ISSN: 2226-9541 (print) ISSN: 2304-6058 (online)
Vol 2 Issue 1 June 2013
JOPSM Journal of Physiotherapy and Sports Medicine Highlights
Efficacy of integrated treatment for knee OA Functional performance of upper extremity in chronic stroke Stretching exercises for shoulder joint propioception MCQs in 3rd year physiotherapy Choice of walking aid and ACL rehabilitation
Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 2, Issue 1, 2013
Editor-in-Chief
Umer Sheikh, MSc. Advancing Physiotherapy (UK), MSc. APA (Ireland/Belgium), MCSP (UK), SRP (UK), MAACP (UK), BSPT (PU), MPPS (PK) - Woking, UK
Associate Editor
Adnan Khan, MSc (UK), MCSP (UK), MICSP (Ireland), MAACP (UK), BSPT (PU) Staffordshire, UK
International Advisory Board
Editorial Board
Muhammad Atif Chishti, MSc. Musculoskeletal Physiotherapy (UK), MCSP (UK), SRP (UK), MAACP (UK), BSPT (PU), MPPS (PK) Middlesborough, UK Sameer Gohir, MSc Sports Physiotherapy (UK), MSc APA (Ireland/Belgium), MCSP (UK), SRP (UK), MISCP (Ireland), MSHC (KSA) - London, UK Rashid Hafeez M.Phil (Physiotherapy), MSc. APA (Belgium/Ireland), BSPT (PK) Dr. Fariha Shah, DPT (USA) - Lahore, PK Mohammad Bin Afsar Jan, MSPT (AUS), BSPT (PK) - Peshawar, PK
Shumaila Umer Sheikh, MSc Paediatric Physiotherapy (UK), MSc APA (Belgium/Ireland), MISCP (Ireland), BSPT (PU) - West Byfleet, UK Muhammad Atif Khan, BSc, MSc, Pgd (Ortho med), ESP, Spinal Practitioner, Berkshire, UK Muhammad Asim Ishaque, MSc Musculoskeletal Physiotherapy (UK), MCSP (UK), SRP (UK), BSPT (PK) London, UK
Dr Junaid Amin DPT (PK), BSPT (PK) KSA Shahbaz Iqbal MSc Physiotherapy (USA), tDPT (USA), McKenzie Cert.
Managing Editor
Beenish Zaman, tDPT (PK), BSPT (PK) Lahore, PK
This journal subscribes to the principles of the Committee on Publication Ethics http://publicationethics.org/
The Journal of Postgraduate Institute of Physiotherapy Visit the journal website at http://www.pgip.co.uk/jopsm
JOPSM Editorial Office | 13/3 New Civil Lines, Sargodha, Pakistan Tel: +92 (423) 2107625 E-mail: info@pgip.co.uk
Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 2, Issue 1, 2013 Table of Content
Editorial.......................................................................................................................................01 Management of Advanced Stage Osteoarthritis of Knee: Efficacy of Integrated Physical Therapy Treatment………………………………………………………………………………………………………………….................03 Effects of Bimanual Functional Practice Training versus Unimanual Functional Practice Training on Functional Performance of Upper Extremity in Chronic Stroke……………………………………..…………...15 The Immediate Effect of Short Durations of Warm up and Stretching Exercises on Shoulder Joint Proprioception – Preliminary Findings…………………………………….………………………………………………….31 Qualitative & Quantitative Analysis of Multiple Choice Questions in 3 rd year Physiotherapy…………………………………………………………...................................................................42 A Comparison of Walking Aids in Patients with Anterior Cruciate Ligament Rehabilitation..............................................................................................................................49 Guidelines for Authors.................................................................................................................56
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
JOPSM Editorial Office | 13/3 New Civil Lines, Sargodha, Pakistan Tel: +92 (423) 2107625 E-mail: info@pgip.co.uk
[Guest Editorial]
Role of Physiotherapist in falls Prevention Umer Sheikh1, Sameer A Gohir2
Physiotherapy is a very diverse profession
people reporting a fall or been considered
that can identify human movement as key
at risk of falling should be observed for
to health and well-being of patient. They
balance and gait deficits and considered
promote preventive healthcare and have
for
expertise not only in treating joint /spinal
interventions to improve strength and
problems but can address posture, balance
balance4.
and gait related discrepancies. The horizon is far bigger and brighter. Physiotherapist can also help the elderly patients to stay safe and avoid the number of falls, they
their
ability
to
benefit
from
Frequent fallers should benefit from physiotherapeutic interventions such as5;6;
Comprehensive assessment of the
encounter. They are able to give a specific
patient targeting musculoskeletal
multi-component exercise programme that
problems or other factors such as
has been proved to reduce falls among
gait assessment etc.
community-dwelling
older
people1.
Improving strength of the muscles,
Physiotherapists can do this in the
balance improvement and any other
community / domiciliary or intermediate
postural issues
care (community hospitals). In sub-acute
Comprehensive
assessment
hospital settings and in nursing homes,
including poly-pharmacy review,
multi-factorial interventions including the
confusion assessment, proper shoe
supervised
wear, vision and auditory issues,
exercise
programmes
are
appear to be effective at reducing falls2. Balance impairment is one of the major risk factor for falls among older people and those with long term conditions, such as stroke or Parkinson’s disease3;4. Older
orientation and awareness of the patients in intermediate setup
Refer to occupational therapist for environmental check / equipment provision to make the patient safe
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 1
[Guest Editorial] In literature various outcome measures were reported and should be used to gage the effectiveness of the program. Most important outcome measures reported are,
Berg Balance Scale
Timed Up and Go Test
Performance-Orientated
Mobility
Assessment
Four-square step test
180 degree turn
Falls Efficacy Scale (FES)
FES - International (FES-I)
Short FES-I
Physiotherapists can help old people in overcoming psychological factors such as fear of falling and prevents various disabling activities
such as
loss of
independence and reduced quality of life7,8,11. Other than that, there is financial aspect of falls9. Patients may fall and suffer from the neck of femur fracture. Ultimately, they have to go for hip surgeries10. The cost of surgery and rehabilitation after the surgery is phenomenal.
So by reducing the
number of falls, physiotherapists help to reduce the cost incurred to the government and private sector.
References 1.
al. Interventions for preventing falls in older people living in the community (Review). Cochrane Database of Systematic Reviews 2009;(2). 2. Cameron ID, Murray GR, Gillespie LD, Robertson MC, Hill KD, Cumming RG et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database of Systematic Reviews 2010;(1). 3. Ashburn A, Stack E, Ballinger C, Fazakarley L, Fitton C. The circumstances of falls among people with Parkinson's disease and the use of falls diaries to facilitate reporting. Disability and Rehabilitation 2008; 30:1205-1212. 4. Lamb SE, Ferrucci L, Volapto S, Fried LP, Guralnik JM. Risk factors for falling in homedwelling older women with stroke. Stroke 2003; 34:494-501. 5. Howe TE, Rochester L, Neil F, Skelton DA, Ballinger C. Exercise for improving balance in older people. The Cochrane Database of Systematic Reviews 2011;(11). 6. Skelton D, Dinan SM, Campbell M, Rutherford OM. Tailored group exercise (Falls Management Exercise - FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005; 34(6):636-639. 7. Rand D, Miller WC, Yiu J, Eng JJ. Interventions for addressing low balance confidence in older adults: a systematic review and meta-analysis. Age Ageing 2011; 40(3):297-306. 8. Zijlstra GAR, van Haastregt JCM, van Rossum E, van Eijk JTM, Yardley L, Kempen GIJM. Interventions to reduce fear of falling in community-living older people: a systematic review. Journal of the American Geriatrics Society 2007; 55:603-615. 9. http://www.dh.gov.uk/en/Publicationsands tatistics/Publications/DH_103146. 10. O’Neill TW, Varlow J, Reeve J et al. Fall frequency and incidence of distal forearm fracture in the UK. J Epidemiol Community Health 1995; 49: 597–8. 11. Delbaere K, Crombez G, Vanderstraeten G, Willems T, Cambier D. Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study. Age Ageing 2004; 33: 368– 73
Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG et
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 2
[Case Report]
Management of Advanced Stage Osteoarthritis of Knee: Efficacy of Integrated Physical Therapy Treatment Atif Dustgir1 B.S.P.T, PP DPT
Abstract: Osteoarthritis (OA) of knee is a major musculoskeletal problem which almost every physical therapist encounters during his or her daily practice. The emphasizes of this study is to find out
the efficacy of integrated physical therapy interventions for the management of
osteoarthritis knee disease at advance stages (Grade IV).The patient presented in this case study is a 85 year old, an obese male with OA symptoms in bilateral knees. Physical examinations revealed characteristic signs of advanced osteoarthritic disease in both knee with resting pain 8/10 on visual analog scale (VAS) and activity of daily livings (ADLs) were severely restricted. Physical therapy Treatment was designed with integrated protocol consisting of acupuncture treatment with physical therapy interventions using combined approach to control symptoms. After 6 week, the patient demonstrated considerable improvement in all outcome measures: pain, stiffness, tenderness, basic ADLs except advanced functional activities (IADLS). The patient maintained the improved condition in 12 week follows up through advised exercises plan and life style modification strategies.
Keywords: Advanced OA knee, Acupuncture, Chronic Pain Management, Physical Therapy Treatment
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 3
[Case Report]
Introduction: Osteoarthritis
(OA),
also
known
chondrocytes to growth factors that
as
stimulate repair.
degenerative joint disease, is a progressive deteriorated disorder of synovial joints that
A decreased responsiveness of
An increase in the laxity of
results in loss of hyaline cartilage and
ligaments
remodeling of surrounding bone over the
making
older
time. There is loss of hyaline cartilage,
unstable
and,
typically at the point of maximum load
susceptible to injury.
bearing1. Osteophyte formation (abnormal outgrowth of cartilage that becomes ossified) occurs at the joint margins and cysts may develop in the bone as disease progresses. Doherty et al2 suggest that
around
joints
evidence of knee OA.
Grade 1: doubtful narrowing of
osteophytic lipping
function.
Other
pathological changes include subchondral
more
utilized grading system for radiographic
caused by increased pressure in the bone
load-distributing
relatively
Kellgren and Lawrence6 defined a widely
joint
its
joints,
therefore,
cysts are small areas of osteonecrosis
when the cartilage is no longer adequate in
the
Grade
space
2:
and
definite
possible
osteophytes,
definite narrowing of joint space
Grade
3:
moderate
multiple
sclerosis, thickening of the capsule and
osteophytes, definite narrowing of
evidence of osteochondral bodies in the
joint
synovium1. Degenerative joint diseases
possible deformity of bone contour
(DJD) affect the thixotropic properties
space, some sclerosis and
Grade 4: large osteophytes marked
(thixotropy is the property of various gels
narrowing of joint space, severe
becoming fluid when disturbed, as by
sclerosis and definite deformity of
shaking) of synovial fluid, resulting in
bone contour.
reduced lubrication and subsequent wear of
the
articular
cartilage
and
joint
The symptoms of this chronic disease are pain, stiffness and potentially reduced
surfaces3, 4
function of affected joints. In OA knee at The
increase
in
the
incidence
and
advanced stage the ability to engage in
prevalence of OA with age is likely a
functional and social activities may be
consequence of several biologic changes
restricted depending upon severity of
5
that occur with aging, including :
disease and, as a consequence, quality of life may be affected. Pain and stiffness
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 4
[Case Report] with restricted mobility are the main
intervention are effectively beneficial in
symptoms.
the long term management of advanced 7
Clinical features of advanced OA include :
Resting Pain
Painful
OA of knee8. Conservative management includes corticosteroid injections, physical therapy/exercises, bracing, walking aids,
creaking,
life style modifications, weight reduction
crunching, grinding sensation on
and medications9. Management strategies
moving the joint).
are considered in relation to the person’s
Moderate to sever synovitis.
quality of life, functional limitations and
Severely reduced in range of
pain experienced. The main focus of
movement.
interventional strategy is to control pain
Limited functional activities.
and improve range of motion (ROM) to
Crepitus
(a
enhance Restricted movement of the joint can occur due to pain, capsular thickening or the
functional
outcomes.
The
evidence in literature supports acupuncture as an effective measure to reduce pain and
1
presence of osteophytes . Crepitus may be noticeable on movement due to the rough articular surfaces and the joint line or periarticular area may be painful on palpation. Pain can be caused directly by increased pressure in the subchondral bone,
trabecular
micro-fractures
or
capsular distension which may occur as a result of bursitis (inflammation of the bursa) or enthesopathy (inflammation of the ligament and muscle attachments to the
the importance of manual therapy and exercises to improve ROM is well recognized8. These available evidences were the main incentive to use integrated physical therapy interventional approach for
pain
management
and
improve
functions respectively. Systemic reviews conclude
that
acupuncture
is
more
effective than placebo for osteoarthritis of knee in addition to exercise and life style modifications10,11.
bone). Reduced muscle strength or wasting of the muscles may be evident in severe
Chronic nociceptive pain of somatic type
OA due to lack of use or reduced function
is the most common determinant for a
of the joint.
patient to seek intervention in case of DJD problem5. It has been documented in
Diagnosis is usually based on history and examination. Invasive procedures like pain
literature that Somatic or Musculoskeletal pain can be generated by:
management techniques and orthopedic
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
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[Case Report]
Convergence of sensory input from
deformation
separate parts of the body to the
compresses or stretches the nociceptive
same dorsal
free nerve endings, with the excessive
primary
horn neuron via sensory
fibers
of
collagen,
which
forces being perceived as pain17. Thus,
(convergence-projection theory)12
specific movements or positions should
Secondary pain resulting from a
influence pain of a mechanical nature in
myofascial trigger point13
other words pain of mechanical origin is
Sympathetic activity elicited by a
continuous with specific postures or
spinal reflex14
movement patterns.
Pain-generating substances12
Acupuncture is reported to be a sensory stimulation by inserting needle into skin
Pain associated with OA is typically
which produce afferent response pattern in
described as dull, aching or throbbing and
peripheral nerves by activating “A” delta
15
localized to a specific region . The
fibers (causing heaviness and distension),
common free nerve endings have two
“A” gamma fibers (causing numbness) and
distinct pathways into the central nervous
“C” fibers causing soreness18.This whole
system, which correspond to the two
afferent response is contributor of classic
different types of pain represented by two
post session sensation of “DeQi”. After
distinct
needling
nerve
pain
pathways:
fast
“A”
delta
fibers
activate
conducting A delta and slow conducting C
mechanoreceptors, the input travels to
fibers. A-delta fibers evoke a rapid, sharp,
brain to release Opiods mainly enkephalin,
lancinating pain reaction; C fibers cause a
which
16
slow, dull, crawling pain . The symptoms of chronic pain typically behave in a mechanical fashion, in that they are provoked by activity or repeated movements and reduced with rest or a movement in the opposite direction5.
in
transmission
action of
suppresses
“C”
fibers
the
(reduce
soreness). It seems to improve function and pain relief as an adjunct therapy for osteoarthritis of knee compare with control group
with
just
education
about
modification in life style19.
Nociceptor stimulation can occur with
Case Presentation
Mechanical deformation. The mechanical
Clinical Examination
cause of constant pain is less understood,
The patient was 85 year old male with
but is thought to be the result of the
weight just over 90 kg .The patient referred for physical therapy by an
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 6
[Case Report] orthopedic surgeon after finding him
(DJD) of the both knees. Radiographic
unsuitable for any invasive procedure
findings indicated severe osteoarthritis
because of his relevant medical problems.
with bilateral decreased joint space &
He was diagnosed as Grade 4 severe
flattening of weight bearing aspect of both
arthritis of both knees with history of
joints. A physical therapy diagnosis was
diabetes, hypertension and stage 3 renal
made with label of impaired joint mobility,
diseases. The Patient was on pain killers
motor function, muscle performance, and
for last 12 years with having history of
ROM associated with bilateral DJD.
more than 30 years of knee pain. The
Interventions
symptoms were exacerbating since a year
It has been documented that Indoor
time with no sign of relief. The patient was
physical activity at home in older adults
a retired school teacher and gave statement
who have difficulty in performing outdoor
that he was in habit of standing about 6-8
activities is a key to documenting baseline
hours for more than 40 years in his life.
physical activity levels to guide physical
Clinical examination revealed bilateral
activity intervention outcome aimed at
knee pain and tenderness over the medial
reducing the rate of decline in mobility20.
joint lines, medial and lateral patellar
In this case, despite of bilateral knee DJD,
facets & patellar ligaments, more on left
the age of patient may also have a major
than right. There was severe pain on
role in his functional limitation in both
anterior and medial aspect of both knees
indoor and outdoor mobility in order to
and generalized pain along the lateral
perform activities of daily livings.
aspect of left thigh. Pain was very intense with rating of 8/10 at rest in both knees on visual analog scale (VAS) which is a 10cm line ranging from zero (no pain) to 10
Activities of daily living (ADLs) are daily self-care activities within an individual's place of residence (indoor), in outdoor environments, or both. The ability or
(most pain).
inability
to
perform
ADLs
is
a
Range of motion was painful and restricted
measurement of the functional status of a
at both joints with no tolerance to weight
person, particularly in regards to people
bearing. Patient was very limited in his
with disabilities and the elderly21. Basic
mobility and completely dependent for his
ADLs (BADLs) consist of self-care tasks22
ADLs performance.
In this case the main areas of our concern
indicated
Clinical findings
patellofemoral
dysfunction
is independent bathing and showering
associated with degenerated joint disease
capability of patient (washing the body)
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 7
[Case Report] with
proper
bladder
sessions, passive stretching to hip flexors
management (recognizing the need to
and calf muscles was added in treatment.
relieve oneself), ability of self dressing and
In
functional mobility (moving from one
movement techniques for patellofemoral
place
performing
joint was added along with hamstring and
activities) while Instrumental activities of
IT band stretching according to the
daily living (IADLs) are not necessary for
tolerance of patient. This treatment was
fundamental functioning, but they let an
continues for another 3 sessions. A
individual
a
reevaluation was made after 2 weeks and
community23 and the focus of our goals is
decided to continue same rehabilitation
housework, shopping for groceries or
plan for another two weeks with addition
clothing and
of exercises plan and reducing in the
to
bowel
another
live
and
while
independently
in
transportation within the
community.
and
desired
outcomes
of
treatment. The main goal determined was the
session
mobilization
with
frequency of treatment to twice a week
The patient interviewed to determine his priorities
third
control
of
Resting
management
of
basic
Pain
and
ADLS.
The
sessions. After 10 sessions (4 weeks), acupuncture treatment was withdrawn and rest of treatment continued for another 4 sessions over next 2 weeks (Total 6 weeks).
interventional plan of care designed with
Reasoning For Acupuncture
acupuncture treatment session integrated
Point Selection:
with physical therapy interventions to
Current
achieve this goal. The 6 weeks plan of care
acupuncture
is
consisting of 15 physical therapy sessions
replacement
of
designed
the
Inflammatory drugs (NSAIDs), being at
condition. The patient was informed and
least equally effective and probably more
obtained consent for use of needles and
cost effective and much safer24. National
manual procedures. In the first 2 weeks
Institute of Health and Clinical Excellence
treatment was given on alternate day basis
(NICE) in 2009 recommends considering
and
to
the
with
main
aim
to
address
emphasize
was
on
offer
evidence
a
demonstrated likely Non
to
provide
Steroidal
therapeutic
that
course
Anti
of
acupuncture treatment and pain inhibiting
acupuncture treatment comprising up to 10
manual therapy interventions. In the first 2
sessions over a period of 12 weeks25.
sessions acupuncture treatment was given
White et al11 defined acupuncture as
with joint traction maneuver. In third
adequate if it is consisted of at least 6
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 8
[Case Report] sessions, at least once per week with at
demonstrated ST36 produce activity in the
least four points for treatment of chronic
descending anti-nociceptive pathways and
knee pain. All 4 local knee points were
in limbic area associated with pain
selected according to the best available
response26. The points in spleen meridian
evidence about their efficacy. Two points
SP9 & SP10 are effective to control joint
stomach meridian points ST35 & ST36
pain in the absence of joint effusion and
and two spleen meridian points SP9 &
swelling. Effusion makes it difficult to
SP10 were included in intervention. ST 35
apply the points especially SP9. They are
is an intra articular point and is effective
known to be effective in reducing pain and
local point to treat knee pain9. Wu et al,
skin hypersensitivity.
Acupuncture Acupuncture treatment was given at ST 35,36 & SP9,10 with 4mm needles for 15 minutes during each session in first 4 weeks
Specific Manual Techniques Used Passive stretching of the bilateral hip flexors, iliotibial band, hamstrings and gastrocnemius. Bilateral patellofemoral joint mobilization techniques. Bilateral MWM technique for patellofemoral joints. Bilateral tibiofemoral joint traction maneuver.
Active Rehabilitation Protocol Range-of-motion exercises mainly for both knees were performed in the non-weight-bearing position. Exercises include: Isometric quadriceps sets at 20 degrees of flexion, progressing to multiple angle isometrics 20 times each in 3 sets. Heel slides with the tibia positioned in internal for 10 times and then external rotation for 10 times in 3 sets. Straight leg raises performed with the thigh externally rotated and the knee flexed to 20 degrees 10 times in 2 sets. Adductors isometrics in crook lying, with pillow between both knees, press and hold for 5 seconds, 20 repetitions in 2 sets. Bridging exercise, with characteristic lift off bed and hold of pelvis for 5 seconds each in 20 repetitions divided in 3 sets.
Table: 1 Reasoning For Application of
OA knee. Bilateral tibiofemoral joint
Manual Therapy (MT)
traction maneuver was introduced as
Techniques:
Grade I distraction (Kaltenborn technique)
MT techniques are used to produce
which was administrated as intermittent
therapeutic benefits in relieving pain and
distraction for 7 to 10 seconds with a few
improving soft tissue extensibility through
seconds of rest in between for several
the application of specifically directed
cycles of repetation29.
external
forces27,28.
Narrowing
of
Dysfunction at the patellofemoral joint is
articulating surface of tibiofemoral joint is
one of the major reasons for anterior knee
the main primary pathology involved in
pain5. Initially, bilateral Grade I & Grade
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 9
[Case Report] II rhythmic oscillations using (Maitland
Outcomes:
Approach) given to inhibit pain which
After 6 physical therapy home Sessions in
progressed through session 3 to 5 into
a span of 2 weeks, a considerable
Bilateral MWM technique (Mulligan’s
reduction in bilateral joint pain and
concept)
joints.
tenderness was noted, resting pain level on
Maitland's grades I and II are used solely
VAS was 5/10 with slight improvement in
for pain relief and have no direct
basic ADLs. After next 8 sessions, in
mechanical effect on the restricting barrier,
duration of 4 weeks, there was no resting
although they do have a hydrodynamic
pain, though it was noted that activity
effect. Mobilization-induced analgesia has
shifts the marker on pain scale to 4/10 but
been demonstrated in a number of studies
there was moderate increase in basic ADLs
in humans
for
30,31
patellofemoral
and is characterized by a
capacity. Though instrumental ADLs were
rapid onset and a specific influence on
not very much affected by physical therapy
mechanical nociception. Grade I and II
treatment in this case but physical therapy
joint
theoretically
interventions helped him by eliminating
effective in pain reduction by improving
the intense resting pain and consequently
joint lubrication and circulation in tissues
improved quality of life.
mobilizations
are
32
Patient was
related to the joint . Rhythmic joint
contacted for follow up inquiry after 12
oscillations also possibly activate articular
weeks and patient informed maintained of
and skin mechanoreceptors that play a role
improved condition through prescribed
in pain reduction
33,34
.
exercises and adopting measures for
The prolonged immobility of patient
modifications in life style.
rendered him to be present during clinical
Discussion
examination in strength deficient and
“Integrative therapy is a term which is
muscular imbalance pattern.
most commonly used to refer treatment
Passive
stretching of the bilateral hip flexors,
approach
iliotibial
and
customized therapeutic approach in which
gastronomies and active strengthening
several different techniques are used to
protocol
manage patient’s symptoms” 35.
band,
of
intervention improvement
hamstrings
quadriceps to in
correct muscle
included and
in
in
psychotherapy.
It
is
target
recruitment
patterns during functional tasks.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 10
[Case Report] Patient Education The patient was instructed: To perform isometric quadriceps and bridging exercises 3-5 times daily, and open chain quadriceps exercises with or without weight for at least twice a day. To avoid sit on low surface. To avoid prolong standing and walking in any case through rest of life. To wear knee support before must do prolong weight bearing activities. To apply prescribed anti inflammatory cream regularly. Table: 2
Additionally, in clinical practice, sometime
were selected for the study and the pattern
it is mandatory for practitioner to adopt
and duration of needle application was
customized
modify
intentionally set unchanged throughout 10
standard guidelines and introduce new and
treatment sessions after observing positive
more effective management strategies.
outcomes from first application. After the
This approach enables practitioner to
first, the patient reported a mild increase in
develop a program designed specifically
general pain which lasted around 12 hours.
for the patient's unique needs, addressing
No other adverse side effects were
patient’s personality and threshold with
encountered during or after intervention.
interventions
that
circumstances and situation rather than providing
simple
treatment
protocols
which may seems to be unproductive in terms of outcomes.
The limitation of this study was to use as minimum points for acupuncture treatment as recommended. There is lot more available that could be added in the study
This case study attempted to analyze and
for more benefits. Evidence in literature
presented the combined physiotherapy
gives reflection that the “four gates” LI4
management and acupuncture of a patient
bilateral (B) and LR3 (B) exhibit a
complaining of bilateral chronic knee pain.
powerful analgesic affect so these points
Treatment
could have been selected initially for a
was
decided
on
pathophysiologic base of pain mechanism
more
with focusing on the chronicity of the
modulation36. KI6 (B) or KI9 (B) could
disorder
as
have been used for strengthening of the
the
bones due to the osteoarthritis presentation
environment of his own home. In this
to aim for a stimulation of the kidney
study 10 acupuncture sessions were given
systemic effect. Additionally, SP6 (B)
restorable
and
realistic
functional
outcomes goals
in
calming
effect
and
pain
in 4 weeks. Local points around the knee
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 11
[Case Report] could have been a good choice to aid 37
reducing the knee inflammation . In
literature
functional mobility in this case?
has
been
The
relieve
pain
therapy in Pakistan with an approach to
associated with osteoarthritis of the knee.
combine other musculoskeletal treatment
It has been shown in studies that Patients
options like acupuncture, acupressure and
with osteoarthritis of the knee appear to
psychotherapeutic measures into a physical
experience
significant
therapy program can be very beneficial for
improvements measured in terms of six-
the patient. The experience of mixing
minute walking distance, pain relief and
acupuncture
mobility
is
Physical therapy integrated approach is a
acupuncture38.
positive hope for patients although in this
repeatedly
acupuncture
long interventions in order to improve
reported
to
clinically
when
supplemented
standard with
care
practice
of
Integrative
physical
with manual therapy as
Acupuncture is not used as treatment
case it has shown
option by physiotherapists in Pakistan.
management with only slight to mild improvement in functional capacities but it
Conclusion
is really concerned with improving quality
The integration of exercises and patient education through life style modifications in combination with acupuncture has demonstrated
good
pain
management
of life.
References 1.
strategy and seems to be helping in achievement of his basic activities of daily living
and
However,
indoor the
functional
intervention
2.
goals. required
significant number of sessions in order to
3.
continue working towards the achievement of his Instrumental activities of daily livings
and
effective in pain
outdoor
mobility
4.
goal.
However, these are hard to justify because of the extent of progression of his disease. The question is: how long can we offer
5.
Jenny Walker. Management of Osteoarthritis. Journal of Nursing Older people 2011:9 : 14-19 Doherty M, Lanyon P, Ralston S (2006) Musculoskeletal disorders. In Boon N, Colledge N, Walker B et al (Eds) Davidson’s Principles & Practice of Medicine. 20th edition. Churchill Livingstone, London. O'Driscoll SW. The healing and regeneration of articular cartilage. J Bone Joint Surg 1998;80A:1795-1812. Dieppe P. The classification and diagnosis of osteoarthritis. In: Kuettner KE, Goldberg WM, eds. Osteoarthritic Disorders. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1995:5-12. Mark Dutton. (2004) Orthopedic, Examination, Evaluation & Interventions : McGRAW-HILL Medical Publishing Division New York.
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Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957;16(4):494-502. Hochberg MC, Altman RD, et al. Guidelines for the medical management of osteoarthritis. Arthritis and Rheumatism. 1995; 38:1541-1546. Soni, A., A. Joshi, et al. (2012). "Supervised exercise plus acupuncture for moderate to severe knee osteoarthritis: a small randomised controlled trial." Acupunct Med 30(3): 176-181. National Institute for Health and Clinical Excellence (2008) Osteoarthritis: The Care and Management of Osteoarthritis in Adults. Clinicalguideline 59. NI CE, London. Ezzo J, Hadhazy V, Brich S, Lao L, Kaplan G, Hochberg M,et al (2001) Acupuncture for osteoarthritis of the knee, a systematic review. Arthritis Rheum 44,819-25. White A.R, Foster N. E, Cummings M & Barlas P (2007) Acupuncture for chronic knee pain: a systemic reviw. Rheumatology 46,384-90 Bonica JJ. Neurophysiological and pathological aspects of acute and chronic pain. Arch Surg 1977;112:750-761. Schmidt RF. Fundamentals of Sensory Physiology in Japanese. Tokyo, Japan: Kinpodo; 1980:120-125. Jinkins JR, Whittemore AR, Bradley WG. The anatomic basis of vertebrogenic pain and the autonomic syndrome associated with lumbar disc extrusion. Am J Roentgenol 1989;152:1277-1289. Cox F (2009) Managing pain in osteoarthritis. Primary Health Care. 19, 7, 38-45. Besson JM. The neurobiology of pain. Lancet 1999;353: 1610-1615. Bogduk N. The anatomy and physiology of nociception. In: Crosbie J, McConnell J, eds. Key Issues in Physiotherapy. Oxford, England: ButterworthHeinemann; 1993:48-87. Hopwood V (2004) Acupuncture in Physiotherapy. Key concept and evidence based practice. Butterworth-Heinemann. Brain M, Berman MD, Lixing L & Patricia L (2004) Effectiveness of Acupuncture as adjunctive Therapy in Osteoarthritis of the knee. American College of Physician 141 (12) 903. Hashidate H, Shimada H, Shiomi T, Shibata M, Sawada K, Sasamoto N.Measuring Indoor Life-Space Mobility at Home in Frail Older Adults With
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Difficulty to Perform Outdoor Activities: J Geriatr Phys Ther 2012 Sep 12. Activities of daily living - Wikipedia, the free encyclopedia [Internet] Cited at 18 May 18, 2013. Available from http://en.wikipedia.org/wiki/Activities_of_ daily_living "Activities of Daily Living Evaluation." Encyclopedia of Nursing & Allied Health. ed. Kristine Krapp. Gale Group, Inc., 2002. eNotes.com. 2006.Enotes Nursing Encyclopedia Accessed on: 18 May, 2013 Roley SS, DeLany JV, Barrows CJ, et al. (2008). "Occupational therapy practice framework: domain & practice, 2nd edition". Am J Occup Ther 62 (6): 625–83. PMID 19024744. White A, Kawakita K (2006) The evidence for knee osteoarthritis- editorial summary on the implication for health policy. Acupuncture medicine 24 (Suppl) S71-76. National Institute for Health and Clinical Excellence (NICE) (2009). Low back pain: Early management of persistent non specific low back pain. Clinical guidelines, CG88. Wu M.T, Hsieh J.c.,Xiong J.ET AL.(1999) Central nervous pathway for acupuncture stimulation: localization of processing with functional MR imaging of the brain-preliminary experience. Radiology 212,133-141. Bourdillon JF. Spinal Manipulation. 3rd ed. London, England: Heinemann Medical Books; 1982. Maitland G. Vertebral Manipulation. Sydney, Australia: Butterworth; 1986. Freddy M. Kaltenborn. Manual Mobilization of the Joints. 6th Edition 2002: Norli Oslo, Norway Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. J Manipulative Physiol Ther 1998;21:448-453. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain 1996;68:69-74. Grieve GP. Manual mobilizing techniques in degenerative arthrosis of the hip. Bull Orthop Section APTA 1977;2:7. Wyke BD. The neurology of joints. Ann R Coll Surg Engl 1967;41:25-50.
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[Case Report] 34. Freeman MAR, Wyke BD. An experimental study of articular neurology. J Bone Joint Surg 1967;49B:185. 35. What is integrative therapy [Internet]. Cited at 2013, Mar 01. Available from.http://www.wisegeek.com/what-isintegrative-therapy.htm 36. Creac‟h C., Henry P., Caille J.M. & Allard M. (2000) Functional MR imaging analysis of pain-related brain activation after acute mechanical stimulation. American Journal of Neuro-radiology 21, 1402–1406.
37. N. Guillen- Obis. A 57 yr old female with chronic bilateral knee pain and lower back pain following an acute exacerbation - An integration of Physiotherapy and Acupuncture: Journal of the Acupuncture Association of Chartered Physiotherapists, Edition 2013 38. Suh-Hwa Maa ,Mao-Feng Sun, Chi-Chuan Wu. The Effectiveness of Acupuncture on Pain and Mobility in Patients With Osteoarthritis of the Knee: A Pilot Study: Journal of Nursing Research Vol. 16, No. 2, 2008
Corresponding Author *Atif Dustgir, B.S.P.T, PP DPT Senior Physiotherapist Sports & Spine Professionals 194 Y St #13 Commercial Area D.H.A Phase III, Lahore Pakistan. Contact # +92 322 441 1000 atifdustgir@gmail.com © 2013 PGIP. All rights reserved.
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 14
[Research Report]
Effects of Bimanual Functional Practice Training versus Unimanual Functional Practice Training on Functional Performance of Upper Extremity in Chronic Stroke Jasmine Anandabai1 PhD Research Scholar, Dr Manish Gupta2 M.B.B.S., M.S (ORTHOPEDICS)
ABSTRACT Objective- To compare the effects of bimanual functional practice training versus unimanual
functional practice training on functional performance of upper extremity in chronic stroke. Design:-Pre-test and Post test design. Setting: - Inpatient and rehabilitation hospital. Participants: - Patients were randomized to receive bimanual functional practice (n=15) or
unimanual functional practice training (n-=15) at 3-4 months post-stroke onset. Intervention:- Supervised bimanual or unimanual practice training for 25 minutes on 5 days
week over 2 weeks using a standardized program. Main Outcome Measures: - Upper extremity outcomes were assessed by Graded Wolf-
Motor Function Test (GWMFT) and Fugl-Meyer scale (F.M.S).
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 15
[Research Report] Results: - No significant differences were found between the group on any measure
(GWMFT-MPT.p=0.75 & GWMFT-FAS. P=0.31 & FMS-p=0.43). But within the group there were significant changes in mean performance time (Bimanual group-p=0.002 & Unimanual group-p=0.029) and there were significant difference found in functional ability scale (GWMFT-FAS Bimanual group p=0.00 & Unimanual group p=0.00), similarly, there were significant changes in Fugl-Meyer score (Bimanual group- p=0.00 & Unimanual groupp=0.00) Conclusion- This study suggest that 20 minutes a day of bilateral training of functionally
related tasks is no more effective than unilateral training for upper limb functional recovery in chronic stroke patients, regardless of the initial severity of the impairment. Furthermore, for recovery of functional motor performance, unimanual training appears less beneficial than bimanual practices. Several other studies have found benefits of bimanual training: therefore, this approach can be accepted as an upper limb intervention in stroke on the basis of finding this study. The study does not suggest the training characteristics, such as the nature of the tasks and strength of inter limb coupling required for effects, may influenced outcomes: therefore future work should examine the optimal timing, dose and training tasks that might optimize the already known facilitatory effects of interlimb coupling. Keywords: Motor performance, stroke, uni-manual, bi-manual
Introduction
field. In the past, stroke was referred to as
Stroke is an acute onset of neurological
cerebrovascular accident or CVA, but the
dysfunction due to an abnormality in
term "stroke" is now preferred.
cerebral circulation with resultant signs and
symptoms
that
corresponds
to
involvement of focal areas of the brain1. This can be due to ischemia (lack of blood supply) caused by thrombosis or embolism or due to a hemorrhage. As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech or inability to see one side of the visual
The
traditional
definition
of
stroke,
devised by the World Health Organization in the 1970s, is a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours". Strokes can be classified into two
major
hemorrhagic.
categories: Ischemia
ischemic is
due
and to
interruption of the blood supply, while hemorrhage is due to rupture of a blood vessel or an abnormal vascular structure.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 16
[Research Report] 80% of strokes are due to ischemia; the
or in the carotid arteries. These break off,
remainders are due to hemorrhage. Some
enter the cerebral circulation, then lodge in
hemorrhages develop inside areas of
and occlude brain blood vessels. As a
ischemia (hemorrhagic transformation).
result the transmembrane ion gradients run
The goal of applying the Bobath concept is
down, and glutamate transporters reverse
to promote motor learning for efficient
their direction, releasing glutamate into the
motor control in various environments,
extracellular space. Glutamate acts on
thereby
and
receptors in nerve cells (especially NMDA
function. This is done through specific
receptors), producing an influx of calcium
patient handling skills to guide patients
which activates enzymes that digest the
through initiation and completion of
cells' proteins, lipids and nuclear material.
intended
was
Calcium influx can also lead to the failure
focused on regaining normal movements
of mitochondria, which can lead further
through re-education.
toward energy depletion and may trigger
improving
tasks.
participation
Bobath
concept
cell death due to apoptosis. In addition to
Pathophysiology
Ischemic - Ischemic stroke occurs due to a
injurious effects on brain cells, ischemia
loss of blood supply to part of the brain,
and infarction can result in loss of
initiating the ischemic cascade. Brain
structural integrity of brain tissue and
tissue ceases to function if deprived of
blood vessels, partly through the release of
oxygen for more than 60 to 90 seconds and
matrix metalloproteases, which are zinc-
after a few hours will suffer irreversible
and calcium-dependent enzymes that break
injury possibly leading to death of the
down collagen, hyaluronic acid, and other
tissue, i.e., infarction. Atherosclerosis may
elements of connective tissue. Other
disrupt the blood supply by narrowing the
proteases also contribute to this process.
lumen of blood vessels leading to a
The loss of vascular structural integrity
reduction of blood flow, by causing the
results in a breakdown of the protective
formation of blood clots within the vessel,
blood brain barrier that contributes to
or by releasing showers of small emboli
cerebral
through
secondary progression of the brain injury.
the
disintegration
of
atherosclerotic plaques. Embolic infarction occurs when emboli formed elsewhere in the circulatory system, typically in the
edema,
Hemorrhagic result
in
-
which
can
Hemorrhagic
tissue
injury
by
cause
strokes causing
compression of tissue from an expanding
heart as a consequence of atrial fibrillation,
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 17
[Research Report] hematoma or hematomas. This can distort
problem in approximately 65% of patients
and injure tissue. In addition, the pressure
with stroke2. Thus, there is a strong need
may lead to a loss of blood supply to
to develop effective arm-hand treatment
affected tissue with resulting infarction,
methods in stroke rehabilitation. The
and
effectiveness
the
blood
released
by
brain
is
based
on
hemorrhage appears to have direct toxic
neurodevelopment techniques, repetitive
effects on brain tissue and vasculature.
unilateral or bilateral training techniques; sensoriomotor
Epidemiology
training
or
constraint
Stroke is a major global health problem. It
induced movement therapy has been
is the third most common cause of death in
evaluated on motor performance of the
world and risk factors for stroke onset are
affected arm of subjects with stroke.
high blood pressure, smoking, diabetes,
Traditional
heart failure, carotid artery stenosis and
rehabilitation focus on first 3 months after
hyperlipidemia3. Approximately 85% of
stroke & consist largely of passive (non
all stroke cases are ischemic, and most
specific) approaches or compensatory
ischemic strokes affect one of the cerebral
training non paretic arm3 The Constraint
hemispheres by occlusion of the middle
induced movement therapy concept has
cerebral artery (MCA). In the acute stage,
been derived from basic research with
mechanisms such as oxygen depletion,
monkeys and consists of a family of
necrosis, brain edema, excitotoxicity and
techniques, i.e., constraining movements
inflammatory processes are at play. After
of the less affected arm and intensively
the acute stage there is a phase of
training of the more affected arm4.
regeneration with neuronal plasticity and (partial) functional recovery4. Many stroke survivors experience impairments such as hemiparesis, spasticity, sensory/perceptual disorders,
hemianopia,
dysphasia
or
cognitive impairments (Gresham et al.)1. The inability to reach, to grasp and to manipulate objects limits activities and causes particular difficulties to perform daily personal care. Perceived loss of arm
methods
of
stroke
Bilateral arm training is an alternative approach
in
neurorehabilitation
for
individuals in poststroke. Bilateral training activities may increase the activity of the affected hemisphere and decrease the activity
of
unaffected
hemisphere
providing a balancing effect between hemispheric
cortocomotorneuron
exitibility5. Bilateral movement training (BMT) uses the intact limb to promote
function has been reported as a major
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 18
[Research Report] functional recovery of the impaired limb
both hands to work co-operatively to hold
through the facilitative coupling effects
and manipulate an object using each hand
between the upper limbs. “Mudie “ and
to perform different actions. Thus the
“Matyas” using single care multiple
objective of this study is to compare the
baseline designs demonstrated strong after
efficacy of bimanual functional practice
– effects of 30-40 sessions of BMT on
with unimanual functional practice on
unilateral performance of the impaired
functional performance of upper extremity
limb in 12 chronic stroke patients. Other
in chronic stroke2.
study has reported positive results using variations of the bilateral training protocol, including
active-passive
movements,
synchronous and alternating movements with
rhythmic
auditory
cueing
and
bilateral movements with neuromuscular
Methodology A total of 30 subjects (26 males and 6 females), at O.P.D. Of Fortis Hospital, Sector-62, NOIDA, U.P, were be included in the study and will be divided by sample of convenience into two groups with 15
stimulation of impaired arm51.
subjects each. Group (1) will be given The practice of bilateral symmetrical
bimanual practice intervention for 5 days a
movements may allow the activation of the
week for 2 weeks. Each treatment session
intact
will be of 1 hour.
hemisphere
to
facilitate
the
activation of the damaged hemisphere leading to improve movement control of impaired
limb
promoting
neural
plasticity51. Bimanual practice is getting
Group (2) will be given unimanual practice intervention for 5 days a week for 2 weeks. Each treatment session will be of 1 hour.
Inclusion Criteria
All Participants suffering from stoke for the first time. Onset from 3-9 months Age group 40-60 yrs. Most component of movement present in affected Extremity but impairment of function relative to Non-affected side (at least 100 of wrist extension And at least 100 of active extension of each metacarpophalengeal joint and interphalengeal joint of all digits. No multiple infarctions. Intact cognitive functions Patients with right hand dominance with affected left Hemispheres.
Exclusion Criteria
Insufficient stamina to participate. Other neurological disorders Previous participation in other pharmalogical or Physical intervention studies. Any severe contractures and deformity in upper Extremity. Aphasia with inability to follow 2 step commands.
Table: 1
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 19
[Research Report] On the first visit a complete neurological
Another to dial the number)
assessment was done. Subjects found
Rolling up a towel
suitable for participants in the study as per
Unscrewing a jar.
the inclusion and exclusion criteria were
Turning the key in lock
requested to sign the consent form. A
Each participants were taught about
detailed subjective examination was taken
individually and Sitting at the chair
regarding type, side, duration, occurrence
comfortably in front of the table.
of stroke, handedness and motor functions.
To ask the patient to hold the one
All the selected subjects were informed in
cup with one hand (non-affected)
detail about the type and nature of the
which was initially filled with
study and
water and asked to hold another
consent.
asked to sign the informed After
taking
down
the
cup with other hand (affected) and
demographic data the measurement of functional performance were assessed by
both hands held up the table.
Fugl- Mayer assessment scale and graded
Instruct the patient to pour the water first from non-affected hand
wolf motor function test.
to affected hand and than affected
Group 1
hand to non-affected. This task was
Participants of group 1 were trained for
performed for 5 minutes daily in
bimanual activity.
two sessions.
Participants were
encouraged to do the bimanual practices
To ask the patients to hold the
for 25 minutes with 10 minutes rest
receiver with one hand (non-
periods. The total time period of the
affected) and the numbers with
bimanual practice was one hour, which
another hand (affected) again this
was divided into two training sessions
task performed alternately hold the
(25*2=50 min) and one rest period of 10
receiver with affected hand and
minutes. Participants were trained for
dials the numbers with affected
following bimanual task practices (15).
hand.
Pouring of water from one cup to
Initially fold the towel lengthwise
another cup with
and asked the patient to roll the
Arm held up.
towel with both hands up to the
Using the telephone (one hand to
towel end.
hold receiver and
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 20
[Research Report]
Asked the patients to hold the jar
Firstly, to trained the patient hold the
with non-affected and practiced to
spoon, and practiced the patient to spoon
open the jar or move the cup of the
out the dry ingredients like Rajma. This
jar to clockwise and anticlockwise.
task was practiced for 5 minutes in two
This task was practiced for 5
sessions. Initially, a patient was trained to
minutes in two sessions.
hold glass by cylindrical grasp and after
Asked the patient to hold the lock
that patient was practiced to supinate the
with non-affected hand and open
forearm tries to touch the glass to table.
the lock or move the key in the
Again, firstly patient was trained to grasp
lock clockwise and anticlockwise
the glass and was instructed to drink the
for 5 minutes daily in two sessions.
water or tries to take the glass near the
Group 2
Participants of the intervention group 2 were taught about the unimanual practice. Participants were encouraged to do the unimanual practice for 5 days in a week for 2 weeks. Total treatment time was 1 hour only. Two treatment sessions were given for 25
mouth. This task was trained for 5 minutes in two sessions. Patient was instructed to bring their own tooth brush and was trained to brush the teeth. This task was practiced for 5 minutes in two sessions. Patients was trained to hold the towel and practiced to wipe the table with full flexion and extension of the arm and the elbow.
minutes and after each treatment session 10 minutes rest was given. Following unimanual activities will be practiced by all Group-Participants:
Spoon out dry ingredients (Rajma)
Grasp the glass and attempts to supinate the forearm
Tries to touch the glass to the table.
Hold the glass to drink the water.
Brush the teeth.
Wipe the table.
Results The results in table 2 show that MPT of Wolf-motor Function Scale after 2 weeks of
bilateral
training
program
was
significantly less. Similarly FAS score improved significantly after a 2 weeks training program.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 21
[Research Report] Variables
Pre-test
Post-test
Paired T test
Day0
Week 2
T value
P value
Mean +- S.D
Mean+-S.D
N=15
N=15
GWMFT FAS
1.75+0.46
2.05+0.57
-7.35
0.00
GWMFT MPT
17.13+4.60
15.80+5.53
3.69
0.002
FMS
36.93+4.07
42.87+5.25
-11.60
0.00
Table: 2 Within group analysis: Group 1 Table 3 shows that the MPT of GWMFT
shows that unilateral arm training also
reduced
provided a significant improve in FMS
significantly
after
unilateral
training, but the improvement was not as
score (table 3)
significant as FAS score. The table also Variables
Pre-test
Post-test
Paired T test
Day0
Week 2
T value
P value
Mean +- S.D
Mean+-S.D
N=15
N=15
GWMFT FAS
1.57+0.52
1.82+0.62
-7.73
0.00
GWMFT MPT
17.93+6.46
16.5+6.88
2.43
0.029
FMS
35.87+4.84
44.53+6.20
-12.73
0.00
Table: 3 Within group analysis: Group 2 The results showed that there was no
intervention and again after 2 weeks of
significant difference in the bilateral and
training.
unilateral arm training group, both pre
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 22
[Research Report] Variables
Group 1
Group 2
Independent T test
Mean +- S.D
Mean+-S.D
T value
P value
N=15
N=15
Pre
1.76+0.46
1.57+0.52
0.76
0.32
Post
2.05+0.58
1.82+0.62
1.030
0.312
Pre
17.13+4.60
17.93+6.46
-0.39
0.70
Post
15.80+5.53
16.53+6.89
-0.32
0.750
Pre
35.87+4.83
36.93+4.08
-0.653
0.519
Post
44.53+5.25
42.87+6.20
-0.80
0.43
WMFT FAS
WMFT MPT
FMS
Table: 4 Between group analysis: Group 1 & 2 Discussion
time (p=0.002) and increase on functional
The study compared the effects of bilateral
ability score (p=0.00) and showed highly
and unilateral upper limb-task training on
significant
upper limb motor functions during post
functional performance of Fugl-Meyer
stroke rehabilitation. The result of this
scale (p=0.00).The mean time to perform
study showed that there was a significant
15 tasks in GWMFT was (17.13+4.60)
improvement in functional performance of
which decreased after 2 weeks of bimanual
upper extremity on G.W.M.F.T. and Fugl-
practice training (15.80+5.53) and the
Meyer scale in chronic stroke patients after
functional
2 weeks of bimanual and unimanual
improved after training (2.05+0.57).The
functional practice. The result of the study
result showed that 2 weeks of bimanual
showed that there was no significant
training
difference in bimanual and unimanual
performance
practice group on GWMFT (Pre MPT:
(42.87+5.25).
p=0.70 & Post MPT: p=0.75 and Pre FAS: p=0.32 & Post FAS: p=0.312) and FuglMeyer score. (Pre: p=0.519 and Post: p=0.43). Participants of bimanual practice group showed a decrease in performance
Similarly
improvement
ability
improved on
score
motor
on
(1.75+0.46)
functional
Fugl-Meyer
participants
of
motor
scale
unimanual
practice group showed a decrease in performance time (p=0.029) and increase on functional ability score (p=0.00) and showed highly significant improvement on
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 23
[Research Report] motor functional performance of Fugl-
tasks, whereas other bilateral training
Meyer scale (p=0.00).The mean time to
studies have involved protocols using
perform
was
simple repetitive movements with electric
(17.93+6.46) which decreased after 2
stimulation48 or auditory cueing35,36. Such
weeks of unimanual practice training
augmentation of bilateral movement may
(16.5+6.88) and the functional ability
provide
score (1.57+0.452) improved after training
coupling and consequent facilitation of the
(1.82+0.62).The result showed that 2
paretic arm than was possible with the free
weeks of bimanual training improved
movements
motor functional performance on Fugl-
suggesting that the effects of bilateral
Meyer scale (44.53+6.20).
training may be influenced by task
15
tasks
in
GWMFT
The result of the study suggested that, training involving the practice of actions bilaterally and simultaneously may be effective in promoting recovery of upper limb motor function in chronic stroke patients. Of particular importance was significant increase in participants of the bilateral training group in functional ability of the upper limb, demonstrating a generalization from the training of a specific movement to general upper limb function. Moreover individuals receiving bilateral training showed improvements in the time to complete the graded wolf motor function test (GWMFT) movement with the impaired limb while little changes
more
effective
practiced
in
upper-limb
the
study,
constraints. Furthermore visualizing and processing information from the nonparetic
limb,
while
simultaneously
attempting to perform new, progressively changing,
relatively
complex
precise
motor goals with both arms may have provided a dual-task challenge greater than in other studies. Evidence suggests that stroke participants find tasks requiring divided attention difficult, and aimed movements of the hemiplegic arm require greater attention resources than aimed movements
in
healthy
subjects.
Participants receiving bilateral training in the study reported ease of performing the task bilaterally.
were also observed in impaired limb
The effectiveness of bilateral movement
movement in individuals engaging in
training in promoting stroke recovery is
unilateral training15.
also likely to depend on the extent of
In the study, participants were trained in
damage sustained to direct corticospinal
complex multijoint functionally relevant
pathways58. While bilateral movements
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 24
[Research Report] may also help recruit secondary motor
related interhemspheric over activity and
areas in both hemispheres, recovery
facilitating
promoted by these areas will be less than
hemisphere as well as from normally
that obtained through direct corticospinal
inhibited
projections58,59. This can be explained by
undamaged
the changes in the functional ability of
movement of the paretic arm50. The
impaired limb as evidenced by GWMFT
extensive
scores and in motor performance by Fugl-
transcollasal inhibition soon after stroke
Meyer score in the patient group used in
may, however render bilateral training
the study. Recent research has shown that
more
lesion location greatly influences the
interhemspheric interactions have resumed
pattern
a more normal balance; therefore the
of
motor
cortex
excitability
60
observed .
output
from
ipsilateral
in
damage
pathway
hemisphere
disruption
chronic
the
to
of
the
augment
of
normal
stages
when
effects of bilateral. Training may be time
Intervention timing may have influenced
dependent.
outcomes. The study showed significant
Interlimb coordination studies in healthy
effects of bilateral training in chronic
adults have identified the coupling of
stroke participants, whereas some studies
homologous muscles as the preferred
showed no effects of bilateral training in
control mode of the motor system. The
patients with acute stroke
34
. Stroke
present results indicate that this tendency
appears to alter normal transcallosal
can be exploited to promote functional
inhibition resulting in increased intact
recovery of a paretic limb in the chronic
hemisphere excitability during hemiparetic
stroke patients. Furthermore, there is a
arm movement that may be inhibitory in
strong neurophysiological evidence to
nature, thus suppressing output from the
suggest that when the impaired and non
damaged hemisphere23. Depending on the
impaired arms are moved symmetrically,
lesion site and size, these over activation
crossed facilitatory drive from the intact
appear
hemisphere will be produced increase
transient,
and
more
normal
contralateral activation pattern resume
excitability
over time49. Identical motor commands
pathways in the impaired limb50, 51.
generated in each hemisphere during bilateral
movement
may
modulate
transcallosal inhibition, balancing stroke
in
homologous
motor
Additionally, cortical damage from stroke produces
hyperexcitability
of
the
contralesional M152 leading to abnormally
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 25
[Research Report] high levels of transcollasal inhibition
and also there might be recruitment of the
(TCI) on the legend hemisphere, thereby
adjacent brain areas23. The improvement
further impairing motor performance of
can also be seen through the unimanual
the paretic hand53. There is recent evidence
training which was task oriented and
of improved affected hand performance in
specific to the affected extremity. Both the
chronic stroke patients from reducing the
training groups showed a significant
abnormal
the
improvement after training, which might
. Furthermore,
be explained by the stage of stroke. The
inhibitory
ipsilesional hemisphere balanced
drive 54,55
interhemspheric
to
interactions
chronic nature of stroke might have
appear necessary for normal voluntary
allowed the plastic nature of brain to adjust
movements56 and the restitution of the
to the various levels of tasks to be
normal
performed,
balance
between
the
two
hemispheres has been linked to better
both
unimanualy
and
bimanually.
57
recovery following stroke . It has been hypothesized that practicing by lateral symmetrical movements may facilitate motor
output
hemisphere
from by
the
ipsilesional
normalizing
(TCI)
influences. Interestingly, in the subset of patients assessed with wolf motor function test and Fugl-Meyer scale in the study the bilateral trained patients exhibiting the largest increase in functional ability. In addition, bilateral training may promote increased involvement of pathways not investigated in the present study such as spared corticopropriospinal pathways50. The
improvement
in
the
unimanual
practice group might be due to greatly improved motor performance. This can be explained by muscle output area size in the affected hemisphere might have enlarged
Initially,
just
after
stroke,
bimanual
movement enhanced activation in the primary motor cortex M1 of the affected hemisphere
did
not
differ
between
unimanual paretic hand and bimanual movement14. Also, the tasks performed both during unimanual and bimanual practice training were almost similar in nature like; turning a key in lock of bimanual practice and grasp the glass and attempts to supinate the forearm of unimanual
practice.
Thus
the
brain
adaptability to specified task was also almost similar in nature. Therefore, nonsignificant between group difference can be explained. The frequency and duration of the program may not have been optimal. One may ask whether 20 25-minutes sessions devoted to
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 26
[Research Report] the bimanual and unimanual task are
bilateral practices. Several other studies
sufficient to trigger brain reorganization
have found benefits of bilateral training:
and to observe a change. This scheduled
therefore, this approach can be accepted as
was based on practical reason and although
an upper limb intervention in stroke on the
it is similar to that used in previous
basis of finding this study. The study does
study34, 61, it has never been experimentally
not suggest the training characteristics,
proven to be the optimal dose. More
such as the nature of the tasks and strength
important is the fact that the participants in
of inter limb coupling required for effects ,
both groups received high level of
may influenced outcomes: therefore future
stimulation
program,
work should examined the optimal timing,
leading to the possibility of a saturation
dose and training tasks that might optimize
effect in arm recovery. In fact, participants
the already known facilitatory effects of
in both groups were stimulated every day
interlimb coupling.
in
the
training
to use their arms in their daily activities. Therefore, the technique used to promote batter recovery could not have had any impact on the final result. In other words, regardless of the technique used, perhaps the important thing in the spontaneous recovery and training period is to provide patients with frequent and continuous opportunities to use their arms in their
One of the limitations of the study was that only chronic stroke patients were included, thus a future research can be carried out using stroke patients at various levels of recovery i.e. acute, sub-acute along with chronic stroke patients.
Conclusion This study suggest that 20 minutes a day
activities.
of bilateral training of functionally related This study suggest that 20 minutes a day
tasks is no more effective than unilateral
of bilateral training of functionally related
training for upper limb
tasks is no more effective than unilateral
recovery
training for upper limb
functional
regardless of the initial severity of the
patients,
impairment. Furthermore, for recovery of
regardless of the initial severity of the
functional motor performance, unimanual
impairment. Furthermore, for recovery of
training appears less
functional motor performance, unilateral
bimanual practices. Several other studies
training appears less
have found benefits of bimanual training:
recovery
in
chronic
stroke
beneficial
than
in
chronic
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
stroke
functional patients,
beneficial
than
Page 27
[Research Report] therefore, this approach can be accepted as
9.
an upper limb intervention in stroke on the basis of finding this study. The study does
10.
not suggest the training characteristics, such as the nature of the tasks and strength of inter limb coupling required for effects,
11.
may influenced outcomes: therefore future work should examine the optimal timing,
12.
dose and training tasks that might optimize the already known facilitatory effects of
13.
interlimb coupling. Thus, null-hypothesis proved.
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[Research Report] 21. Y. Laufer et al, L. Gattenio et al and B. Sinai et al. The time related changes in motor performance of upper extremity ipsilateral to the side of the lesion in stroke survivors. Neurorehabilitation and neural repair2001 Vol 15 No.3 167-172 22. Michaelsen et al and Stella Maris et al. Specific training with trunk restraint on arm recovery in stroke: RCT. Stroke 2006 Vol 37(1) 186-192. 23. Liepert et al. Treatment induced cortical reorganization after stroke in humans. Stroke 2000, 31 1210-1216. 24. Timothy J. Carrroll et al and Michael Lee et al. Unilateral practice of a ballistic movement causes bilateral increases in performance and corticospinal excitability. J. Appl. Physiology 2008; 104: 16561664. 25. Carole G. Ostendorf et al and Steven L. Wolf et al. Effect of forced use of upper extremity of a hemiplegic patient on changes in function. Physical Therapy July 1981, Vol 61 No.7, 1022-1028. 26. Johanna H. Van der Lee et al and Robert C. Wagenaar et al. Forced use of the upper extremity in chronic stroke patients. Stroke 1999: 30, 2369-2375. 27. Edward Taub et al, Neal E. Miller et al and Thomas et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil April 1993; Vol 74: 347-354 28. Wolfgang H.R. Miltner et al and Monika Sommer et al. Effects of constant induced movement therapy on patients with chronic motor deficit after stroke. Stroke, 1999; 30: 586-592. 29. Steven L. Wolf et al, Carolee J. Winstein et al and Philip Miller et al and Edward Taub et al. Effect of constant induced movement therapy on upper extremity function in 3 to 9 months after stroke. JAMA 2006; 296:2095-2104. 30. Cathrin Butefisch et al and Horst Hummelsheim et al. Repetitive training of isolated movements improves the outcome of motor rehabilitation of centrally paretic hand. Journal of neurological sciences 1995; 130: 59-68. 31. Sandy McCombe Waller et al and Jill Whitall et al. Fine Motor Control in adults with and without chronic hemiperesis: Baseline comparison to nondisabled and effects of bilateral arm training. Adults. Arch Phys Med Rehabil July 2004; Vol 85: 1076-1082. 32. Dorian K. Rose et al and Carolee J. Winstein et al. Bimanual training after
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[Research Report] 44. Lewis GN, Byblow WD. Neurophysiological and behavioral adaptation to a a bilateral training intervention in individuals following stroke. Clin Rehabil 2004; 18: 48-59. 45. Dorian K. Rose and Carolee J. Winstein. Bimanual training after stroke: Are two hands batter than one? Topics in stroke rehabil, 2004; 11(4):20-30. 46. Hesse S, Suhulte-Tigges G, Konard M, Baradeleben A, Werner C. Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects. Arch Phys Med Rehabil 2003; 84; 915-920. 47. Janet Car, Roberta Shepherd: Bimanual Practice Neurological Rehabilitation Optimizing Motor Performance (1998;142-145) 48. Cauraugh JH, Kim S. Two coupled motor recovery protocols are batter than one: electomyogram-triggered neuromuscular stimulation and bilateral movements. Stroke 2002; 33: 1589-94. 49. Feydy A, Carlier R, Roby-Brami A. Longitudinal study of motor recovery after stroke: recruitment and focusing of brain activation. Stroke 2002; 33; 1610-1617. 50. Cauraugh JH, Summers JJ. Neural plasticity and bilateral movements: a rehabilitation approach for chronic stroke. Prog. Neurbio. 2005; 75: 309-20. 51. Carson RG. Neural pathways mediating bilateral interaction between the upper limbs. Brain Res. Rev. 2005; 49: 641-62. 52. Shimizu T, Hosaki A, Hino T, Sato M, Hiraiand S. Motor cortical disinhibition in the non-affected hemisphere after
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Corresponding Author Jasmine Anandabai1, PhD Research Scholar, Singhania University Jasmine Anandabai 333 Pocket -5, Phase-1, Mayur Vihar, DELHI-110091, INDIA Mobile No. 9811220770 Dr Manish Gupta2, Consultant Orthopaedics, Kapoor Medical Center
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 30
[Research Report]
The Immediate Effect of Short Durations of Warm up and Stretching Exercises on Shoulder Joint ProprioceptionPreliminary Findings Bala Jyoti, Research Scholar, Singhania University Gupta Manish Dr, Consultant Orthopaedics, Kapoor Medical Center Kumar Satish Dr, Consultant,Sir Ganga Ram Hospital, New Delhi, India
ABSTRACT Objective- To study the immediate effect of Short Durations of Warm up and Stretching
Exercises on Shoulder joint Proprioception. Design:-Pre-test and Post test control group design. Setting: - Inpatient and rehabilitation hospital. Participants: - A total number of 75 subjects free from pain and discomfort and any
pathology in and around shoulder joint are allocated randomly into 1 of 5 groups; Intervention: - Group A received 1 min. of warm up and stretching (n=15), Group B
received 2 min. of warm up and stretching (n=15), Group C received 3 min. of warm up and stretching (n=15), Group D received 4 min. of warm up and stretching (n=15) and Group E control group received no warm and stretching (n=15). All groups received intervention. Main Outcome Measures: - A Continuous Passive Motion (CPM) Machine was used to
move a desired joint continuously through controlled ROM without the subject’s active effort. To measure the Joint Position Sense (JPS) passive CPM was used. Outcomes were measured before and immediately after intervention. All JPS scores were measured on same day.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 31
[Research Report] Results: - Outcome measures for all groups showed that at 2 min, 3 min and 4 min of warm
up and stretching, the improvements in the joint position sense appreciation were significant at all ranges/target positions checked. The group which had 3 minutes warm up had the maximum gains, Group A had the minimum gains and Group D had the fewer gains possibly due to the effects of muscular fatigue as reported by the subjects after performing this warm up. The control group showed the minimum non-significance across all the groups. Conclusion- This study concludes that warm up and stretching exercises improve shoulder
joint position sense appreciation. Keywords: contract-relax stretch, performance, proprioception, sports, and injury prevention
Introduction
capsules, ligaments, menisci, labrum and the
fat pads3. Recent research has identified
cumulative input to central nervous system
ruffiniď€like ending in the glenohumeral
from specialized nerve endings called
joint capsules, found pacinian corpuscles
mechanoreceptors. They are located in the
in glenohumeral ligaments, and free nerve
joint capsules, ligaments, muscles, tendon
endings in the glenoid labrum of human
and skin1. It is currently acknowledged
cadavers3. Most proprioception research
that proprioception is a complex entity
has examined the elbow, wrist, knee, and
encompassing
ankle.
Proprioception
is
defined
several
as
different
Some authors have attempted to
components such as sense of position,
generalize their findings to other joints.
velocity, movement detection, and force
However,
and that the afferent signals that give rise
differ depending on the joint tested.
to them may well have origins in different types of receptors2. Proprioception is the ability to determine the location of a joint in space where as kinesthesia is the ability to detect movement. Joint position sense is mediated by joint and muscle receptors as well as visual, vestibular and cutaneous input3. Early research suggested that the joint receptor had the predominant role in proprioception and kinesthesia.
Joint
receptors have been identified in joint
proprioceptive
control
may
The exact mechanism of proprioceptive control remains unclear, particularly in the shoulder.
Shoulder proprioception is
indispensable because the glenohumeral joint relics primarily on dynamic restraint of rotator cuff to maintain stability. Proprioception may also affect injury predisposition and rehabilitation. Several studies
suggest
that
shoulder
proprioception is impaired after fatigue, injury and in overhand athletes. Clinicians
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 32
[Research Report] commonly use proprioception exercise
durations and intensities of stretching for
during rehabilitation of shoulder because
different
the rotator cuff is vital for glenohumeral
extensibility modulation, prevention of
joint stability4. In the present study our
injury during sporting activity and also to
focus is on position sense here in defined
increase
as the awareness of actual position of the
joints12,13,14,15,16. Therefore this study is
limb.
aimed to investigate whether varying
Many researchers have used joint position sense appreciation tests to evaluate knee joint performance after the administration
purposes
viz.
proprioception
soft
in
tissue
human
intensities of warm up and stretching exercises helps in improving shoulder joint position sense appreciation.
of warm up exercises and stretching of
Methodology
different duration and intensities5,6,7,8,9,10.
A total number of 75 subjects (N=15 X 5
Stretching is used as a part of physical
groups) were included in the study. They
fitness and rehabilitation programs because
were recruited from the physiotherapy
it is thought to positively influence
department of Sir Ganga Ram Hospital,
performance
and
injury
11
prevention .
New Delhi, India.
Many researchers also have used different Inclusion Criteria
Exclusion Criteria
Mean Age of subject is 20-30 years Right Hand Dominant Free from pain and discomfort in and around shoulder joint. No pathological conditions affecting musculoskeletal and neuromuscular system. Only Males are included.
Patients with previous shoulder surgery Patients who have signs and symptoms of gross shoulder instability Patients who had red flags suggesting serious shoulder pathology Patients with cardio –pulmonary diseases Patients with tumor, infection and fracture Patients with History of soft tissue injury in one last year Patients pathological conditions affecting musculo-skeletal and neuromuscular system
Table: 1
Subjects who were willing to participate,
method, the subjects were assigned to 1 of
were interviewed and examined by a
5 intervention groups. Group A received 1
clinical physiotherapist of City Hospital
min. of warm up (30 Seconds) and
who
group
stretching (30 Seconds) (n=15), Group B
allocations. By using random sampling
received 2 min. of warm up (1 min) and
was
unaware
of
their
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 33
[Research Report] stretching
(1 min) (n=15), Group C
been shown to maximally stimulate slowly
received 3 min. of warm up (1 and ½ min)
adapting
and stretching (1 and ½ min) (n=15),
receptors. The rotation axis of shoulder
Group D received 4 min. of warm up (
was adjusted by laser detection ray, which
2min) and stretching (2 min) (n=15) and
was present in machine.
Group E control group received no warm
seated in a chair and blind folded and
and stretching (n=15). The joint position
cotton gauge was put in the ear.
sense score was measured before warm up and
stretching,
after
warm
up
and
stretching with the help of Continuous Passive Motion (CPM) Machine. CPM machine was considered most appropriate and yield reliable and valid data. The subjects were instructed to remove their shirt and vest to allow for acclimatization
Subjects were
and
capsular
Subjects were
required to match a
previously presented angle from starting position to target position by machine respectively i.e. Flexion 30-90, flexion 60-120 and flexion 90-150.
The
shoulder joint (arm) was passively moved at 2 degree/sec to predetermined target position.
to room temperature for 10 minutes.
ligamentous
The arm remained at target
position for 5 sec. (Same duration for all The rig of CPM machine and chair was
trials) and returned at a speed 2/sec to
adjusted so that the rotation axis of the rig
starting position. Three familiarizing trails
was
of
were given before data was collected.
glenohumeral joint. CPM rotated arm at
Stop switch was given to subjects. When
speed 2 degrees/sec the same speed that
the button was pressed by the subject, it
congruent
with
centre
1
was used in previous researches . The aim
indicated recognition of target position.
of low speed 2 degrees/sec was to
Each movement data was collected two
primarily stimulate the mechanoreceptors
times measurements of JPS difference
17
located at the joint . This speed was
between the perceived angle and angle of
selected because it was slow enough to
flexion was recorded with the +ve sign of
minimize
error. After recording data, warm-up and
32
receptors .
contribution John
et
from al
muscle
quoted
that
stretching were performed by the subjects
measurement speed 2 degrees/sec was
for 1 min (Group A), 2 min (Group B), 3
chosen so that reflex muscle contraction
min (Group C), 4 min (Group D) and no
18
did not occur during passive movement .
exercises for control group (Group E).
Very slow passive change of position has
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 34
[Research Report] It was found during the study that subjects
Anova was not used, instead Non-
experienced muscular fatigue during 4
parametric tests were used. Wilcoxon-
minutes warm up and thus there were
signed ranks test was used to compare the
lesser proprioceptive gains in this group.
pre-intervention,
These findings are in accordance with the
collection
findings of some previous researches done
(between group comparisons) for all the 5
by Carpenter JE, Blasier RB who found
groups. One way Anova was used to
that there is a decrease in proprioceptive
calculate the significance value of pre-
performance following muscular fatigue
intervention and post-intervention data
and quoted that fatigue may play a role in
collection of all the 5 groups for both
decreasing athletic performance and in
between-group comparison and within
fatigue related shoulder dysfunction19.
group comparison. Post-HOC and Mann-
post-intervention
errors
among
data
themselves
Whitney tests were used to compare
Results
significance values among all the groups
Since the data did not follow normal
(multiple comparisons).
distribution, therefore, repeated measure Group
Angle
Pre Int VS Post Int p value
1
30-90 60-120 90-150 30-90 60-120 90-150 30-90 60-120 90-150 30-90 60-120 90-150 30-90 60-120 90-150
0.002 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.006 0.001 0.006 0.435
2
3
4
5
Table 1: Wilcoxon Signed Ranks Test
Examining the results (through master
minute warm up had the minimum gains
chart) from a clinical perspective, we
and 4 minute warm up had the fewer gains
observe that the third group i.e. 3 minutes
due to the effects of muscular fatigue as
warm up had the maximum gains, 1
reported by the subjects after performing
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 35
[Research Report] this warm up. Examining Mann Whitney
shoulder joint position sense appreciation.
multiple group comparison test results the
This
3
showed
position sense appreciation enhances with
maximum significance across all the
increase in duration and intensity of warm
groups and the control group showed the
up to 4 minutes. At 4 minutes there are
minimum non-significance across all the
lesser gains in joint position sense because
groups. Findings of this study indicate that
muscular fatigue starts setting in.
minute
warm
up
group
improvement
in
shoulder
joint
warm up and stretching exercises improve Graph 1: Pre Int Vs Post Int P Value.
PRE INT vs POST INT P VALUE 0.5 0.4 0.3 0.2 0.1 0
1
2
3
4
90-150
30-90
60-120
90-150
30-90
60-120
90-150
30-90
PRE INT vs POST INT P VALUE
5
Interpretation: The Table-1 showed that
multiple group comparison test results the
Wilcoxon-signed ranks test was used to
3
compare the pre-intervention and post-
maximum significance across all the
intervention (between group comparisons)
groups. And the control group showed the
for all the 5 groups. The gains in joint
minimum non-significance across all the
position
groups.
sense
appreciation
were
significant after 1 min, 2 min, 3 min and 4 min of warm up and stretching. The control
group
result
indicated
no
improvements at all target positions checked.
minute
up
group
showed
Discussion The findings of this study indicate that warm up and stretching exercises improve shoulder joint position sense appreciation. This
The table- 2, 3, 4 (Appendix A) showed
warm
improvement
in
shoulder
joint
position sense appreciation enhances with
that three Examining Mann Whitney
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 36
[Research Report] increase in duration and intensity of warm
minimum non-significance across all the
up upto 4 minutes. At 4 minutes there are
groups. The results of this study match
lesser gains in joint position sense because
with the results of previous studies done
muscular fatigue starts setting in. In this
on same subject indicating that warming
study, the gains in joint position sense
up exercises improve joint position sense
appreciation were significant after 1 min of
appreciation5,20. MJ Bartlett and PJ Warren
warm up at all the target positions
found in their study that joint position
checked. The effect of warm up and
appreciation
stretching still persisted after 5 min of 2nd
sensitive after warm up. It was quoted (in
data collection, except at 150 degrees of
their article) that after warm up exercise
shoulder flexion. Similarly, at 2 min, 3
there is an improvement in measured joint
min and 4 min of warm up and stretching,
position
the improvement in joint position sense
explained by an increase in the sensitivity
appreciation
all
of mechanoreceptors around the joint or a
ranges/target positions checked and this
more central mechanism5. In their research
improvement sustained even after 5 min of
done by Bouet.V., Gahery Y., the results
2nd data collection.The control group
showed an improvement in position sense
result indicated no improvements at all
appreciation after exercise and proposed
target positions checked.
that whatever the mechanisms involved,
were
significant
at
Examining the results (through master chart) from a clinical perspective, we observe that the third group i.e. 3 minutes warm up had the maximum gains, 1 minute warm up had the minimum gains and 4 minute warm up had the fewer gains due to the effects of muscular fatigue as reported by the subjects after performing this warm up. Examining Mann Whitney multiple group comparison test results the 3
minute
warm
up
group
showed
maximum significance across all the groups. And the control group showed the
was
significantly
appreciation
which
more
may be
enhanced motor performance after exercise can be due not only to improved mechanical properties of muscles but also to better kinesthetic sensibility20. Exercise has been shown to have a beneficial effect on proprioception. Bernauer et al found that young men on bed rest could significantly improve proprioception just after 30 days of isotonic exercise9. These findings were consistent with the study done by R.J.Petrella and P.J. Lattanzio which
revealed
proprioceptive
significantly
ability
in
the
better elderly
subjects who had engaged in isotonic and
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 37
[Research Report] isokinetic exercise training for a period of 9
cannot be observed accurately with naked
1 year or more .
eye during clinical assessment4.
In the present study different durations of
However, several studies have shown a
stretching (10 seconds, 20 seconds, 30
significant
seconds, 40 seconds) were incorporated in
predisposed population, suggesting that
the warm up protocols and the group with
this small difference may indeed be
3 minutes of warm up which had 30
clinically significant4. K R Grab et al
seconds
concluded
stretch
gave
maximum
change
that
in
there
injured
remain
or
no
proprioceptive output. This indicates that
comprehensive methods for measuring
30 seconds stretching is better than 10
proprioception. The results of studies
seconds, 20 seconds or 40 seconds
which use only either joint position sense
stretching.
or kinesthesia test must be interpreted with
Passive
presentation/passive replication technique
care. Furthermore the term proprioception;
was used because this method minimizes
kinesthesia and joint position sense should
the rate of change of muscle length and
not be used synonymously.
primarily measures ligament rather than muscle based proprioception5. The mean error
difference
ranges
between
2-8
degrees. Two previous studies measuring joint position sense of knee reported that a mean difference of 1.7 degrees between error scores was significant for statistical difference. They further suggested that conclusions can be inferred from those differences about proprioceptive control mechanisms. A similar difference was found to be statistically significant in the shoulder of over hand athletes. Although a
Future Research It is recommended that future studies should take into account different methods of warm up for shoulder joint for rehabilitation or research purposes to find out which of the available methods is most appropriate with regards to joint position sense appreciation enhancement. Future studies should also include a larger group with regards to qualifying subjects with varying shoulder joint activities (Throwing athlete, occupational uses, house wife etc)
small change in error scores is enough to
Relevance to Clinical Practice
identify a reliable, statistically significant
This
difference, a question of clinical relevance
exercises consisting of active shoulder
exists. A difference of a few degrees
exercises and active stretching up to 3
study
suggests
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
that
warm-up
Page 38
[Research Report] minutes
will
be
appropriate
for
athletes. The results suggest that shoulder
proprioceptive training of athletes and
joint position sense alter across the ROM
patients with less proprioceptive acuity at
with potentially greater position sense
shoulder joint. Evidence supporting the
acuity in the outer range of shoulder
proposition that
flexion where there is more tension upon
athletes might
have
superior levels of joint sense compared to all others, is minimal and equivocal. While two studies of position sense tests have suggested that various categories of sports persons have superior joint sense, an unpublished study by Barry C Stillmann, Joan
M
McMeeken
and
Richard
Macdonell found no significant different in position sense accuracy when active position sense tests results from 43 footballers were compared to results from 16 age matched control subjects8.
Limitations of study Temperature
of
shoulder
cannot
be
recorded. Method of checking shoulder Joint Position Sense appreciation will be recorded passively.
Conclusion The findings of this study support the experimental hypothesis that the larger amount or duration of warm up and stretching will give more accuracy of joint position sense before the occurrence of muscular fatigue. Clinicians should be aware of this information in making decisions during rehabilitation of shoulder injuries or proprioceptive training of
the restraints of motion.
References 1.
Voight L.M., Allen J., Turner A,Tippett S. and Gary C., The effect of muscle fatigue and relationship of arm dominance to shoulder proprioception, J.O.S.P.T., 2(6), 348-352(1996) 2. Lonn J., Albert M.S. and Pederson., Position sense testing: influence of starting position and type of displacement, APMR., 81, 592-593(2000) 3. Marnic A., M Scott S.L., J.I.and F.H., Shoulder kinesthesia in healthy unilateral athletes participating in upper extremity sports, J.O.S.P.T., 21(4), 220-226( 1995) 4. Drover G., M.S., C.A.T., A.T.C and Powers M.E.,Cryotherapy does not impair shoulder joint position sense, APMR., 85, 1241-1246(2004) 5. Br. J. SP., Effect of warm up exercises on knee proprioception before sporting activity, Med.,36,132-134(2002) 6. Effects of static stretch and warm up exercises on hamstring length over the course of 24 hours, J.O.S.P.T., 33(12), 727-33(2003) 7. In sports & exercise:- A randomized trial of pre-exercise stretching for prevention of lower limb injury, Med. & Sc. 8. After effects of resisted muscle contraction on accuracy of joint position sense in elite male athletes, A.P.M.R.,79,1250-1254(1998) 9. Effects of age and activity on knee joint proprioception, Am.J.Phys.Med. Rehab., 9,235-241(1997) 10. Knee proprioception: A review of mechanism, measurements, and implications of muscular fatigue, Orthopedics., 21(4),463-471 (1998) 11. Effect of superficial heat, deep heat, active exercises warm up on extensibility of plantar flexors, Phys. Ther., 81, 12061214(2001) 12. The effect of time on static stretch on flexibility of hamstring muscles, PHY. THER.,74(9),845-850(1994)
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 39
[Research Report] 13. The effect of duration of stretching of hamstrings for increasing ROM in people aged 65 years or older, PHY. THER., 81(5),1110-1117(2001) 14. Duration of stretching effect on ROM in lower limb, A.P.M.R., 66,171-173(1985) 15. Effects of static stretch versus static stretch and U.S. combined on triceps surae muscle extensibility in healthy women, PHY. THER.,67(5), 674-679 (1987) 16. SWD and prolonged stretching increase hamstring flexibility more than prolonged stretching alone, J.O.S.P.T.,34( 1), (2004) 17. B.Ulkar, B.Kunduracioglu, C.Cetin, RS. Guiner. Effects of position and bracing on
passive position sense of should joint. Br.J.Sp.Md. 38, 549-552 (2004). 18. J.Guide, ML. Voight, TA Blackburn. Effects of chronic effusion on knee joint proprioception. JOSPT Vol. 25, No.3, 208-212 (1997). 19. The effects on shoulder joint position sense of muscular fatigue carpenter JE.Localized Muscle fatigue decreases the acuity of movement sense in human shoulder. MSSE Vol. 31, No. 7, PP 10471052 (1999). 20. Muscular exercise improves knee position sense in humans. Neuroscience letters Aug 4, 289(2), 143-6, (2000).
Corresponding Author Jyoti Bala B67/2,Naraina Vihar,Naraina,New Delhi-28,India +91 9811345170 Š 2013 PGIP. All rights reserved
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 40
[Research Report] Appendix A A
B
1--2
0.539
0.002
1--3
0.148
0
1--4
1
0.744
1--5
0.87
0.267
2--3
0.285
0
2--4
0.539
0.003
2--5
0.367
0
3--4
0.202
0
3--5
0.116
0
4--5
0.653
0.389
Graph 2: Multiple Group Comparison (A And B) 1 0.8 0.6 0.4 0.2 0
A B 1--2 1--3 1--4 1--5 2--3 2--4 2--5 3--4 3--5 4--5
30 - 90
Table 2: Mann Whitney Tests (Multiple Group Comparison) C 0.595 0.461 0.539 0.653 0.217 0.233 0.806 0.624 0.267 0.567
D 0.023 0 0.345 0.037 0 0.003 0 0 0 0.202
Graph 3: Multiple Group Comparison (C And D) 1 0.8 0.6
C
0.4
D
0.2 0 1—2 1—3 1—4 1—5 2—3 2—4 2—5 3—4 3—5 4—5
60-120 1—2 1—3 1—4 1—5 2—3 2—4 2—5 3—4 3—5 4—5
Table:3 Mann Whitney Tests (Multiple Group Comparison) E
F
1—2
0.935
0.003
1—3
0.074
0
1—4
0.713
0.217
1—5
0.967
0.002
2—3
0.116
0
2—4
0.567
0
2—5
0.838
0
Graph 4: Multiple Group Comparison (E And F) 1 E
0.5
F
0 1—2 1—3 1—4 1—5 2—3 2—4 2—5 3—4 3—5 4—5
90-150
Table:4 Mann Whitney Tests (Multiple Group Comparison)
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 41
[Research Report]
Qualitative & Quantitative Analysis of Multiple Choice Questions in 3 rd year Physiotherapy Suvarna Ganvir, BPhT, MPhT, PGDR, FNR, Shyam Ganvir, BPhT, MPhT,PGDGC
Abstract: Objectives: To carry out the detailed analysis of Multiple Choice Questions (MCQs) asked
in the preliminary examination of 3rd year physiotherapy. Methods: MCQs for the preliminary examinations of three years were analysed in detail
about their difficulty index, discrimination index, distractor performance, types & percentage of MCQs in each question paper, their relationship with each other. Results: Qualitative analysis indicates that out of 120 items, only 28% (n=34) were of
interpretation type and 36% the problem solving. Mean difficulty index was 61.7Âą 20.1 and discrimination index was 26.8Âą 15.8. The proportion of items containing 0, 1, 2, and 3 functioning distractors was 8.3%, 28.1%, 44.8%, and 18.8% respectively. 36% of problem solving type plus 27% interpretation type of questions constitutes fairly significant number of higher cognitive domain questions. The wide scatter of item discrimination values for questions with a similar level of difficulty may reflect that some extent of guessing practices is done by the students. Conclusion: Results of this study shows the quality of MCQs still needs to be enhanced
may it be the type of MCQ, or difficulty or discrimination index or distracter performance so that this tool can be effectively used for the assessment. Keywords: MCQs, assessment methods, item analysis
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 42
[Research Report] Introduction:
Qualitative analysis deals with the type of
Multiple Choice Questions (MCQs) as a
MCQs
tool for assessment has been very widely
technology. Quantitative analysis deals
used. As with other health professional
with item analysis in the form of
training, the effective measurement of
calculating
knowledge is an important component of
discrimination index.
both medical education and practice1. Furthermore, the methods used to analyse the evidence resulting from the tasks (i.e. interpretation) need to be aligned with the aspects of achievement that are to be assessed (i.e. cognition) and the tasks used to
collect
evidence
about
students’
achievement (i.e. observation)2. The MCQ format allows the teachers to efficiently assess large numbers of candidates and to test a wide range of content. If properly constructed, MCQs are able to test higher levels of cognitive reasoning and can accurately discriminate between high- and low-achieving students. Therefore, it is important for us to evaluate our MCQ
used
according
difficulty
to
Bloom’s
index
&
Methodology: A pilot study with twenty MCQs was done as a part of the Advanced Course On Health Sciences Education Technology. Clearance from institutional review board was not obtained as the study did not involve any human subjects. Data collection: The study began with
compilation of question papers of last three years’ preliminary question papers. The preliminary examination is conducted at the end of academic session of third year where in the questions are expected to be based on the contents of the entire syllabus.
items to see how effective they are in
Scoring of MCQs: The MCQs were of the
assessing the knowledge of our students.
single best response type with a stem &
With this information in hand it will be
four options. The students had to choose
easy for us to comment on the level of
the most appropriate answer. Students
MCQs used in our examination system so
scored 1 mark for each correct answer &
that appropriate up gradation if required
there was no negative marking. No marks
can be done.
were awarded if the students did not
Purpose of the study: Hence the purpose
of this study was to analyse the MCQ items used during previous examinations.
attempt the question or more than one answer was given for one question. The next task was analysis to determine level of difficulty and power of discrimination.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 43
[Research Report] Item analysis: The results of students’
Discriminating power is an index that
performance in these MCQ tests were then
measures the difference in the proportion
used to determine the difficulty index and
of responses between the upper and lower
discrimination index of each MCQ item in
27% of examinees4. Items are considered
the respective tests. In this study, the item
discriminating if the index for the correct
difficulty index (P) refers to the percentage
response is positive and the same statistic
of the total number of correct responses to
for the distractors is negative5.
the test item. It is calculated by the formula P = R/T, where R is the number of correct responses and T is the total number of responses (i.e., correct + incorrect + blank responses). Hence, the higher this index value, the lower is the difficulty, and the greater the difficulty of an item, the lower is its index. The item discrimination index
(D),
however,
measures
the
difference between the percentage of students in the upper group (PU), i.e., the top 27% scorers, who obtained the correct response, and the percentage of those in the lower group (PL), i.e., the bottom 27% scorers, who obtained the correct response; thus D = PU - PL. The higher the discrimination index, the better the item can
determine
the
difference,
i.e.,
discriminate, between those students with high test scores and those with low ones3.
Results: Qualitative analysis indicates that out of 120 items, 36 percent (n=45) were of recall type whereas only 28% (n=34) were of interpretation type. The problem solving type constituted another 36%. Table 1 shows mean difficulty index & mean discrimination index for the test items. There was a wide spectrum of level of difficulty among the MCQ items in all question papers. The difficulty index of these papers ranged from as low as 1% to 7% (“extremely difficult” items) to as high as 99% to 100% (“extremely easy” items). On average, 36.5 ± 6.0% (mean ± SD) of the test
items in each paper had a
difficulty index of ≥75% (“very easy” items), while about 8.9 ± 2.6% items had a difficulty index of <25% (“very difficult” items), as shown in Table 2. About two-
Distractor Effectiveness: First, a non-
thirds of these “very easy” and “very
functioning option was defined as one that
difficult” items had poor or even negative
was chosen by fewer than 5% of
discrimination
examinees. Second, we assessed the
discrimination correlated positively with
discriminating power of the options.
difficulty at the “easy end” (P between
(D
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
≤20%).
Generally,
Page 44
[Research Report] 80% and 100%) of the curve, but
between 0% and 20%) of the curve.
negatively at the “difficult end” (P Year of examin ation
No of student s
Test items
Difficulty Index P (%) (mean+ SD)
Discrimination Index D (%) (Mean + SD)
2007
27
40
65.7 ± 20.8
32.9 ± 15.2
2008
31
40
61.9 ± 21.0
25.8 ± 16.9
2009
29
40
57.6 ± 19.6
21.9 ± 15.9
61.7± 20.1
26.8± 15.8
Table 1. Mean Difficulty Index (P) and Discrimination Index (D) Discussion:
university examination, more number of
There were total 60 test items in three
higher domain MCQs should be included.
examinations
Qualitative
36% of problem solving type of questions
analysis revealed different percentages of
plus 27% interpretation type of questions
different types of MCQs. Though there are
constitutes fairly significant number of
no norms for the specific percentage of
higher
each type of MCQ, it is very much
Another 36% was constituted by recall
expected that considering preliminary
type.
concerned.
cognitive
domain
questions.
examination to be a replica of the Year of examination
Very easy items (%)
Very difficult items (%)
2007
30.4
8.8
2008
40.4
9.0
2009
38.8
9.1
Average
36.53 ± 6.0% (mean ± SD)
8.9 ± 2.6% (mean ± SD)
Table 2 showing % of the MCQs according to level of difficulty
On item analysis of these, it was found that
in that poor discriminatory items are a
the average Difficulty index was 61.7±
valuable
20.1 & Discrimination index was 26.8±
wording, grey areas of opinion and
15.8. Discrimination indices are important
perhaps, even wrong keys. The wide
signpost
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
towards
ambiguous
Page 45
[Research Report] scatter of item discrimination values for
small) include ambiguity in the wording,
questions with a similar level of difficulty
areas of controversy, and perhaps, even
may reflect that some extent of guessing
that the wrong key was given. It is possible
practices is done by the students. Out of 25
that a “good” student might not risk
items, 36% were very easy questions
attempting a “difficult” MCQ item for fear
whereas 8% were difficult6,10. Test items
of losing hard-earned marks on the other
with very poor discrimination indices
items of the same question. However, a
should be reviewed by the respective
“weak” student might take the risk to
disciplines. It serves as an effective
guess as he knows so little on the topic that
feedback to the departments concerning
he has nothing much to lose, and the least
their educational activities6. When a test
he can obtain for the whole question is
item appears to be very difficult (i.e. P is
zero marks. This could then result in a
very small), it may be that the topic tested
negative
is inappropriate at this stage of students’
Furthermore, other research suggests that
training, or that it is not taught well or not
even professionally developed test items
taught at all in this particular academic
on standardized exams rarely have more
session. Other possible reasons for poor
than two functional distracters7,8,9.
discrimination
index.
performance on the items (i.e., D is very Sr. No
2007
2008
2009
Total
No of items
40
40
40
120
No of distracters
160
160
160
480
49(30.6) 38(23.6) 22(13.9) 7 (4.2) 49(30.6) 96 (59.7)
58(36.1) 55(34.7) 29(18.1) 18 (11.1) 58 (36.1) 76 (47.2)
68(42.2) 54 (34.1) 37(23.3) 22 (16.3) 68(42.2) 75(46.9)
13 (8.3) 45(28.1) 70(44.8) 30(18.8)
24 (15.3) 68(41.7) 58 (36.1) 11 (6.9)
24(15.1) 65(40.7) 52 (32.6) 19 (11.6)
Distracters with Frequency <5% n (%) Discrimination ≥ 0 Both Frequency = 0% n (%) Frequency <5% n (%) Functioning distractors per test n (%) Functioning distractors per item n (%) None One Two Three
Table 3 Distracter Performance
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 46
[Research Report] Distracter
that
distracters which needs revision so that it
approximately 14% of the items had three
is converted into the functioning distractor.
functioning
performance
distracters.
shows
This
low
percentage calls for revising the items & distracters. The reason for this may be the fact that the teachers find it difficult to find three distracters for each item & the distracters may just become the ‘fillers’. Study by Haladyna and Downing7 found that approximately two-thirds of all fouroption items they reviewed had only one or two functioning distractors. They further found that none of the five-option items had four functioning distractors. Hence the MCQs with three options need to be considered if we really wish to elevate the standards of our examination systems. There are certain limitations of this study. This study did take into account the MCQs
Conclusion: Results of this study shows the quality of MCQs still needs to be enhanced may it be the type of MCQ, or difficulty or discrimination
effectively
used
for
analysis of MCQs university
the
assessment.
appeared in the
examination
of
the
physiotherapy subjects. Also it is planned to reduce the number of options from four to three by eliminating non functioning distractor & to further carry out item analysis of these revised MCQs.
References 1.
2.
remarks. Also, with recent advances in 3.
technology computer assisted technology can be used to carry out item analysis. This study may prove to be useful for the novel 4.
education. This study suggests that there 5.
should be balance between various types of MCQs in one set of question papers. It also helps to identify the non functioning
distracter
Further it is planned to conduct the
period is needed to make fairly general
researchers in the field of physiotherapy
or
performance so that this tool can be
of only last three years examination. More extensive study with MCQs over a wide
index
6.
Ross MM, McDonald B, McGuinness J. The palliative care quiz for nursing (PCQN): the 1996;23:126-37. Pellegrino J, Chudowsky N, Glaser R, editors. Knowing What StudentsKnow: The Science and Design of Educational Assessment. Washington,DC: National Academic Press, 2001. Backhoff E, Larrazolo N, Rosas, M. The level of difficulty and discrimination power of the Basic Knowledge and Skills Examination (EXHCOBA). Revista Electrónica de Investigación Educativa, 2000;2(1). Ebel RL, Frisbie DA. Essentials of educational measurement. 5. Englewood Cliffs, N.J.: Prentice Hall; 1991. Osterlind SJ. Constructing test items: Multiple-choice, constructedresponse,Performance, and other formats. 2. Boston: Kluwer Academic Publishers; 1998. Marie Tarrant, James Ware, and Ahmed M Mohammed, An assessment of
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 47
[Research Report] 7.
8.
functioning and non-functioning distractors in multiple-choice questions: a descriptive analysis BMC Med Educ. 2009; 9: 40. Haladyna TM, Downing SM. How many options is enough for a multiple-choice test item? Educ Psychol Meas. 1993;53: 999–1010. Schuwirth LWT, Vleuten CPM van der: Different written assessment methods: what can be said about their strengths and weaknesses? Med Educ. 2004; 38: 974– 979.
9.
Crehan KD, Haladyna TM, Brewer BW. Use of an inclusive option and the optimal number of options for multiple-choice items. Educ Psychol Meas. 1993; 53:241– 247. 10. 10. Si-Mui Sim, Raja Isaiah Rasiah: Relationship Between Item Difficulty and Discrimination Indices in True/False-Type Multiple Choice Questions of a Paraclinical Multidisciplinary Paper, Ann Acad Med Singapore 2006;35:67-71
Corresponding Author Mrs Suvarna Ganvir BPhT, MPhT, PGDR, FNR, CMCL_FAIMER Fellow Professor, PDVVPF's College of Physiotherapy, Vilad Ghat Ahmednagar, Maharashtra 414111. © 2013 PGIP. All rights reserved.
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 48
[Research Report]
A Comparison of Walking Aids in Patients with Anterior Cruciate Ligament Rehabilitation 1
Shaji John Kachanathu, 2Ashraf Hafez Ramadan, 3Shibili Nuhmani, 4Sajith Vellapallil
Abstract Background: Ligament reconstruction is the current standard of care for active patients with
an anterior cruciate ligament (ACL) rupture. Although the majority of ACL reconstruction (ACLR) surgeries successfully restore the mechanical stability of the injured knee, postsurgical outcomes remain widely varied. However functional outcomes after ACLR are poor, thus it is a necessary to investigate the out comes of different usage of walking aids in patients with ACLR. Methods: Total 60 subjects of post ACLR with mean age of 32Âą5.2 were participated in the
study. Subjects were divided into groups A, B and C for rehabilitation with single, double elbow crutches and walker respectively, along with conventional exercises for 6 weeks. After 4th week walking aids were discarded for all groups. Interventional outcomes were assessed by static, dynamic stability and knee functional score at 4th and 6th weeks for all three groups. Results: All three groups showed improvement in static and dynamic stability at 4th and 6th
weeks, however elbow crutch groups showed highly significant difference (p<0.001). Whereas lysholm score at 4th week was non-significant for all three groups p=0.54, although it had improved at 6th week p=0.02. Conclusion: Study concluded that knee Stability (static and Dynamic) and lysholm
functional knee score were improved in all walking aids groups along with conventional rehabilitation of post ACLR, however study outcomes were more significantly effective with single elbow crutch training than double and walker training groups. Key words: ACL Repair, Lysholm Knee Score, Elbow Crutch, Knee Stability.
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 49
[Research Report] Introduction
two
The anterior cruciate ligament (ACL) is the important ligament to stabilize the knee. The rupture of the ACL is a common injury in recreational and competitive sports, as well as other activities. When the affected knee is left with substantial instability
during
sport
and/or
daily
activities, a ruptured ACL is a risk factor for meniscal and cartilage injury linked to later
1
osteoarthritis .
ligament
Anterior
reconstruction
cruciate
(ACLR)
is
standard practice for individuals that desire to return to high-level activities, but excellent
outcomes
are
not
as
commonplace as previously reported2,3. Recent literatures advocate a more oblique ACLR to more closely recreate normal knee
kinematics
and
eliminate
rotational
laxity.
intensive
rehabilitation
A
pathologic
supervised program
and is
necessary to achieve desired results. A more oblique placement of the ACL graft has been related to better control of rotatory knee stability. Femoral fixation with a transverse system might injure its posterolateral
4
structures .
years
in
spite
of
extensive
3,5
rehabilitation . It has been reported that patients who were rehabilitated with the help of elbow crutches immediately after ACLR could achieve to their previous level of activity sooner than those who use brace after ACLR6. Studies have been done on elbow crutch
training
separately
mobilization after ACLR7,8.
on
early
It is also
described that there is no difference in pain or any of the secondary outcomes when elbow crutches are given immediately after ACLR9.
As there has been much
advancement in the ACLR in terms of graft used, femoral tunnel placement according to which rehabilitation of the patient and ability to bear weight should also
be
changed10.
demonstrated
that
Some
immediate
authors weight
bearing with the help of two elbow crutches after reconstruction helps the patient to return to non-pivoting sport at 4 months and also there are no deleterious effects of early weight bearing on stability or function of vastus medialis8,11.
Currently,
success after ACLR is measured using
A key predictor for ACLR outcome is
return-to-sport rates. Abnormal movement
rehabilitation. Current data support the
patterns and below normal knee function
principles of accelerated rehabilitation
are characteristic of athletes in the months
protocols including early weight-bearing
following ACLR and often persist up to
and range of motion training. The purpose of this study was to see the stability and
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 50
[Research Report] functional knee score responses with
functional score at 4th and 6th weeks for
different walking aids, which are used for
all three groups. Cryotherapy was applied
gait training immediately after ACLR
before and after exercises. Rehabilitation
along with conventional physiotherapy
started day one after the repair, after
management.
ACLR subjects were given walking aids given for respective group for 4 weeks.
Materials and Methods
Total duration of the study was for 6
Current study was included the subjects of post ACLR done with hamstring graft. All cases were unilateral involvement and had isolated ACL tear. These procedures were performed by one of two surgeons in one clinic. The subjects who not met the inclusion criteria were excluded from the
weeks, after 4th weeks walking aids were discarded
for
all
study
groups.
Rehabilitation outcomes were assessed by static, dynamic stability and the lysholm knee score for post intervention at 4th and follow-up at 6th weeks post operatively for all groups.
study such as patellar tendon graft, age beyond 30 years, any abnormality in knee,
Results
vertical fixation in the graft and double
Collected data were analyzed by SPSS 17
bundle ACLR. Each subject was clearly
version software. A t-test was used to
explained about the study and informed
compare the difference between 4th and
consent was collected from the patient as
6th week in the static and dynamic
well as the orthopaedic surgeon, and also
stability and lysholm knee score within the
obtained ethical committee clearance from
each groups showed significant difference
parent organization. Total 60 subjects with
(Table1.), however single elbow crutch
age of 20-40 years (32Âą5.2) were included
groups
in the study. Subjects were randomly
improvement (p<0.001) than double and
divided into groups A, B and C for
walker
rehabilitation with single, double elbow
lysholm score at 4th week was non-
crutches and walker respectively (n=20 in
significant for all three groups p=0.54,
each group), along with conventional
although it had improved at 6th week
exercises for 6 weeks. After 4th week
p=0.02.
walking aids were discarded for all groups. Interventional outcomes were assessed by static,
dynamic
stability
and
knee
found
groups
more
(Figure
significant
1.).
Whereas
Discussion The current study was designed to see the effect on stability and functional score
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 51
[Research Report] after giving gait training with different
non-significant for all three groups p=0.54,
walking aids immediately after ACLR.
although it had improved at 6th week
According to the results, All three groups
p=0.02,
showed
and
rehabilitation of post ACLR, however
dynamic stability at 4th and 6th weeks,
study outcomes were more significantly
however elbow crutch groups showed
effective with single elbow crutch training
highly significant difference (p<0.001).
than double and walker training groups.
improvement
in
static
along
with
conventional
Whereas lysholm score at 4th week was Variables
Single
Double
Walker
P value
4th week SS 5.2±1.1 3.7±1.4* 3.1±1.2* <0.001 th 34.5±8.2 31.3±7.5 21.9±7.4* <0.001 4 week DS th 50.9±10.2 49.5±10.1 47.4±9.6 0.54 4 week LKFS ‘*’Represents group is significantly different from Single; ‘#’ ’Represents group is significantly different from Double 8.1±1.4 6.2±1.8* 5.9±1.8* <0.001 6th week SS # th 47.3±8.6 43.3±9.3 35.4±9.1* <0.001 6 week DS th 90.5±5.7 82.9±10.1* 84.3±9.6 0.02 6 week LKFS
Table: 1 Between groups comparison
It was also observed that knee stability and
initial four weeks might be due to pain,
functional
slight
score
improved
by
early
weakness
and
decrease
in
mobilization with double elbow crutches
confidence level. When static and dynamic
and walker independently, although there
stability were compared between groups
is no significant difference between double
4th and 6th week, it was seen that single
elbow crutches and walker8. Whereas
and double elbow crutch groups showed
study also reported that stability and
p<0.001 at 4th week and at 6th week. This
functional score more significant in single
means that the patients who were using
elbow crutch group than walker and also
elbow crutches gained static and dynamic
recommended early weaning off walking
stability at 4th week post operatively and
aids
during
patients who used walker were more stable
7
at 6th week.
for
faster
rehabilitation of
outcomes
post ACL repair . The
reason could be with the patients were unable to gain knee functional score in the
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 52
[Research Report] There reason of gaining stability in the 4th
placement and the graft used in the
week and improved lysholm knee score in
reconstruction procedure. The pain was
the patients with elbow crutches could be
evaluated using lysholm knee score and
due to the surgical advancements in the
demonstrated a greater improvement in the
ACLR
patients with early weight bearing11.
in
terms
of
femoral
Singl e
tunnel
Double
100 80 60 40 20 0 4SS
4DS
4LKFS
6SS
6DS
6LKFS
Figure 1. Between groups comparison There is still a lot of controversy
The reason for insignificant result with
concerning
in
walker could be supported by previous
rehabilitation following ACLR. Some
observations, has been established that
provide their patients with soft braces or
ambulation with a cane of any type slows
bandages12, while other surgeons believe
gait compared to ambulating with no
bracing to be unnecessary or, in certain
cane15,16, cognitive and physical demands
cases, even harmful13. The studies, though,
to ambulate with a more cumbersome
also admit that the protective value ceases
device, the mechanical nature of the cane,
as soon as the stress on the joint is
and the complexity of striking all four tips
the
use
of
braces
14
increased . It is reported that use of
on the ground while walking. One of the
crutches after ACLR reported decrease in
actions healthcare professionals can take is
the incidence of pain and swelling in the
to screen for and prescribe the proper use
patients with ACLR. This method of
and type of canes based on the needs of the
rehabilitating a patient immediately after
individual17. The other factors contributed
ACLR proved beneficial as it helped in the
to the current result could be conventional
9
earlier recovery of the patients .
physical therapy regime used in this study consisted
of
isometrics,
open
chain
isotonic such as active range of motion
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
Page 53
[Research Report] with the weight of the ankle, and straight leg rises. These exercises are generally low load and independently may not prevent the disuse muscle atrophy that affects the knee
joint.
The
goal
in
the
early
rehabilitation period is the progression of the weight bearing process. Again, a range of weight bearing progression exists in current protocols, some of which advocate immediate full weight-bearing in a locked extension brace, while others advocate the use of crutches for upwards of four to five weeks. The concept of immediate full weight bearing programs has prevailed with the thought that the weight bearing facilitates
faster
extensor
mechanism
return. Thus usage of walking aids still a controversial topic among surgeons and physical therapist however it needs more scientific supports than personal choice of rehabilitation specialist.
Conclusion According to the current study results, it is concluded that knee Stability (static and Dynamic) and lysholm functional knee score were improved in all walking aids groups
along
with
conventional
rehabilitation of post ACLR, however study outcomes were more significantly effective with single elbow crutch training than double and walker training groups.
References 1.
Voigt C, Schoenaich M, Lill H. Anterior cruciate ligament reconstruction: state of the art. European Journal of Trauma 2006; 32(4): 332-9. 2. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and metaanalysis of the state of play. Br J Sports Med 2011; 45: 596-606. 3. Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Huang B, Hewett TE. Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med 2010; 38:1968â&#x20AC;&#x201C;1978. 4. Gelber PE, Reina F, Torres R, Monllau JC. Effect of Femoral Tunnel Length on the Safety of Anterior Cruciate Ligament Graft Fixation Using Cross-Pin Technique: A Cadaveric Study. The American Journal of Sports Medicine 2010; 38(9): 1877-84 5. Logerstedt D, Lynch A, Axe MJ, SnyderMackler L. Symmetry restoration and functional recovery before and after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2013;21(4):859-68. 6. Nazem KHA, Sadeghian H. Anterior cruciate ligament reconstruction: with brace vs without brace after operation. A randomized controlled clinical trial. Journal of Research in Medical Sciences 2001; 7(1): 68-76. 7. Kachanathu SJ, Hafez AR, Zakaria AR. Effect of early elbow crutch mobility on patients with post anterior cruciate ligament repair. Indian Journal of Medical Sciences 2011; 65(11):30-37. 8. Kachanathu SJ. Early gait training with double elbow crutches on stability and functional knee score in patients with anterior cruciate ligament repair. National Journal of Integrated Research in Medicine 2012; 3(2):152-158. 9. Laurie A, Hiemestra. Knee immobilization for pain control after ACL reconstruction. A randomized control trial. Am J sport med 2009; 37: 155-157. 10. Lee M, Scong S. Vertical femoral tunnel placement results in rotational knee laxity
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[Research Report] 11.
12.
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after ACL reconstruction. J of arthroscopy and related surgery 2007; 23: 771-777. Tyler, Wnorowski. Comparison of immediate weight bearing with delayed weight bearing after ACL reconstruction. J. Knee surgery 2008; 21: 225-238. Muellener, Colombett, Song DH. No benefit of bracing on early outcome after ACL reconstruction. Knee surg. Sports Traumatology 1998; 6(12): 88-92. Hoeher J. Rehabilitation following anterior cruciate ligament reconstruction; rehabilitation nach operativem Ersatz des vorderen Kreuzbandes. Arthroskopie 2005; 18(1): 41–7. Harilainen A, Sandelin J. Post-operative use of knee brace in bone–tendon–bone patellar tendon anterior cruciate ligament reconstruction: 5-year follow-up results of a randomized prospective study. Scand J Med Sci Sports 2006; 16(1): 14–8. Nolen J, Liu H, Liu H, McGee M, Grando V. Comparison of Gait Characteristics with a Single-Tip Cane, Tripod Cane, and
Quad Cane. Phys Occup Ther Geriatr 2010; 28:387-95. 16. Aragaki DR, Nasmyth MC, Schultz SC, et al. Immediate effects of contralateral and ipsilateral cane use on normal adult gait. AAPM&R 2009;1:208-13. 17. Liu H. Posture, gait, and falls among older assistive ambulatory device users. J of Gannan Med Univ 2011; 31:661-7.
Corresponding Author Shaji John Kachanathu PT PhD Department of Rehabilitation Health Sciences, College of Applied Medical Sciences, King Saud University, P.O Box: 10219 Riyadh, Zip: 11433, Kingdom of Saudi Arabia Mobile +966534781109 Office: +966014696228 Fax: +966014355883 E-mail: johnsphysio@gmail.com © 2013 PGIP. All rights reserved.
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
[Journal of Physiotherapy & Sports Medicine][Volume 2][Issue 1][June 2013]
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Welcome to the Postgraduate Institute of Physiotherapy, we are the team of professional physiotherapists working in United Kingdom promoting and uplifting the physiotherapy profession in developing countries particularly in South Asia. Our well trained and qualified physiotherapists conduct postgraduate courses in various countries. The courses ranged from Musculoskeletal Manual Therapy to Sports Physiotherapy. The basic aim is to provide evidenced based way of practice and education to physiotherapy societies of developing nation so that they can uplift the profession and become the contributors to the profession. Date: 00/00/00
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Diagnostic Assessment 2. Management of Neck Disorders 3. Neurodynamics and Neuromatrix 4. Lumbar Spine 5. Cervical Spine 6. Treating Cervicogenic Headaches 7. Low back pain and evidence base approach 8. Spinal Manipulation 9. Evidence Based Practise 10. Clinical Reasoning 11. Professionalism, Empowerment and Autonomy 12. Sports Rehabilitation and injuryIPrevention