Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 3, Issue 1, 2014
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
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Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 3, Issue 1, 2014 Table of Content
Editorial........................................................................................................................................01 Lower Extremity Muscle Activity during Squatting with Unstable Shoes.…….…………………………………………………………………………………………………………………..................03 Effects of low frequency electrical stimulation on fracture healing of long bones of lower limb……………………………………………………………………………………..……………………………………..……………..17 Reliability and validity of the three visual assessments of lower limb function comprising FootFAST: a repeated measure cohort study............................................…………………………………..26 A Pragmatic approach to the development of a therapeutic protocol for enhancing motor control and coordination in chronic stroke patients – Review Study .........................................................36 Effectiveness of Incentive Spirometry with and Without Deep Breathing Exercises In Post-Coronary Artery Bypass Grafting Physical Therapy Management……………………..………………………………………..49 Guidelines for Authors..................................................................................................................56
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Postgraduate Institute of Physiotherapy
JOPSM Editorial Office | 4 Brantwood Drive, West Byfleet, Surrey, United Kingdom E-mail: info@pgip.co.uk
[Editorial]
Thinking beyond Horizons Chishti Muhammad Atif1, Sheikh Umer Qaiser2
Physiotherapists in the UK are the first in
Physiotherapists will now be able to
the world to be able to independently
deliver more effective patient services,
prescribe medication to their patients.
give patients a better experience, free up
Indeed, it is a very historic event and
valuable GP time and promote the value of
shows recognition of our profession by
physiotherapy in managing care pathways.
other
health
professions.
Previously,
physiotherapists must refer a patient to a GP in order to get a prescription. Now practitioners can issue prescriptions after completing a training course and are able to prescribe medications in their specific
independent prescription and there are ongoing
misconceptions
regarding
independent prescription. We would like to clarify this in wider interest of profession. Independent prescribing is the process by
area. An independent prescriber is someone who is able to prescribe medicines on their own initiative
from
the
British
National
Formulary (BNF). Eight Physiotherapists who
There have been numerous queries about
have
trained
in
South
Bank
University in London have already started prescribing and imprinted their names in the history. These physiotherapists have
which a practitioner is responsible and accountable for the assessment, diagnosis and treatment of a patient’s condition and for
decisions
management
about
the
required,
clinical including
prescribing. Only GP’S and dentist were allowed
previously
to
prescribe
independently.
become pioneers after attended one of the
There
has
been
UK’s first independent prescribing courses
physiotherapists to be able to prescribe and
for physiotherapists and other allied health
the move comes after 10 years of
professionals.
campaigning by the Chartered Society of Physiotherapy.
growing
Advanced
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][Dec 2014]
need
for
practice
Page 1
[Editorial] physiotherapists are now able to prescribe
advanced practitioners in musculoskeletal,
any licensed medicine relevant to their
neurology and cardio respiratory fields and
particular scope of practice, and for a wide
now
range of conditions such as asthma,
prescription
neurological disorders, rheumatological
professional growth and recognition.
conditions, women’s health problems and pain. This means that physiotherapists will have similar prescribing responsibilities to nurses and pharmacists.
has to complete recognised independent course.
Not
all
the
physiotherapist will be able to prescribe, only
advanced
new will
era
of
lead
independent to
further
These extended roles on one side are a token of appreciation of continuous hard work of professionals but it does not undermine basic physiotherapist skills
To be eligible to prescribe, Physiotherapist prescription
this
physiotherapist
practitioners working in a specialist area
which are at the very heart of profession. I wish this new era will open the new horizons for our profession and hopefully other countries will follow the same foot step.
on completion of appropriate training will be able to prescribe. Essential elements include appropriate training and skillsbased recognition within the discipline and the broader health team, and the need to overtly demonstrate effectiveness and
Corresponding Author 1 Atif Chishti Extended Scope Practitioner Connect Physical Health, Essex 36 Apex Business Village Cramlington, Northumberland, NE23 7BF 2 ICATS Extended Scope Practitioner, Oxleas NHS Foundation Trust, UK
safety. The whole process will not only improve patient’s adherence to the treatment but will also improve their experience of health system through easy access to medicine and improve delay in patient care, quality of care and patient pathways. With the greater recognition comes the greater responsibility. Physiotherapist have
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
proven record of working successfully as
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][Dec 2014]
Page 2
[Research Report]
Lower Extremity Muscle Activity during Squatting with Unstable Shoes Horsak Brian1,2, Hochhauser Manon1, Bruckner Johannes1, Brauneis Werner1,2, Wondrasch Barbara1,2, Figl-Hertlein Astrid1,2
Abstract: Objectives: In physiotherapy, squat exercises are commonly used to strengthen lower
extremity muscles. Wearing an unstable shoe construction can increase muscle activation during walking and running. However, little is known about their contribution to muscle activity when wearing them during squatting. The aim of this study was to assess changes of the mean activation of selected lower extremity muscles during squat exercises. Design: Controlled laboratory study using a repeated-measures, counterbalanced design. Setting: Twelve healthy subjects were recruited (6 men, 6 women; mean±SD: age, 25±7
years; height, 1.71±0.9 m; body mass, 65±10 kg). Main outcome measures: Mean activation of the vastus medialis, gluteus maximus, tibialis
anterior and gastrocnemius medialis of the dominant leg were monitored during three squat exercises using regular and unstable shoes. A two-way repeated-measures ANOVA was utilised to identify changes in mean activation between both test situations. Results: Muscle activation for all exercises increased for vastus medialis by 9% and for
tibialis anterior by 13% when using unstable shoes (p<0.05). The gluteus maximus and gastrocnemius medialis failed to reach significance. Conclusion: Even though vastus medialis, as part of one major muscle group to train with
squats, showed a slight increase, no changes were observed for gluteus maximus and gastrocnemius. Therefore, unstable shoes do not seem advantageous in increasing muscle activation during squatting.
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 3
[Research Report] Keywords: biomechanics/lower extremity, electromyography, strength training, unstable shoes
Introduction
increases
Squatting and its variations are widely
material in the medio-lateral direction
used exercises to train lower extremity
(Figure 1).
muscles in physiotherapy and fitness training1–4. The main purpose of squat training is to develop strength in the lower extremities and the lower back. Healthy function of these muscles groups are a basic prerequisite for participating in sports activities and for activities of daily living. The double-leg squat exercise performed with and without an additional barbell (e.g. back squat) and variations of the single-leg squat are often used in physiotherapy and fitness practice. Major lower extremity muscles involved during these
squatting
quadriceps,
exercises
hamstrings,
are
the
gastrocnemius,
gluteus maximus as well as muscles encompassing the ankle and hip joints3,5.
instability through
its
soft
Research has suggested that such unstable shoe constructions produce changes in kinematics and kinetics, as well as changes in muscle activation patterns of the lower extremity during gait and standing6–8. One of the findings from recent research was, that wearing unstable shoes increases body sway in stance6,9. Due to this increased instability, important
a
continual
stabilizing
activation
lower
of
extremity
muscles is needed to maintain postural stability9. It has been shown that walking and standing in unstable shoes increases the activity of lower limb muscles (e.g. gastrocnemius,
vastus
lateralis
and
medialis and gluteus maximus) and, as a result, could provide a sufficient stimulus
In the past few years, unstable shoe
for training these muscles7,9. Based on
constructions
popular,
these results, it is suggested that unstable
especially for training lower extremity
shoes could be beneficial for training
muscles during walking and standing,
postural stability and strength7,9–11. There
hence during daily living. Masai Barefoot
is also a significant amount of evidence
Technology (MBT, Winterthur, CH) is
showing that training on unstable surfaces
such an unstable shoe construction. The
(e.g. wobble boards, soft pads) can
MBT shoe has a rounded sole providing
improve global knee function, as well as
instability
dynamic knee stability4,12,13.
became
in
the
more
anterior-posterior
direction and a cushioned heel, which
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 4
[Research Report] Additionally, it was hypothesised by Kornecki
Zschorlich14
and
the
squat exercises, when using an unstable
combination of strength exercises together
shoe construction and regular training
with training on unstable surfaces, hence
shoes.
greater instability during exercises, can
activities of the vastus medialis, gluteus
stress the neuromuscular system to a
maximus,
greater extent than traditional training
gastrocnemius medialis of the dominant
methods using more stable conditions.
leg
Based
wearing
electrodes. A repeated-measures analysis
unstable shoe constructions during squat
of variances (ANOVA) was utilised to
exercises
identify global changes in mean activation
on
this
information,
could
combination.
that
muscles during three different types of
This
be
a
may
beneficial
lead
to
an
increased difficulty for the neuromuscular
Electromyographic
tibialis
were
monitored
(EMG)
anterior
using
and
surface
amplitudes between the stable and unstable test situation.
system to maintain postural and dynamic joint stability and may lead to higher muscular
activation.
Therefore,
the
purpose of this study was to compare mean activation of selected lower extremity muscles during three different types of squat exercises using an unstable shoe construction and a regular pair of training shoes. It was hypothesised that using unstable shoe constructions compared to normal
shoes
increases
total
mean
activation of lower extremity muscles during exercises.
Subjects
Twelve healthy subjects were recruited for this study (6 men, 6 women; mean±SD: age, 25±7 years; height, 1.71±0.9 m; body mass, 65±10 kg) from the local University community as a sample of convenience. Subjects were included if they were able to safely perform all three investigated types of squat exercises. Subjects were excluded if
significant
musculoskeletal
or
neurological dysfunctions were existent or in case of any history of lower extremity injury or surgery within the last half year.
Methods
The dominant leg was determined by
Study design
asking the subjects to kick a soccer ball15.
A controlled laboratory study using a
Prior to participation, all subjects were
repeated-measure, counterbalanced design
informed about the testing procedures.
was used to evaluate mean activation
Subjects
patterns of selected
participation by reading and signing a
lower extremity
denoted
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
their
voluntary
Page 5
[Research Report] University approved informed consent
Conditioning Association3 and practiced
form. Rights of subjects were protected.
these exercises to the beat of a metronome (20 beats per minute) to familiarize
Data collection and processing
All data were captured in a single testing session. A repeated measures study design was used where independent variables included three variations of squat exercises (double-leg squat, wide double-leg squat and split squat) whilst wearing either an unstable shoe construction or regular training shoes. The MBT Mahuta model
themselves with each exercise. Prior to testing, subjects warmed up by using a stationary bike at submaximal speed for 5 minutes and practiced all three exercises, without load, for a few repetitions. All warm-up activities were supervised and monitored by the investigators to reduce the possible effect of fatigue.
was used in the unstable shoe condition
Subjects then performed all three squat
(Figure 1). The conventional street shoes
exercises (double-leg squat, wide double-
of the participants were used as the regular
leg squat and split squat) for the test
(control) shoes. Exclusion criteria for the
situations with both normal and unstable
regular shoe were: heeled shoes, open
shoes. Figure 2 shows how the split squat
shoes or sandals. Dependent variables
was performed. To account for possible
were defined as the total mean activity
fatigue effects between both test situations,
(ÂľV) for the selected lower extremity
half of the subjects started with the
muscles during squatting.
unstable shoe construction, the others
Ten days prior to the testing session, the subjectsâ&#x20AC;&#x2122; individual muscular endurance training loads were determined. The external load was determined were the subjects were able to perform a maximum of about 25 repetitions for the double-leg squat3. This load then was used for all exercises and test sessions. Subjects were instructed on how to perform all three squat
exercises
in
accordance
with
guidelines of the National Strength and
started with regular shoes. Each subject then performed six repetitions for each squat exercise and for each test situation to a metronome, set at 20 beats per minute, to ensure similar rates of motion among both test situations16. Subjects were instructed to flex the hip and knee joints at one beat, getting to the lowest squat position and then extending hip and knee joints again to get back to the starting position with the following beat. After a brief rest period this procedure was repeated until six trials
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 6
[Research Report] for each squat were captured. Between the
gastrocnemius medialis of the dominant
different squat exercises, rest periods of 5
leg
minutes were given to each subject to
recommendations18.
ensure that fatigue was not an issue.
electrode was placed at the centre of the
Furthermore, individual stance width, foot
patella. In general, electrodes were placed
progression angle and step length (for the
along the longitudinal axes of each muscle
split squat) for each subject were marked
having the electrode pair itself placed
on the floor and used to establish same
above the most prominent aspect of each
foot position within each subject when
muscle. Muscles were selected according
wearing regular and unstable shoes.
to their functional contribution to squat
according
to
the
SENIAM
One
reference
exercises. Raw EMG data were captured EMG is a valuable technique for studying human movement, evaluating mechanisms involving neuromuscular physiology, and diagnosing neuromuscular disorders17. In this study, EMG data were captured using pre-gelled
bipolar
Ag/AgCl
surface
electrode pairs (Blue Sensor SP, Ambu GmbH,
DE),
a
portable
4-channel
telemetry EMG system (MyoTrace 400, Noraxon, US ) and the software Myo Research (XP Master’s Edition 1.07). The EMG amplifier base gain was 1000 with a bandwidth frequency of 20 to 500 Hz, an input impedance of >100 MΩ and a CMR of >100 dB. Prior to electrode placement the skin was shaved, slightly abraded and disinfected with alcohol. The circle shaped electrodes, with a 3 mm sensor-diameter, 13 mm gel-area and an inter-electrode distance of 35 mm were placed in a bipolar configuration at the vastus medialis,
using a sampling rate of 1000 Hz. EMG signals were full wave rectified and smoothed using a RMS with a window length of 100 ms. The beginning and end of each repetition for each squat were manually determined by one assessor by assessing when muscle activity was at baseline during rest periods, when muscle activity began to rise during descent and reached activity of rest periods again after ascent.
Maximum
differences
in
determined time intervals among each subjects’ repetitions were typically less than 8% for each squat and shoe condition. Mean muscle activity was determined by calculating the mean amplitude value (µV) of each trial. The mean amplitude value of a selected analysis interval describes best the gross innervation input of a selected muscle for a given task, because it is less sensitive
to
duration
differences
of
gluteus maximus, tibialis anterior and
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 7
[Research Report] analysis intervals than the integrated EMG
activation amplitudes between both test
and therefore, is very applicable for
situations for all exercises. ANOVA was
comparison analysis19.
run separately for all four muscles. Data were analysed and processed using a
After electrode cables were secured using elastic adhesive tape to reduce movement artefacts, the investigator inspected the correct placement of the electrodes during standing and during a squat. Then raw EMG traces were inspected during rest and contraction for clear signals with minimal offset. Because EMG data were captured without removing electrodes or altering placement between both test sessions,
custom written programme in MatLab. Statistical analysis was conducted using IBM SPSS Statistics 19. The level of significance was set a priori at 0.05 for all analyses. Reliability of all mean muscle activity parameters, based on the data from three trials under each condition, were assessed using a two-way random effects model intraclass correlation coefficient (2,1) for absolute agreement (ICC).
subjects acted as their own control. Therefore, amplitude normalisation was not required
20,21
Results
. For all mean muscle
The values for ICC for the mean muscle
activity parameters, the data from three
activation showed very good agreement
trials under each condition were averaged
reliability of 0.89 (95%CI: 0.87 to 0.90).
for each subject and used for statistical
No significant interactions were found for
analysis. Because the signals of one
the ANOVA when comparing muscle
subject showed high signal artefacts, the
activities between the shoe conditions
data was not considered in the analysis.
across squat exercises. However, there was
Therefore analysis was performed using 11
a significant main effect for the shoe
subjects.
condition. When averaging across all squat
Statistical Analyses
A two-way repeated-measures ANOVA using two within-subject factors (squat exercise: double-leg squat, wide doubleleg squat and split squat; and test situation: with regular and unstable shoes) was utilised to identify total difference in mean
exercises, the average vastus medialis and tibialis
anterior
significant
activities
increase
when
showed
a
using
an
unstable shoe construction compared to the regular shoe condition, F(1,10)=14.034, p=0.004,
respectively
F(1,10)=18.200,
p=0.002. Total muscle activation increased for the vastus medialis 8.9% (95%CI:
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 8
[Research Report] 2.85% to 14.95%) from 245.8±104.1 µV
different types of squat exercises using an
to 268.3±113.8 µV when using unstable
unstable shoe construction and a normal
training shoes compared to regular shoe
pair of training shoes. It was hypothesised
constructions. The tibialis anterior showed
that the use of unstable shoe constructions
an increase of 12.6% (95%CI: 6.10% to
will increases the mean activation of lower
19.10%)
extremity muscles during squat exercises.
from
171.9±64.2
µV
to
192.8±71.6 µV when using an unstable shoe. Both the gluteus maximus and gastrocnemius medialis failed to reach
In this study an overall increase of muscle activity was found for the vastus medialis and tibialis anterior when wearing unstable
significance.
training shoes during squat exercises There were also significant exercise effects
compared to normal shoes. Both the
present for gluteus maximus, vastus
gluteus
maximus
medialis
medialis
failed
and
gastrocnemius
medialis,
and to
The
gastrocnemius
reach
statistical
F(1.023,10.23)=13.440, p=0.004, F(2,20)=
significance.
increased
muscle
6.961, p=0.005, F(2,20)=24,292, p=0.000.
activity, when using an unstable shoe construction, is in accordance with the data
Figure 3 and Tables 1 and 2 give an overview
of
statistical
analyses
and
descriptive statistics for all muscles and exercises in both test sessions.
of Maior et al.22 who also have found greater
muscle
activation
for
the
quadriceps when using an unstable surface. They found an increase of muscle activity
Discussion
for the vastus lateralis, rectus fermoris and
Research suggests that the combination of
vastus medialis of 21%, 18% and 16% and
strength
exercises
with
training
on
assumed that an unstable condition may be
unstable
surfaces
can
stress
the
incorporated in some periods of strength
neuromuscular system to a greater extent
training to increase quadriceps muscle
than traditional training methods using
activity. In contrast Li et al.23 did not
more stable conditions14,22. Therefore, the
observe
purpose of this study was to compare mean
activation when using unstable surfaces.
activation of the gluteus maximus, vastus
They examined muscle activities for the
medialis,
and
soleus, vastus lateralis, vastus medialis,
three
rectus femoris, biceps femoris, gluteus
gastrocnemius
tibialis medialis
anterior during
any
differences
in
muscle
maximus, gluteus medius and upper
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 9
[Research Report] lumbar erector spinae during a deep squat
shoe. This could in consequence increase
task on the Reebok Core Board in
the external plantarflexion moments which
comparison to stable conditions.
will need higher activation of the tibialis anterior to sustain stability.
Most studies assessing mean muscle activity during an exercise situation used
The unstable shoe construction used in this
soft pads or similar devices as unstable
study has, next to the rounded sole, a
surfaces22â&#x20AC;&#x201C;25.
best
cushioned heel, which increases instability
knowledge this study is the first using
by its soft material in the medio-lateral
unstable shoe constructions as unstable
direction. The increased muscle activation
surfaces. These shoes have a rocker
of the vastus medialis may be ascribed to
bottom, which provides instability in the
the medio-lateral instability induced by the
anterior-posterior and the medio-lateral
cushioned
directions. The increased activity of the
medialis is primary a major knee extensor.
tibialis anterior found in this study during
Several authors have observed increased
the squat exercises may be ascribed to this
muscle activation of the vastus medialis
anterior-posterior rounded shape of the
and/or vastus lateralis while walking with
unstable shoes. While performing the squat
unstable shoes, especially during first half
exercises and flexing/extending knee and
of stance phase7,10. This increase of muscle
hip joints, the unstable shoes decrease
activation as well as concomitant co-
stance stability in the anterior-posterior
contraction of these muscles may be
direction and, therefore, the plantarflexors
ascribed to the increased instability during
and dorsiflexors have to be higher
gait and therefore as a mechanism to
activated than with regular shoes, although
manage instability10,26. However, another
only the tibialis anterior showed
a
explanation for the increased activity of
significant increase. One reason for the
the vastus medialis during squatting could
gastrocnemius medialis failing to reach
be the rounded anterior-posterior shape of
significance could be the high variability
the unstable shoes. As mentioned above,
in the data, especially for the double leg
an evoked posterior shift of the center of
squat and the split squat (Figure 3).
mass may be present, resulting in the need
Another reason might be a provoked
for an increased knee extensor torque.
posterior shift of the centre of mass due to
Another muscle which is involved in
the rounded anterior-posterior shape of the
frontal knee plane alignment is the gluteus
To
the
authors`
heel,
even
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
though
vastus
Page 10
[Research Report] maximus27. Therefore, one would expect
when performing a squat. They found that
greater muscle activation when increased
a progressively increased trunk tilt tends to
medio-lateral stance instability is present,
increase muscle activity of the hamstrings
but no changes in muscle activity were
and decrease muscle activity of the
observed in this study. Whether or not this
quadriceps. Future studies therefore should
is in consequence of the partly high
consider
variability of the data or the inability of
position. The use of a metronome for
unstable shoes in increasing muscular
establishing quasi-similar rates of motion
activation cannot be distinguished.
among test situations may also have a lack
monitoring
hip
and
trunk
of accuracy in controlling motion speed This study is subject to several limitations. The use of young healthy subjects, in general, limits the application of the findings of this study to patients and clinical settings. However, findings can be used in the setting of prevention, health promotion and strength training. Although shoe order was counterbalanced to protect against order effects, exercise order was not
randomised.
This
could
have
introduced a fatigue effect for the different squat exercises. The purpose of this study was to investigate differences between two shoe
conditions
and
not
differences
between squat exercises, and therefore any effects may be considered as negligible. As highlighted by Lubahn et al.27 trunk lean and pelvis position can have an influence on the magnitude of muscle activation. This was also shown by Ohkoshi et al.28 who analysed anterior cruciate ligament loading for different
between all performed trials. Determining time intervals for squats manually as well as calculating mean activation over the concentric and eccentric phase of the entire squat cycle may also have been a limitation in this study. While depend parameters
seemed
to
introduced
variability
be
reliable,
could
have
eliminated some important differences. Another limiting factor in this study is the use of unnormalized EMG data to quantify differences between the two test situations. Even though, other authors20,29 have adopted similar methods in analysing muscle
intensities
it
may
be
more
advantageous for future studies to use normalized data. In addition future studies may
also
include
inverse
dynamic
approaches in combination with EMG. In respect to the limitations mentioned above, results of this study show that the use of unstable shoe constructions in
knee flexion angles and trunk positions
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 11
[Research Report] healthy subjects lead to a slight increase of
References
muscle activation of the vastus medialis (9%) and tibialis anterior (13%) when performing
squat
exercises.
Our
hypothesis that squatting in unstable shoes increases muscle activation of lower extremity muscles can only be supported to a certain extent. Even though vastus medialis as part of one major muscle group to train with squats, showed a slight increase, no changes were observed for gluteus
maximus
and
gastrocnemius.
Therefore, unstable shoes at this point of view do not seem advantageous in increasing
muscle
activation
during
squatting. Research needs to address the above mentioned limitations, as well as replicate and extend these findings. Future studies may also evaluate how other types of unstable shoes, as for example toning shoes30, can contribute to muscle activity during exercises.
Conclusion Results of this study show that the use of unstable shoe constructions in healthy subjects lead to a slight increase of muscle activation of the vastus medialis (9%) and tibialis anterior (13%) when performing squat exercises. However, the practical relevance of the relatively small increase of 9% and 13% EMG activity, although statistically significant, may be questioned.
1. Andersen LL, Magnusson SP, Nielsen M, Haleem J, Poulsen K, Aagaard P. Neuromuscular activation in conventional therapeutic exercises and heavy resistance exercises: implications for rehabilitation. Phys Ther. 2006;86(5):683–97. 2. Bade MJ. Early High Intensity Rehabilitation Following Total Knee Arthroplasty Improves Outcomes. J Orthop Sports Phys Ther. 2011;41(12):932–942. doi:10.2519/jospt.2011.3734. 3. Baechle TR, Roger WE. Essentials of strength training and conditioning. Champaign IL: Human Kinetics; 2008. 4. Risberg MA, Holm I, Myklebust G, Engebretsen L. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. Phys Ther. 2007;87(6):737–50. 5. Escamilla RF. Knee biomechanics of the dynamic squat exercise. Med Sci Sports Exerc. 2001;33(1):127–41. 6. Nigg B, Hintzen S, Ferber R. Effect of an unstable shoe construction on lower extremity gait characteristics. Clin Biomech Bristol Avon. 2006;21(1):82–88. 7. Romkes J, Rudmann C, Brunner R. Changes in gait and EMG when walking with the Masai Barefoot Technique. Clin Biomech Bristol Avon. 2006;21(1):75–81. 8. Taniguchi M, Tateuchi H, Takeoka T, Ichihashi N. Kinematic and kinetic characteristics of Masai Barefoot Technology footwear. Gait Posture. 2012;35(4):567–72. doi:10.1016/j.gaitpost.2011.11.025. 9. Landry SC, Nigg B, Tecante KE. Standing in an unstable shoe increases postural sway and muscle activity of selected smaller extrinsic foot muscles. Gait Posture. 2010;32(2):215–219. doi:10.1016/j.gaitpost.2010.04.018. 10. Buchecker M, Wagner H, Pfusterschmied J, Stöggl TL, Müller E. Lower extremity joint loading during level walking with Masai barefoot technology shoes in overweight males. Scand J Med Sci Sports. 2010;22(3):372–380. doi:10.1111/j.1600-0838.2010.01179.x. 11. Stewart L, Gibson JNA, Thomson CE. In-shoe pressure distribution in “unstable” (MBT) shoes and flat-bottomed training shoes: A comparative study. Gait Posture. 2007;25(4):648–651. doi:http://dx.doi.org/10.1016/j.gaitpost.2006.06.01 2. 12. Chmielewski TL, Rudolph KS, Snyder-Mackler L. Development of dynamic knee stability after acute ACL injury. J Electromyogr Kinesiol. 2002;12(4):267–74.
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[Research Report] 13. Williams GN, Chmielewski T, Rudolph K, Buchanan TS, Snyder-Mackler L. Dynamic knee stability: current theory and implications for clinicians and scientists. J Orthop Sports Phys Ther. 2001;31(10):546–66. 14. Kornecki S, Zschorlich V. The nature of the stabilizing functions of skeletal muscles. J Biomech. 1994;27(2):215–25. 15. Bisson EJ, McEwen D, Lajoie Y, Bilodeau M. Effects of ankle and hip muscle fatigue on postural sway and attentional demands during unipedal stance. Gait Posture. 2011;33(1):83–87. doi:10.1016/j.gaitpost.2010.10.001. 16. Bolgla LA, Uhl TL. Electromyographic analysis of hip rehabilitation exercises in a group of healthy subjects. J Orthop Sports Phys Ther. 2005;35(8):487–494. 17. Kamen G, Gabriel DA. Essentials of electromyography. Champaign, IL: Human Kinetics; 2010. 18. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development of recommendations for SEMG sensors and sensor placement procedures. J Electromyogr Kinesiol. 2000;10(5):361–74. 19. Konrad P. The ABC of EMG: A Practical Introduction to Kinesiological Electromyography. Noraxon Inc.: U.S.A; 2005. 20. Edwards L, Dixon J, Kent JR, Hodgson D, Whittaker VJ. Effect of shoe heel height on vastus medialis and vastus lateralis electromyographic activity during sit to stand. J Orthop Sports Phys Ther. 2008;3(2):1:7. doi:10.1186/1749-799X-3-2. 21. Soderberg GL, Knutson LM. A guide for use and interpretation of kinesiologic electromyographic data. Phys Ther. 2000;80(5):485–498. 22. Maior AS, Simão R, Freitas de Salles B, Miranda H, Costa PB. Neuromuscular activity during the squat exercise on an unstable platform. Braz J Biomotricity. 2009;3(2):121–129. 23. Li Y, Cao C, Chen X. Similar EMG Activities of Lower Limbs between Squatting on a Reebok Core Board and Ground. J Strength Cond Res. 2012;[Epub ahead of print]. doi:10.1519/JSC.0b013e318267a5fe. 24. Saeterbakken AH, Fimland MS. Muscle force output and electromyographic activity in squats with various unstable surfaces. J Orthop Sports Phys Ther. 2012;27(1):130–136. doi:10.1519/JSC.0b013e3182541d43. 25. Zemkova E, Jelen M, Kovacikova Z, Olle G, Vilman T, Hamar D. Power outputs in the concentric phase of resistance exercises performed in the interval mode on stable and unstable surfaces. J Strength Cond Res. 2012;26(12):3230– 6. doi:10.1519/JSC.0b013e31824bc197.
26. Horsak B, Baca A. Effects of unstable shoe construction on EMG and lower and upper extremity gait biomechanics. J Biomech. 2012;45, Supplement 1:222. doi:10.1016/S00219290(12)70223-3. 27. Lubahn AJ, Kernozek TW, Tyson TL, Merkitch KW, Reutemann P, Chestnut JM. Hip muscle activation and knee frontal plane motion during weight bearing therapeutic exercises. Int J Sports Phys Ther. 2011;6(2):92–103. 28. Ohkoshi Y, Yasuda K, Kaneda K, Wada T, Yamanaka M. Biomechanical analysis of rehabilitation in the standing position. Am J Sports Med. 1991;19(6):605–611. 29. Goryachev Y, Debbi EM, Haim A, Wolf A. The effect of manipulation of the center of pressure of the foot during gait on the activation patterns of the lower limb musculature. J Electromyogr Kinesiol. 2011;21:333–339. doi:10.1016/j.jelekin.2010.11.009. 30. Horsak B, Baca A. Effects of toning shoes on lower extremity gait biomechanics. Clin Biomech Bristol Avon. 2013;[Epub ahead of print]. doi:http://dx.doi.org/10.1016/j.clinbiomech.2013.0 1.009.
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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[Research Report] Figures
Figure 1. Illustration of the unstable test shoe used in this study. The rounded shape of the sole and the soft heel material induce instability during walking and standing in both the anterior-posterior and medio-lateral directions.
Figure 2. Starting/End position (A), middle (B) and lowest position (C) of the split squat exercise.
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[Research Report]
Figure 3. Total mean muscle activation (A) and mean activation for each squat exercise (B) with 95%CI bounds when performing squats with stable and unstable shoes. Positive values indicate an increase when using the unstable shoe construction. * p<0.05
Tables Table 1. Two-way repeated measures ANOVA for mean (SD) muscle activation during exercises with regular and unstable training shoes EMG (ÂľV)
RS
US
Mean activity*
Mean activity*
GM
51.2 (37.6)
VM GMM TA
Two-way repeated ANOVA
50.9 (37.0)
Shoe effect n.s.
Exercise effect 0.004
Interaction effect n.s.
245.8 (104.1)
268.3 (113.8)
0.004
0.005
n.s.
55.1 (22.4)
58.5 (20.6)
n.s.
0.000
n.s.
171.9 (64.2)
192.8 (71.6)
0.002
n.s.
n.s.
Abbreviations: RS, regular training shoe; US, unstable training shoe; GM, gluteus maximus; VM, vastus medialis; GMM, gastrocnemius medialis; TA, tibialis anterior. n.s., not statistically significant (p>0.05). * Mean muscle activity for all three squat exercises.
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[Research Report] Table 2. Mean differences (95%CI: lower to upper bound) of muscle activity between both test situations for all three squat exercises EMG (%)
Difference (US - RS) DLS
SS
WDLS
GM
3.53 (-14.2 to 21.30)
3.90 (-4.40 to 12.20)
-2.17 (-12.40 to 8.10)
VM
9.65 (-2.69 to 21.99)
8.07 (-4.45 to 20.59)
14.50 (3.85 to 25.15)
GMM
21.83 (-4.66 to 48.32)
3.16 (-31.64 to 37.96)
33.10 (9.63 to 56.57)
TA
10.53 (-0.93 to 21.99)
21.20 (-8.09 to 50.49)
15.31 (4.86 to 25.76)
Abbreviations: RS, regular training shoe; US, unstable training shoe; GM, gluteus maximus; VM, vastus medialis; GMM, gastrocnemius medialis; TA, tibialis anterior; DLS, double-leg squat; SS, split squat; WDLS, wide double-leg squat.
Source of funding: This study was supported by the St. Poelten University of Applied Sciences.
Corresponding Author * Brian Horsak, 3100 St. Poelten, Matthias Corvinus StraĂ&#x;e 15, AT. E-mail: brian.horsak@fhstp.ac.at 1 Department of Physiotherapy, St. Poelten University of Applied Sciences 2 Institute for Sciences and Services in Health, St. Poelten University of Applied Sciences Š 2014 PGIP. All rights reserved.
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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[Research Report]
Effects of low frequency electrical stimulation on fracture healing of long bones of lower limb Sandeep1, Paramjot2, Jagmohan3
ABSTRACT Aims: This study has been designed to see the fracture healing of long bones of lower limb
with low frequency electrical stimulation. Methods: Total 5 adult patients aged above 18 years with non infected fractures with simple,
fresh (< 7 days) traumatic diaphyseal fractures of both bones of leg managed conservatively were included in this study. Electrical stimulation was given to the patients from 0 week to 6 weeks. Radiological views and RUST scores were taken at 0,2 and 6 weeks. Findings: Fracture healing was seen at 2 and 6 weeks. Statistically significant results were
found at initial and final values with p values 0.0022.In all 5 patients, we were able to predict fate of fracture healing process by serial estimation of RUST levels. Conclusion: In the present study, statistically significant improvement in RUST score has
been found after 6 weeks of treatment. Keywords: Fracture, Capacitative Coupling, RUST
Introduction
organic matrix, known as osteoid and its continuous
subsequent mineralization, thus bridging
physiological process to achieve union1.
the gap between two bony fragments
This
is
(bridging callus). This fracture healing
characterized by the production of a new
process should be serially quantifiable /
Fracture
healing
process
of
is
a
fracture
union
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 17
[Research Report] measureable8. Till date, clinically validated
more advanced imaging techniques, such
method to measure healing progression is
as nuclear scintigraphy, is still limited to
not available. So a valid measurement for
only few centers in our country7.
bony union should be desired to measure the bony union process. Thus, the values yielded by measurement should be on a continuous numerical scale17. However till now, researchers have used an end point for completely healed fracture at a point of time without documenting the values signifying progress of union before that time2.
Presently,
commonly
fracture
assessed
healing
clinically
The development of alternative techniques to treat non-union or bone defects offers promising perspectives for a large number of patients. Physicians treating fractures have an increasing variety of options available, some of which can supersede harvest of bone autograft.
is
Physical methods are non-invasive and
and
have been shown to offer beneficial effects
radiologically. The probability of correct
in
radiological evaluation of the stage of
(mechanical
union in fractures of tibia has been shown
stimulation), and in the treatment of
to be only about fifty percent. So, the
hypertrophic nonunion and congenital
radiographic assessment is not an optimum
pseudoarthroses (electromagnetic fields).
method to assess the fracture healing, a
Heckman et al (1997) stated that these
fact borne out by a study on radiological
methods
evaluation of the stage of union in
especially since some have been shown to
6
the
healing
of
fresh
loading,
may
be
useful
fractures ultrasound
clinically,
fractures of tibia . None of the available
reduce substantially the costs of treatment.
measures of union will help in the early
These techniques are non invasive and
detection of problems in the bone healing
inexpensive. Moreover the enhancement of
process,
in
fracture healing is a major issue of health-
outcome i.e. bone union . As the routine
care; with potential benefit for millions of
methods of diagnosis available may not be
patients every year3. There are currently
able to identify the complications like
three different
delayed / nonunion early, so patients will
stimulation
have to suffer for a longer period.
current capacitively coupled and pulsed
Furthermore, it is sometimes hard to
electromagnetic fields.
resulting
into
problems
5
methods of electrical
devices
available:
direct
distinguish early, a delayed union from nonunion radiologically, and the use of
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 18
[Research Report] Direct current devices require surgical
is the need of the hour to explore the
implantation and extraction, necessitating
situation and see the effect of non invasive
two additional surgeries. With direct
methods such as low frequency current on
current devices, one would use a negative
fracture healing.
cathode directly over the impaired healing site. Capacitively coupled and pulsed electromagnetic
field
devices
utilize
electrodes that one places externally on the skin4. Onibere, R. & Khanna, A. (2009) stated that electrical stimulation (ES) is therefore an alternative, less invasive form of treatment which has shown great potential in management of complicated
We designed this prospective case series to analyze the correlation of low frequency electrical stimulation with progression of fracture healing process and to evaluate the relationship
between
low
frequency
electrical stimulation and fracture healing outcome.
Material and Methods
fractures. Various human randomized clinical and animal studies have shown ES
Setting- Experimental study.
to improve fracture healing time, since ES
Location- Department of Physiotherapy,
plays a significant role in the management
Gian Sagar College of Physiotherapy,
of large scale bone defects/fracture11. In a
Banur
prospective
Hospital Ludhiana Punjab India
study
performed
on
35
&
Christian
Medical
College
nonunions treated by stimulation with
Month –April 2012-August 2013
inductive coupling, Sedel et al (1981)
Year- 2012-2013
reported positive effects in 14. There is, to
Participant-Total 5 patients above 18
our
years of age
knowledge,
prospective,
however,
randomised
only
one
double-blind
Nature of sample-Convenience sampling
study which has been performed on the use
Research variables-
of EM for treating pseudarthroses.15
Independent variable- low frequency electrical stimulation Dependent variable-Fracture healing
Further independent research needs to be conducted
to
make
quantified
measurements in vivo, to ascertain the role of these techniques in improving the healing of fractures with identification of
Inclusion
Non infected fractures Fresh (< 7 days) traumatic diaphyseal fractures of both bones of leg Types of Fractures: Transversal fracture, longitudinal fracture and
the most effective non invasive method. It
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 19
[Research Report]
middle or distal third of tibia are included. Only patients who previously were in good health and mobile were included in the material. The patients in the stimulated group have to consent to partaking in the experiment. All patients were to be follows by the same doctor and as far as possible receive a standard treatment.
of two cutaneous electrodes on the opposite sides of the bone to the stimulated. A power source will be attached to the patients cast will connected to the electrodes forming an electric field with the fracture site. Using potentials of 1 to 10V at frequencies between 20 and 200 KHz creates electric fields of 1 to 100 mV/cm which will be efficient for bone
Exclusion
stimulation.
Intervention: Treatment time will be 30
Open wounds Infected fractures, Bone grafted fractures Patients diagnosed with diabetes mellitus (type 1 & type 2) Patients receiving immunosuppressive drugs Those not willing for inclusion in study.
minutes -1 hour 3- × daily. And will be compared with R.U.S.T taken during these visit (monthly intervals). Follow ups were done at admission, after 2nd, 6th week counted from day of trauma and last sample at clinic radiological union or at 6th month.
Study Protocol: After obtaining ethical
clearance
from
departmental
research
review committee, all 5 patients were
Tool
The tool consists of three parts:
(reduction setting and above knee Bi
Part 1: Socio demographic profile and sample characteristics Part 2: Data collection sheet on assessment of fracture by radiological images (X-Ray CT Scans). Part 3: Rust score Clinical Examination: Gentle clinical
valled or long leg splints was applied) All
examination of the fracture site was done
were discharged after 24 – 48 hours with a
at 6th, 10th week, for the assessment of –
standard advice written on discharge card.
skin condition, abnormal mobility, and
We used following research tools in our
bony tenderness. Further, follow up and
study.
management
was
decided
by
the
investigator/
co-investigators
as
per
included in this study from 2012 to 2013. Informed consent was taken. After the recording of demographic characteristics, all 5 patients were managed conservatively
Testing
Procedures
Capacitative
progression of union.
coupling involves non- invasive placement
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 20
[Research Report] Standard
each group, a hypothesis test of the same
plain radiographs of the affected leg
variable over time was carried out using
including knee and ankle joints (AP and
analysis of variance on the repeated
Lateral views) were done and separately
measures. Statistical analysis between
these were assessed by at least 02
groups was performed using a 95%
investigators for evidence of progression
confidence interval of mean. The 5% level
of bony union, if any (as per RUST
was considered significant. All the analysis
score)12. Radiological follow ups were
were done by using SPSS Software (15.0
done at 6, 10 weeks (Further, follow up
version).
and management was decided by the
Results and Discussion
Radiological
investigator/
Examination:
co-investigators
as
per Total 5 patients were enrolled and studied.
progression of union).
Paired t-test was applied on initial and Clinical bone union was defined as the
final.
stage in the healing process when the fracture site was painless (no tenderness), motionless (no abnormal mobility) with presence
of
transmitted
movements.
Radiographic bone was defined when bony callus was evident on at least 3 cortices in standard AP and Lateral views and with
Values
Initial value
Final Values
Mean
4.00
10.25
SD
0.00
1.26
SEM
0.00
0.63
N
5
4
RUST score more than six .The individual cortical scores ( anterior, posterior, medial and lateral) are added to provide a RUST value for a set of radiographs of 4 ( definitely not healed) to 12 (definitely
P value and statistical significance- P value is 0.0022. By conventional criteria, this difference is considered to be very statistically
healed) . Confidence interval:
The
mean
values,
serially
recorded
throughout the follow up period, were compared with others subjects in the same
The mean of Group One minus Group Two equals -6.25 95% confidence interval of this difference: From -8.25 to -4.25.
group at different time intervals. The data collected were entered in Microsoft Excel and were checked for any inconsistency. In
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 21
[Research Report] Intermediate values
injury. The control group was composed of 11 patients treated with a placebo unit.
t = 9.9340 df = 3 standard error of difference = 0.629
There were five cases of nonunion of the tibia in the active group and ten in the
Discussion
control group. Healing was achieved in In our study, changes in RUST score level
60% of the patients treated by capacitative
in 5 patients paralleled the process of
coupling stimulation at a mean of 21
fracture healing as documented by clinico-
weeks, while none of the control group
radiological evidences. Fracture healing
healed.11
was seen at 2nd and 6th week. Statistically significant results were found at initial and final values with p value 0.0022. In all 5 patients, we were able to predict the fate of fracture healing process by the serial estimation of RUST levels. We observed that RUST level at 6 week was correlated with future outcome of these fractures. We may predict the future outcome of these
Similar results were found in the review made by Griffin and Bayat in 201110. Direct current was found to be effective in enhancing bone healing in spinal fusion but only LOE-4 supported its use for nonunion. Eleven studies were retrieved for
capacitive
coupling
with
LOE-1
demonstrating its effectiveness for treating nonunion. The majority of studies utilized
fractures at as early as 6 week.
inductive coupling with LOE-1 supporting In
study
and
its application for healing osteotomies and
Hausman, these potentials could play a
nonunions. In vitro studies by Ryaby
role
demonstrate
in
conducted
by
the
Rubin
process
of
Although
the
healing by changes in growth factors and
study by Scott and King, suggests that
transmembrane signaling although no clear
there are some positive effects of the
mechanism has been defined13. In order to
treatment of nonunionby electromagnetic
mimic these effects, several investigators
stimulation, these results must be assessed
have proposed administering an exogenous
in
trials
electrical field at the site of the fracture.
with
According
mechanotransduction.12
larger
comparing
controlled this
clinical
treatment
that
to
ES
Trock,
enhances
bone
Electromagnetic
conventional autograft procedures. This
fields (EM) can be delivered by direct-
consisted of 23 patients with established
current
nonunion at a mean of 28 months after
electrodes (invasive), inductive coupling
stimulation
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
using
implanted
Page 22
[Research Report] produced by a time-varying magnetic field
Unit Head, Christian Medical College and
(non-invasive), or by capacitative coupling
Hospital, Ludhiana, Dr Uttam B George,
(non-invasive)
16
. Overall, the studies,
Professor And Head, Radio diagnosis,
although in favor of ES application in bone
Christian Medical College And Hospital,
repair, displayed variability in treatment
Ludhiana for the immense support.
regime,
primary
outcome
measures,
follow-up times, and study design, making critical evaluation and assessment difficult. Electrical stimulation shows promise in enhancement of bone healing; however, better-designed clinical studies will enable the optimization for clinical practice.
Conclusion In
the
present
study,
statistically
significant improvement in RUST score has been found after 6 weeks of treatment. Simple
diaphyseal,
fresh
traumatic
fractures, the serial measurement levels during the fracture healing process in combination
with
clinic-radiological
examination can be an additional, useful, reproducible, patient-clinical friendly and cost effective tool in predicting whether fractures
are
at
risk
of
developing
complications like delayed union/nonunion and in aiding the clinician to intervene properly at an appropriate.
Acknowledgement We are grateful to Dr Jagmohan Singh, Principal, College of Physiotherapy, Gian Sagar Medical College, Banur, Patiala, Dr
References 1. Davis B.J et al.Reliability of radiographs in defining union of internally fixed fractures injury .(2005);35(6): 557-561 2. Hammer R et al, Accuracy of radiological assessment of tibial shaft fractures in humans, Clin Orth Res.(1985);19(9):233-238 3. Heckman, J.D. and Sarasohn, Kahn. J. The economics of treating tibia fractures: the cost of delayed union. Bull Hosp Jt Dis (1997);56: 63-72. 4. Jeffrey C et al. Bone stimulation for non-union: What the evidence reveals.Podiatry Today(2011);Vol.24(9):52-57 5. Marsh D.Concepts of fracture union, delayed union and non-union, Clin Orthop (1998);35(5):2230 6. Mc Closkey E.V et alThe assessment of vertebral deformity: a method for use in population studies and clinical trials, Osteoporosis International (1993);3(3):138-147 7. McKibbin BThe biology of fracture healing in ling bones, J Bone Joint Surg Am.(1978); 60(B):150-162 8. Meller Yet al. Meneral and endocrine metabolism during fracture healing in dogs, ClinOrthop (1984); 187:289-295 9. Meister, K et al The role of bone grafting in the treatment of delayed unions and nonunions of the tibia. Orthop Rev(1990); 19:260-271. 10. Michelle, Griffin. & Ardeshir, Bayat. Electrical Stimulation in bone Healing: Critical Analysis by evaluating Levels of Evidence. 2011;11:34 11. R Onibere and A Khanna. The Role Of Electrical Stimulation In Fracture Healing. The Internet Journal of Orthopedic Surgery. (2008.) 11 (2) 12. Rubin, CT. and Hausman, MR. ‘The cellular basis of Wolff’s law: transduction of physical stimuli to skeletal adaptation’. Rheum Dis Clin North Am.(1998); 14:503-517. 13.Ryaby, JT.Clinical effects of electromagnetic and electric fields on fracture healing’ Clin Orthop .(1998);355:205-215. 14 Scott G and King JB. A prospective, doubleblind trial of electrical capacitive coupling in the treatment of non-union of long bones.J Bone Joint Surg Am.(1994);76(6):820-6.
Jeewan S. Prakash, Professor Orthopedics,
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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[Research Report] 15. Sedel et al. Acceleration of repair of nonunions by electromagnetic fields’ Rev Chir Orthop Reparatrice Appar(1981) 16. Trock, DH. Electromagnetic fields and magnets: investigational treatment for
musculoskeletal disorders Rheum Dis Clin North Am.(2002);6:. 51-62. 17. Wade R. and Richardson J.Outcome in fracture healing – a review, Injury.2001;32 (2) ,109-114
Graphs
(RUST) SCORE
RUST SCORE
12
10
10
8
8
6
6 (RUST) SCORE
4
4
RUST SCORE
2
2
0
0 0 week
2nd week
0week
6th week
Figure 1 Patient A Graph representing RUST scores
2nd week
6th week
Figure 2 Patient B Graph representing RUST score
RUST SCORE
14 12
12
10
10
8
RUST SCORE
8
6
6
4
4
2
2
0
RUST SCORE
0 0 week
2nd week
6thweek
Figure 3 Patient C Graph representing RUST
0 week
2nd week
6th week
Figure 4 Patient D Graph representing RUST score
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 24
[Research Report] 25
RUST SCORE
20
12 10
15
8
10
6
5
RUST SCORE
4
Series3 Series2 Series1
0
2 0 0 week
2nd week 6th week
Figure 5 Patient E Graph representing RUST score
Figure 6 Rust score showing variation in patients
Corresponding Author Sandeep Singh Saini College of Physiotherapy, CMCH,Ludhiana Email:sssainicmc@yahoo.co.in Contact-0161-2660044 1. Associate Professor,College of Physiotherapy, Christian Medical College And Hospital,Ludhian, India Contact Detail- 0161-2660044 Fax- 0161-2660044 email-sssainicmc@yahoo.co.in 2. Assistant Professor, College of Physiotherapy, Christian Medical College and Hospital, Ludhiana,India Contact Detail- 0161-2660044 Fax- 0161-2660044 email- dhillonphysio@gmail.com 3. Principal, College of Physiotherapy, Gian Sagar Medical College, Banur, India Contact Detail- 09417222468 email- jagmohansingh@rediffmail.com
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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[Research Report]
Reliability and validity of the three visual assessments of lower limb function comprising FootFAST: a repeated measure cohort study Marian Baxter 1, David McBride, Paul Hendrick, Daniel Cury Ribeiro
ABSTRACT Objective: To investigate the reliability and validity of FootFAST; a novel screening tool. Design: Repeated measures cohort design. Setting: Primary care, three centers involved. Participants: Eighteen participants and eighteen assessors completed the study. Participants
had no previous injury in the last three months prior to data collection. Assessors were recruited from three professional groups: registered sports medicine practitioners, clinical physiotherapists, and New Zealand army medics. All had a minimum of three years clinical experience.
Assessors independently assessed participants according to the FootFAST
protocol on three separate occasions. Inter-rater and intra-rater reliability were investigated. Criterion based validity was assessed by comparing the results from the assessors to objective, software based measures.
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 26
[Research Report] Outcome measures: Cohenâ&#x20AC;&#x2122;s weighted Kappa was used to evaluate the agreement for intra-
rater reliability and criterion based validity. Fleissâ&#x20AC;&#x2122; weighted Kappa was used to evaluate inter-rater agreement. Results: Inter-rater reliability scores of all three test components were K=0.450. Intra-rater
reliability ranged from K=0.890 to 0.940. Criterion based validity ranged from K=0.390 to 0.830. Conclusion: Agreements for all three tests were above the clinically acceptable minimum of
K=0.400 except for the criterion based validity scores of the heel raise test. The results support a continued use of the FootFAST protocol, providing the recommended amendments are made to the heel raise test. Keywords: Reliability, validity, injury risk, screening tool.
Introduction
Thus, the aim of the current study was to
The traditional, but informal, screening
add to knowledge by investigating the
tool utilized within the physiotherapy and
psychometric properties of a recently
sport medicine clinic involves a visual
developed
assessment of function which aims to
FootFAST (Foot Functional Assessment)
identify those who are at risk of overuse
9
injury
screening
tool:
, the three components of which are single
injury 1. For use as a formal screening test
leg stance, hindfoot angle and the heel
the psychometric properties of these
raise test. A recent report suggests that
assessments must be measured, and adhere
these three functional tests have reasonable
to a clinically acceptable level. Clinicians
validity in the identification of overuse
must
assessments
injury risk10. More specifically, FootFAST
justify their
was able to identify between those who did
practices, and the requirement for accuracy
and did not experience a lower limb
be
aware
limitations, be
of
the
able to
of the procedures must be emphasized Research
regarding
the
2, 3
.
psychometric
properties of such tests has been a comparatively recent appearance in the peer-reviewed literature 4. Studies of this nature are somewhat scarce, and the results of such tests have been highly varied, according to a recent review 4-8.
overuse injury during a three month basic fitness training program 10. Despite
this
psychometric
encouraging properties
of
result,
the
the
test,
specifically, inter and intra-reliability and criterion based validity of FootFAST, has not been assessed. Such knowledge is essential if FootFAST is going to be
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 27
[Research Report] recommended as a clinical screening tool.
A pilot test was conducted by the authors
This
the
in order to ensure a robust methodology,
psychometric properties of the three visual
and to calculate participant and assessor
assessments of function which comprise
numbers required for an 80% powered
FootFAST.
study
study
therefore
assesses
11
. Amendments were made to the
proposed methodology based on the
Methodology
findings in order to ensure that there was
Design
minimal ambiguity in the protocol and
A repeated measures cohort study.
instructions. The pilot study indicated that,
Participants, therapists, centers
The participants consisted of eighteen New Zealand army soldiers. None of the participants had a current injury, or had experienced an injury three months prior to
to detect an agreement with a 95% confidence interval width of less than Kappa = 0.200, eighteen assessors and eighteen participants were required.
data collection, that affected their normal
Procedure
ambulation. Participants were recruited
FootFAST consists of three tests which are
from
independently assessed by the practitioner
Burnham
Military
camp,
10
Christchurch, New Zealand.
. The first test is an assessment of
hindfoot angle, and involves a visual The
assessors
consisted
of
eighteen
clinically experienced practitioners, with a minimum of three years of clinical practice. Assessors were recruited from three professional groups, who represented practitioners who would typically use such a
tool:
physiotherapists
six from
musculoskeletal the
School
of
Physiotherapy, University of Otago, six sports medicine practitioners and six New Zealand army medics who were stationed at Burnham military camp during October
estimation of the angle of the hindfoot, as the patient stands in a neutral pose, facing away from the practitioner. The second test is an evaluation of a single leg stance performance. The practitioner assesses the performance
based
on
the
patientâ&#x20AC;&#x2122;s
steadiness, and how long they can maintain the posture. The final test is an assessment of a heel raise performance, which is similarly graded based on the stability
and
effectiveness
of
the
movement.
2012. Assessors were asked to score the tests according to the FootFAST protocol
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
10
.
Page 28
[Research Report] The procedure is described in detail in
camera view and perpendicular to the
Table 1, but to provide the material for the
floor. This distance was used for scalar
assessors the hindfoot angle was recorded
calibration of these images when they were
in a still image (both with and without
viewed within the computer assisted
anatomical markers), the single leg stance
design (CAD) software program- Silicon
and heel raise test were by video footage.
CoachTM.
The images were presented in randomized sequence on a DVD sent to each assessor; the sequence generated by the random function in Microsoft Excel, and was randomized again for the two further repeated assessments, giving three sets of scores from each assessor.
Once an initial image was captured, joint markers and anatomical reference marks were placed on the participant. These mark/ers were placed in similar locations as used by Davison et al
14
, and included:
one on each ankle malleolus, one on the lateral epicondyle of the tibia, one on the
Data collection
medial epicondyle of the fibula, one on the
Hindfoot angle. The participant was in
proximal head of the calcaneus, one on the
bare feet and wore clothing above knee
fusion point of the gastrocnemius muscle
level. The distance between the ischial
and the Achilles tendon, and two marks
tuberosities (identified through palpation)
2cm in length on the lateral and medial
was measured using a 1.5 meter measuring
borders of the calcaneus where they made
tape. Lines were drawn on the ground,
contact with the ground. The participant
perpendicular to the wall, the distance
was returned to the same position as
apart as measured between the ischial
described, and a second image was
tuberosities. The participant placed both
captured.
feet on these lines, with the line running through the middle of their heel and then under the second toe. Although this may not be indicative of typical stance, it minimizes parallax error as the heel is optimally aligned within the optical field of view. 12, 13
Single leg stance. All marks and markers
were removed from the participant. The environment was set up as follows: The RS ScanTM was placed in the center of the room so that the participant could not fall or use a wall for support. Cameras were placed on the medial side and to the front
A distance reference line 10cm in length
of the planted foot. To avoid parallax error
was drawn on the wall, within the field of
the cameras were placed as far from the
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 29
[Research Report] mat as possible (12.5m, the length of the
differences between scoring outcomes was
laboratory floor), and perpendicular to the
conducted during the pilot test. It was
mat. The foot and the lower half of the
determined that the reliability of assessors
shank were included in the field of view.
from all three clinical groups were not
The participants stood on the RS ScanTM
statistically different (p-values of 0.523 to
mat with their foot pointing parallel to
0.898), and therefore no distinction was
longest side, and were instructed to stand
made as regards occupation.
in their normal posture. When instructed to, the participant lifted one foot off the ground and attempted to remain balanced for as long as possible. Once the participant could no longer maintain balance the trial was accepted as being complete. There were no practice attempts and no repeated trials. Heel raise. The environment was the same
as that for single leg stance. When instructed to, participants lifted one foot off the ground and attempted to rise unto the toes of the planted foot. The participant was requested to; if possible, remain at their maximum height reached on their toes for about three seconds. Again, there was only one attempt allowed for this test and no repeated trials.
Statistical analysis
Linear weighted Cohen’s Kappa scores were used to assess intra-rater reliability and
criterion
based
validity.
Linear
weighted Fleiss’ Kappa test provided scores of inter-rater reliability. For intrarater reliability, each assessor (N=18) completed the entire FootFAST protocol on three occasions. Cohen’s weighted Kappa score was calculated to determine the within assessor agreement level. Criterion based validity was assessed by comparing the assessor scores with those obtained from software based technology. Cohen’s Kappa was used to determine the agreement level between the assessors and the relevant software for each of the three tests.
Data analysis
For all outcomes, the clinically acceptable
Results
minimum level of agreement was taken as
No Participant characteristics are presented
Kappa greater than 0.4, as described by
in
Table
2.
The
results
from
the
15
Sim and Wright .
calculations
Outcome measures
reliability, and criterion based validity are
Each of the three tests was analyzed independently.
A
p-value
test
of
inter
and
intra-rater
presented in Table 3.
for
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 30
[Research Report] The level of intra-rater agreement was
facilitated fine tuning of the protocol and
classified as ‘very high’ across all three
instructional material, also conducive to
tests (K=0.890 to 0.940). The level of
optimal levels of reliability and validity 18.
inter-rater agreements were consistently
The inclusion of experienced assessors
K=0.450 across all three tests, and met the
also tends to improve reliability 7,
clinically
main weakness was that the assessment
acceptable
minimum
of
K>0.400. The results of the criterion based
16
. The
was, to some extent, a simulation.
validity agreements scores ranged between poor and very good (K=0.390 to 0.830). The criterion based validity comparison for the heel raise test was below the
There were similar studies identified in the literature. Haight
7
also investigated the
inter-rater and intra-rater reliability, and criterion based validity of a visually based
acceptable minimum (K=0.390).
hindfoot angle assessment, and results
Discussion
were similar to those reported here (ICC =
Our principle finding was that inter and
0.56-0.65, ‘satisfactory’; ICC = 0.88-0.98,
intra-rater reliability and criterion based
‘excellent’;
validity of the three tests comprising
‘acceptable’ respectively). In their study,
FootFAST are at a clinically acceptable
two blinded assessors visually measured
level, the single exception being the
eighteen participants on two occasions,
criterion based validity assessment for the
and
heel raise test. Further to this, the narrow
assessments made using a goniometer.
95% confidence interval widths gained across all agreement scores (less than K=0.200) suggests that there is little variability in the results 11.
and
results
19
Trojian assessors)
were
(forty and
participants,
ICC
=
compared
with
participants,
Finnoff
three
0.64-0.95,
20
assessors)
two (thirty also
investigated the inter-rater reliability of a
A key strength of the current study was the
single leg balance test. Both previous
simplicity of
studies reported inter-rater reliability of
the
FootFAST
scoring
20
system, a factor previously shown to
‘high’ or better. Further, Finnoff
decrease variability5,
. The quality of
assessed intra-rater reliability and found an
the images presented is also important 5, 17;
ICC=0.88. There were some differences
and we achieved standardisation in terms
between the results of the current and
of field of view, lighting and proximity to
previous studies with respect to scoring-
the camera. The feasibility study further
Trojian
16, 17
19
required either a ‘pass’ or ‘fail’
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 31
[Research Report] outcome, and Finnoff
20
scored the tests
latter is a time-to-boundary assessment,
based on observable faults. Despite these,
which
the results of previous studies are in
spatiotemporal characteristics of postural
agreement with the results of the current
control,
study.
detecting postural unsteadiness
Dennis et al 21 performed an inter-rater and
is
used
and
has
to
quantify
been
the
validated 22,
in 23
,
however, further research is needed to identify its limitations.
intra-rater reliability assessment of a calf raise test, which is essentially the same as
Implications for clinical practice
the heel raise test investigated in the
Our findings support those of a previous
current study. They identified ICC>0.80
study
for both inter and intra-rater reliability,
the FootFAST tool are at a clinically
which is in agreement with the reliabilities
acceptable
reported in the current study (K=0.450 to
promise as a screening tool which can
0.940). Unfortunately, no previous studies
support injury prevention programmes.
of comparison were identified which
However, we do caution that the results
investigated the criterion based validity of
may only be generalizable to assessors
either single leg balance or the heel raise
with a minimum of three years of clinical
test.
experience, novice practitioners might not
10
, that psychometric properties of
level.
It
therefore
shows
be expected to give the same results 7. The knowledge that the heel raise test does not meet the minimum standard for
The one-on-one ‘digital’ assessment of a
criterion based validity highlights the
realistic patient achieved a high level of
potential need for further development of
ecological validity, however it was not a
the test. Although it is beyond the scope of
real-time assessment, thus diminishing the
the current paper to develop this further,
external validity of the investigation. A
there are a number of potential options to
‘real
explore in this regard: restructuring of the
benefits: it allows the practitioner to view
measurement process used within the test,
the patient from any number of angles;
considering why the test is used and how it
facilitates examination of the complete
is scored, investigating the criterion the
patient and provides the opportunity to
test is scored against, or perhaps changing
perform several other tests. Because of
the comparison for the criterion based
this, although our results are promising,
validity assessment. One option for the
we cannot be certain whether we could
life’
assessment
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
has
additional
Page 32
[Research Report] replicate these findings in a real life
the clinical setting to confirm the screening
setting. Previous research has indicated
properties
that the agreement between video and real-
prevention.
time
assessments
performed
physiotherapists is highly variable
by 24
. It
may be that because the assessors in the current trial were able to replay the images as many times as they wish, and utilise ‘pause’ and ‘slow time’ features, that the performances were easier to grade. Future research should be
directed towards
of
FootFAST
in
injury
Acknowledgement The authors wish to thank all volunteers from
the
Dunedin
School
of
Physiotherapy, the New Zealand Sports Medicine Society, and the New Zealand army for
their
time
and
effort
in
completing this study.
investigating these assumptions when FootFAST is performed under clinical conditions.
Conclusion Given the lack of reliable data, the justification
for
clinical
use
of
functionally-based assessments of injury risk has been somewhat controversial. The current investigation has contributed to an under-developed
area
of
research.
However, there is a need to investigate other functionally-based assessments of injury risk to find out which are suitable, which need revision, and which should be discontinued. In summary, we find support for the continued use of the hindfoot angle and the single leg balance test. We suggest that the heel raise test be revised to improve reliability and criterion based validity. Further research should be carried out in
References 1 Lawry GV. Systematic musculoskeletal examinations. California: McGraw-Hill 2012. 2 Whatman C. Physiotherapist agreement when visually rating movement quality during lower extremity functional screening tests. Physical Therapy in Sport. 2012; 13: 87-96. 3 Whatman C, Hume P, Hing W. The reliability and validity of physiotherapist visual rating of dynamic pelvis and knee alignment in young athletes. Physical Therapy in Sport. 2012; 14: 16874. 4 Baxter M, McBride DI, Cury-Ribeiro D, Hendrick P. Psychometric properties of lower limb and lower back injury risk assessment: A narrative review. Australian Conference of Science and Medicine in Sport. Phuket 2013. 5 Gabbe BJ. Reliability of common lower extremity musculoskeletal screening tests. Physical Therapy in Sport. 2004; 5: 90-97. 6 Frigg A, Nigg B, Davis E, Pederson B, Valderrabano V. Does alignment in the hindfoot radiograph influence dynamic foot-floor pressures in ankle and tibiotalocalcaneal fusion? Clinical Orthopaedics and Related Research. 2010; 468: 3362-70. 7 Haight HJ. Measuring standing hindfoot alignment: Reliability of goniometric and visual measurements. Archives of Physical Medicine and Rehabilitation. 2005; 86: 571-75. 8 Takala EP. Do functional tests predict low back pain? Spine (Philadelphia, Pa 1976). 2000; 25: 2126. 9 Baxter M, McBride DI, Milosavljevic S, Hendrick P. A background and justification of the novel injury risk assessment protocol: FootFAST.
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 33
[Research Report] Australasian Podiatric Societies Annual Conference. Sydney 2011. 10 Baxter ML, Baxter DG, Baycroft C. Lower limb injuries in soldiers: Feasibility of reduction through implementation of a novel orthotic screening protocol. Military Medicine. 2011; 176: 291. 11 Donner A. Sample size requirements for reliability studies. Statistics in Medicine. 1987; 6: 441-48. 12 Garzia RP. Foundations of Binocular Vision: A Clinical Perspective. New York: McGraw Hill 2000. 13 Simpson JA, Weinar ESC. The Oxford English Dictionary. London: Clarendon Press 2002. 14 Davidson PL. Examination of interventions to prevent common lower-limb Injuries in the New Zealand defense force. Military Medicine. 2009; 174: 1196. 15 Sim J, Wright CC. The kappa statistic in reliabiltiy studies: use, interpretation and sample size requirements. Physical Therapy. 2005; 85: 257-68. 16 Murphy DR. Interexaminer reliability of the hip extension test for suspected impaired motor control of the lumbar spine. Journal of Manipulative and Physiological Therapeutics. 2006; 29: 374. 17 Eechaute C, Vaes P, Duquet W. The dynamic postural control is impaired in patients with chronic ankle instability: reliability and validity of the
multiple hop test. Clinical Journal of Sport Medicine. 2009; 19: 107-14. 18 Meijne W, Neerbos K, Aufdemkampe G, Van Der Wurff P. Intraexaminer and interexaminer reliability of the Gillet test. Journal of Manipulative and Physiological Therapeutics. 1999; 22: 4-9. 19 Trojian TH. Single leg balance test to identify risk of ankle sprains British Journal of Sports Medicine. 2006; 40: 610-13. 20 Finnoff JT, Peterson VJ, Hollman JH, Smith J. Intrarater and interrater reliability of the Balance Error Scoring System (BESS). Physical Medicine and Rehabilitation. 2009; 1: 50-54. 21 Dennis RJ, Finch CF, Elliot BC, Farhart PJ. The reliability of musculoskeletal screening tests used in cricket. Physical Therapy in Sport. 2008; 9: 9. 22 Hertel J. Time-to-boundary measures of postural control during single leg quiet standing. Journal of Applied Biomechanics. 2006; 22: 67. 23 Hertel J, Olmsted-Kramer LC. Deficits in timeto-boundary measures of postural control with chronic ankle instability. Gait and Posture. 2007; 25: 33-39. 24 Wiles C, Newcombe R, Fuller K, Jones A, Price M. Use of videotape to assess mobility in a controlled randomized crossover trial of physiotherapy in chronic multiple sclerosis. Clinical Rehabilitation. 2003; 17: 256-63.
Tables Test Number 1 Hindfoot angle
2 Single leg stance
3 Heel raise
Assessment outcome Ideal rearfoot alignment Slightly everted Excessive eversion Inverted rearfoot greater than 4 degrees Stable Mild instability Unstable Laterally unstable Grossly unstable Smooth transition Unstable Resisted Inversion
Score 0 1 2 3 0 1 2 3 4 0 1 2 3
Table 1 The FootFAST assessment
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 34
[Research Report] Variable Sex Age Height Weight Ethnicity
Range Male (N=18) 18 to 25 years 163 to 184cm 72 to 112kg Maori (N=9) Pacifica (N=1) Asian (N=2) European (N=6)
Table 2 Characteristics of participants included in this study (N=18)
Test
Hindfoot angle
Single leg stance
Heel raise
Linear weighted Cohen’s Kappa test scores for intrarater agreement (95% confidence interval) Linear weighted Fleiss’ Kappa scores for inter-rater agreement (95% confidence interval) Linear weighted Cohen’s Kappa test scores for criterion based validity assessments (95% confidence interval)
0.920 (0.881 to 0.958)
0.890 (0.839 to 0.941)
0.940 (0.860 to 1.000)
0.450 (0.399 to 0.502)
0.450 (0.418 to 0.481)
0.450 (0.400 to 0.499)
0.448 (0.375 to 0.521)
0.830 (0.750 to 0.911)
0.390 (0.305 to 0.445)
Table 3 Kappa test scores for intra and inter-rater reliability, and criterion based validity of the three tests comprising FootFAST. Corresponding Author Marian Baxter, Marian.Baxter@aoraki.ac.nz. Aoraki Polytechnic, 32 Arthur Street, Private Bag 902, Timaru 7940. Phone: 006436855722, 0064273782757. *David McBride: University of Otago. david.mcbride@otago.ac.nz **Paul Hendrick: University of Nottingham. Paul.Hendrick@nottingham.ac.uk ***Daniel Cury Ribeiro: University of Otago. daniel.ribeiro@otago.ac.nz The corresponding author receives a PhD scholarship from The FootScience Foundation NZ. All authors receive funding in the form of salaries from their respective educational institutions. © 2014 PGIP. All rights reserved
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 35
[Research Report]
A Pragmatic approach to the development of a therapeutic protocol for enhancing motor control and coordination in chronic stroke patients â&#x20AC;&#x201C; Review Study Shashank Ghai1*, Ishan Ghai2
Abstract: This review shall help to present an ideological therapeutic practice for management of patients suffering from stroke especially with chronic duration. This incorporates evaluating, execution and arrangements of different treatment and maneuvers applied in the treatment, in a significant order, so as to enhance and produce early rehabilitation. Various rehabilitative techniques for instance relaxation technique, inhibition technique, facilitation technique, mobilization maneuvers, proprioceptive facilitation techniques in a specific pattern, might produce an efficient and viable rehabilitative approach. Formulating a functional exercise regime, post initiation of these techniques, shall produce effective results, adding to the benefits in a better rehabilitation process. In addition to these techniques, a regular motivating approach with the patient, repetition of such techniques and exercise regimes on regular
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 36
[Research Report] intervals and encouraging the patient to perform the given activities, while verbalizing them, are very important and has been found to be extremely effective. The application of manual techniques, under guidance of a highly skilled physical therapist shall have proven productive results, extremely beneficial in rehabilitating stroke patients. Keywords:
Therapeutic,
Maneuvers,
Relaxation,
Inhibition,
Facilitation,
Mobilization,
Proprioceptive
Introduction:
a sudden initiation of neurological signs many worst
and symptoms as a result of interruption in
neurological ailment ever encountered, it
blood supply to definite regions in the
affects both the physical as well as the
brain. A stroke arises as a result of
mental aspect of the patient.. If this
cerebrovascular mishaps, which could be
condition is not attended immediately the
characterized as Ischemic or hemorrhagic.
patient is left with severe physical and
Roughly
mental disabilities, fully dependent on the
cerebrovascular mishaps are as a result of
family /society for its care. Further, as the
Ischemia, twenty percent occur as a result
time passes, the physical and mental
of hemorrhage and the remaining ten
condition of patient further deteriorates1. A
percent are of idiopathic origin3-5.
majority of patients fail to recover and lead
ď&#x201A;ˇ
Stroke
is
one
of
the
a normal healthy life. The stroke affects
Ischemic CVA - It arises from hypoxia
of a stroke and occurs due to hindrance
neurological disability suffered by the
in one of the vital cerebral arteries
adult population throughout the world. It is
middle, posterior and anterior cerebral
the prime cause for about twenty five
arteries or their minor perforating
percent of all accounted deaths in the
branches to deeper parts of the brain.
developed nations; also it is one of the
They may happen as an outcome of
major causative factors for permanent
thrombosis and those that resulted
disabilities, most prevalent among the
from a stroke, every year. Stroke stands for
all
blood supply. It is most common cause
be one of the most common reasons of
above the age of forty five years suffer
of
brain tissues as an outcome of scarce
on the entire family. Stroke is depicted to
hundred people, out of every one lakh,
percent
or diminished oxygen supply to the
not only the patient, but also has a bearing
elderly population2. Approximately four
seventy
from an embolus. ď&#x201A;ˇ
Hemorrhagic CVA â&#x20AC;&#x201C; This condition is triggered
by
subarachnoid
hemorrhage,
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
intra-cerebral, arterial-
Page 37
[Research Report] venous deformity and lacunar infarcts
develops
characteristic
patterns
of
8
resulting from irregular bleeding from
hypertonicity or spasticity . Spasticity, a
rupture of a cerebral vessel. The
motor
incidence of the hemorrhage is less
exaggerated deep tendon reflexes and
among people those are younger than
increased muscle tone. It develops from
forty five years of age, furthermore the
hyper-excitability of monosynaptic stretch
chances of stroke grows after sixty five
reflex.
years. The combined cause of intra
spasticity
cerebral hemorrhage includes vessel
resistance to passive stretching of the
malformation and changes in the
involved muscle, hyper-reflexia of deep
integrity of cerebral vessels brought on
tendon
by the properties by hypertension and
extremities in flexion or extension, co-
2, 5
ageing
.
disorder
is
Clinically,
characterized
the
presents
reflexes,
patient
with
by
with
increased
posturing
of
the
contraction of muscles, and stereotypical
Necessity for mobility is the key reasons
movement patterns which are called
for admitting of a patient to an In-patient
synergies. Other impairments may include
restoration department post stroke. A lot of
Sensory
the exertion is engaged in the patients to
impairments,
retain the ability to walk at least in the
respiratory impairments, Bowel bladder
7
home, prior to their discharge . Despite of these efforts majority of the survivors with initial paralysis of the leg do not retain the normal gait pattern, and roughly all other survivors are unable to walk without full physical assistance. The primary clinical manifestation in patients following stroke, is the spectrum of motor problems resulting from damage to the motor cortex. Initially, a patient may present with a state of low muscle tone or flaccidity. Flaccid muscles lack the ability to generate muscle contractions and coordinate movements. This condition of relative low muscle tone is usually transient, and the patient soon
impairments,
Communication
orofacial
impairments,
dysfunction etc9. Objective of Study
The objective of the review study is to enhance the rehabilitation process of a patient suffering from chronic stroke, specifically aiming towards for their speedy motor control and co-ordination10. Our effort shall be conceptualize an ideal exercise regime accompanied by various maneuvering
techniques,
approach
contributing a bit towards easing the suffering of stroke patients, expedite recovery leading to early rehabilitation, thereby paying back for betterment of our society2.
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 38
[Research Report] Relaxation Therapy Maneuvers:
techniques are found to be most effective
Relaxation techniques (Diagram 1.0) are
in case of patients
exceptionally beneficial for promoting
spasticity8.
relaxation in the patients affected by
implemented in order to attain a lower
6
Various
presenting with methods
can
be
chronic stroke . The relaxation technique
tone. The main emphasis is on reflex
helps in reducing the mental stress the
inhibiting
patient suffers whilst he/she is affected by
development of righting and equilibrium
stroke;
the
reactions and the use of key points of
confidence and determination of a patient
control. Also, inhibition of muscle groups
it
helps
in
alleviating
7
patterns
of
activity,
the
towards the treatment .
by influencing the bias placed on muscle
It helps in reducing the spasticity the
spindles through the tendons of Golgi
patient
organ10.
encounters
as
a
clinical
manifestation of chronic stroke.
The goal of the therapy is to oppose the
It helps in reducing the stiffness, which
irregular postural reflex, the actions and
also serves as a clinical manifestation
also to facilitate normal motor patterns and
and arises as a result of immobilization
balance
reactions11.
and sustained spasticity.
activities
mainly
It helps in relaxation and strengthening
segments is important if the desired
of the respiratory component which
outcome is to change the tone more
also
distally. Movement must be superimposed
is
affected
as
a
-clinical
Commencing in
proximal
the body
manifestation of chronic stroke.
on the improved tonal state if carryover is
The relaxation component of the
to occur. Prolonged application of ice
therapeutic protocol can include deep
might be beneficial. Weight bearing is
breathing
another
techniques,
positioning, passive
appropriate
inhibitory
technique.
relaxed
Positioning a limb in an inhibitory pattern
suspension
is extremely important; Air splints could
hydrotherapy, movements,
useful
also
techniques etc.
be
employed
to
assist
with
positioning, tone reduction and sensory Inhibitory Therapy Maneuvers:
The further hypothesis of the proposed study
includes
implementation
and
awareness12, 13. Mobilization of Joints:
execution of Inhibitory techniques and
For refining the range of motion of the
positions
patient’s joint can be accomplished by use
(Diagram
2.0).
Inhibitory
of mobilization maneuvers, it also terms to [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 39
[Research Report] benefit as mobility exercises. In addition to
The
this, mobilizing the joints in the direction
implemented by stimulating:
of facilitation
ď&#x201A;ˇ
of Proprioceptive, neural
facilitation
Cutaneous
methods
receptors:
can
Quick
be
light
and muscular parts patterns has proven to
brushing, application of ice, brisk
be useful14. The range of the particular
stroking by manual touch, tapping etc.
grades of mobilization should be taken
Muscle
very carefully. These manipulations should
unexpected stretch, slow full stretch,
only be executed by a skilled physical
vibrations
therapist.
weight bearing and an approximation
spindle
receptors:
(Mechanical
Quick
vibrators),
of joints etc also executing Primitive Facilitation Therapy Methods
(spinal) or tonic (brain stem) reflexes
It is extremely important to perform facilitation techniques to prepare the patient for the performance of functional activities15. The facilitation techniques are based on the known physiological facts that skeleton-motor units with different enzyme profiles play a distinct role in the control of movement and posture, and how afferent input can influence different controls on these in the Central nervous system16. The Selection of appropriate afferent stimuli is important to exploit the potentiality of tissues to change at the molecular level. This facilitates attainment of motor goals, and helps to prevent perpetuation
of
abnormal
influences
imposed by pathological changes. These are implemented in order to reduce the protective muscle spasm, increase soft tissue range, and elicit normal postural reactions and to strengthen and activate the 17
weaker muscle groups .
are extremely beneficial18. Proprioception, Neural and Muscular Facilitation and Development:
Proprioception is well-defined as the perception of oneself in harmony to the atmosphere
(Diagram
3.0).
The
proprioceptive facilitation methods depend largely
on
stimulation
of
the
proprioceptors (special position sensing receptors) for growing the request made on the neuromuscular mechanism to attain and facilitate its reaction19. Management by these methods aims to summate the effects of facilitation to increase the reaction of the neuromuscular mechanism. Proprioceptive stimulation (Diagram 4.0) is mainly instigated to increase the demands made by intentional efforts, the initiation of some reflex reactions and physiological principles concerned with the interaction of antagonistic muscles are used in a few methods20. Resistance and
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 40
[Research Report] stretch are employed manually to muscles
An exercise regime (Diagram 4.0 – 8.0)
occupied to accomplish patterns of mass
involving simple practical activities of
movement and active instructions provide
day-to-day life is exceptionally vital for
encouragement to the patient’s intentional
teaching normal control and coordination
effort. Maximal resistance is measured to
to a patient27-29. The simple goal is to
be the most vital means for stimulating the
establish control of movement; such that
proprioceptors21. The methods concerned
the patient is able and self-assured in his
with its application are rudimentary.
skill to carry out those activities which are
Methods of emphasis are intended to
vital for freedom in day-to-day life. The
correct
the
intact sensory mechanism of sight, sound
neuromuscular feature of the body22. The
and touch can be utilized for prompt
numerous methods are cited as follows:
results29-31. The additional significant vital
incoordination
within
Movement on patterns (Diagram
issues are attentiveness, accuracy and
5.0, 6.0, 7.0, 8.0).
replications. The rapidity, replication and
Manual contact.
respite periods must be allotted rendering
Stretch stimulus and stretch reflex.
to the patient’s potential. The complication
Traction and approximation
in
Spoken instructions to the patient
progressively through the course of the
Consecutive
therapy.
timing
of
muscle
exercise
designs
should
intensify
contractions.
Other Employable Approaches:
Resistance.
Motivation is an extremely imperative
Reinforcement.
feature of the therapy. It should be
These procedures of the therapy, gain the
instigated
maximum amount of action which could
recovery. A patient suffering from stroke,
be accomplished at each voluntary effort
is not only affected physically, mentally
and the maximum possible number of
but emotionally also. The low down
replications of the activity to stimulate the
sentiment, subtle moral and breakdown is
response23-26. This procedure demonstrates
very common in such patients. It plays a
to be an effective means of gaining and
noteworthy
hastening the patient’s recovery.
rehabilitation of these problems. The
Employable Exercise Regimes:
during
role
the
in
progression
managing
of
the
therapists aim should be to not just employ physical exercise, but also to build an sensitive rapport with the patient, boosting
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 41
[Research Report] their morale and confidence of patients,
First and foremost the implementation
enabling better recovery and preparing
of the Relaxation techniques shall be
them to engage towards future recovery
extremely useful for reducing the
tasks30.
developed
Application of patient friendly
and
stiffness
among the chronic stroke patients3.
methods where the Physical therapist who remains consulted by a sociologist, clinical
spasticity
Followed by this regime, introduction
psychologist, furthermore, he/she conducts
of inhibitory techniques shall prove
a method on various groups of patients,
exceptionally beneficial, as deploying
inspiring them to together speak their
post relaxation techniques to the
actions and execute the actions as they do
patient, the developed spasticity and
so,
stiffness could be effectively reduced.
originally
comparatively
beginning
simplified
with
patterns
of
Inhibitory
techniques
implemented
exercise and during the advanced stages of
against the synergy patterns would not
recovery, continuing to more compound
only help in reducing the developed
and practical activities31. Replications of
spasticity, but also would help in
regime of actions, over sufficient periods
developing
of time, is anticipated, to influence change in muscle unit type so that they are more
movements
32
the 32-33
functional
.
Later, with the introduction of the
suitable to the demands made upon them .
Facilitation
For example, the execution of Frenkel
Mobilization techniques on patients,
movements accomplished at consistent
might prove to be very useful, as the
intermissions with aggregated complexity.
manual mobilization when applied to
techniques
and
the
the affected joints, helps improve the
Probable outcome of this approach:
certain
range of motion at the patient’s joint,
techniques have been conceptualized for
in addition to maintaining the muscle
speedy rehabilitation of chronic stroke
mobility (as the already relaxed spastic
patients.
and stiff muscles would allow the joint
For
the
proposed
Based
research,
upon
my
practical
to move) 34.
experience in treating stroke patients, In this
review,
we
have
formulated
a
The Facilitation techniques on the
Hypothesis, by deploying various physical,
other hand might prove to be effective
sociological & psychological techniques to
when applied with the mobilization
rectify symptomatic manifestations, in the
techniques
patient’s, on one-to-one basis.
spasticity would exert less stress on the
because
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
the
reduced
Page 42
[Research Report]
opposite muscle group and hence its
touch, and hearing, to develop the
implementation would help develop
coordination. The replications are very
and strengthen the weaker muscle
significant; the intricacy, the sessions
groups35.
of exercise must be preceded slowly as
Proprioceptive drills are valuable at
the condition of the patient recovers36-
advanced phase, as during this period
39
the spasticity is reduced; after the
Replication of these procedures on a
mobilization, the range of motion
consistent
increases
significant.
and
the
facilitation
techniques help stimulate the weaker muscle(s)
hence
performing
the
proprioception at this stage might prove
to
be
most
is
extremely
Encouraging the patient at regular
treatment is essential.
Dynamic involvement of the patient in
in
the management is extremely valuable,
improving the coordination patterns
furthermore making the patient speak
within the affected parts.
effective
interval
intervals during the course of the
functional activities that improve the
.
36
the
movement
accordingly
whilst
Presenting plain, functional exercise
accomplishing
regimes at this stage is valuable; the
treatment will deliver supplementary
main
benefits40-43.
module
unharmed
is
sensory
to
employ
aspects
the
2.
3.
4.
5.
throughout
the
vision,
References 1.
it
Adamson J, Beswick A, Ebrahim S. Is stroke the most common cause of disability? J Stroke Cerebrovasc Dis, 2004; 13(4):171-7. Wade DT, Hewer RL. Functional abilities after stroke: measurement, natural history and prognosis. J Neurol Neurosurg Psychiatry, 1987; 50(2):177-82. Post MW, Witte LP, Schrijvers AJ. Quality of life and the ICIDH: towards an integrated conceptual model for rehabilitation outcomes research. Clin Rehabil, 1999;13 (1): 5-15. Wade DT. Epidemiology of disabling neurological disease: how and why does disability occur? J Neurol Neurosurg Psychiatry, 1996; 61(3):242-9. Jackson D, Turner-Stokes L, Williams H, Das-Gupta R. Use of an integrated care pathway: a third round audit of the
management of shoulder pain in neurological conditions. J Rehabil Med, 2003; 35(6):265-70. 6. Langhorne P, Pollock A, Stroke Unit Trialists’ Collaboration. What are the components of effective stroke unit care? Age Ageing, 2002; 31(5):365-71. 7. Langhorne P, Stott DJ, Robertson L, MacDonald J, Jones L, McAlpine C, et al. Medical complications after stroke: a multicenter study. Stroke, 2000; 31(6):1223-9. 8. Bernhardt J, Thuy MNT, Collier JM, Legg LA. Very early versus delayed mobilization after stroke. Cochrane Database of Systematic Reviews, 2009; 1. 9. Chatterton HJ, Pomeroy VM, Gratton J. Positioning for stroke patients: a survey of physiotherapists’ aims and practices. Disabil Rehabil, 2001; 23(10):413-21. 10. Carr EK, Kenney FD. Positioning of the stroke patient: a review of the literature. Int J Nurs Stud, 1992; 29 (4): 355-69.
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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[Research Report] 11. Borisova Y, Bohannon RW. Positioning to prevent or reduce shoulder range of motion impairments after stroke: a metaanalysis. Clin Rehabil., 2009; 23 (8): 6816. 12. Lehrer, Paul M.; David H. (FRW) Barlow, Robert L. Woolfolk, Wesley E. Sime. Principles and Practice of Stress Management, Third Edition, 2007; 46–47. 13. Irvine KN, Warber SL, Devine-Wright P, Gaston K . "Understanding Urban Green Space as a Health Resource: A Qualitative Comparison of Visit Motivation and Derived Effects among Park Users in Sheffield, UK". Int. J. Environ. Res. Public Health, 2013; 10 (1): 417–442. 14. Taub, E., Crago, J.E., Burgio, T. An operant approach to rehabilitation medicine: Overcoming learned non-use by shaping. Journal of the Experimental Analysis of Behaviour, 1994; 61, 281– 293. 15. Schrag A, Jahanshahi M, Quinn N. How does Parkinson’s disease affect quality of life? A comparison with quality of life in the general population. Mov Disord, 2000; 15:1112–1118. 16. Bloem BR, Beckley DJ, van Dijk JG, Zwinderman AH, Remler MP, Roos RA. Influence of dopaminergic medication on automatic postural responses and balance impairment in Parkinson’s disease. Mov Disord, 1996; 11:509 –521. 17. Keus SHJ, Bloem BR, Verbaan D. Physiotherapy in Parkinson’s disease: utilization and patient satisfaction. J Neurol, 2004; 251:680–687. 18. Goede CJ, de, Keus SH, Kwakkel G, Wagenaar RC. The effects of physical therapy in Parkinson’s disease: a research synthesis. Arch Phys Med Rehabil, 2001; 82:509 –515. 19. Hendriks HJM, Bekkering GE, van Ettekoven H, Brandsma JW, van der Wees PhJ, de Bie RA. Development and implementation of national practice guidelines: a prospect for continuous quality improvement in physiotherapy. Introduction to the method of guideline development. Physiotherapy, 2000; 86:535–547. 20. Deane KHO, Ellis-Hill C, Jones D, et al. Systematic review of paramedical therapies for Parkinson’s disease. Mov Disord, 2002; 17:984 –991. 21. Tetreault, P., Krueger, A., Zurakowski, D. & Gerber, C. Glenoid version and rotator cuff tears. Journal of Orthopaedic Research, 2004; 22 (1), 202–207.
22. Urquhart, D.M., Hodges, P.W. & Story, I.H. Postural activity of the abdominal muscles varies between regions of these muscles and between body positions. Gait and Posture, 2005; 22, 295–301. 23. Van Kan, P.L.E. & McCurdy, M. Role of primate magnocellular red nucleus neurons in controlling hand during reaching to grasp. The Journal of Neurophysiology, 2000; 85, 1461–1478. 24. Voight, M. & Thomson, B. The role of the scapula in the rehabilitation of shoulder injuries. Journal of Athletic Training, 2000; 35 (3), 364–372. 25. Willems, J.M., Jull, G.A. & Ng, J.K. An in vivo study of the primary and coupled rotations of the thoracic spine. Clinical Biomechanics, 1996; 11, 311–316. 26. Yue, G. & Cole, K.J. (1992) Strength increases from the motor program: Comparison of training with maximal voluntary and imagined muscle contractions. Journal of Neurophysiology, 1992; 67, 1114–1123. 27. Hakkennes S, Keating JL, Constraintinduced movement therapy following stroke: a systematic review of randomized controlled trial, Aust J Physiotherapy. 2005; 51(4): 221-31. 28. Asanuma, H. Experiments on functional role of peripheral input to motor cortex during voluntary movements in the monkey. J. Neurophysiol, 1984; 52(2):212-227. 29. Basmajian, JV. Motor learning and control: a working hypothesis. Arch Phys Med rehab, 1977; 58(l): 388-41. 30. Hellebrandt, FA. The physiology of motor learning. Cerebral Palsy Rev, 1958; 19:914. 31. Iriki, A- Long term potentiation in the motor cortex. Science, 1989; 245(4924): 1385-1387. 32. Janda, V. Muscles, central nervous motor regulation and bacak problems. In: Korr, I (ed) The Neurobiologic Mechanisms in Manipulative Therapy. Phenurn Press, London, 1978 33. Janda, V. Muscle weakness and inhibition in back pain syndromes In: Grieve, GP (ed) Physical Therapy of the Low Back. Churchill Livingstone, London, 1987. 34. Jarus, T. Motor learning and occupational therapy: the organization of practice. Am J Occup Ther, 1994; 48(9): 810-816. 35. Kabat, H, McLeon, M. Athetosis: neuromuscular dysfunction and treatment. Arch Phys Med, 1959; 40:285-292.
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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[Research Report] 36. Knott, M. Neuromuscular facilitation in the treatment of rheumatoid arthritis. Phys Ther, 1964; 44:737-739. 37. Sady, SP, Wortman, M, and Blanke, D. Flexibility training: Ballistic, static, or proprioceptive neuromuscular facilitation? Arch Phys Med Rehab, 1982; 63: 251. 38. Scholz, JP, Campbell, SK. Muscle spindles and the regulation of movement. Phys Ther, 1980; 60:1416-1423. 39. Voss, DE. Everything is there before you discover it. Phys Ther, 1982; 62(11): 1617-1624. 40. Wardlaw, C. Evaluation and treatment of the movement system with proprioceptive
neuromuscular facilitation. Rehab Training Network Leaming Lab, 1997. 41. Bloem BR, van Vugt JP, Beckley DJ. Postural instability and falls in Parkinson’s disease. Adv Neurol, 2001; 87:209 –223. 42. Garrett NA, Brasure M, Schmitz KH, Schultz MM, Huber MR. Physical inactivity: direct cost to a health plan. Am J Prev Med, 2004; 27:304 –309. 43. Pressley JC, Louis ED, Tang MX, et al. The impact of comorbid disease and injuries on resource use and expenditures in Parkinsonism. Neurology, 2003; 60:87– 93.
Diagram 1.0
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[Research Report]
Diagram 2.0
Diagram 3.0
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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[Research Report]
Diagram 4.0
Diagram 5.0
Diagram 6.0
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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[Research Report]
Diagram 7.0
Diagram 8.0
2.
Corresponding Author *Corresponding Author Depâ&#x20AC;&#x2122;t. Of physiotherapy, Savig Healthcare Clinic New Delhi, India shashank_ghai@live.com Contact +9111- 47541414 shashank_ghai@live.com 1. Physiotherapist, Savig Healthcare Clinic, New Delhi, India. Research Scholar, Jacobs University gGmbh, Bremen, Germany. Š 2014 PGIP. All rights reserved.
Available online at www.pgip.co.uk/jopsm
Postgraduate Institute of Physiotherapy
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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[Research Report]
Effectiveness of Incentive Spirometry with and Without Deep Breathing Exercises In Post-Coronary Artery Bypass Grafting Physical Therapy Management Arooj Fatima*, Ashfaq Ahmed**, Filza Shoukat***, Halima Shoukat****, Mehreen Fatima*****
Abstract Background: Coronary artery bypass grafting (CABG) is a surgical procedure in which the
blocked coronary arteries are bypassed by the blood vessel grafts. Cardiac surgery is associated with an occurrence of respiratory complications. Chest physiotherapy techniques play an important role in preventing or treating post-operative respiratory complications in CABG patients. Study design: Randomized controlled trial. Objectives: To determine the efficacy of incentive spirometry with or without deep
breathing exercises in patients undergoing CABG. Interventions: One group had done incentive spirometry and other group had done incentive
spirometry and deep breathing exercises Randomisation: Out of 40 patients, 20 were randomly allocated into 2 groups by systematic
sampling.
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 49
[Research Report] Results: Study includes 40 participants, Having 20 in each group. By applying paired t-test,
in subjects doing incentive spirometry only, the p-value for arterial oxygen tension (pO2), arterial carbon dioxide tension (pCO2) and oxygen saturation (SaO2) was found to be statistically significant (p=0.000, p=0.006 and p=0.000 respectively), while in subjects doing both incentive spirometry and deep breathing exercises, p-value for pO2and SaO2 was found to be significant (p=0.000, p=0.000), and for pCO2 it was insignificant (p=0.244). With the application of Analysis of Variance (ANOVA), p-value for pO2 and SaO2 was found to be insignificant (p=0.084 and p=0.125 respectively), and for pCO2, it is significant (p=0.015). Conclusion: In both groups, improvement in arterial blood gases and oxygen saturation is
observed without any significant difference between the groups. Both interventions are equally effective in the prevention and treatment of chest complications in patients which may occur after bypass surgery. Key words: CABG. Chest physiotherapy techniques. Deep breathing exercises. Incentive
spirometry.
Introduction
effusion, pulmonary edema or shortness of
The purpose of this study is to compare the
breath.4,5 Risk factors for the respiratory
efficacy of incentive spirometry and deep
complications
breathing
exercises
to
prevent
the
development of respiratory complications in patientsâ&#x20AC;&#x2122; undergone CABG surgery and to develop awareness in people about the significant role of chest physiotherapy in preventing post-op complications.
are
smoking,
advanced age or lung diseases.
obesity,
6,7
Chest physiotherapy techniques play an important role in preventing post-operative respiratory
complications
in
bypass
patients.8,9,10 About 1 million coronary artery bypass surgeries (CABG) are
Bypass grafting is a surgical procedure in
carried out in the world per annum. Most
which a graft is used to bypass the blocked
of the patients develop chest complications
coronary arteries to restore blood supply to
after surgery as a result of general
the ischemic myocardium.1 Respiratory
anesthesia
complications develop after surgery which
Mechanical devices such as incentive
affects
and
spirometer have been frequently used in
compliances.2,3 Complications may include
United States after thoracic surgery.11
lung collapse, respiratory failure, pleural
Deep breathing exercises are used in post-
their
lung
volumes
and
prolonged
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
bed
rest.
Page 50
[Research Report] CABG patients to improve pulmonary
the aid of any mechanical devices, have
ventilation and restore lung volume by
been done along with incentive spirometry.
opening
and
On 1st post-op day, supplemental oxygen
preventing lung collapse.12 The evidence
was administered by facemask at 6.0
for the advantageous effects of these
L/min. In subsequent days, in case of need
techniques is inconclusive.13
for supplemental oxygen, the evaluation
the
collapsed
alveoli
was performed after removing the source
Materials and Methods
of oxygen for ten minutes. The outcome
Inclusion criteria: Patients undergone
bypass surgeries, of either gender or age were included.
of lung diseases, tuberculosis of bones, arthritis,
osteoporosis,
neurological disorders, any previous chest surgery and unstable hemodynamics were excluded. Study
arterial blood gases (ABGs) and SaO2 by pulse oximetry on daily basis half an hour
Exclusion criteria: Patients with history
infective
measures are pO2, pCO2 measured by
setting:
after chest physiotherapy treatment by taking the blood sample. The instruments used in the study were the incentive spirometer, perfoma sheet and treatment bed. Statistical analysis: Using SPSS 20 data
Doctorâ&#x20AC;&#x2122;s Hospital &
Medical Centre, Lahore from July, 2013 -
has been recorded and analyzed and p-
Jan, 2014.
value
Group I consists of 20 patients who are
less
than
0.05
(p<0.05)
was
considered statistically significant. The
treated with incentive spirometry only. Group II consists of 20 patients who are
quantitative data has been presented in the
treated with incentive spirometry & deep
form of frequency tables and mean S.D.
breathing exercises. Participants received treatment twice daily
The qualitative data has been presented in form of frequencies and percentage.
for 20 minutes in ICU in each session. In Group I, patients inspire slowly until the
Repeated measure ANOVA test has been
desired level marked in the spirometer is
used to compare the interventions between
achieved. In Group II, three sets of ten
two groups. Paired t-test was used to
deep breaths through slow and uniform nasal inspiration, progressing to slow flow
observe the effects of these interventions.
until the total lung capacity (TLC), without
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 51
[Research Report] Results
By applying paired t-test, in subjects doing
The study involved 70% males (n=28) and
incentive spirometry only, the p-value for
30% females (n=12). About 62.5% were
arterial oxygen tension (pO2), arterial
smokers (n=25) and 37.5% non-smokers
carbon dioxide tension (pCO2) and oxygen
(n=15). All the patients had undergone off-
saturation (SaO2) was found to be
pump CABG surgery (n=40) and almost
statistically significant (p=0.000, p=0.006
97.5%
and
(n=39)
patients
developed
p=0.000
respectively),
while
in
respiratory complications after surgery. It
subjects doing both incentive spirometry
was calculated from the data that among
and deep breathing exercises, p-value for
the
developed
pO2and SaO2 was found to be significant
atelectasis (n=29), 15% pleural effusion
(p=0.000, p=0.000), and for pCO2 it was
(n=6), and 12.5% pulmonary edema (n=5)
insignificant (p=0.244).
total
patients,
72.5%
while no one developed pneumothorax.
With the application of Analysis of
It was observed that 77.5% (n=31) of the
Variance (ANOVA), p-value for pO2 and
patients usually involved both sides of
SaO2 was found to be insignificant
lungs and triple grafts are placed in 60%
(p=0.084 and p=0.125 respectively), and
patients (n=24). According to the data, it
for pCO2, it is significant (p=0.015).
was reported that upper lobes were spared in all the subjects, 60% (n=24) had secretions accumulated in their lower lobes, and 40% (n=16) had affected middle lobe of right lung.
were discharged on 5th post-op day, 22.5% (n=9) patients on 6th day, 15% (n=6) on 7th day while 15% (n=6) had more than 7 days stay in hospital. Patients who had incentive
The aim of the study is to find out the effectiveness of incentive spirometry with and without deep breathing exercises in preventing the chest complications in post-
Data shows that 47.5% (n=19) patients
done
Discussion
spirometry and
deep
breathing exercises had shorter hospital stay as compared to patients who had done incentive spirometry only.
CABG patients. In this study, incentive spirometry was used along with deep breathing exercises post-operatively
to
treat
chest
complications. This study reveals that both groups showed improvement in restoring the oxygen saturation and ABGs, but there is no significant difference in ABGs and oxygen saturation among the groups.
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 52
[Research Report] Respiratory complications develop as a
There is a limited data available regarding
result of general anesthesia or prolong
chest physiotherapy techniques used for
immobility after surgery which impairs the
the treatment of respiratory complications
lungs function by reducing the oxygen
after bypass surgery. There is not even a
saturation, lung volumes and capacities.2,3
single study that suggests the supremacy
After bypass surgery, many physiotherapy
of one therapy technique over another.
techniques have been used to improve
None of the above mentioned studies
oxygenation of lungs, to remove secretions
suggested the use of both deep breathing
from them and to reduce risk of pulmonary
exercises and incentive spirometry as an
complications.14,8 Some studies showed
important treatment option.
the effectiveness of these techniques in the prevention or treatment of complications. Studies
have
shown
that
chest
physiotherapy can improve lung functions by the use of deep breathing exercises
Conclusion Deep breathing exercises and incentive spirometry
are
preventing
and
complications
which help in clearing the lung fields.15
equally
in
effective
in
treating
the
lung
patients
undergoing
coronary artery bypass grafting, as they An RCT was conducted to compare the
improve ABGs and oxygen saturation. But
effects of breathing exercises or incentive
there is no significant difference among
spirometry with early mobilization in 49
the
bypass patients. Deep breathing exercises
complications.
or
incentive
spirometry
showed
groups
1.
Another trial of Freitas et. al. showed that
2.
incentive spirometry have no advantage over standard physical therapy.17 However, in a review by Pasquina et. al., it is
3.
concluded that there is lack of evidence advantages
of
chest
References
after the surgery.16
the
improving
no
beneficial effect over early mobilization
supporting
in
chest
physiotherapy after cardiac surgery.18 4.
Olendorf, D., et al. The Gale encyclopedia of medicine. 1999, Detroit, MI: Gale Research Vargas FS, Terra-Filho M, Hueb W, Teixeira LR, Cukier A, Light RW. Pulmonary function after coronary artery bypass surgery. Respir Med 1997;91:62933 Shapira N, Zabatino SM, Ahmed S, Murphy DM, Sullivan D, Lemole GM. Determinants of pulmonary function in patients undergoing coronary artery bypass operations. Ann Thorac Surg 1990;50:268-73 Rady MY, Ryan T, Starr NJ, Early onset of acute pulmonary dysfunction after cardiovascular surgery: Risk factors and
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
Page 53
[Research Report] 5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
clinical outcome. Crit Care Med 1997;25:1831-9 Brooks-Brunn JA. Post-operative atelectasis and pneumonia: risk factors. American Journal of Critical Care 1995;4:340-9 Ferdinande P, Lauwers P, Van Buyten L, Van de Walle J. Pulmonary function tests before and after open heart surgery. Acta Anaesthesiol Belg 1980;31 Suppl;127-36 Jenkins SC, Moxham J. The effects of mild obesity on lung function. Respir Med 1991;85:309-11 Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson BI, Timmermans C, et al. the effect of incentive spirometry on post-operative pulmonary complications: a systematic review. Chest 2001;120:971-8 Pasquina P, Tramer MR, Walder B. Prophylactic respiratory physiotherapy after cardiac surgery: systematic review. 2003;327:1379 Innocenti D. An overview of the development of breathing exercises into speciality of physiotherapy for heart and lung conditions. Physiotherapy 1995;81:681-93 Crowe JM, Bradley CA, The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Phys Ther 1997;77:260-8 Hough A. Physiotherapy in respiratory care. An evidence-based approach to respiratory and cardiac management. 3rd ed. Cheltenham: Nelson Thornes Ltd;2001 Susan Jenkins , Susan Soutar , Barry Gray , Jane Evans and John Moxham The acute effects of respiratory manoeuvres in post-operative patients 1988, Vol. 4, No. 2, Pages 63-68 Morran, CG, Finaly, IG, Mathieson, M, et al Randomized controlled trial of physiotherapy for postoperative pulmonary complications.Br J Anaesth1983;55,1113-1117
15. Bartlett RH. Respiratory therapy to prevent pulmonary complications of surgery. Respir Care 1984;29:667-79 16. Dull JL, Dull WL. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass? Phys Ther 1983;63:655-9 17. Freitas ERFS, Soares BGO, Cardoso JR, Atallah Ă N. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD004466 18. Pasquina P, Tramer MR, Walder B: Prophylactic respiratory physiotherapy after cardiac surgery: systematic review. BMJ 2003, 327(7428):1379
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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[Research Report] Variables
Mean
Standard deviation
PO2 (Day 1)
136
23.03778
PO2 (Day 4)
74.42
16.21608
SaO2 (Day 1)
98.525
1.67925
SaO2 (Day 4)
94.075
2.35761
PCO2 (Day 1)
42.3225
4.56809
PCO2 (Day 4)
40.075
3.49518
t
p-value
16.013
0.000*
9.214
0.000*
2.905
0.006*
Table 1 Paired Sample Test for Group I (n=20) given incentive spirometry *p-value <0.05 is considered significant
Variables
Mean
Standard deviation
PO2 (Day 1)
127.965
16.994
PO2 (Day 4)
70.805
10.89
SaO2 (Day 1)
97.900
1.997
SaO2 (Day 4)
95.400
2.036
PCO2 (Day 1)
40.855
4.033
PCO2 (Day 4)
39.615
3.402
t
pvalue
12.897
0.000*
4.291
0.000*
1.202
0.224*
Table 2 Paired Sample Test for Group II (n=20) given incentive spirometry and deep breathing exercises *p-value <0.05 is considered significant Corresponding Author *Dr. Arooj Fatima, Physical Therapist,Physiotherapy Lecturer at University of Lahore, Pakistan King Edward Medical University, Lahore, Pakistan 98-H, DHA-EME sector, Lahore, Pakistan aruj43@hotmail.com 0092-341-4391882 **Dr. Ashfaq Ahmed, Physical therapist ****Dr. Halima Shoukat, Physical Therapist Assisstant Professor at University Institute of Physical Physiotherapy lecturer Therapy, University of Lahore halima.shoukat@gmail.com *****Ms. Mehreen Fatima ashfaaqpt@gmail.com ***Dr. Filza Shoukat, Physical Therapist Bio-statician Physiotherapy lecturer mehreen.fatima@uipt.uol.edu.pk filzashoukat21@gmail.com Š 2014 PGIP. All rights reserved.
Available online at www.pgip.co.uk/jopsm
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Welcome to the Postgraduate Institute of Physiotherapy, we are the team of professional physiotherapists working in United Kingdom promoting and uplifting the physiotherapy profession in developing countries particularly in South Asia. Our well trained and qualified physiotherapists conduct postgraduate courses in various countries. The courses ranged from Musculoskeletal Manual Therapy to Sports Physiotherapy. The basic aim is to provide evidenced based way of practice and education to physiotherapy societies of developing nation so that they can uplift the profession and become the contributors to the profession. Date: 00/00/00
Time: 00:00
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Encouraging Better Education Ob j e ct ive s
Co ur se s:
Provision of education and training in 1. Spinal Examination and physiotherapy to the public at large Enabling patients to relieve or assist in relieving their own suffering/conditions To persons (professionally qualified or not) providing paid or voluntary care to any person in need of physiotherapy Promotion of research and the dissemination to the public at large of the results of research in the field of physiotherapy
Diagnostic Assessment 2. Management of Neck Disorders 3. Neurodynamics and Neuromatrix 4. Lumbar Spine 5. Cervical Spine 6. Treating Cervicogenic Headaches 7. Low back pain and evidence base approach 8. Spinal Manipulation 9. Evidence Based Practise 10. Clinical Reasoning 11. Professionalism, Empowerment and Autonomy 12. Sports Rehabilitation and injuryIPrevention