Maestri, MD et al. in their study investigated the

with Parkinson's disease. Unfortunately, evidence-

effectiveness of a cueing with treadmill. One group

based knowledge about effects of cueing in PD is

of patient get treated with treadmill and other get 27

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conventional treatment.15

Appropriate and precaution taken to avoid any fall. For subject both the groups were assessed in both

Cueing strategies are thought to reroute the pathway,

“ON” and “OFF” drug phase. Group A (is “ON”

removing it from the automatic basal ganglia

drug patient) subject received training in “ON” drug

movement

through

nonautomatic

pathway. Leland E. Dibble found that visual and

phase. Group B (is “OFF” drug patient) subject

auditory cueing

received training in “OFF” drug phase.

technique

functional

and

Each

movement time task separately and results suggest

participant received cueing training in the supervised

that both technique get improve but visual cueing

situation with the help of a prototype cueing device.

effects are not limited to gait tasks and auditory

This cueing device provided 2 rhythmical cueing

cuing results that cadence and stride length has been

modalities: (a) an auditory modality (a beep), (b) a

shown to consistently increase when auditory cues

visual feedback Cueing training was delivered in the

are present relative to when cues are not

home setting. Participants were instructed to listen to

present.

1,7,13,23,36,37,38

the cueing when they are performing tasks. They

Sensory cue enhanced gait training in mild to

were encouraged to listen to the rhythmical cue and

moderate PD patients. Treadmill with music has

to try to match their heel strike with the beat of the

been proved to give additional benefits for

beep sound on the device and try to match heel strike

improving gait related parameters.6

with visual cue make on ground. The results were analyzed for within group and between the groups comparison.

METHODOLOGY Subjects were selected through convenient sampling. After having the informed consent of 8 subjects

and fulfillment of inclusion criteria

systematic randomization was done and the subject were assigned to the particular group according to their sequence of approach i.e. 1st, 3ed, 5th, 7th in group A and 2ed, 4th, 6th, 8th in group B . Protocol All subjects underwent 20 minutes of each session including rest time (2 min), rest time to decrease the effect of fatigue, 1 session (Monday to Saturday) in a day for 2 weeks for 11 day , one day rest between the two subsequent weeks.

DESIGN AND PROCEDURE They were then randomly directed into 2 groups at baseline, all subject were assessed for gait (10 MWT), balance (BBS), and function (NQS). 28

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

RESULTS AND DISCUSSION

WITHIN THE GROUP

Both of the groups showed clinically significant

Within

the

groups

subject

improved

improvement in both on and off drug phases. Both

significantly in all the parameters namely gait,

phases have shown improvement in gait and balance

balance and function. Both of the groups showed

parameters specially step length, speed, sit to stand,

clinically significant improvement in both on and off

turning, time taken.

drug phases. Both phases have shown improvement in gait and balance parameters specially step length, speed, sit to stand, turning, time taken.

ON Drug Phase Group A patient initially did not have any difficulty to start the training as compared to Group B. The on phase of the disease in group A was improved i.e. these patients showed an increased step length, increased step per minute, reduced timing of sit to stand, during their on drug period. Also they had positive effects of cueing on gait and Graph of mean difference between Group A and

gait related mobility. These patients had shown an

Group B.

improvement in their balance because of the challenges they faced during the gait training. significant

Subjectively also these patients reported that after

improvement in both “ON” and “OFF” drug phases,

intervention they were able to walk much more

both phases have shown improvement in gait and

independently and safely and their day to day

balance parameters specially time taken for 10

activities were much easier now. Some of the

meter, sitt to stand timing and speed.

subjects in this group who complained of giddiness

Clinically

and

subjectively

during initial assessment and training were now much better and their giddiness disappeared after the intervention. Also they had better endurance and their breathing abilities were improved; as reported by these subjects. These changes were evident in both “ON” drug and “OFF” drug periods of these subjects.

OFF Drug Phase

Graph of mean difference between Group A and

Group B patients initially had many difficulties

Group B significant variable.

in starting and performing the training sessions. As 29

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synaptogenesis7,36,37,38,13,9

training for these subjects was given in “OFF” drug phase, without the effect of medication they had

Cueing technique acts like a pacemaker and

difficulty in concentrating visual and auditory cueing

provides an external rhythm that is able to stabilize

simultaneously. Patient use to get puzzled between

the defective internal rhythm of the basal ganglia.

visual and auditory cues but after 2 days of training

Increased activation of the lateral premotor cortex in

they learnt how to synchronies the visual and

PD patients during cueing lends support to this view

auditory cue to use them simultaneously. They had

(Hanakawa et al., 1999b).14

improved gait parameter like sit to stand, speed, time taken for 10 meter, step length after intervention.

BETWEEN THE GROUPS

Neurophysiologically these improvements in

Subjectively also group B patient reported

both the groups can be attributed to the fact that

better

sensory cueing training strengthens the neurons in

Subjectively, after intervention these subjects (group

cerebral cortex bypassing the damaged basal ganglia

B) reported, that now if some time they have a delay

thereby cortex is independent of the damaged basal

in taking medicine timely or skip the drug dosage,

ganglia signals for performing the movements and

still their symptoms did not worsen; infect they were

functions.

improvement

compare

with

group

better now compared to pre-intervention time. Also

Several authors have suggested that predictive

the fear of fall became less after the treatment,

external sensory cues, such as auditory rhythm, can

confidence level was increased.

provide the necessary trigger in Parkinson's disease

Because of training was given to them in the

to switch from one movement component in a

same phase (OFF drug). This “context specific

movement sequence to the next and thus bypass

training” helped them for better learning and hence

25, 26

more benefits. Carr and Sepherd.27 in their works

possibly via the lateral premotor cortex which

have emphasized the importance of “context specific

receives sensory information in the context of

training” in rehabilitation.

defective internal pallidocortical projections,

externally guided movements.27, 32 However,

the

neurophysiologic

Plasticity is a general term describes the ability basis

for

show

modification.

Plasticity,

neural

auditory-motor interactions is not well understood.

modifiability, may be seen as a continuum from

There is some evidence that rhythmic sound patterns

short-term changes in the efficiency or strength of

can increase the excitability of spinal motor neurons

synaptic connection to long term structural changes

via the reticulospinal pathway, thereby reducing the

in the organization and number of connections

amount of time required for the muscles to respond

among neurons.4, 33

to a given motor command.32

Learning also can be seen as a continuum of

Recent work with animal models of PD indicate

short term to long term changes in the ability to

that rehabilitative training can stimulate a number of

produce skilled action. The gradual shift from short

plasticity-related events in the brain, including

term to long term learning reflects a move along the

neurotrophic

continuum of neural modifiability, as increased

factor

expression

and 30

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

synaptic efficiency gradually gives way to structural

will improve their balance, gait and function in

changes, which are the underpinning of long term

much more beneficial way and may reduce or alter

modification of behavior.

their dependency on drugs; thereby providing them a complete rehabilitation. So rehabilitation given in “OFF” drug phase may help to decrease or alter the

CONCLUSION Sensory cueing using visual and auditory cues

drug usage by these patients and to provide an

is beneficial for Parkinson’s disease. It improves

overall rehabilitation program to this population give

their

activity.

the treatment in “OFF” drug phase because patient

Subjectively and objectively group B (subjects for

have more difficulty in “OFF” drug phase and

whom training was given in off drug phase) showed

context specific training, tasks specific training give

significantly better results. We suggest that training

better results.

gait,

balance

and

functional

given in “OFF” drug phase to Parkinson’s patients

REFERENCES: 1. A Nieuwboer, G Kwakkel, L Rochester, D Jones, E van Wegen, A M Willems, F Chavret, V Hetherington, K Baker, I Lim, “Cueing training in the home improves gait-related mobility in Parkinson’s disease: the RESCUE trial” Journals Neurol Neurosurg Psychiatry 2007;78:134–140. doi: 10.1136/jnnp.200X.097923 2. Azulay JP, Masure S, Amblard B, et al. Visual control of locomotion in Parkinson’s disease. Brain 1999;122 (Part 1):111–120 3. Anne Shumway-Cook, Marjorie H , chapter- motor learning and recovery of function book—“Motor Control theory and practical application” , second edition Philadelphia: Lippincott Williams and Wilkins 2001. page nub 42, contextual interference 4. Anne Shumway-Cook, Marjorie H , chapter- motor learning and recovery of function book—“Motor Control theory and practical application” , second edition Philadelphia: Lippincott Williams and Wilkins 2001. page nub 92, contextual interference 5. Arias, P., Chouza, M., Vivas, J., & Cudeiro, J. (2009). Effect of whole body vibration in Parkinson's disease: a controlled study. Movement Disorders, 24: 891–898. 6. Chulalongkorn University “Treadmill and Music Cueing for Gait Training in Mild to Moderate Parkinson's Disease” Dootchai Chaiwanichsiri, MD, Faculty of Medicine, Chulalongkorn University, clinical trail gov. i.d. nu. NCT00750945 7. Cohen AD,Tillerson JL, Smith AD, Schallert T, ZigmondMJ. Neuroprotective effects of prior limb

ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji

use in 6-hydroxydopamine-treated rats: possible role of GDNF. J. Neurochem. 2003;85(2):299-305. 8. Cunnington R, Iansek R, Bradshaw JL, Phillips JG. Movement-related potentials in Parkinson's disease: presence and predictability of temporal and spatial cues.Brain 1995;118:935-50. 9. David A. Lehman, PhD, PT;1 Tonya Toole, PhD;2 Dan Lofald, PhD;3 Mark A. Hirsch, PhD4 “Training with Verbal Instructional Cues Results in Near-term Improvement of Gait in People with Parkinson Disease”, Journal of Neurological Physical Therapy Vol. 29 • No. 1 • 2005 10. Ebersbach, G., Edler, D., Kaufhold, O., & Wissel, J. (2008). Whole body vibration versus conventional physiotherapy to improve balance and gait in Parkinson's disease. Archives of Physical Medicine and Rehabilitation, 89: 399–403. 11. Farley BF and Koshland GF (2005a). Training BIG to move faster: The application of the speedamplitude relation as a rehabilitation strategy for people with Parkinson’s disease. Exp Brain Res 167(3): 462- 467 (Epub Nov 11).

Farley BF and Koshland GF (2005b). Efficacy of a large-

amplitude exercise approach for patients with Parkinson’s disease- bradykinesia to balance. 9th International Congress of Parkinson’s Disease and Movement Disorders, Abstract #466. 12. Folstein MF, Folstein SE, McHugh PR: “Mini-mental state: A practical method for grading the cognitive state of patients for the clinician.” J Psychiatry Res 1975; 12:189-198. 13. Fisher BE, Petzinger GM, Nixon K, et al. Exercise induced behavioral recovery and neuroplasticity in the 1-methyl-4-phenyl 1,2,3,6-tetrahydropyridine-lesioned mouse basal ganglia. J Neurosci Res. 2004;77(3):378-390. 14. Gerald C McIntosh, Susan H Brown, Ruth R Rice, Michael H Thaut , Rhythmic auditory-motor facilitation of gait patterns in patients with Parkinson's disease Journal of Neurology, Neurosurgery, and Psychiatry 1997;62:22-26 15. Giuseppe Frazzitta, MD,1* Roberto Maestri, MD, “Rehabilitation Treatment of Gait in Patients with Parkinson’s Disease with Freezing: A Comparison Between Two Physical Therapy Protocols Using Visual and Auditory Cues with or Without Treadmill Training” Movement Disorders Vol. 24, No. 8, 2009, pp. 1139–1143 _ 2009 Movement Disorder Society 16. Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell JL (April 2008). "The effectiveness of exercise interventions for people with Parkinson's disease: a systematic review and metaanalysis". Mov. Disord. 23 (5): 631–40. doi:10.1002/mds.21922. PMID 18181210 17. Haas, C.T., Turbanski, S., Kessler, K., & Schmidtbleicher, D. (2006). The effects of random wholebody-vibration on motor symptoms in Parkinson's disease. NeuroRehabilitation, 21: 29–36 18. Halsband U, Ito N, Tanji J, Freund HJ. The role of premotor cortex and the supplementary motor area

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

in the temporal control of movement in man. Brain 1993;116:1017-43. 19. Inge Lim, PhD, Erwin van Wegen, PhD, Diana Jones, PhD, Lynn Rochester, PhD, Alice Nieuwboer, PhD, Anne-Marie Willems, PhD, Katherine Baker, PhD,Vicki Hetherington, MSc, and Gert Kwakkel, PhD Does Cueing Training Improve Physical Activity in Patients With Parkinson’s Disease 20. Jeffrey M. Hausdorff, Justine Lowenthal,at all, “Rhythmic auditory stimulation modulates gait variability in Parkinson’s disease” European Journal of Neuroscience, Vol. 26, pp. 2369–2375, 2007 21. King, L.K., Almeida, Q.J., & Ahonen, H. (2009). Short-term effects of vibration therapy on motor impairments in Parkinson's disease. Neuro Rehabilitation, 25: 297–306 22. Janet H Carr, Roberta B. Shepherd, chepter- Background to the Development of the M.R.P. book- A Motor Relearning Programme For stroke , second edition reprint 1986, London Publisher-Aspen ,1986 23. Leland E Dibble at all, “Sensory Cueing Improve Motor Performance and Reabilitaion in Person With Parkinson’s disease. ” Vol 21 No 4 1997 24. Minna Hong, PT, PhD, and Gammon M. Earhart, PT, PhD, “Effects of Medication on Turning Deficits in Individuals with Parkinson’s Disease” JNPT • Volume 34, March 2010 25. McIntosh et al., 1997; Brotchie et al., 1991; Thaut, 2003; Jantzen et al., 2005; Zelaznik et al., 2005; Nagy et al., 2006. RAS may circumvent the pallidal- supplementary motor area pathway, possibly via the premotor cortex, and provide external cues to guide movement (Mushiake et al., 1991; Halsband et al., 1993; Hanakawa et al., 1999a; Elsinger et al., 2003) 26. Morris ME, Iansek R, Matyas TA, Summers JJ. Stride length regulation in Parkinson’s disease. Normalization strategies and underlying mechanisms. Brain 1996;119:551–568 27. Mushiake H, Inase M, Tanji J. Neuronal activity in the primate premotor, supplementary, and precentral motor cortex during visually guided and internally determined sequential movements. J Neurophysiol 199 1;66:705-18 28. Miyai, I., Fujimoto, Y., Yamamoto H., et al. 2002. Long-term effect of body weight-supported treadmill training in Parkinson’s disease: a randomized controlled trial. Arch Phys Med Rehabil, 83(10):1370-1373. 29. Morris ME, Iansek R, Matyas TA, Summers JJ. The pathogenesis of gait hypokinesia in Parkinson's disease. Brain 1994;117:1169-81. 30. O'Sullivan & Schmitz 2007, pp. 873, 876 31. O'Sullivan & Schmitz 2007, p. 879

ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji

32. Paltsev YI, Elner AM. Change in the functional state of the segmental apparatus of the spinal cord under the influence of sound stimuli and its role in voluntary movement. Biophysics 1967;12:1219-26 33. Reiko Kawagoe, Yoriko Takikawa and Okihide Hikosaka, “Expectation of reward modulates cognitive signals in the basal ganglia” 1998 Nature America Inc. •http://neurosci.nature.com, nature neuroscience • volume 1 no 5 • september 1998 34. Rubinstein TC,GiladiN,Hausdorff JM. The power of cueing to circumvent dopamine deficits: a reviewof physical therapy treatment of gait disturbances in Parkinson’s disease. Mov Disord. 2002; 17:1 148-1160. 35. Sean Ledger, Rose Galvin, Deirdre Lynch and Emma K Stokes , “A randomised controlled trial evaluating the effect of an individual auditory cueing device on freezing and gait speed in people with Parkinson's disease” , 11 December 2008 BMC Neurology 2008, 8:46 doi:10.1186/1471-2377-8-46 36. Tillerson JL, Cohen AD, Caudle WM, Zigmond MJ, Schallert T, Miller GW. Forced nonuse in unilateral parkinsonian rats exacerbates injury. J Neurosci. 2002;22(15):6790-6799. 37. Tillerson JL,Cohen AD,Philhower J,Miller GW,Zigmond MJ,Schallert T.Forced limb-use effects on the behavioral and neurochemical effects of 6-hydroxydopamine. J Neurosci. 2001;21(12):44274435. 38. Tillerson JL, Caudle WM, Reveron ME, Miller GW. Exercise induces behavioral recovery and attenuates neurochemical deficits in rodent models of Parkinson’s disease. Neuroscience. 2003;119(3):899-911. 39. The

National

Collaborating

Centre

for

Chronic

Conditions,

ed.

(2006). "Other

key

interventions". Parkinson's Disease. London: Royal College of Physicians. pp. 135–46.ISBN 186016-283-5.

CORRESPONDING AUTHOR: * Department of Physiotherapy, Dolphin (P.G.) institute of bio medical and natural sciences, Dhradun , H.N.B. Garhwal University, Srinagar, Uttarakhand, India. Email: sidd2sinha@gmail.com ** Department of Physiotherapy, Dolphin (P.G.) institute of bio medical and natural sciences, Dhradun , H.N.B. Garhwal University, Srinagar, Uttarakhand, India.

CONGENITAL TALIPES EQUINOVARUS (CTEV) Mayank Pushkar. BPT, MSAPT*

deformities- Equinus, Varus, Adductus and cavus4.

INTRODUCTION

The ‘equinus’ deformity is present at the ankle joint, Congenital telipesequinovarus (CTEV) is a

TCN joint and forefoot. The ‘varus’ component

common congenital limb deformity involving one

occurs primarily at TCN joint and the hind foot is

foot or both1. “Congenital” means a deformity that is

rotated inward. The ‘adductus’ deformity takes place

present at birth, “Telipes” means simply the foot and

at the talonavicular and the anterior subtalar joints.

ankle, and “Equinovarus” refers to position of the

The ‘cavus’ component involves forefoot plantar

foot, which points downward and inward. CTEV is

flexion, which contributes to the composite equinus.

also known as “Clubfoot”. An estimated 30000 children born with CTEV every year in India2, although a rate of 1.24 or greater have been reported in UK. It is a common birth defect, occurring in about 1/1000 live births. Almost half of the cases of CTEV are bilateral. Male children are more affected than female children with a ratio of approximately Fig- 1- Showing CTEV in both the foot.

2:13.

AETIOLOGY

PATHOANATOMY

Genetic factors play an important role in

The true clubfoot is characterized by different 35

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inheritance of CTEV as a polygenic multifactorial

neural tube defect are some of the other causes of

trait5. Maternal Hyperthermia is also one of the

structural CTEV4.

causes for CTEV6, as maternal hyperthermia acts as 2. POSTURAL CTEV: This type of CTEV is

adverse environmental factor in the sensitive period

caused due to the compression in utero with the feet

of intrauterine development.

held in equionovarus position in final trimester. Mainly there are 3 broad categories responsible CLINICAL FEATURES OF CTEV

for CTEV deformity in newborn7-

Idiopathic clubfoot is characterized by a bean-

1. NEUROLOGICAL DAMAGE

shaped foot prominence of the head of Talus, medial 2. MUSCULO-SKELETAL DEFORMITY

plantar cleft, deep posterior cleft, absence of normal creases over the insertion of tendon achilies,

3. POSTURAL DEFORMITY

calcaneal tuberosity situated at a higher level and

1.NEUROLOGICAL DAMAGE: Spina bifida

atrophy of calf muscle4. Three major components of

overta with failure of development of the sacral part

deformities, those are, equinous, varus and adducts,

of the spinal cord but normal proximal development

are obvious on examination. Presence of other

can results in an equinovarus deformity of the foot.

anomalies implies a non-idiopathic type of clubfoot. Hypertrophy of calf muscle is present and

MUSCULO-SKELETAL

DEFORMITY:

dorsiflexion and eversion are limited. Lateral

CTEV can results because of composite intrinsic

malleolus is very prominent while the medial

pathology of muscle and the bone. There are

malleolus is buried in a depression because of the

varieties of other conditions which affectthe

inversion at the subtalar joint. There is also

peripheral musculoskeletal tissues and cause an

exaggeration of longitudinal arch of the foot.

equinovarus deformity. ASSESSMENT OF CTEV 3. POSTURAL DEFORMITY: Some children born with equinovarus deformity of the feet, if they

ANTENATAL DIAGNOSIS: The clubfoot can be

have been tightly packed in the utero with the feet

diagnosed at 18-20 weeks of gestation with the

fixed in an equinovarus position for some week prior

advert of Ultrasound. Amniocentesis is made at < 20

to birth.

weeks to check for the high incidence of associated genetic anomalies7,8.

TYPES OF CTEV POSTNATAL DIAGNOSIS: The child as well as 1. STRUCTURAL CTEV: This type of CTEV is

foot must be carefully assessed at birth.

caused by genetic factors such as- a genetic defect with 3 copies of chromosome 18, which is known an

The early assessment of CTEV can be carried out by

“Edward

two methords9:

Syndrome”.

Compartment

syndrome,

Larsen’s syndrome, congenital heart defect and

1. Photographic Assessment 36

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 1, Year: 2013

2. Radiological Assessment

CTEV is the correction of the deformity followed by maintenance of the in the corrected position.

1.PHOTOGRAPHIC ASSESSMENT: Photograph of resting forefoot supination is recommended at

The management of CTEV can be conservative

birth. The focus of the camera is centred at the level

(Non-operative) method as well as operative

of the ankle joint and an assistant holds the knee

depending on the severity of deformity and age of

between finger and thumb and rotates the leg

child.

outward until the forefoot is superimposed upon the CONSERVATIVE TREATMENT

line of tibia. From the photograph it is then possible to measure an angle subtended by the forefoot on the

The

conservative

method

comprises

line of the tibia (Fig. 2). Children with more than 90

manipulation with or without strapping or corrective

of resting forefoot supination at birth were more

plaster casts. The goal of physiotherapy management

resistant to surgical correction.

of CTEV consisted of short term and long term goals14.

The short term goal is to correct the

deformity so that ankle assumes plantigrade positioning by the time the child would be 3 months. The long term goal is to maintain the corrected ankle in the situ and follow up the maintained correction until the child start walking. MEANS

PHYSIOTHERAPY

MANAGEMENT 1. Rhythmic

and

repeated

gentle

manipulation10 Fig. 2- Showing the measurement of angle.

2. Strapping and Plaster of Paris

2.RADIOGRAPHIC ASSESSMENT: A standard

3. Education and instruction to the mother and/ or parents10

lateral soft tissue radiograph of the lower leg can be used for the assessment of CTEV. But X-Rays are

1. RHYTHMIC AND REPEATED GENTLE

not routinely prescribed at birth as few bones in the

MANIPULATION:

foot are ossified4. Also there is not much of clinical

provide

gentle

manipulation, the PT placed the knee at 900 of

use of radiographic assessment as it does not make

flexion to prevent the damage to the lower end of

any difference in management of CTEV.

tibia and fibular epiphysis and the ankle joint. To correct the adduction, the soft tissue of foot is

MANAGEMENT OF CTEV

passively stretched as- the forefoot is uncurled so The main principle of the management of

that it moves away from epsilateral heel i.e. forefoot 37

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correction by this technique is 20.4.

abduction. To correct the inverted foot, the foot is turned such that the sole face outward i.e. eversion.

Ponseti’s Technique4: In Ponseti’s technique, first 2

Finally, to correct the equinus, the heel is cupped

casts are applied with the supination of forefoot so

with the one hand from the front of the foot and an

as to bring into alignment with the hind foot12. The

upward pressure is applied, which brings the ankle

third cast is applied with the forefoot abducted and

into dorsiflexion. The entire procedure is repeated 3-

simultaneous counterpressure over the head of talus.

4 times in each foot.

In the fourth cast, the forefoot is further abducted. 2. STRAPPING AND PLASTER OF PARIS: This

Before the application of fifth cast, the degree of

can be useful for fairly mild cases and should be

dorsiflexion is assessed and if the dorsiflexion is not

started at birth. Strips of adhesive strapping are

possible beyond neutral, then a “Percutaneous

passed around the foot, up the side of legs, and over

AchiliesTenotomy” is required, this is done under

the top of the knee, to hold the foot in a corrected

local anaesthesia. The casts are changed weekly

position. This is usually done weekly, followed by

intervals, before tenotomy, while the cast after the

some manipulation by the physiotherapist.

tenotomy is removed at the end of 3 weeks. After the removal of cast the patient is placed in modified

According to the “International Clubfoot Study

“Foot Abduction Orthosis (FAO)”. FAO is initially

Group (2003)”, Kite’s, Ponseti’s and Bensabel’s

used 23 hrs.a day for 4 months and then

techniques have been approved as the standardized

subsequently for night-time for 3 years13. The

conservative regimes for the management of

average number of casts required with this technique

CTEV11.

is 5.4.

Kite’s Technique4: This technique was derived from

French Technique4: This technique involves daily

the concept of three-point pressure. In this method,

manipulation

the manipulation can be started soon after birth. The

the

child’s

Physiotherapist for 30 minutes,

forefoot is grasped and distracted while the other

clubfoot

followed by

stimulation of muscles (especially Peroneal muscle)

hand holds the heel. The counterpressure is applied

around the foot and then adhesive strapping is

over calcaneocuboid joint and the navicular is

applied.

pushed laterally. The heel is everted as the foot is

Daily

treatment

required

for

approximately 2 months and then reduced to 3

abducted. This is followed by application of slipper

sessions per week for an additional six months.

cast, which is extended to below the knee with the

Tapping is continued until the patient is ambulatory.

foot everted with gentle external rotation. Once the

Once the child starts ambulation, then night-time

adduction and varus are corrected, then the foot is

splint is given for additional 2 to 3 years.

pushed into dorsiflexion to correct the equinous. The casts are changed every week. Following full

3. EDUCATION AND INSTRUCTION TO THE

correction, the foot are placed in a “Denis Brown

MOTHER: The mother should be assured and

Bar”. The average number of cast required for

reassured that with her co-operation, consistency and 38

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

compliance to treatment, the deformity could be

prevent stiffness, which can be done with following

corrected. She should be taught how to mobilize the

physiotherapy interventions15.

feet in the absence of strap10. She is advised to take

•

care and observed every time when a fresh strapping

Movement of toe, hip and knee in the plaster cast only, by tickling or by holding child

or plaster is applied and also to prevent the plaster or

high in suspension.

strapping from being wet or soiled either by water or •

any other fluid.

To improve strength and stability gradual active non-weight bearing and resisted foot

SURGICAL/ OPERATIVE MANAGEMENT

and ankle exercises are given, followed by The operative treatment is required once the

progression to weight-bearing exercises.

conservative treatment fails or the chance of correction

deformity

with

•

conservative

To maintain the correction and avoid recurrence, Night splint are provided. Some

management is very less. Different operative

of the splints used in the management of

procedures are performed based on the age of child.

CTEV areAt 9 months – 3 years: A Postero-medial soft tissue release (PMR), which was introduced by Turco14 is

1. CTEV Splint

performed and followed by “Dennis Brown splint”

2. Dennis Brown Splint (Fig-4)

for 2 years. In this technique, the correction of the 3. CTEV Shoes (Fig-5)

abnormal tarsal relationship is prevented by rigid pathological soft tissue contracture.

•

Gait training with proper foot position is taught to the patient.

At 3 years- 8 years: At this age, soft tissue release along with Wedge Osteotomy of cuboid bone, which

•

is known as EVANS is performed.

Special CTEV shoes are given to the patients. The shoes got straight inner borer,

At 8- 12 years: At this age, the Wedge Osteotomy

which prevents forefoot adduction, outer

of calcaneum (Dwyer’s Operation) along with

shoe raise to prevent inversion and no heel

wedge osteotomy of tarsal bone is performed.

to avoid equinus. •

Above 12 years: A triple arthrodesis of 3 joints of

An effective training is given to the mother

foot (i.e. subtalar, calcaneo-cuboid and talo-

or both parents for home care programme to

navicular joint) is performed.

maintain the correct position of the limb and how to give the exercise in correct way.

POST-OPERATIVE

PHYSIOTHERAPY

MANAGEMENT The main objective of physiotherapy after surgical procedure is to keep the other joints mobile and 39

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Fig-3- CTEV Splint Fig-5- CTEV Shoes Splint

Fig-4- Dennis Brown

REFRENCES 1.Macnicol M. F.The management of Clubfoot: Issues for debate. J Bone Joint Surg[Br],2003;167-170. 2. Global clubfoot initiative. Last assessed on 15th May 2012 at: http://globalclubfoot.org/countries/india/ 3. Macnicol M. F. and Murray A. W. Changing Concepts in the management of congenital talipesequinovarus.Paedetrics and child health,2008; 272-277. 4. Anand, A. and Sala, D.A. Clubfoot: Etiology and treatment. Indian J Orthop,2008;42:22-28. 5. Lehman, W.B. The clubfoot. JB Lippincott: New York; 1996 6. Edwards, M.J. The experimental production of clubfoot in guinea pigs by maternal hyperthermia during gestation. J Pathol, 1971;103:49-53. 7. Katz K, Meizner I, Mashiach R, Soudry M. The contribution of prenatal sonographic diagnosis of clubfoot to preventive medicine.J Pediatr Orthop,1999;19:5-7 8. Roye, B.D., Hyman J., Roye, D.P. Jr. Congenital idiopathic talipesequinovarus. Pediatr Rev, 2004;25:124-30. 9. Porter, R. Club foot. The foot,1997;7: 181-193. 10.Ezeukwu, A.O. and Maduagwu, S.M. Physiotherapy management of an infant with bilateral congenital talipesequinovarus. African Health Science, 2011;11(3): 444-448.

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

11. Bensahel, H., Guillaume, A., Czukonyi, Z. andDesgrippes, Y. Results of physical therapy for idiopathic clubfoot: A long term8follow up study. J Pediatr Orthop,1990;10:189-92. 12. Ponseti IV, Campos J. Observations on pathogenesis and treatment of clubfoot. ClinOrthop, 1972;84:50-60. 13. Ponseti IV. Congenital clubfoot: Fundamentals of treatment. Oxford University Press: Oxford, England; 1996. 14. Turco VJ. Clubfoot. Churchill Livingstone: New York; 1981. 15. Goel RN. Goel’s Physiotherapy.Shubham Publication- Bhopal, Vol II, 2000.

CORRESPONDING AUTHOR: * Email: physio.mayank.pushkar@gmail.com

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ANALYSIS OF WATER QUALITY OF HALENA BLOCK IN BHARATPUR AREA Sunil Kumar Tank*, R. C. Chippa**

ABSTRACT Bharatpur is the well known place because of “Keoladeo Ghana National Park” due to which it is a world fame tourist place. The present study deals with the water quality of Halena block in Bharatpur area, which is assessed by examine various physico-chemical parameters of open wells, bore wells and hand pumps. The studies reveal that the water of most of the sampling area is hard and contaminated with higher concentration of total dissolved solids. KEYWORDS: Water pollution, Health problems, Bharatpur, Analytical techniques, Standard Data

earth. Over 70 per cent of the earth’s surface

INTRODUCTION

materials consists of water and apart from the air Water is life. Without water, man’s existence on the

man breathes, water is one of the most important

earth would be threatened and he would be driven

elements to man. The quality of water is of great

close to extinction. All biological organisms depend

importance also for human lives as it is commonly

on water to carry out complex biochemical

consumed and used by households. In industry, it

processes which aid in the sustenance of life on

serves as a solvent, substrate or catalyst of chemical 42

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

reactions (Goncharuk 2012; Holt 2011; Van

pollution also occurs when rain water runoff from

Leeuwen 2012; Petraccia et al. 2011). The physical,

urban and industrial area and from agricultural land

chemical and bacterial characteristics of ground

and mining operations makes its way back to

water determine its usefulness for domestic,

receiving waters (river, lake or ocean) and in to the

industrial, municipal and agricultural applications

ground.

(CGWB, 2004 and Adhikary et al. 2010). The

gate of Rajasthan is situated between 26 22’ to 27

quality of water is more important compared to

and

Tanriverdi

al.

longitude. Bharatpur is well known place because

for drinking purposes (CPHEEO 1998, Patnaik et 2002

83’ north latitude and 76 53’ to 78 17’ east

quantity in any water supply planning, especially

al.

Bharatpur (Fig.1: Study Area), eastern

of Keoladeo Ghana National Park. Keoladeo

2010).The

National Park is the only the largest bird sanctuary

accumulation of high levels of pollutants in water

in India. “Ajan Bandh” is the main water source to

may cause adverse effects on humans and wildlife,

fill the various lakes, ponds of the park and

such as cancer, reproductive disorders, damage to

villagers use this water for drinking purposes. In the

the nervous system and disruption of the immune

present study several points of ground water

system. Thus, it is an important requirement to

sources such as open wells, bore wells and hand

interpret water quality status, identify significant

pumps have been selected to check the potability of

parameters, and characterise the pollution sources

water.

as well as their quantitative contributions to water MATERIAL METHOD

quality issues for conducting pollution management (Zhou et al. 2011). Water pollution means

Water quality is the physical, chemical and

contamination of water by foreign matter such as

biological characteristics of water in relationship to

micro-organisms, chemicals, industrial or other

a set of standards. Water quality is a very complex

wastes, or sewage. Such matters deteriorate the

subject, in part because water is the complex

quality of the water and renders it unfit for its

medium intrinsically tied to the ecology of the

intended uses. Water pollution is the introduction

earth. The physico – chemical quality of drinking

into fresh or ocean waters of chemical, physical, or

water was assessed during the month of January,

biological material that degrades the quality of the

2011 by standard methods as suggested by APHA

water and affects the organisms living in it.

(1995) and compared with the values as guided by

Although some kinds of water pollution get occur

ICMR.

through natural processes, it is mostly a result of

The present research work is based on 15 ground

human activities. The water we use is taken from

water samples collected from open wells, bore

lakes and rivers, and from underground [ground

wells and hand pumps in cleaned and screw capped

water]; and after we have used it and contaminated

polythene bottles. At the time of sampling, these

it – most of it returns to these locations. Water

bottles are thoroughly raised 23 times using the 43

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ground water to be sampled.

RESULTS AND DISCUSSION The physico-chemical parameters which were analysed in Post-monsoon season, January 2012 have been shown in Table-2. Colour: Fig . 1

The colour of a small water sample is caused by both dissolved and particulate material in water,

These water samples are collected after pumping

and is measured in Hazen Units [HU]. Colour in

the water for 10 minutes (CPHEEO 1998, Chhabra

water may be caused because of the presence of

2008 and Shyam & Kalwania 2011).

natural metallic ions (iron and manganese) humus, as

planktons etc. The presence of colour in water does

1,2,3,4,5,6,7,8,9 and 10 and a record was prepared

not necessarily indicate that the water is not

which is indicated in Table 1.

potable. Colour is not removed by typical water

All

the

samples

were properly labeled

filters; however, slow sand filters can remove colour, and the use of coagulants may also succeed in trapping the colour causing compounds within the resulting precipitate. In the present study water is almost colourless. Odour: When minerals, metals and salts from soil etc. come in contact with water, they may change its taste and odour. Analyzed water samples are found odourless. 44

Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 1, Year: 2013

Temperature:

over falls and rapids; and as a waste product of

Use appropriate thermometer for calculating water

photosynthesis. In general, rapidly moving water

temerature.

contains more dissolved oxygen than slow or

Water temperature affects the ability of water to

stagnant water and colder water contains more

hold oxygen, the rate of photosynthesis by aquatic

dissolved oxygen than warmer water. In the studied

plants and the metabolic rates of aquatic organisms.

water samples DO ranged from 4.6 to 7.8 mg/l. As

Temperature of water samples is varied from

DO level falls; undesirable odours, tastes and

26.0 C to 27.2 C the variation of the water

colours reduce the acceptability of water. The

temperature

lowest DO value indicates not good healthy

having

effect

directly or

indirectly on all life processes.

condition for the community (Jeena. B et al 2003).

PH:

Total Alkalinity:

Ph is measured by Ph meter.

Total alkalinity is calculate by Titration Method. Alkalinity is not a pollutant. It is a total measure of

The balance of positive hydrogen ions (H ) and

the substance in water that have â&#x20AC;&#x153;acid-neutralizingâ&#x20AC;?

negative hydroxide ions (OH ) in water determines

ability. The main sources of natural alkalinity are

how acidic or basic the water is. In pure water, the

rocks, which contain carbonate, bicarbonate, and

concentration of positive hydrogen ions is in

hydroxide compounds, borates, silicates, and

equilibrium with the concentration of negative

phosphates may also contribute to alkalinity.Total

hydroxide ions, and the pH measures exactly 7. pH

alkalinity is the total concentration of bases in

is a term used to indicate the alkalinity or acidity of

water expressed as parts per million (ppm) or

a substance as ranked on a scale from 1.0 to 14.0.

milligrams per liter (mg/l) of calcium carbonates

In the present study area the pH value ranged from

(CaCO ). These bases are usually bicarbonates 3

7.70 to 8.76. A pH range from 7.0 to 8.5 is

(HCO ) and carbonates (CO2- ), and they act as a

desirable concentration as per guided by ICMR. It

is known that pH of water does not cause any

buffer system that prevents drastic changes in pHs

severe health hazard. Water of study area is

Water with high total alkalinity is not always hard,

somewhat alkaline.

since the carbonates can be brought into the water

Dissolved Oxygen (D.O.):

in the form of sodium or potassium carbonate. The

DO can be determining by use of DO meter as well

desirable limit of total alkalinity is 200 mg/l

as measure by Winkler

(ICMR). The value of study area is ranged from

titration method.

DO is the most important water quality parameter

161 to 202 mg/l. Alkalinity in itself is not harmful

which shows the amount of oxygen present in

to human being, but in large quality, alkalinity

water. It gets there by diffusion from the

imparts bitter taste to water.

surrounding air, aeration of water that has jumbled

Total Hardness: 45

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Complexometric titration using EDTA

ions present. The maximum limit of hardness in

The total hardness is the sum of the hardness

drinking water is 600 mg/l (ICMR). Total hardness

formers in a water (Ca, Mg, Ba and Sr ions) in

is measured in grains per gallon (gpg) or parts per

mmol/l. Originally hardness was understood to be a

million (ppm). If water contains less than 3.5 gpg, it

measure of the capacity of water to precipitate soap.

is considered soft water. If it contains more than 7

Soap is precipitated chiefly by the calcium and Mg

gpg, it is considered hard water.

Hardness Description

Hardness range (mg/l as CaCO )

Soft

0-75

Moderately hard

75-100

Hard

100-300

Very Hard

> 300

The total hardness value ranged in the studied area

A measure of the amount of calcium in water

from 96 to 488 mg/l. So, the water of almost all

measured in ppm. High levels can cause scale

sampling stations is hard.

buildup. Low levels can cause etching and

Calcium Hardness:

equipment

corrosion.

Calcium

Complexometric titration using EDTA hardness is sometimes confused with the terms

(ICMR). Mg hardness value in studied area ranged

water hardness and total hardness. Too little

from 11.54 to 91.78 ppm.

calcium hardness and the water are corrosive. Too

Chloride:

much calcium hardness and the water are scale

Using silver nitrate titration method for calculate

forming. The maximum permissible limit of

chloride in water.

calcium hardness is 200 mg/l (ICMR). The value of

The

sampling stations ranged from 32.06 to 68.13 ppm.

chloride is 1000 mg/l. (ICMR). So except some

Thus sampling stations 5 and 12 have greater

points the chloride contents of water samples are in

calcium hardness.

limit. It varies from 53.76 to 406.07 ppm

Magnesium Hardness:

Sulphate:

Complexometric titration using EDTA

Ion chromatography is the only instrumental

Magnesium salts have a laxative and diuretic effect.

method for the direct determination of sulphate.

The maximum permissible

Sulphate may be precipitated either with Ba2+ or 2-

limit of magnesium hardness is 150 mg/l

aminoperimidinium salts. The precipitate may be 46

maximum

permissible

concentration

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

weighed for a direct determination of the sulphate

fluoride can be determined by spectrophotometry or

as a gravimetric method.

by ion-chromatography.

The maximum permissible limit of sulphate is 400

Fluoride is more common in ground water than in

mg/l (ICMR). In the sampling areas the sulphate

surface water. The main sources of fluorine in

concentration ranged from 15.25 to 71.00 ppm.

ground water are different fluoride bearing rocks.

Waters with higher concentration of sulphate may

The guideline value of fluoride is 1.5 mg/l in

cause intestinal disorders.

drinking water. In studied area, it ranged between

Nitrate:

0.010 to 1.180ppm.

Use spectrophotometer for calculating nitrate in

Electrical Conductivity:

water.

Electrical conductivity estimates the amount of

Nitrate is a major ingredient of farm fertilizer and is

total dissolved salts (TDS), or the total amount of

necessary for crop production. Nitrate stimulates

dissolved ions in the water. Its SI derived unit is the

the growth of production. Nitrate stimulates the

siemens per meter, (A S m Kg ) or more simply,

2 3

growth of plankton and waterweeds that provide

-1

electric field strength or, in more practical terms; is

is 50 mg/l (ICMR). Nitrate in water supplies in over

100

mg/l.

-1

Sm . It is the ratio of the current density to the

food for fish.Maximum permissible limit of nitrate

concentration

-3

equivalent to the electrical conductance measured

causes

between opposite faces of a 1-meter cube of the

“methamoglobinamia”.

material under test. Pure water is a poor conductor

Generally NO concentration is found in higher

of electricity. Acids, bases and salts in water make

concentration in rural areas because of runoff of

it relatively good conductor of electricity. Electrical

nitrate rich fertilizers and animal manure into the

conductivity in studied area ranged between

water supply.

7.5x102 to 2.1x103 µmhos/cm.

The nitrate value ranged in

investigated area is between 17.06 to 93.2 ppm.

CONCLUSIONS

Total Dissolved Solids (TDS):

The present results of water investigation show that

Use an appropriate TDS meter. Freshwater meters:

the waters of study area are highly contaminated

0-1990 ppm (parts per million).

with total dissolved solids. Because of high

The term TDS describes all solids [usually mineral

concentration of TDS water loss its potability and

salts] that are dissolved in water. Desirable limit of

high concentration of TDS also reduces the

TDS is 500 mg/l (ICMR). All the values obtained

solubility of oxygen in water. Water of almost all

are much higher than the limit except points-1 and

study points are hard also because of this people of

2. It is an important parameter for imparts a

Bharatpur area are facing many problems like

peculiar taste to water and reduce its potability.

stomach diseases, gastric troubles etc. At some

Fluoride:

points nitrate level is also high than the permissible limit. It is recommended that water should be used 47

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after boiling by the people of Bharatpur because

concentration of total dissolved solids can also be

after boiling the water, temporary hardness

decreased. Alum treatment is also a good option to

[carbonate

make potable the water.

hardness]

can

removed

and

TABLE-1 Area, sourceof the sampling stations. Sample No.

Area

Source

Halena

Hand pump

Halena bus stop

Hand Pump

Chhonkarwara Bus stand

Bore Well

Aamoli

Bore Well

Chote chhonkarwara

Hand Pump

Bijwari

Bore Well

Khedli Mod

Bore Well

Bachren

Hand Pump

Salempur Khurd

Hand Pump

Kamalpura

Hand Pump

TABLE-2 PARAM

S.1

S.2

S.3

S.4

S.5

S.6

S.7

S.8

S.9

S.10

8.03

7.62

7.86

7.94

7.88

8.09

7.57

7.80

7.24

8.25

1.2x103

2.1x103

8.6x102

8.9x102

1.3x103

8.8x102

1.5x103

9.0x1

1.9x1

7.5x1

ETER

0 TDS

650

1170

497

485

690

485

760

493

1090

02 404

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

248

464

152

148

212

312

208

488

192

168

183

185

191

175

174

161

176

202

188

5.7

7.6

7.8

5.7

5.9

6.1

5.5

4.6

5.6

Ca+2 ppm

56.91

64.93

44.89

32.06

49.70

32.87

67.33

55.31

68.13

48.90

30.57

87.10

11.54

19.61

25.38

14.04

41.53

20.19

91.78

20.18

90.39

176.87

50.57

83.26

138.69

94.99

110.86

51.29

118.2

89.72

Mg ppm

Na + ppm

2 Cl- ppm

149.99

406.07

53.76

87.93

197.85

81.95

262.13

69.69

340.1

84.03

4 SO42-

15.25

41.25

14.75

50.50

71.00

39.00

51.25

21.50

64.75

28.00

NO3- ppm

93.2

80.8

17.60

18.2

56.4

41.4

72.6

69.6

46.8

60.0

F- ppm

0.130

1.30

0.170

0.010

0.020

0.250

0.050

0.130

0.560

1.180

ppm

REFERENCES 1. APHA (American Public Health Association) (1995). American Water Works Association and Water th

Pollution Control Federation, Standard Methods of Examination of Water and Waste Water, 19 Edition, New York, USA. 2. Goncharuk, V. V. (2012). A new concept of supplying the population with a quality drinking water. Journal of Water Chemistry and Technology, 30, 129–136. 3. Holt, M. S. (2011). Sources of chemical contaminants and routes into the freshwater environment. Food Chemistry and Toxicology, 38, S21–S27. 4. Jena B, R. Sudarshana and S.B. Chaudhary ((2003)). Nat. Environ. Poll. Technol., 2(3), 329. 5. Kulshrestha S, S.S. Dhindsa and R.V. Singh (2002). Nat. Environ. Poll. Tech., 1(4), 453. 6. Petraccia, L., Liberati, G., Masciullo, S. G., Grassi, M., & Fraioli, A. (2011). Water, mineral waters and health. Clinical Nutrition, 25, 377–385. 7. Van Leeuwen F. X. R. (2012). Safe drinking water: The toxicologist’s approach. Food Chemistry and Toxicology, 38, S51–S58. 49

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8. Zhou, F., Guo, H. C., Liu, Y. & Jiang, Y. M. 2011 Chemometrics data analysis of marine water quality and source identification in Southern Hong Kong. Marine Pollution Bulletin 54 (6), 745–756. 9. Adhikary P. P., Chandrasekharan H., Chakraborty D. and Kamble K., 2010, Assessment Of groundwater pollution in West Delhi, India using geostatistical approach, Environmental Monitoring Assessment, 167, pp 599615. 10. Central Ground Water Board (CGWB), 2004, Annual report and other related reports on ground water quality, Central Ground Water Board, New Delhi. 11. Patnaik K. N., Satyanarayan S. V. and Poor R. S., 2002, Water pollution from major industries in Paradip area A case study. Indian Journal of Environmental Health,44(3), pp 203211. 12. Tanriverdi C., Alp A., Demirkıran A. R. and Uckardes F., 2010, Assessment of surface water quality of the Ceyhan River basin, Turkey, Environmental Monitoring Assessment, 167, pp 175–184.

CORRESPONDING AUTHOR: *

Department

Chemistry,

Suresh

Gyan

Vihar

University

Jaipur

(Rajasthan).

sunilkumar.179@rediffmail.com ** Associate Professor, Department of Chemistry, Suresh Gyan Vihar University Jaipur (Rajasthan)

Email:

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