June2013

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]

Page 5

[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] 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.

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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

ruffini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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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

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