Journal of Rehabilitation

-1-Volume I |Issue 1 |January- June 2015 ISSN : 2350-1235

Journal of Rehabilitation

The official journal of

Swami Vivekanand National Institute of

Rehabilitation Training and Research

January -June 2015 |Volume I |Issue 1

Editor -in-ChiefDr.Patitapaban Mohanty

Editorial board membersDr.Pabitra Kumar Sahoo (Physical Medicine and Rehabilitation)Mrs.Monalisa Pattnaik (Physiotherapy)Mrs. Anurupa Senapati (Occupational Therapy)Mr.Srikant Moharana (Prosthetics and Orthotics)Mr.G.Shankar Ganesh (Physiotherapy)


The Swami Vivekanand National institute of Rehabilitation Training and

Research is one of the most prestigious and premier institute in the field

of locomotor rehabilitation, under the Department of Disability Affairs,

Ministry of Social Justice and Empowerment, Government of India. It is

situated in Olatpur at the banks of holy river Prachi, a remote village in

the Cuttack district of Odisha state. This institute is rendering services

in the field of locomotor disability since 1975. Moreover the institute

has taken the responsibility towards development of human resources

and public services to the persons with disabilities in consultation with

Physical Medicine and Rehabilitation, Occupational Therapy,

Physiotherapy, Prosthetics and Orthotics, Clinical Psychology, Speech

and Hearing, Social work and vocational counseling. The institute

conducts a series of specialized Bachelor and Master Degree courses

under the affiliation of Utkal University: Bachelor of Physiotherapy (4.6

years duration), Bachelor of Occupational Therapy (4.6 years duration),

Bachelor of Prosthetics and Orthotics (4.6 years duration), Master of

Physiotherapy (2 years duration), Master of Occupational Therapy (2

years duration), DNB (PMR) and many periodical seminars and

workshops.

The institute has a good infra-structure for direct sample testing and its

value based research work is also acclaimed nationally and inter-

nationally. Moreover the design of modular prosthesis developed by

SVNIRTAR has been dedicated to the whole nation by the then president

of India Late Dr. APJ Abdul Kalam. SVNIRTAR is a good knowledge

hub for researchers, educators and practitioners for enquiring a new

quest of lives through advancement of technology.


Journal of Rehabilitation

General Information

About this journal

Journal of Rehabilitation (JOR) is the official journal of the Swami Vivekanand National Insti-tute of Rehabilitation Training and Research (SVNIRTAR). The main objective of the journal isto promote multidisciplinary practice in the field of rehabilitation by collaborating with acade-micians, clinicians, researchers and educators from India and abroad. JOR is dedicated to thepublication of research activities undertaken by the various departments of SVNIRTAR to fos-ter education, research and professionalism in the field of rehabilitation of persons with disabili-ties. The journal is also open to publication of review articles, rehabilitation education articles,interesting case reports, rehabilitation teaching methodologies, special articles, commentary inthe field of disability and letters to the editor. JOR is published biannually in January and July.The journal will be indexed shortly.

Subscription Information

Annual subscription rate outside SVNIRTARInstitutional Rs.1200Personal Rs. 800Prices include postage.

Copyright

The entire contents of the JOR are the property of SVNIRTAR. The contents of the journal shallbe used by third parties after getting prior permission from the editor -in-chief and by properattribution of authorship.

Permissions

The interested persons / institutes may request permissions by writing to the editor [email protected]

Disclaimer

The information and opinions presented in the JOR reflect the findings and views of the authorsand not the journal or editorial board or the institute. Publication does not constitute endorse-ment of the interventions or views by the journal or institute. Readers are encouraged to selfanalyze the merits of the publications before applying to their individual practice.

Address

Editorial OfficeDr.Patitapaban Mohanty, PhD,Associate Professor in Physiotherapy,SVNIRTAR, Olatpur,P.O.Bairoi,Cuttack Dt., Odisha - 754010,India.


CONTENTS

EDITORIAL

ORIGINAL ARTICLES

1 Lateral shelf acetabuloplasty and trochanteric epiphysiodesis in severe

perthe's disease 06-12

2 Management of sacral pressure sore by superior gluteal artery perforator

based fasciocutaneus flap in patients with spinal cord injury 13-16

3 The Effect of relaxation technique on the upper extremity functional task

performance in stroke patients with depression. 173-20

4 Effect of task related circuit training on performance of locomotor task

of chronic stroke patients. 21-26

5 Effect ofcervico-thoracic mobilization on shoulder pain and functional

independence in paraplegics 27-31

6 Relationship between isokinetic and clinical measurement of spasticity in

patients with spinal cord injury 32-40

7 Effect of disease specific conservative treatment on trunk muscle

strength in males with chronic low back pain 41-50

8 Effect of auditory& visual biofeedback with electrical stimulation of the

tibialis anterior muscle on active rom & selective motor control of ankle

of children with spastic cerebral palsy 51-55

9 Comparison between the effects of two core stabilization-directed to trunk

muscle vs arm exercises with breathing in treatment of chronic low back pain 56-62

10 Utility of ICF checklist in identifying most common problems in functioning

in paraplegic patients in post acute phase of rehabilitation 63-73

11 The effect of wrist and thumb kinesio taping on functional grasp in children

with spastic hemiplegic cerebral palsy presenting thumb in palm position 74-80

12 Influence of developmental coordination disorder comorbidity in adhd children

who received visual perceptual skill training 81-86

13 Effect of verbal and videotape feedback on upper body dressing skill of male

stroke survivors 87-95

TECHNICAL REPORT

14 Modular post-operative below knee Prosthetics 96-102

15 Knee Ankle Foot Orthosis for fixed flexion contracture 103-105


Editorial

Journal of Rehabilitation's first issue was circulated among various colleges,

Universities and rehabilitation institutes within India. The journal garnered

a positive reviews. I would like to thank the editorial board and all the

contributors for this sucess. In commitment to the journal's mission of

publishing research work that has important implications for the

rehabilitation of the physically challenged, this issue brings a total of 15

articles, out of which 13 are original research and 2 are technical reports.

The fundamental goal of research is to create effective changes and exposure

to new concepts. The knowledge gained through research ultimately results

in the benefit of all involved in the delievery of care to persons with different

abilities.

We would also like to start a new 'letters to editor' section where, any

constructive criticism and debates with respect to the articles published

would be entertained. The journal also has plans to publish speciality issues

wherein focus will be provided to a particular topic of interest. I solicit

your thoughtful suggestions, ideas and the research articles which I am

confident, and anticipating the journal more purposeful. I appeal to all the

experts, professionals and others interested in the area of disability

rehabilitation to send their contribution for making it more comprehensive

and timely.

Dr. P. P. Mohanty

Editor - in-Chief


LATERAL SHELF ACETABULOPLASTY AND TROCHANTERICEPIPHYSIODESIS IN SEVERE PERTHE'S DISEASE

Dr Sakti Prasad Das1, Dr Sudhakar Pradhan2, Dr Narendra Behera2,

Dr Jaganath Sahoo2, Dr Swati Sinha3, Dr R N Mohanty4

Department of Physical Medicine and Rehabilitation, SVNIRTAR1-Assistant Professor, 2-Lecturer, 3-DNB (PMR) Student, 4-Associate Professor and Officiating Director

ABSTRACT

The aim of the study was to retrospectively review results of operative treatment for coverage deficit of femoral headin children with severe epiphysis displacement in Legg-Calvé-Perthes (LCP) disease. The material included 23shelf acetabuloplasty procedures for LCP disease. The average age at diagnosis was 11.1 years (range 7-15). Meanfollow-up was 5.8 years (range from 2.2 to 11.2 years). Mean Reimer's index decreased statistically significantlyfrom a mean of 32% before surgery to 10.0% at the last follow-up . The mean Wiberg center-edge angle increasedalso statistically significantly from a mean of 17° before procedure to 32° at the last follow-up . According to theStulberg classification, type I was observed in 2, type II in 7, type III in 3, and type IV in 1 hips. There wereimprovement in the range of motion in preoperative and postoperative ROM. Partial, not significant, bone graftresorption was noted in 6 cases in the first 6-9 months after surgery. To conclude, shelf acetabuloplasty allowsachieving good midterm results in the treatment of severe stages of LCP disease. The procedure improves coverageof femoral head and allows its remodeling.

INTRODUCTION

More than one hundred years ago the Legg-Calvé-Perthes disease was presented to orthopaediccommunity. Since that time there are stillcontroversies according the management of thisdisease. There is no one treatment protocol forchildren with Legg-Calvé-Perthes (LCP) disease.The primary goal of treatment for Perthe's diseaseis to help the femoral head recover and grow to anormal shape. Treatment aims are to reduce hippain and stiffness, to reduce hip irritability andrestore and maintain hip mobility, and also toprevent the femoral head from extruding orcollapsing to regain a spherical femoral head toprevent deformity of the femoral head. In most ofthe cases the goal of treatment can be achieved byconservative methods; but in severe ones withfemoral head deformity and subluxation of theepiphysis the surgery would be indicated. Theshelf acetabuloplasty is assumed to stabilizeacetabular labrum and it has been proved to havestimulatory effect on acetabular growth 1-4. It maybe performed to assure sufficient coverage of the

extruded femoral head due to lack of eitherconcentricity or congruence. This procedure canbe performed in the early stage of the disease toprevent further deformation of the femoral head5 or in the treatment of residual deformity 6. Aimof trochanteric epiphysiodesis is to decreaseovergrowth leading to Trendelenberg gait andlimping.

The aim of the study was to retrospectively reviewresults of operative treatment for coverage deficitof femoral head in children with severe LCPdisease.

MATERIALS AND METHODS

Between 2002 and 2012, a total of 149 children weretreated for LCPD in our institution. Vast majorityof patients were treated conservatively and byVDRO. From this 149 patients 20 had shelfacetabuloplasty

We retrospectively review results of 20 consecutivepatients (17 boys and 3 girls) who underwent 23shelf acetabuloplasty procedures in our institutionfor LCP disease. Bilateral procedure wasperformed in 3 cases. Left hip was treated in 12and right hip in 11 cases. All those patients werecapable of attending final follow-up. The average

The first author can be contacted at :[email protected] and 9437742303


age of our patient cohort at diagnosis was 11 years(range 7-15). Mean age at surgery was 9.3 years(range: 7 to 14 years) . Mean follow-up was 5.8years (range: 2.2 to 11.2 years) and median follow-up 5.7 years. Before surgery all children had onlyconservative treatment including physiotherapy,bed rest, and traction in abduction or trilateralabduction orthosis . None of them had surgery oninvolved hip.

Our Inclusion criteria's include :

- Epiphysial involvement- (Catterall's) III, IV,Salter-Thompson B, Herring B,C.

- Older age group- More than 7

- Stage of Evolution- IIb,IIIa (late fragmentationand early regeneration)

- Epiphysial extrusion- More than 20%

- Decrease ROM of Hip

- No previous surgery

The decision to perform a shelf acetabuloplastywas based on clinical and radiological signs. Theindication for surgery on anteroposterior (AP) X-ray film was femoral head subluxation more than20% according to the Reimer index 7 or thepresence of hinge abduction, a flat uncoveredfemoral head, and the Wiberg center-edge angle8 less than 20°. Additionally in all cases the lateralshape of acetabulum was classified into group Bor C according to Grzegorzewski et al.classification system [1]. Before surgery we triedto restore a good range of motion in the hip jointby using physiotherapy and bed rest and tractionin abduction, particularly hip abduction (at least15°) and internal rotation (at least 10°). Thesechildren were all treated after the preferred periodof preventive surgery.

Clinical data and radiographs in AP andLauenstein position were used for evaluation.According to the Herring classification 9 hips weregrouped into types B, B/C, and C, and accordingto the Catterall classification 10 hips were groupedinto types III, and IV and we looked for "head atrisk" signs. The Reinberg classification was usedto evaluate the stage of disease 11 . The Reimerindex 7 , the Wiberg center-edge angle 8 , andLLD were evaluated in every case. The Wibergcenter-edge angle at the final follow-up was

measured to the end of solid bone graft. The leglength discrepancy (LLD) and range of motion inthe operated hip joint were also measured. TheStulberg classification was used for final results ofradiological assessment 12 .

TECHNIQUE

Bikini incision given. A gap was created betweenSartorius and TFL.The reflected tendon of therectus femoris is divided from the direct portionand dissected posteriorly. A curvilinear slot isproduced in the subchondral bone of theanterolateral aspect of the acetabular roof, 3-3.5cmin length, 2-3mm in height, and 1cm in depth, inan ascending direction from lateral to medial andfrom distal to proximal. One or two cortical graftsare harvested from the iliac wing, tightly insertedin the slot with an extrusion of 1.5-2cm lying onthe hip capsule after its exposure. Cancellous grafttaken from ilium were placed over it and securedwith the reflected head of the rectus femoris. Thisis sutured back to its origin on the direct headkeeping 5-6mm of the most lateral aspect of thegraft, exposed in such a way as to be in contactwith the cancellous and cortical graft harvestedfrom the same iliac wing, and put on top of it.Trochanteric epiphysiodesis is percutaneous screwfixation under image intensifier. Patient wasimmobilized in spica cast for 6 weeks afteroperation and then we started physical therapyand walking with crutches without bearing.Weight bearing was allowed 2 months aftersurgery

RESULTS

Out come measures include :

- Sphericity of femoral head - Stulbergclassification

- Hip passive ROM in abduction and rotationby goniometer

- Iowa Hip Score

Radiographic parameters :

- Femoral - head subluxation ratio

- Femoral head size ratio

- Sharp angle

- Percentage of acetabular coverage


- Wiberg center-edge angle (CE)

Neck-shaft angle (NSA)Sixteen patients hadnormal and 3 patients almost normal and painlesship joint mobility at last follow-up (Figure 1-9). Onepatient had limitation of the hip joint range ofmotion, particularly the abduction and internalrotation (patients with Stulberg type IV). The rangeof motion has improved at final follow-upcomparing to preoperative status. Three patients(15%) had an obvious Trendelenburg gait, 5 (25%)had a moderate limp, and 12 (60%) had a normalgait pattern.

Femoral head "at risk signs" were present in allcases ranging in number from one to four (one risksign, 9%; two, 17%; three, 22%; and four, 52%).Mean Reimer's index decreased significantly froma mean 32% before operation to 10.0% at lastfollow-up . The mean Wiberg center-edge angleincreased significantly from a mean 17° beforeprocedure to 32° at last follow-up . According tothe Stulberg classification there were type I in 2,type II in 7 (together 15 good results, 65.2%), typeIII in 3 (satisfactory, 26.1%), and type IV in 1 hipjoints (poor, 8.7%). Final radiographic results(Stulberg classes) were not related to gender,involved side, age at diagnosis, number of "headat risk" signs, and Catterall, Herring, and Reinbergstages of the disease Iowa hip score improved from71 to 92. (Table 1)

During operation we did not observe anycomplications. The lateral part of the acetabulumwas intact and there was no cup growthdisturbance during follow-up. Nevertheless,during follow-up on X-ray film we detected partialbone graft resorption in lateral part of the graft in6 cases. The maximum bone disappearing wasobserved in the first 6-9 months after surgery anddid not exceed 7mm. This phenomenon seen wasnot cinically significant and satisfactory resultsaccording to the Stulberg classification. No patientsrequired additional surgery.

Sharp angle improved from 45 to 39 degrees inaverage and acetabular coverage improved from

17 to 32 %.

Outcome Pre-op score

Post op score

femoral - head subluxation ratio

1.65 1.32

femoral head size ratio( affected hips versus the contralateral normal Hips)

1.11 1.24

Sharp angle 45 39

percentage of acetabular coverage

17

32

Weber center-edge angle (CE) (in degrees)

neck-shaft angle (NSA) (in degrees)

140 120

Stulberg staging- 13 cases at maturity

I-2, II-7, III-3, IV-1, V-0

Iowa hip score 71 (30 to 91)

92 (76 to 100)

Range of motion (in degrees) – abduction & Int. rotation

20/15 45/35

DISCUSSION

Analysis of results in our patients confirms thatshelf acetabuloplasty gives satisfactory results ofinvolved hip. In our opinion it is effective in themanagement of severely involved hips withsubluxation, incongruence, and hinge abduction.We consider shelf acetabuloplasty as an operativetreatment in these cases, which allowed for theacetabulum and femoral head restoration whenperformed in late fragmentation or in earlyregeneration stage. The shelf acetabuloplastyprovides good containment and gives goodsupport allowing for remodeling of the femoralhead. Preventive operative treatment methods forLCPD-proximal femoral varus osteotomy or Salterpelvis osteotomy-are rarely used in our practice.

Wright Perry DC and Bruce reviewed data of 24patients older than eight years of age who had shelfacetabuloplasty 13 . They noted medial joint spaceratio and the acetabular cover ratio improvement.Most of their patients were Stulberg II or III at


skeletal maturity 13 . In the study of van der Geestet al. 6 patients at skeletal maturity had goodresults (Stulberg 1 or 2), 10 hips had a fair result(Stulberg 3), and 2 hips had a poor result (Stulberg4 or 5), but it was better than the natural history ofthe disease 14 . These findings are similar to ours.

Ghanem et al. reported more satisfactoryimprovement in clinical and radiologicalparameters in consecutive series of 30 patients withlateral shelf acetabuloplasty with or without varusosteotomy. At last follow-up all patients were painfree, had satisfactory hip motion, mild or nolimping, and most of them were classified asStulberg 1 or 2 15 .

Hsu et al. performed a systematic review of themedical literature. They found that this proceduresignificantly improves coverage of femoral headmeasured by most popular indexes. This is a safeprocedure and no major complications were noted.However, there is no evidence that the procedureprevents development of degenerative jointdisease or improves long-term function 16 .

Yoo et al. identified prognostic factors to acetabularremodeling. They concluded that hinge abductionand marked collapse of the epiphysis werenegative prognostic factors 17 .

However, Freeman et al. reported relatively goodresults compared with historical controls in 27children with Perthes disease and hinge abductionat minimum 2 years follow-up 6 .

Domzalski et al. found that the shelfacetabuloplasty performed just above lateral rimof cup and joint capsule attachment to the iliac bonestimulates the acetabulum to growth 2 .

Some surgeons perform shelf acetabuloplasty attime of diagnosis on all children older than sevenor eight years rather than waiting for subluxationthat will inevitably occur in that age group 5, 18-20.

Vast majority of the children older than 8 years inthe Perthe's study group were candidates forsurgery because only one patient older than age 8remained Harring A throughout the course ofdisease. All others became B, B-C, or C. Childrenyounger than 8 are observed for subluxation andonly have surgery when that happens but olderchildren rarely need to wait 19 . Stulberg et al.

showed that 100% of children older than 9 willdevelop poor outcomes unless they are treated 12, but Herring et al. lowered that age to 8 years 19and Joseph to 7 years 20 . In our study weperformed shelf acetabuloplasty at the age of 7years on the time of surgery. We want to emphasizethat this procedure was performed for hipincongruence and subluxation after conservativemethods of treatment had failed.

In the study of Daly et al. on skeletally maturepatients, who were treated with shelf procedurein the initial stage of the disease, 22 of 27 hips wererated as Stulberg groups 1 to 3. Poor results werefound mostly in girls over 11 years and with severeform of the disease 18 . Jacobs et al. assessed thisprocedure in the early stage of LCP disease asappropriate surgical treatment for children olderthan 5 years of age 5.

There are several complications reported in theliterature following this procedure. Growthdisturbance of the lateral aspect of the acetabulumdid not occur in any of our patients. Similar toDomzalski et al. and Daly et al. 2,18 we found thatacetabulum continues to grow following surgeryadequately covering the femoral head.

When bony shelf is stabilized using the reflectedhead of the rectus femoris tendon, proximal shelfmigration is unlikely. We observed bone graftresorption in lateral part of the graft in our studygroup. In our opinion the reason of bonedisappearing is most likely not loading in this areaof the acetabulum.

This paper has limitations. The most important isrelatively small number of cases, which makesstatistical analysis not very reliable.

CONCLUSION

Shelf acetabuloplasty allows achieving goodoutcomes in the treatment of severe LCP disease.The procedure improves coverage of femoral headallowing its remodeling and ending in goodStulberg staging and good ROM helps in squattingand cross legged sitting which is the need of Indianpopulation.


REFERENCES

1. A. Grzegorzewski, M. Synder, P. Koz?owski, W.Szymczak, and R. J. Bowen, "The role of theacetabulum in Perthes disease," Journal of PediatricOrthopaedics, vol. 26, no. 3, pp. 316-321.

2. M. E. Domzalski, J. Glutting, J. R. Bowen, and A.G. Littleton, "Lateral acetabular growth stimulationfollowing a labral support procedure in Legg-Calvé-Perthes disease," Journal of Bone and JointSurgery A, vol. 88, no. 7, pp. 1458-1466, 2006.

3. J. A. Herrera-Soto and C. T. Price, "Coredecompression and labral support for the treatmentof juvenile osteonecrosis," Journal of PediatricOrthopaedics, vol. 31, no. 2, supplement, pp. S212-S216, 2011.

4. W. J. Yoo, I. H. Choi, T.-J. Cho, C. Y. Chung, Y.-W.Shin, and S. J. Shin, "Shelf acetabuloplasty forchildren with Perthes' disease and reduciblesubluxation of the hip: prognostic factors relatedto hip remodelling," Journal of Bone and JointSurgery B, vol. 91, no. 10, pp. 1383-1387, 2009.

5. R. Jacobs, P. Moens, and G. Fabry, "Lateral shelfacetabuloplasty in the early stage of Legg-Calvé-Perthes disease with special emphasis on theremaining growth of the acetabulum: a preliminaryreport," Journal of Pediatric Orthopaedics Part B,vol. 13, no. 1, pp. 21-28, 2004.

6. R. T. Freeman, A. M. Wainwright, T. N. Theologis,and M. K. Benson, "The outcome of patients withhinge abduction in severe Perthes disease treatedby shelf acetabuloplasty," Journal of PediatricOrthopaedics, vol. 28, no. 6, pp. 619-625, 2008

7. J. Reimers, "The stability of the hip in children. Aradiological study of the results of muscle surgeryin cerebral palsy," Acta Orthopaedica Scandinavica,Supplement, vol. 184, pp. 1-100, 1980.

8. G. Wiberg, "Studies on dysplastic acetabula andcongenital subluxation of the hip joint: witchspecial reference to the complication ofosteoarthritis," Acta Chirurgica Scandinavica, vol.83, supplement 58, 1939.

9. J. A. Herring, H. T. Hui, and R. Browne, "Legg-Calvé-Perthes disease. Part I: classification ofradiographs with use of the modified lateral pillarand stulberg classifications," Journal of Bone andJoint Surgery A, vol. 86, no. 10, pp. 2103-2120, 2004.

10. A. Catterall, "The natural history of Perthes'disease," Journal of Bone and Joint Surgery B, vol.53, no. 1, pp. 37-53, 1971.

11. M. O. Tachdijan, Pediatric Orthopedics, W.B.Saunders, Philadelphia, Pennsylvania, 1990.

12. S. D. Stulberg, D. R. Cooperman, and R.Wallenstein, "The natural history of Legg-Calve-Perthes disease," Journal of Bone and Joint SurgeryA, vol. 63, no. 7, pp. 1095-8304, 1981.

13. D. M. Wright Perry DC and C. E. Bruce, "Shelfacetabuloplasty for Perthes disease in patients olderthan eight years of age: an observational cohortstudy," Journal of Pediatric Orthopaedics B, vol. 22,no. 2, pp. 96-100, 2013.

14. I. C. M. van der Geest, M. A. P. Kooijman, M. Spruit,P. G. Anderson, and P. M. A. de Smet, "Shelfacetabuloplasty for Perthes' disease: 12-year follow-up," Acta Orthopaedica Belgica, vol. 67, no. 2, pp.126-131, 2001.

15. I. Ghanem, E. Haddad, R. Haidar et al., "Lateralshelf acetabuloplasty in the treatment of Legg-Calvé-Perthes disease:improving mid-termoutcome in severely deformed hips," Journal ofChildren's Orthopaedics, vol. 4, no. 1, pp. 13-20,2010.

16. J. E. Hsu, K. D. Baldwin, M. Tannast, and H.Hosalkar, "What is the evidence supporting theprevention of osteoarthritis and improved femoralcoverage after Shelf procedure for Legg-Calvé-Perthes disease?"Clinical Orthopaedics and RelatedResearch, vol. 470, no. 9, pp. 2421-2430, 2012.

17. W. J. Yoo, H. J. Moon, T.-J. Cho, and I. H. Choi,"Does Shelf acetabuloplasty influence acetabulargrowth and remodeling?" Clinical Orthopaedicsand Related Research, vol. 470, no. 9, pp. 2411-2420,2012.

18. K. Daly, C. Bruce, and A. Catterall, "Lateral shelfacetabuloplasty in Perthes' disease. A review at theend of growth," Journal of Bone and Joint SurgeryB, vol. 81, no. 3, pp. 380-384, 1999.

19. J. A. Herring, T. K. Hui, and R. Browne, "Legg-Calvé-Perthes disease. Part II: prospectivemulticenter study of the effect of treatment onoutcome," Journal of Bone and Joint Surgery A, vol.86, no. 10, pp. 2121-2134, 2004.

20. B. Joseph, "Prognostic factors and outcomemeasures in Perthes disease," Orthopedic Clinics

of North America, vol. 42, no. 3, pp. 303-315, 2011.


PHOTOGRAPHS

Fig 1. Pre operative x-ray in advanced stage of Perthe'sdisease(Case No 5)

Fig. 2. Immediate Post operative X-ray(Case No 5)

Fig. 3 - 1 year follow up X -ray(Case No 5)Fig4. Post op 5 year follow up function-cross legged

sitting (Case No 5)

Fig. 5. Squatting is possible(Case No 5)Fig No 6- Pre op X-ray. (Case No 17)


Fig. No 9- 3 years follow up- squatting(Case No 17)

Fig. No 7- Post op follow up X-ray of 3 years duration Fig. No 8- 3 years follow up- cross legged sitting(Case No 17)


MANAGEMENT OF SACRAL PRESSURE SORE BY SUPERIOR GLUTEAL ARTERYPERFORATOR BASED FASCIOCUTANEUS FLAP IN PATIENTS WITH SPINAL CORD INJURY.

Dr. Pabitra kumar Sahoo1, Mamata Manjari Sahu2, Dr Pramod Kumar Parida3, Dr S P Das1,Dr Ram Narayan Mohanty4,

Department of Physical Medicine and Rehabilitation and Physiotherapy, SVNIRTAR1-Assistant Professor, 2-Senior Physiotherapist cum Junior Lecturer, 3-Lecturer,

4-Associate Professor and Officiating Director

ABSTRACT

Prolong confinement to bed in spinal injury patients imparts constant pressure on bony prominences resultingimpairment of blood flow to local tissue.Constant pressure of 2hrs or more produces irreversible changes leading totissue necrosis and development of pressure sore. Sacrum encounters highest pressure in supine position and is thecommonest site of pressure sore in spinal cord injury patients followed by trochanter and heel. 13 patients of spinalcord injury patients presented with sacral pressure sore were managed surgically using superior gluteal arteryperforator based flap coverage. In 10 patients the flap was heeled uneventfully, one had significant complicationwith wound dehiscence.

Objective of the study: Superior gluteal artery flap can be designed using anatomical land marks and successfulflap cover can be done for sacral pressure sore even in the absence of facility of Doppler probe for isolation ofsuperior gluteal arterial perforators.

Key words : pressure sore, sacrum, fasciocutaneus flap, spinal cord injury, paraplegia

INTRODUCTION :

Up to 80% of spinal cord injury patients developpressure sore at some point in their lifetime.Sacrum encounters highest pressure in supineposition and is the commonest site of pressuresore( Fig-1) in spinal cord injury patients followedby trochanter and heel.

Reconstruction of pressure sore has always beenchallenging. Immobile patients are prone todevelop pressure sores from unrelieved pressureon tissue over the sacral area, with shear, friction,moisture and malnutrition as contributing factors.Up to one-third of immobilized patients in long-term care facilities will develop pressure sores [ 1,2 ]. These defects have traditionally beenreconstructed with gluteusmaximusmusculocutaneous flaps. However, therehas been a change from the musculocutaneous flapto the fasciocutaneous flap, with the superiorgluteal artery perforator (SGAP) fasciocutaneousflap adapted for sacral pressure sorereconstruction.

An anatomical study of the gluteal region byAhmadzadeh et al.[3] revealed that (i) the superiorgluteal region is supplied by 5±2 cutaneousperforators arising from the superior gluteal artery;(ii) all perforators are musculocutaneous, with 50%passing through the gluteus maximus musclewhile the remaining 50% pass through the gluteusmedius muscle; (iii) the average diameter of theperforators arising from the superior gluteal arteryis 0.6±0.1 mm and the average pedicle length fromthe deep fascia is 23±11 mm; and (iv) the averagecutaneous vascular territory for the superiorgluteal artery is 69±56 cm2 with each perforatorsupplying an area of 21±8 cm2 . The superiorgluteal artery perforating vessels are verticallyorientated, travelling directly to the superficialtissue up through the muscle. Generally laterallyplaced perforators are preferred, as they yield alonger vascular pedicle after dissection of theperforator and its main source.

MATERIALS AND METHODS

All the patients with spinal cord injury admittedto Physical medicine and RehabilitationDepartment of SVNIRTAR from January 2012 to

The first author can be contacted at :[email protected] and 9437081993


December 2014 are evaluated for presence of sacralpressuresore. 13 patients with stage 4 sacralpressure sore were included for the study and wereplanned for pressure sore coverage with superiorgluteal artery perforator based fasciocutaneus flap.11 were male and 2 female with average age45.3years ( range 32 - 58 years). 8 patients wereparaplegic and 5 were quadriplegic , 9 hadincomplete lesion , 4 had complete lesion and allare non ambulatory patients. 11 patients withspinal cord injury had traumatic origin 2 caseswere Potts paraplegia.

As a part of preoperative evaluation, X-ray pelviswith sacrum was done for all cases to look for boneinvolvement. Routine blood investigationsincluding Hb , DC,TLC, ESR,CRP, HIV HbSAg andSerum Albumin was done for all the patients. Caseswith hypoalbuniemia (serum albumin <3.5gm/ml)and anemia were corrected preoperatively. Oneunit of blood was kept reserve for surgery in allthe cases. As a pre requisite all the patients mustable to sleep in prone posture for a long period.For ensuring flap success and preventingrecurrence , strict guide line were followed like:(i) strict pre-operative as well as postoperativecontrol of medical conditions such as diabetesmellitus and hypertension. (ii) good control overspasticity(iii) adequate intra-operativedebridement of the sore with completebursectomy; (iv) maintaining a prone position for2 weeks postoperatively; and (v) pre-operative andpostoperative optimisation of nutrition. Thosepatients having sacral sore with features of chronicosteomyelitis,urethral fistula, fecal soiling ofpressure sore and patients with poor complianceare excluded from the study.

SURGICAL PROCEDURE

The patient was placed in a prone position on theoperating table. The site where the SGA enters thebuttock is identified at the junction of the proximaland middle thirdsjunction of a line connecting theposterior superior iliac spine (PSIS) to the apex ofthe greater trochanter of the femur correspondingto greater sciatic notch (Fig. 2). A line is then drawnbetween the PSIS and the coccyx. The position ofthe piriformis is located by joining the middle ofthe PSIS-coccyx line to the superior edge of thegreater trochanter. As the SGA supplies thesuprapiriform portion of the gluteus maximus,

perforators located cranial to the piriformis andlateral to the SGA exit point are the importantperforators considered for designing the flap. Thesacral sore was then thoroughly debrided withcomplete bursectomy( Fig-3). According to theresultant sacral defect, the superior gluteal arteryperforator based flap was fashioned in an ellipticaldesign of corresponding size (Fig-4).As peranatomical land marks superior gluteal arterialperforators weremarked. The skin, subcutaneoustissue and deep fascia were incised at the superiorborder of the flap. Elevation was performedstrictlyin a subfascial plane. All cares were taken to avoidinjury to major perforators.. Good haemostasis wassecured after the flap circulation was ensured. Theflap was transposed into the sacral defect, takingcare to avoid any twisting, kinking, compressionor undue tension on the pedicle (fig-5). The donorsite was closed primarily.Close suction draindrainwas placed under the flap .Drain wasremoved at a average of 4th day. The patient wasmaintained in a prone position for 2 weeks afterwhich suture removal and gradual mobilizationwas allowed.Good control of spasticity being anessential factor to prevent tension over the flap.Post operative therapy carried out by therapist toreduce spasticity and immobilization relatedcomplications. All the patients were instructed toavoid sleeping in supine posture for 8 weeks.

RESULTS

Out of 13 flaps 10 were heeled uneventfullywithout any major complications. One case ofpostoperative haematoma below the flap wasencountered leading to wound dehiscence.(Fig-6)subsequently heeled with dressing. Superficialstitch abscess was marked in 2 cases managed withantibiotics. No recurrence of a bedsore occurredafter an average follow-up of 9 months (range 5 -18 months).

DISCUSSION

Looking towards morbidity of a spinal cord injurypatient, conservative approach still remains thefirst line of management for pressure sores.Pressure relief, daily wound dressing, andoptimising the patient's nutrition aim at preventionof infection and enhancing wound healing.Conservative treatment is mostly effective in stage1 and 2 pressure sores. Stages 3 and 4, as well as


failure of conservative treatment in treating stage1 and 2 sores, require surgical management.Common options include primary closure, skingrafting, local random flaps, muscle flaps and therecently developed pedicled perforator flap.

Pressure sore cover withSurgical managementhas always been a challenge, with the idealoperation still being sought. Davis in 1938,1stsuggest replacing the unstable scar of a healedpressure sore with a flap tissue

The most commonly used method of sacralpressure sore reconstruction is the gluteusmaximusmusculocutaneous flap, which has a goodreliable vascularity and greatly reducespostoperative wound complication. However,taking out of a portion of gluteus maximus maycause gait disturbances in patients with expectedambulation in future. Modification to thatprocedure was made bye sliding gluteus maximusflap, whereby structural and functional integrityof the muscle was preserved. [4] .Otherdisadvantages such as intra-operative blood lossand limitation of future reconstructive options incase of recurrence encouraged surgeons to try newmethods of reconstruction, which marked thebeginning of perforator based flap era. Koshimaet al. 1stdescribed the gluteal artery perforator flapbased on parasacral perforators[5] basedfasciocutaneous flap evolved on furtherdevelopment of the work by Kroll andRosenfield.[6] The The superior gluteal arteryperforator flap was elevated on perforators fromthe superior gluteal artery by careful dissection ofthe musculocutaneous perforators from thegluteus maximus muscle. This yielded afasciocutaneous flap consisting exclusively of skinand subcutaneous fat, which retains the reliableblood supply of the musculocutaneous flap but isassociated with reduced donor site morbidity.Thisflap is muscle-sparing and therefore bene-ficial inambulatory patients. Higgins et al. suggest thatmuscle sparing should be considered not only inambulatory and sensate patients, but in paraplegicpatients as well.[7] Muscle sparing is alsoadvantageous in that future reconstructive optionsstill exist in the case of failure of the perforatorflap or recurrence. The likelihood of perforator flapfailure is minimal. Fasciocutaneous flaps providebetter long-term results in surgical reconstruction

of pressure sore than musculocutaneous flaps asshown by Yamamoto et al.[8]

CONCLUSION

Superir gluteal artery perforator based flap canbe elevated on a single perforator without fear offlap necrosis. Pre-operative preparation is the mostimportant factor for maintaining a healed woundafter flap closure. Spinal cord injury patients areespecially prone to postoperative recurrence oftheirpressure sores. This type of flap, being afasciocutaneous flap, lacks muscle 'cushioning' andcontinued pressure over it will lead to recurrenceof the sore. Pre-operative pressure relief protocolsas well as ensuring patient compliance aretherefore mandatory before planning a flapcoverage procedure. Complete flap survival withstable wound coverage, muscle-sparing propertiesfor future reconstructive options, minimal intra-operative blood loss and minimal donor sitemorbidity make the superior gluteal arteryperforator based flap a reliable option for sacralpressure sore reconstruction.

REFERENCES

1. Berlowitz DR, Wilking SVB. The short-termoutcome of pressure sores. J Am GeriatrSoc1990;38:748-752.

2. Perez ED. Pressure ulcers: Updated guidelines fortreatment and prevention. Geriatrics 1993;48:39-41.

3. Ahmadzadeh R, Bergeron L, Tang M, et al. Thesuperior and inferior gluteal artery perforator flaps.PlastReconstrSurg 2007;120:1551-1556.

4. Ramirez OM, Orlando JC, Hurwitz DJ. The slidinggluteus maximusmyocutaneous flap: its relevancein ambulatory patients. PlastReconstrSurg1984;74:68-75.

5. Koshima I, Moriguchi T, Soeda S, Kawata S, OhtaS, Ikeda A. The gluteal perforator based flap forrepair of sacral pressure sores. PlastReconstrSurg1993;91:678-683.

6. Kroll SS, Rosenfield L. Perforator-based flaps forlow posterior midline defects. PlastReconstrSurg1988;81:561-566.

7. Higgins JP, Orlando GS, Blondeel PN. Ischialpressure sore reconstruction using an inferiorgluteal artery perforator (IGAP) flap. Br J PlastSurg2002;55:83-85.

8. Yamamoto Y, Tsutsumida A, Murazumi M,Sugihara T. Long-term outcome of pressure sorestreated with flap coverage. PlastReconstrSurg1997;100:1212-1217.


Figure - 1 Figure - 2




THE EFFECT OF RELAXATION TECHNIQUE ON THE UEFUNCTIONAL TASK PERFORMANCE IN STROKE PATIENT’S

WITH DEPRESSION.

Anurupa Senapati,Assistant Professor &HOD.

Department of Occupational Therapy

ABSTRACT:

Depression is a common and important sequel of stroke, which may interfere with the functional recovery andrehabilitation outcome of the stroke patient. The objective of this study is to find out the effect of relaxation techniquealong with conventional Occupational therapy treatment on upper extremity functional task performance in strokepatient.

Methods: Twenty subjects of stroke patients were selected for the study; those were screened by Beck depressionInventory and confirmed having moderate to severe depression. The base line data of upper extremity functionaltask performance were obtained by using Motor activity log. The subjects were randomly divided into two groups.The subjects of both the groups had undergone conventional OT treatment for two month. The subjects ofexperimental group had additional relaxation therapy for 20-30 minutes along with conventional therapy. Posttreatment data were obtained at the end of treatment. Baseline and post treatment data were taken for statisticalanalysis.

The result of statistical analysis reveals that the subject of both the group showed improvement however theexperimental group showed better improvement than the control group.

Therefore it can be concluded that the relaxation therapy can be used as an adjunct to conventional OccupationalTherapy treatment for stroke patient, where the therapist can use holistic approach of treatment.

Key Ward: Depression, stroke, Upper extremity function.

INTRODUCTION:

Depression is a frequent complication of strokewith prevalence of 25% to 70%. Hadidi,N, teatjacobsan(2009) stated that Patient with PSD showsless recover from functional impairment ascompare to non depressed patient. Alexopoulos etal postulated that the controlled motor movementwhich is affected in stroke due to ischemic lesionand pyramidal tract involvement may also beaggravated due to depression. Studies, alsosuggest that extent of functional impairment is oneof the risk factor for development of PSD as wellas anxious personality. Dr Jacobson stated 'ananxious mind cannot exist in a relaxed body.Progressive relaxation technique is helpful incontrolling anxious mind, Research has focused onthe incidence, phenomenology course, and risk

factor of PSD. Special attention has been given tobiological explanatory model, Such of PSD suchas lesion, location and vascular depressionhypothesis in addition to such biological approach,the role of psychosocial facters should not beneglected. The proceeding in PSD researchemphasize the need for a biopsychosocialapproach. Depression must not be accepted as anon- modifiable eventuality of stroke. The onusis on the rehabilitation process to interveneaggressively to decrease post stroke depression.Mr.A. K. Mandal(2009) suggested that there is apositive correlation between UE motor functionand functional recovery in stroke patient.

Carin-Levy, G., Kendall, M., Young, A., & Mead,G. (2009). The psychosocial effects of exercise andrelaxation classes for persons with stroke surviver.The result reveals that, The classes motivated

The author can be contacted [email protected] and 09437631491.


participants to take part in other purposefulactivities, to continue to practice what they hadlearned, it also led to an improvement of self-perceived quality of life, specifically, improvedconfidence, physical ability, psychosocialfunctioning, and a sense of empowerment. Takingpart in relaxation classes after stroke can contributeto improved self-perceived quality of life,improved psychosocial functioning, and improvedmotivation to take an active role in the recoveryprocess

Alexopoulos et al postulated that late onsetdepression often results from damage to frontalsub cortical path ways associated with moodregulation and cognition.The controlled motormovement which is affected in stroke due toischemic lesion and pyramidal tract involvementmay also be aggravated due to depression.. It isstated by Dr Jacobson 'Progressive musclerelaxation is especially helpful for people whoseanxiety is strongly associated with muscle tension.Progressive muscle relaxation helps in increasingsense of control over moods, increase self esteemincrease spontaneity and creativity

AIM

To find out the Effect of relaxation technique onthe UE functional task performance in strokepatient with depression.

ALTERNATIVE HYPOTHESIS

There is a significant difference in UE functionaltask performance after using relaxation techniquealong with conventional OT in stroke patient withdepression.

NULL HYPOTHESIS

There is no significant difference in UE Functionaltask performance after using relaxation techniquealong with conventional OT in stroke patient withdepression

METHODOLOGY

A total of 30 stroke survivors with unilateral CVA,due to hemorrhage and infarction of eitherhemisphere, both males & females between 25-85years of age, 1st Stroke after six month to one year,having no history of previous Mental Illness, withmoderate to severe depression according to Beck

depression Inventory, with no perceptual,cognitive deficits (MMSE >24) were taken fromSVNIRTAR Department of Occupational Therapyfor the study. Pre and post experimental designwas used. Subjects having Upper limb musculo-skeletal or neurological condition other thanstroke, having receptive aphesia & visualimpairments were excluded from the study. Afterscreening, informed consent obtained from thesubjects and they were consecutively assigned tocontrol and experimental groups respectively. Thebase line data were obtained for by administeringUE Motor Activity Log. The subjects of the controlgroup were provided the conventionalOccupational therapy for one hour, five days in aweek for two months and the subjects of theexperimental group were provided progressivemuscle relaxation therapy for thirty minutes perday for five days a week for two month in additionto the Conventional Occupational therapy. At theend of two months post treatment data wereobtained.

DATA ANALYSIS

The Test parameters were compared before andafter therapy. Statistical calculations wereperformed with SPSS version 16.0 package.Statistical tests were carried with the level ofsignificance set at p? 0.05. The changes in theoutcome measures within control andexperimental groups were analyzed usingWilcoxon Sign Ranks Test. Mann-Whitney U Testwas performed for knowing the significancebetween the groups.

RESULTS

The individual characteristics of control andexperimental group are given in table 1

Table - 1: Descriptive characteristics

S. No.

Baselines Characteristics

Group A (control)

Group B (experimental)

1. No of subjects 15 15

2. Age range ( years) 34-77 34-68

3. Mean age (±Std Dev.) 53.2(±12.417) 51.933(±10.443)

4. Gender (M/F) 13/2 12/3

5 Right /left hemiplegia 9/6 10/5

Control group consisted of 15 subjects (13 male, 2female), Mean age is 53.26, 9 Right & 6 Left


hemiplegia, age range is 34-77 years. Experimental

group consisted 15 subjects (12 male , 3 female)

Mean age is , 10 Right & 5 Left hemiplegia, age

range is 34-68 years.

Table - 3: Showing results of Wilcoxon Sign Rank

Test for UE Motor Activity Log scale within the

groups.

GROUPS Mean diff. z p (2 -tailed)

CONTROL 0.732 -3.410 0.001 *

EXPERIMENTAL 2.65 -3.408 0.001*

* Level of Significance

The results show that there is a significant

improvement in control & experimental group

with p values of 0.001 and 0.001 respectively.

Graph 1: showing mean score changes in the UE

Motor activity log scale of both the groups.

Table - 4: Mann-Whitney U tests results betweenthe groups.

OUTCOME MEASURES

MEAN DIFF.

z value p Value

UE MAL 2.06 - 2.800 0.004 *

*Level of Significance

The Experimental group shows higher scores than

Control group in the outcome measure but it was

statistically significant as shown by results of Mann

Whitney U test at the p value 0.004.

DISCUSSION

The present study was designed to examine the

effects Progresive muscle relaxation therapy on UE

Functional task Performance. This study suggest

that Progresive muscle relaxation Therapy with

conventional occupational therapy can improve

UE functional task performance.

Stroke patients often do not use their more affected

arms for ADLs, even when they are capable of

doing so. In addition to causing a greater handicap

level, this non-use can undermine motor return,

because limb use appears to be related to cortical

reorganization and, ultimately, to reacquisition of

motor function.

The mean value of motor activity log scale, pre and

post scores are, 3.833 and 5.89 respectively. On

statistical analysis, the values were determined to

be significant at 0.004 level (table 4) which program

to improved UE functional task performance in

stroke survivors (graph 1).

The above results may be due to increased

motivation and decreased muscle tension by

progressive muscular relaxation therapy

programme. As the muscle tension which was

supper imposing on the neuro physiological

aspects of CVA leading to inability of using the UE

efficiently in the ADL function due to anxiety.

The above statement may be substantiated with

the study done by Carin-Levey G et al, 2009 who

stated that taking part in either exercise or

relaxation classes after stroke can contribute to

improved self-perceived quality of life, improved

psych0-social functioning, and improved

motivation to take an active role in the recovery

process.

The above results may also contributed to the fact

that the relaxation technique used through sensory

motor approach has a positive effect on

hypertonicity(K walse,2001), these techniques are

incorporated through Progressive relaxation

Therapy programme. As the client were advised


to contract and relax the muscles during

Progressive muscle relaxation programme.

CONCLUSION

Progressive muscle relaxation programme is a

promising area of research and can be efficiently

used in clinical practice for treating stroke patients

with depression along with other convention

therapy.

This study concluded that Progressive muscle

relaxation programme is effective in improving UE

Functional task performance and in Stroke patients

and aultimately total functional recovery. It can

be used as an adjunct to Conventional

Occupational Therapy so that a holistic approach

of treatment of the stroke survivors can be done

by Occupational Therapist.

LIMITATIONS AND RECOMMENDATIONS

Number of sample size is only 30, hence

studies including larger groups are

recommended.

Follow up retention of the effects of

Progressive muscle relaxation programme

was not done. Future studies recommended

doing the follow up effects.

Further study is recommended to compare the

effects of Progressive muscle relaxation

programme in males vs females.

REFRENCES1. Scogin, F, Rickard, H, Keith, S, Wilson, J, McElreath

L (1992) "Progressive and Imaginal Relaxation

Training for Elderly Adults with Subjective

Anxiety" Psychology & Aging 7(3):419-424,

September 1992

2. Yucha, C, Tsai, P, Kalderson, K Tian, L (2005)

Biofeedback assisted training for Essential

Hypertensions: Who is most likely to benefit?

Journal of Cardiovascular Nursing 20(3):198-205,

May/June 2005

3. Sue- Min Lai Stephenai Studenski, Lorie

Richards,Subhasan Perrera, Dean Reker, Sally

Rigler and palmela W Duncan.(2006, Feb)

Therapeutic exercise and depressive symtoms after

stroke.Journal of American geriatric Society, 54,

240-7

4. Teng, XF, Wong, MY, Zhang YT (2007) The effect

of music on hypertensive patients. Conf Proc IEEE

Eng Med Biol Society 2007; 2007:4649-51

5. Sarcamo, T, Tervaniemi, M, Laitinen, S, Forsblom,

A, Soinila, S, Mikkonen et al (2008), Music listening

enhances cognitive recovery and mood after

middle cerebral artery stroke. Brain 2008, March

131 (Pt 3):866-76

6. Amit kumar Mandal et al (2009), Effect of

Occupational therapy task oriented approach on

recovery of UE motor function and ADL in stroke

patient. The Indian Journal of Occupational

Therapy : Vol. XLI : No. 2 (May 2009 - August 2009)

7. Carin-Levey G, Kendall, M, Young A, Mead,

G.(2009) The psychosocial effects of exercise and

relaxation classes for persons surviving a stroke

Canadian Journal of occupational Therapy Vol 76,

no 2 April 2009.

8. Demiralp, M, Oflaz, F, Komurcu S. (2010) the effect

of Progressive relaxation training on sleep quality

and fatigue in patients with breast cancer

undergoing adjuvant chemotherapy Journal of

Clinical Nursing 19(7-8):1073-1083, April 2010


EFFECT OF TASK RELATED CIRCUIT TRAINING ONPERFORMANCE OF LOCOMOTOR TASK OF

CHRONIC STROKE PATIENTS

Kshanaprava Mohakud,Occuaptional therapist

Department of Occupational Therapy

ABSTRACTObjective : To evaluate the immediate and retention effects of task related circuit training program onthe performance of locomotors related tasks in chronic stroke patients.Design : Randomized controlled studySetting : Department of Occupational therapy , S.V NIRTAR.Subject : 30 stroke subjects were randomly assigned to experimental and control group.Intervention:- Both experimental and control groups participated in therapy , 5 times a week for 4weeks.Therapy was basically strengthening activities of lower extremity arranged in a circuit for experimentalgroup and conventional therapy for control group.Main Outcome Measures : lower limb function was evaluated by measuring walking speed, endurance,sit to stand and step test.Result : The experimental group demonstrated significant improvement (p <0.05 ) in comparison withthe control group.Conclusion : This study provides evidence for the efficacy of a task related circuit training for improvinglocomotor function in chronic stroke.Key words:- Stroke, rehabilitation, motor relearning, locomotion.

INTRODUCTION

Stroke is a major cause of disability and handicapin adults. Rehabilitation of stroke patients aims toreduce disability by optimising the performanceof everyday tasks where as many individuals aresignificantly disabled and handicapped (Hill k.Ellis1997, Dean C.M.et al1997). The ability to walkindependently is a prerequisite for most dailyactivities. Walking speed should be optimum thatenables an individual to cross the street in allottedtime of pedestrian light, to step on and of a movingwalkway, walk around and over object. It has beenreported that only 7% of patients discharged fromrehabilitation met the criteria for communitywalking which includes the ability to walk 500meters continuously at a speed that would enablethem to cross a road safely. So they can not be afunctional walker.

Walking dysfunction is common in neurologicallyimpaired individuals arising not only from theimpairment associated with the lesion but alsosecondary to cardiovascular and musculoskeletalconsequences of disuse and physical inactivity(Carr and Shepherd 2003). Stroke patients selfselect a speed that require least energy (Gumby1983) and may not have the ability to increasewalking speed without increasing energydemands beyond their capacity ( Holden etal1986). Such individual requires exercises forincreasing their walking speed and endurance.Through research it has been found that practiceof an exercise will not generalise into improvedperformance of functional task even with learnerwho have no motor control deficits. Sorehabilitation of stroke patients should be basedon everyday tasks using information frombiomechanics and motor learning as well asknowledge of pathology of impairment associatedwith stroke (Carr and shepherd1987).MoreoverCarr and shepherd have suggested that training

The author can be contacted [email protected] 09437311347


can be organised into a circuit with a series ofwork station designed to strengthen affectedmuscles and provide the opportunity for task(having clear purpose product) practice which willimprove locomotion and the circuit trainingprogram is a better method of fatigue managementand conditioning program over a control group.

AIM & OBJECTIVE

The main objective of the study is to investigatethe effects of task related circuit training onperformance of locomotor function.

METHOD

A convenience sample consisting of 30 subjectsrecruited for the study purpose and they wereallocated to two groups through simplerandomization. To participate in the study thesubject had to meet the following criteria, Firststroke resulting in hemiplegia and is of at least 3month of post stroke, Patient is able to walk 10meters independently. All patients were of agegroup of 50±20 with no sex barrier. Patients wereexcluded if they had Medical conditions likehypertension, joint arthraitis, cardiac diseaseswhich prevented participation in therapy programand patients having psychiatric manifestationsscrutined by psychiatrist and having severecognition deficit which was measured with minimental state examination scale (MMSE).Psychiatric illness was assessed by ICD -10diagnostic criteria by psychiatrist.

All subjects had given their informed consentand all procedures were performed in accordancewith the ethics approval granted by the S. V.NIRTAR ethical committee.

DESIGN

This study was a randomized pre test and post testcontrol group design to find out the effect oftherapy.

30 patients were selected for the study. 15 of themreceived task related circuit training program (group A) and 15 of them received conventionaltherapy .

All the patients were selected from inpatient andoutpatient department coming to OccupationalTherapy Department of S.V. NIRTAR.

INTERVENTION

The patients received therapy program 5 times aweek for 4 weeks. For experimental group thetherapy was designed as a circuit program withsubjects completing practice at a series of workstations. The work stations were designed tostrengthen the muscle in the affected leg in afunctionally relevant way and provide for practiceof loco motor related tasks.

Tasks for Experimental group patients were :

Sit to stand

Sit to stand from appropriate seat height (heightof the chair is decided by the intervening therapist,according to the ability of patients and graduallyheight of the chair was decreased in every weak.)During the activities feet were flat with no flexionwithin upper body, throughout action by giving atarget to the eyes which is placed 2-3 meter in frontof eye level.

Stepping up and down

Patient was standing 15 centimetres away from the15 centimetre wooden high block repeatedly upand down the unaffected foot by standing on theaffected foot. During the activity patient wasinstructed to do as fast as possible.


Stair climbing.

Patients were instructed to advance the uninvolvedleg first then the involved foot during ascendingof stairs and during stair descent involved leg firstthen uninvolved leg and to walk reciprocallywithout any support.

Heel raise and lower

The patient were asked to bear weight on forefeetwhile standing on a stair remaining the heels free,heels are lowered as far as possible, then raisedagain to plantigrade with the hip and kneeextended.

Over ground forward walking, walking sidewaysand walking backward. During walking patientswere instructed to take equal, even and long steps.

All the activities were done for 5 minutes each.Before starting the training program and after endof the training 5 minutes of warming up andcooling down period was there.

Therapy given to conventional group Patientswere- Loco motor training emphasizing on hipextension and weight transference by assistancegiven to either side of the pelvis and with both thepatients arm held behind him, extended andexternally rotated to control his hip and kneeextension adequately. Shoulder rotation of patientswere facilitated with assistance of therapist toinhibit arm hyper tonicity which prevents armswing. walking was facilitated in inhibitorypattern with the hemiplegic arm resting ontherapists shoulder, rotation of pelvis wasfacilitated and one arm was held forward andupward in external rotation during walking. Withone hand against the patient's thoracic spine otheragainst his sternum, orientation of trunk correctlyover pelvis was facilitated.

During therapy program feedback was given toboth the group of patients.

EVALUATION

Subjects were evaluated twice; before the training(pretraining) and at the end of the training (posttraining) .

CLINICAL TESTS /Outcome measures

Speed test.

Walking speed was measured by timing subjectover 10 meters with a stop watch. To avoid theeffects of acceleration and decelerationmeasurement s were taken over the middle 10meter of 14 meter walkway.

Step test

It was used to evaluate the ability to support andbalance the body mass by the affected lower limb(dynamic balance) while stepping with theunaffected limb. Briefly subjects started with theirfeet parallel 5 cm in front of a 7.5c-m - high woodenblock. They were required to place their unaffectedfoot wholly onto the block, and then return it tothe floor repeatedly as fast as possible for 15seconds. The number of completed steps in a 15seconds period was recorded. (Hill K.D,BernhardtJ.& Anne M et al (1996).

Get up and go test

Subjects were required to stand up from a chairwith arm rest, walk 3 meters, turn around, returnto chair, and sit down. The time taken to completethe task was measured with a stop watch. (Mathiaset al (1986).

6 minute walk test

It was used to measure the endurance. The patientswere asked to walkway which was marked inevery 5meter interval. The distance covered in 6minutes was measured by meters.

All the tests were carried out on the same dayexcluding the 6 minute walk test which was donethe next day to avoid the effect of fatigue ofpatients. (paul Enright MD, (2003).

Data analysis

The unpaired "t '' test was used to compare thetherapeutic results between the groups. The paired


"t "test was used for determining changes after thetreatment within each group. The Data wereanalysed by paired "t" test. Differences wereconsidered significant if the p value was < 0. 05.Statistical tests were completed using SPSSversion -17.

RESULT

Overall analysis of the change scores indicated thatthe experimental group performed significantlybetter than the control group after training.

PATIENT CHARACTERISTICS

The table-1 depicts in group A - majority of patientwere in age group 51- 60 years age. The majoritypatients presented for study were male 86.7% andrest were female. In group B all age groups wereof equal distribution. Male female ratios were sameas group A.

Speed test

The result shows that There is significantimprovement in speed test in experimental groupand the p value is <0.01. Where as in control groupthere is no significant improvement.(p .=.1).

Step test

Subjects in the experimental group, but not thecontrol group increased the number of repetitionsof the step test after the intervention. These results

indicate that there is significant improvement inexperimental group where as no significantimprovement in control group.(TABLE-3).

Six minute walk test

The experimental group increased the distancewalked to a significantly greater extent than thecontrol group after the therapy. The statisticalanalysis shows p is <0.01 in experiment group

but in control group p>0.01 .

and go test

Subjects in the experimental group reduced thetime taken to complete the get up and go test. Thereis significant difference in experimental group,Whereas the control group had no significantdifference in get up and go test.)


DISCUSSION

The major finding of this study was that subjectswith chronic stroke who participated regularly in4 weeks of task related circuit training programbasically designed to improve the strength,endurance of the affected lower limb andfunctional performance, demonstratedimprovement over the patients who receivedconventional therapy.

From the result it was found that patients in thegroup A(task related circuit training group)significantly improved in speed test as comparedto group B(control group). So it suggests that thereis significant improvement in gait velocity aftertask related circuit training, which accords withthe finding of Dean et al. 2000. The increase inspeed may be due to increase in strength of ankleplantar flexors, hip extensors and flexors. Theplantar flexors and hip extensors are the majorpower generators for push up and pull-up duringpropulsion (Richard et al. 1999; Teixeira salmela1999, 2000).

After training the experimental group hadincreased significantly in step test. Theimprovement in step test indicates the dynamicbalance of experimental group increased aftertraining. As stepping up and down task is thespecific training practiced by the experimentalgroup, following the specificity of training thereis functional improvement. This may be due toincrease in strength and synergic relationshipbetween hip, knee, and ankle extensors of theaffected limb (Carr and Shepherd 2002). Thesignificant improvement in 6 minute walk test ofexperimental group may be because ofimprovement in Vo2 max as well as strength aftertraining which are diminished in stroke patients(Joanna O Kelly et al. 2003) due toneurophysiological and environmental factors. Theneurophysiological factors are loss of strength andcoordination (Burke D 1988) resulting in reductionin no of motor units (Potempa et al. 1989) anddiminished capacity for oxidative metabolism inparetic muscle tissue (Joanna O Kelly et al. 2003).Environmental factors that may contribute toimpairment in fitness include bed rest and physicalinactivity (Mackey 2002) as the patient spend morethan 70% of the day pursuing activities unrelated

to physical outcome (Mackey F Ada et al. 1996).

All patients except one in the experimental groupregardless of skill level, made some improvementin performance of the clinical tests. Though thepatient in the control group received therapy forsame period of time as experimental group, didnot improve significantly. The significantdifference between the groups reflects the efficacyof training. The control group did not improvesignificantly this may be because of therapy thatare imposed on them are based on passive ratherthan active view of motor learning. It alsoemphasized on learning movement pattern ratherthan to solve motor problems (James Gordon).According to Gliner et al. (1984) patients inrehabilitation must relearn voluntary control overinjured muscles or learn new motor skills throughthe use of functional activities. These functionalactivities can be practiced efficiently in differentcontext for requisition of skills, optimal retentionand transfer of the learned skill. Task relatedcircuit training was conducted basing on thesefundamentals. So there was significantimprovement. More over tasks are alternated soas to give rest to different muscle groups. Eachmuscle group is given more time to rest before itstarts working again . As a result there issignificant improvement in strength and fatiguemanagement. The observations suggests thatindividual after stroke are at risk of becomingsocially isolated and more disabled afterdischarged from rehabilitation particularly inambulation skills. Those are inferior to the levelrequired for effective community ambulation. Inthis study mean duration of stroke from on set is1.34 year. The improvement in performance of gaitsuggests that to maximize potential strokerehabilitation needs to continue in the long tem,rather to stop within 3 month to 1 year pos stroke.Circuit training was given 2 to 3 patients at a time,for the purpose of increasing social interaction andmotivating to subjects to improve performance bypromoting competition and cooperation. So afterdischarge from institute all the patients continuedthe activities in their home as regular basis astheir confidence level has been increased andmotivation for activities are increased. Thelimitation of the study is it did not include followup program to know the retention effect of skill


because of poor financial condition of patients,who could not come for further follow up.

CONCLUSION

The result of the study demonstrated that patientsgetting task related circuit training had moreimprovement than the conventional therapy.Hence task related circuit training has better effectthan conventional therapy. It is also very feasibleto conduct and less time consuming as it can begiven to a group of patients at a time. Very lessnumber of equipments are needed to conduct thetraining. Hence it is also cost effective. All theactivities can be performed in home environment.So patient can continue these activities at home ona regular basis.

REFERENCES

1. Ada L., Dean C.M., and Hall J.M. et al., (2003) : Atreadmill and over ground walking programimproves walking in persons residing incommunity after stroke: placebo controlled,randomized trial. Achieves Physical MedicineRehabilitation, 1486-91.

2. Bobath B. : Adult Hemiplegia : Evaluation andtreatment. Butterworth Heinemann. Ed 3. Chapter-1.

3. Bohannon R.W. (1989) : Selected determinants ofambulatory capacity in patients with hemiplegia.Clinical Rehabilitation. Journal of Neurology,Neurosurgery and Psychiatry, 74, 1465.

4. Bassile C.C, Dean C., and Boden B. Et al (2003) :Obstacle training programme for individual poststroke : disability. Clinical Rehabilitation, 17, 130-36.

5. Carr JH, Shepherd RB and Gordon J et al.(1987) :Foundation of Physical Therapy in Rehabilitation,MD Aspen Publishers Rock Ville, Chapter 1,2,3.

6. Bracewell R.M. (2003) : Stroke : Neuro plasticityand recent approaches to rehabilitation Journal ofNeurology, Neurosurgery and Psychiatry, 74, 1465.

7. Carr JH and Shepherd RB, (1998) : Neurologicalrehabilitation optimizing motor performance.Butterworth-Heinemann Oxford, In Chapter-1,4,5,11.

8. Chou SW, Leong CP, Hong WS, Tang FT and LinTH, (2000) : Postural Control during Sit-to-stand

and gait in stroke patients. American Journal ofPhysical Medicine Rehabilitation. ; 82, 42-47.

9. Carr JH, Shepherd RB, (2003) : A motor relearningprogram for stroke. MD Aspen publishers,Rockville ed 2.

10. Davisa PM, (1976) : Steps to follow : A guide to thetreatment of adult hemiplegia, Chapter-6,9.

11. Dean C.M.,Richards C.L., Malouin F., (2000) : Taskrelated circuit training improves performance oflocomotor tasks in chronic stroke : ARandomized,controlled pilot trail, Archieves Physical MedicineRehabilitation, 81, 409-17.

12. Darcy A.U., (2001) : Neurological rehabilitation :Mosbey, ed 4 in. Chapter-5,25.

13. Flinn N (1995) :Clinical interpretation of effects ofrehabilitation tasks on organization of movementafter stroke, American Journal of OccupationalTherapy, 53, 345-347.

14. Fuscaldi L., Salmela T. And Olney Sj. Et al (1999) :Muscle strengthening and physical conditioningto reduce impairment and disability in chronicstroke survivors. Archieves Physical MedicineRehabilitation, 80, 1211-18.

15. Fuscaldi L., Salmela T. And Madeau S. Et ai., (2001): Effects of muscle strengthening and physicalconditioning training on temporal, kinematic andkinetic variables during gait in chronic strokesurvivors. Journal of Rehabilitation Of Medicine,33, 53-60.

16. Green J, Forster A, and Young J, (2002) : Reliabilityof gait speed measured by a timed walking test inpatients one year after stroke. ClinicalRehabilitation, 16,306-14.

17. Hopkins HS. and Smith HD. (1993) : Willard andSpaksman's occupational therapy. J.B. LippincottCompany. Ed 8.

18. Hsiech C.L, Nelson D.L., and Smith D.A (1996) : Acomparison of performance in added purposeoccupations and rote exercise for Dynamic standingBalance in persons with Hemiplegia. AmericanJournal of Therapy, 50(1), 10-16.

19. Hill K.D. Bernhardt J. And Anne M. Mc Gann etal., (1996) : A new test of dynamic standing balancefor stroke patients. Reliabilitry, validity andcomparison with healthy elderly. Physiotherapy

Canada.


EFFECT OFCERVICO-THORACIC MOBILIZATION ONSHOULDER PAIN AND FUNCTIONAL INDEPENDENCE

IN PARAPLEGICS

Garima Gedamkar,MPT student

Department of Physiotherapy

ABSTRACT

BACKGROUND : Pain is a common complication after spinal cord injury which can significantly impact upona person's functional ability and independence, ability to return to work and quality of life. There is a gap in theliterature regarding standardized exercise interventions for individuals with SCI (duration and frequency).Therapeutic exercises appear to be more effective when combined with joint mobilization technique focused onupper quarter. PURPOSE: To determine if manual therapy in addition with shoulder exercises is effective inreducing pain and increasing function in persons with paraplegia having shoulder pain. METHOD: 30 subjectswere randomly recruited for the study. Group 1 received C5-T1 Maitland mobilization with stretching andstrengthening exercises while group 2 received exercises only. SPADI, WUSPI and FIM were used as outcomemeasures. RESULTS: The overall result of the study suggest that both the groups (Manual therapy and exercisetherapy) improved significantly from pre to post treatment in all the three variables (SPADI, WUSPI, and motorscore of FIM) at the end of four weeks. Manual therapy group showed significantly better improvement in SPADIand WUSPI. However, the improvement shown in the motor score of FIM was not statistically significant betweenthe two groups (p= 0.05). CONCLUSION: Manual therapy combined with stretching and strengthening exercisesis superior to exercises alone in reducing shoulder pain in individuals with paraplegia.

KEYWORDS: Paraplegia, shoulder pain, functional independence, cervico-thoracic mobilization

INTRODUCTION

Pain is a debilitating accompaniment of SCI thatimposes a major burden on individuals who havealready suffered substantial emotional andphysical trauma. Paraplegic individuals have beentraditionally rehabilitated to use wheelchairs forfunctional locomotion and sports practice. Themost common complaint in manual wheelchairusers is shoulder pain which is commonly causedby overuse. It leads to increased risk of shoulderpathology- impingement syndrome and muscleimbalance. If left untreated, pain can limit mobility,independence and ADLs which will increase thehealth risk and pressure sores. The demandsplaced on the shoulder include transfers,wheelchair propulsion, pressure relief and ADLactivities. It is estimated that 30%-50% of theindividuals with SCI have shoulder pain of suchseverity that it interferes with transfers, manual

wheelchair propulsion, overhead reaching, andsleep; it can also limit vocational and recreationalpursuits.This prevalence increases with time. Themuscle imbalance that occurs includes tightanterior shoulder musculature, fatigue of scapulamuscles, increased scapula protraction, weakenedor lengthened posterior musculature and scapulastabilizers. Present treatment includespharmacological intervention (NSAIDs andnarcotics), corticosteroids injection, surgery(rotator cuff repair), rest, modalities (eg.Ultrasound, TENS, acupuncture), strengtheningand flexibility exercises, postural advice anddecreasing stress by using compensatorytechniques. Long term adverse effects of presentmanagement have been noted. Also, there is a gapin the literature regarding standardized exerciseinterventions for individuals with SCI (durationand frequency). Evidences suggest that inclusionof manipulative interventions indeed may behelpful in treatment of individuals with shoulder

The author can be contacted [email protected] and 09699063119


pain. Therapeutic exercises appear to be moreeffective when combined with joint mobilizationtechnique focused on upper quarter. The additionof manipulative therapy resulted in significantimprovements in short and long term recoveryrates and severity in individuals with shoulderpain without paraplegia but no published studyhave been found which has studied the effect ofcervico-thoracic mobilization in shoulder pain andfunctional independence in paraplegics and thereis a need in that respect.

METHODOLOGY

o STUDY DESIGN: Pre-test and post-testexperimental study design

o SOURCE OF DATA: SVNIRTAR, Cuttack,Odisha

o SAMPLE SIZE : 30 subjects

o POPULATION: Paraplegic subjects who metthe inclusion and exclusion criteria wererecruited for the study. A written informedconsent was obtained from each subject.

o GROUP ASSIGNMENT: Selected subjectswere randomly assigned to the two groupsafter getting written consent.

INCLUSION CRITERIA

o Paraplegics having shoulder pain.

o Able to propel wheelchair independently oneven surface and on ramp.

o Adult population: 18-50 years of age.

o Both the genders were included in the study.

EXCLUSION CRITERIA

o Any change of medication less than 2 weeksbefore or during the study.

o Any other treatment of shoulder joint pain.

o History and physical diagnosis of shoulderdislocation, subluxation or fracture, rotatorcuff tear.

o Elbow, wrist and hand pain

o Acromioclavicular joint pathology

o History of cervical, shoulder or upper trunksurgery.

o Hypermobility

o Any systemic disease or malignant condition

o Any congenital disorder.

VARIABLES

INDEPENDENT- i) cervicothoracic mobilization,ii) exercise therapy (stretching and strengthening)

DEPENDENT- i) pain, ii) functional independence

OUTCOME MEASURES

o Shoulder pain and disability index (SPADI)

o Wheelchair User's Shoulder Pain Index(WUSPI)

o Functional independent measure (FIM)-motor score

PROCEDURE

After fulfilling the inclusion and exclusion criteriasubjects were asked to fill the consent form.Subjects were then randomly assigned into manualtherapy and exercise therapy group. Detailedassessment was done for all the subjects and thedependent variables were measured. Followingmeasurement of the dependent variables theparticipants were asked to come next day forbeginning of the therapy session. Total durationof treatment was 5 days a week, one session for aday for 4 weeks.

EXERCISE THERAPY

Exercise therapy group received stretching andstrengthening exercises in the department for 4weeks. Upper trapezius, pectoralis major,pectoralis minor, long head of biceps and posteriorcapsule were stretched. Strengthening of serratusanterior, middle trapezius, lower trapezius, andexternal rotators of shoulder was done.

MANUAL THERAPY

Manual therapy group received same exercisetherapy along with cervico-thoracic mobilizationfor a period of 4 weeks. Central PA mobilizationwas done from C5 to T1 spinous process for twominutes at each segment with a frequency of 2Hzand amplitude as tolerated by the patient with littlediscomfort and no pain.


DATA ANALYSIS

Statistical analysis was performed using SPSSversion 16.0. The dependent variables wereanalyzed using repeated measures ANOVA. Therewas one between factor (group) with two levels(groups : manual therapy and exercise therapy)and one within factor (time) with two levels (pre-test and post-test). All pair wise post-hoccomparisons were analyzed using a 0.05 level ofsignificance.

RESULTS

The overall result of the study suggest that boththe groups (Manual therapy and exercise therapy)improved significantly from pre to post treatmentin all the three variables (SPADI, WUSPI, andmotor score of FIM) at the end of four weeks.Manual therapy group showed significantly betterimprovement in SPADI and WUSPI. However, theimprovement shown in FIM was not statistically

significant between the two groups.

Graph 1: Shoulder Pain and Disability Index(Mean±SEM)

Graph 1 illustrates that there was improvement inSPADI in both the groups following treatment for4 weeks. The manual therapy group showedgreater improvement in pain and disability asmeasured by SPADI in the post- treatmentmeasurements as compared to the exercise therapygroup. There was main effect for time F (1,28,0.05)= 95.309, p= 0.000. There was also a main effect forgroup F (1,28,0.05) = 9.267, p= 0.005. The maineffects were qualified into time × group interactionF (1,28,0.05) = 20.848, p= 0.000. Tukey's Post Hocanalysis shows that there was a significantimprovement in SPADI score for both the groups.However, the manual therapy group showedsignificantly greater improvement than exercisetherapy group at the end of 4 weeks.

Graph 2: Wheelchair Users Shoulder Pain Index

Graph 2 illustrates that there was improvement inWUSPI in both the groups following treatment for4 weeks. The manual therapy group showedgreater improvement in the post- treatmentmeasurements as compared to the exercise therapygroup. There was main effect for time F (1,28,0.05)= 106.376, p= 0.000. There was also a main effectfor group F (1,28,0.05) = 6.757, p= 0.015. The maineffects were qualified into time × group interactionF (1,28,0.05) = 17.260, p=0.000. Tukey's Post Hocanalysis shows that there was a significantimprovement in WUSPI score for both the groups.However, the manual therapy group showedsignificantly greater improvement than exercisetherapy group at the end of 4 weeks.

Graph 3 : Functional Independence Measure (FIM)

Graph 3 illustrates that there was improvement inthe motor score of FIM in both the groupsfollowing treatment for 4 weeks. The manualtherapy group showed improvement in the post-treatment measurements as compared to theexercise therapy group. There was main effect fortime F (1,28,0.05) = 45.508, p= 0.000. The main effectfor group did not achieve significant level F(1,28,0.05) = 1.616, p= 0.214. The main effects werequalified into time × group interaction F (1,28,0.05)= 5.141, p=0.031. Tukey's Post Hoc analysis showsthat there was a significant improvement in FIMmotor score for both the groups. However, boththe groups did not show statistically significantdifference at the end of 4 weeks of treatment.


DISCUSSION

The reason for the improvement of both the groupswith treatment may be because of the commonexercise protocol. The exercise therapy treatmentwas designed to treat the altered muscle length andstrength (i.e. muscle imbalance) which helped tobreak the vicious cycle of chronic pain. Soreduction of pain in both the groups could beascribed to the common treatment. The possiblemechanisms responsible for pain reduction byexercise therapy includes- i) stimulation ofmechanoreceptors, ii) production of beta-endorphins, iii) reduce muscular imbalance, iv)increase extensibility of soft tissues, v) reducefatigue, and vi) decreases fear avoidance. In thisstudy, there is significant greater reduction in painin manual therapy group. This could be attributedto the fact that in addition to the effects of exercisetherapy, subjects got additional benefits of cervico-thoracic mobilization. It was proposed that manualtherapy technique relieves pain by- i)neurophysiological, ii) biomechanical and iii)psychological effects.

Findings of the present study showed significantimprovement in motor score of FIM in both theexercise therapy and manual therapy group at theend of 4th week. But there was no significantdifference between the two treatment groups.Although the pain was reduced significantly inmanual therapy group, WUSPI scores also showedsignificant difference but it could not be transferredto ADLs as measured by FIM. The FIM does notmeasure the abilities of the person; instead scoresare given based on what the person does. Thiscould be a reason that the differences in FIM scoresare not statistically significant between the twogroups. Also, in spite of the abilities, the functionalindependence in paraplegia also depends upon-i)level of injury, ii) level of impairment, iii)motivation, and iv) environmental factors. Thesefactors could be important in determining themaximum functional level a person may achieveand the amount of assistance required to performthe activities of daily living following spinal cordinjury.

CONCLUSION

Manual therapy combined with stretching andstrengthening exercises is superior to exercises

alone in reducing shoulder pain in individualswith paraplegia.

LIMITATIONS

Small sample size, no control group, no follow-upwas taken and strength of shoulder muscles hasnot been measured which might be helpful topredict the effect of both therapies on the shouldermuscle strength.

RECOMMENDATIONS

o Large sample size can be taken

o Same type of study can be conducted onindividuals

- With complete versus incomplete paraplegia

- With higher paraplegia versus lowerparaplegia

o A follow-up study after withdrawing manualtherapy can be done to establish the carry-overeffect of manual therapy.

o WUSPI alone can be used to determine theeffect of shoulder pain on the functionalabilities in persons with paraplegia.

CLINICAL UTILITY

Cervico-thoracic mobilization can be performed inclinical settings for reduction of shoulder pain inindividuals with paraplegia.

REFERENCES

1. Bang MD, Deyle GD. Comparision of supervisedexercise with and without manual physical therapyfor patients with shoulder impingement syndrome.J Orthop Sports PhysTher. 2000; 30: 126-137.

2. Bergmann GJ, Winter JC, Groenier KH, et al.manipulative therapy in addition to usual medicalcare for patients with shoulder dysfunction andpain: A randomized control trial. Ann Intern Med.2004; 141: 432-439.

3. Curtis KA, Drysdale GA, Lanza RD, et al. shoulderpain in wheelchair users with tetraplegia andparaplegia. Arch Phys Med Rehabil 1999; 80: 453-457.

4. De Meirlier et al. Exercise and brainneurotransmission. Sport Med. 1985; 20, 160-188.

5. Gellman H, Sie I, Waters RL, et al. latecomplications of the weight bearing upper


extremity in the paraplegic patient. Clin Orthop1988; 223:132-135.

6. Jean-Se'bastein Roy et al. Effect of motor controland strengthening exercises on shoulder functionin persons with impingement syndrome: A single-subject study design. Manual Therapy. 2009. 14:180-188.

7. Lutho M, Duance VC, Restall D. collagen andfibronectin in a healing skeletal muscle injury. Animmunohistological study of the effects of physicalactivity on the repair of injured gastrocnemiusmuscle in the rat. The Journal of Bone and JointSurgery. 1985; 67B (5), 820-828.

8. Maitland G.D., Banks K., and Hengeveld, E. 2005.Maitland's Vertebral Manipulation. 7th Ed.Edinburgh. Butterworth Heinemann. ISBN 0 75068806 8.

9. McClatchie L, Laprade J, Martin S, Jaglal SB,Richardson D, Agur A. Mobilizations of theasymptomatic cervical spine can reduce signs ofshoulder dysfunction in adults. Man Ther.2009;14:369-74.

10. Mulroy S, Thompson L, Kemp B. Strengtheningand Optimal Movements for Painful Shoulders

(STOMPS) in chronic spinal cord injury. ARandomized Controlled Trial. Physical TherapyJournal. 2011. 91 (3); 1-20.

11. Nawoczenski D, Ritter-Soronen J, Wilson C et al.clinical trial of exercise for shoulder pain in chronicspinal cord injury. Research Reoprt PhysicalTherapy.2006; 86: 1604-1618.

12. Norlander S, Gustavsson B-A, Lindell J, NordgrenB. Reduced mobility in the cervico- thoracic motionsegment-a risk factor for musculoskeletal neck-shoulder pain: A two-year prospective follow-upstudy. Scand J Rehab Med 1997; 29:167-174.

13. Vicenzino B et al. specific manipulative therapytreatment for chronic lateral epicondylalgiaproduces uniquely characteristic hypoalgesia. ManTher 2001; 6: 205-12.

14. Waddell G, Newton M, Henderson I, SomervilleD, Main CJ. A Fear-Avoidance BeliefsQuestionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain anddisability. Pain. 1993 Feb; 52(2):157-68.

15. Wright A, Vecenzino et al. Hypoalgesia postmanipulative therapy: A review of potenatialneurophysiological mechanism. Manual Therapy

1995; 1:11-6.


RELATIONSHIP BETWEEN ISOKINETIC AND CLINICALMEASUREMENT OF SPASTICITY IN PATIENTS WITH

SPINAL CORD INJURY

Antony Kabasi1, Monalisa Pattnaik2, Dr. P. P. Mohanty3


1- MPT student, 2- Assistant professor in Physiotherapy, 3- Associate Professor in Physiotherapy

The most cited definition of spasticity is: Spasticityis a motor disorder characterized by a velocitydependent increase in tonic stretch reflexes(muscle tone) with exaggerated tendon jerks,resulting from hyperexcitability of the stretchreflex, as one component of the upper motorneuron syndrome' (Lance, 1980). Spasticity is acommon sequel to an insult to the upper motorneuron (UMN) of cortical, subcortical or spinalcord origin. Spasticity is often cited as a significantproblem in multiple sclerosis, traumatic braininjury, cerebral palsy, spinal cord injury, stroke etc.

Among the many impairments of SCI, spasticityplay an important role (Vijayakumar and Singh,2004 ). Spasticity may contribute to pain, fatigue,development of contractures, pressure ulcers,compromising safety, & overall negativelyinfluence the quality of life through restricting theADLs. Spasticity is one of the major constraints forthe function and its documentation is equallyimportant to understand its nature andfluctuations over time and with treatment. In astudy of 96 persons with acute SCI, Maynard etal., found the incidence of spasticity to be 67% with37% requiring treatment by the time of discharge& 78% & 49% respectively by the time of the firstannual follow up visit.

Assessment of spasticity is complex due to itsvarious manifestations, difficulties to distinguishbetween neural and non-neural components, anddifferent characteristics during passive and active,more functional movements. Additionally, therecan be a discrepancy between outcomes ofobjective tests and the patients' perception and,finally, a single momentary assessment may be

erratic. Clinical scales for the assessment ofspasticity mainly concentrate on resistance topassive movement. In laboratory settings,biomechanical or neurophysiological methods ofmeasurement can be used, assessing either theresistance to imposed passive movement or theelectrical activity of the involved muscles. The mostwidely accepted clinical scale to measure muscletone is the modified Ashworth Scale (Pandyan etal., 1999, Skold et al., 1999, Gregson et al., 2000,Satkunam, 2003, Ivanhoe et al., 2004). An adaptedversion, called the modified Ashworth Scale wasintroduced by Bohannon and Smith (1987) with anadditional category of +1 falling between 1 and 2,which aimed to increase the sensitivity of the scaleby identifying the phenomena of catch a suddenincrease in muscle stiffness in response to a briskmuscle stretch (van der Salm et al., 2005). TheAshworth and the modified Ashworth scales havegarnered controversy regarding their metricproperties. These scales have been applied to amyriad of disease conditions (brain injury, stroke,MS, SCI, and other neurodegenerative conditions)which have implications of spasticity. Modifiedmodified Ashworth Scale (MMAS) omits theambiguous category +1 and redefines the grade 2(Ansari et al., 2006).

Apart from MMAS, in clinical setting, spasticitycan be assessed by Spinal Cord Assessment ToolFor Spastic Reflexes (SCATS) to measure SCIspasms & spastic hypertonia. The SCATS is aphysiologically based measure for spastic reflexesfor use in individuals with SCI. It was developedin response to the demand for a standardized,simple clinical measure that encompasses theprimary spastic reaction in the SCI population. TheSCATS is split into 3 subscales, each addressing aseparate spasm: clonus; flexor spasms; extensorspasms. Penn Spasm Frequency Scale (PSFS) is a

The author can be contacted at [email protected] and 09836750346


patient's self-report on perception of spasticityfrequency & severity. The modified PSFS queriedfrequency & severity separately. If no spasm isreported, severity rating is not necessary. PSFS isdeveloped to augment clinical ratings of spasticityand provide a more comprehensive understandingof an individual's spasticity status. Patients reporttheir perceptions of spasticity with regards tofrequency and severity. In general, self-reportmeasures of spasticity correlate only moderatelywith clinical examination suggesting that theelements of spasticity evaluated in the physicalexamination do not represent what is importantto persons with SCI spasticity.

To more fully understand spasticity as experiencedby the client, self-report spasticity measures arean important adjunct to other clinical measures ofspasticity. Use of Isokinetic dynamometry tomeasure spasticity has been recommendedbecause of the difficulties associated with clinicalscales. Spasticity evaluation is now frequently doneby Isokinetic dynamometers because ofstandardized & controlled displacement of boththe velocity & range of motion. The ability to varyvelocities allows for the evaluation of the ratedependent characteristics of muscle tone. Use ofisokinetic dynamometer, allows for evaluation ofthe rate dependent characteristic of muscle toneas well as increased stiffness of non-reflexcomponents. Measuring the magnitude ofspasticity is essential for determining theeffectiveness of therapeutic intervention. Spasticityis measured by using a dynamometer by movinga limb passively through a defined range of motionwhile the peak resistive torque is calculated.Another method to measure spasticity throughisokinetic dynamometry data to perform aregression analysis to derive a slope value frommechanical work measurements calculated atmultiple velocities. According to Akman et al(1919) peak resistive torque should be used tomeasure spasticity whereas slope value frommechanical work measurements can be used toquantify hypertonus of any type. Reliability ofisokinetic dynamometer measurement has beenexamined in several studies, from which it can beconcluded that the resistive force values are highlyreproducible for low as well as high angle

velocities in able body persons as well asindividuals with neurological insult.

Several studies have demonstrated that reductionsin spasticity as measured clinically necessarilycorrelated with improvements in function(Lechner et al., 2006, Adams et al., 2007). Finally,multijoint flexor & extensor spasms, which areprevalent in SCI, are not accounted for in theAshworth Scale MAS (Benz et al., 2005). Skold etal. (1999) reported a relationship between self-reported spasticity and impaired range of motionfor hip abduction and flexion bilaterally. Theyrecommend self-reporting of spasticity withregular intervals over several consecutive days.Repeated modified Ashworth ratings would alsobe beneficial in determining the character of theindividual experience of spasticity. Using a Spasmseverity scale (SSS) Lechner and colleagues (2006)compared present spasticity (SSS present, thatexperienced during testing) with general spasticity(SSS general, that ordinarily experiencedthroughout the day). They found a goodcorrelation (r=.70) between the Ashworth Scale andSSS present, but a weak correlation of r=0.36between the Ashworth Scale and SSS general. Thissuggests that while Ashworth scores may offerinsight into the patient's perceptions of theirspasticity at the time of testing, they cannot be usedas a measure to reflect the patient's generallyperceived spasticity. A co relational analysis of SSSpresent and SSS general would have enabledfurther discernment.

Only Priebe and colleagues (1996) have drawncomparisons between self-report measures ofspasticity. A sample of veterans with SCI showedweak correlations between Penn Spasm FrequencyScale and self-report scales of interference withfunction (estimated polychoric correlation =0.407)and pain (estimated polychoric correlation= 0.312).The SCATS flexors spasm & clonus scorescorrelates well with MAS but only the SCATSclonus score correlated significantly with PSFS (r=0.59) (Benz EN 2005).

Based on the literatures review, in the presentstudy the above 3 clinical tools will be used; whichare well tolerated by the patients during routineassessments, simple to administer & requiring nospecialized equipments. Spasticity due to spinal


cord injury encompasses clinically increasedmuscle tone, exaggerate tendon reflexes, clonus,& spasms. None of the clinical scale includes allthe aspect of spasticity during measurement on theother hand isokinetic measurement of spasticity(passive resistive torque ) is said to be highlyreproducible where both the velocity & range ofmotion can be controlled.

METHODOLOGY

A total of 50 (47 males & 3 females) subjects withSCI, who met the inclusion & exclusion criteria &who gave a written consent were recruited.Inclusion Criteria were persons with spinal cordinjury (both traumatic greater than 3months & non-traumatic), having spasticity of the lower limb.Patient should be co-operative, oriented &medically stable & able to maintain sitting posturefor 30 minutes, with or without support. ExclusionCriteria were orthostatic hypotension andassociated neurological diseases, limited range ofmotion of hip, knee & ankle due to contractures,heterotopic ossification (HO) at hip & knee, wherepassive range of motion is contra-indicated,subjects enrolled in another clinical trial or researchor intervention to lower extremity and patientstaking anti-spastic medicine.

The details of examination & measurementprocedure were explained to the subjects & awritten consent was taken. Spasticity wasmeasured using Modified Penn Spasm FrequencyScale (PSFS), Spinal Cord Assessment Tool forSpastic Reflexes (SCATS), Modified ModifiedAshworth Scale (MMAS) & by Isokineticdynamometer randomly.

Commercially available computerized isokineticdynamometer (CSMI HUMAC/NORM ™Isokinetic device) was used to quantify passiveresistance. The individuals were secured on theisokinetic dynamometer seat with pelvic & thighstraps. For the ankle tests the foot was strappedinto a modified footplate & heel cup was attachedto the lever arm with the patient in supine & histhigh supported by a thigh pad. The joint axis wasaligned with the lever arm. The lever arm wasanatomically referenced to the ankle joint. Ankledorsiflexion & planterflexion range of motionlimits were established. Knee measurements were

done in the sitting position with the leg hangingout of the seat and the rotation axis of thedynamometer was set to correspond with therotational axis of the knee joint. The hip wasmaintained at 85° flexion with the attachment ofthe lower extremity to lever of the dynamometerwas made 4 cm above the lateral malleolus. Wefollowed Akman (1999) protocol & added it to thecontinuous passive motion mode menu of themachine in order to standardized our methodThree consecutive passive joint motions wereperformed at four selected velocities (60°, 90°, 120°,and 180°) for each motion type. Correction forgravity was undertaken to account for the weightof the limb. According to the set up of the machine,concentric torque values represent the forcespushing against lever, while eccentric torquerepresent pulling forces. For each joints, resistanceto passive motion was determined by recordingthe 3 eccentric peak torque values in Newton-meter (N-m) at all velocities & joint motions. Themaximum peak torque (MT) values of 3 repetitions& the sum of 3 peak torques (ST) for each jointmotion at each velocity were recorded. AverageMTs & STs were also calculated for each subject bysumming the 3 MTs & STs at four velocities &dividing by four. Prior to evaluation a trial sessionwas applied to get the client acquainted with theprocedure.

A single passive movement were done todetermine the spasticity during knee ( quadriceps,& hamstring ) & ankle ( planter flexor ) movementaccording to MMAS grading. For knee flexor &extensor grading the patient was in side lyingposition with the hip in neutral in position. Forthe ankle joint, patient was positioned in supinewith the knee extended.

SCATS: Clonus: Clonus of the plantarflexors wasquantified in response to a rapid passivedorsiflexion of the ankle. The ankle was dorsiflexedat an angle that triggered clonus, and the durationof clonic bursts was timed. An ordinal rating from0 to 3 was determined by the duration of clonicactivity where 0 is no reaction; 1 is mild, clonuswas maintained

less than 3 seconds; 2 is moderate, clonus persistedbetween 3 and 10 seconds; and 3 is severe, clonuspersisted for more than 10 seconds.


SCATS: flexor spasms. With the knee and hipextended to 0°, the clinician applied a pinprickstimulus for 1 second to the medial arch of thesubject's foot. Excursion of the big

toe into extension, ankle dorsiflexion, and knee andhip flexion were visually observed for severity. Therating scale consisted of a score from 0 to 3, where0 is no reaction to stimulus; 1 is mild, less than 10°of excursion in flexion at the knee and hip orextension of the great toe; 2 is moderate, 10° to 30°of flexion at the knee and hip; and 3 is severe, 30°or greater of knee and hip flexion.

SCATS: extensor spasms. With the contralaterallimb extended, the tested knee and hip werepositioned at angle of 90° to 110° of hip and kneeflexion, and then both joints were simultaneouslyextended. One hand cupped the heel while theother was placed on the outside of the thigh. Oncea reaction was elicited, the duration of visiblemuscle contraction

in the quadriceps muscle was measured byobserving superior displacement of the patella. Thetimed scale (0 -3) that was used for clonus was alsoapplied to the timed extensor spasms.

Patients reported their perceptions of spasticity withregards to frequency and severity. The Firstcomponent is a 5 point scale assessing the frequencywith which spasms occur ranging from "0= Nospasms" to "4 = Spontaneous spasms occurring morethan ten times per hour". The second component isa 3 point scale assessing the severity of spasmsranging from "1 = Mild" to "3 = Severe". The secondcomponent is not answered if the person indicatesthey have No spasms in part 1.

DATA ANALYSIS

Kendall Correlation Coefficient analysis was doneto find out the relationship between isokineticmeasurement of passive resistance torque andclinical scales of spasticity measurement (MMAS,SCATS, PSFS). All the data analysis was done withthe SPSS software version 16.0.

RESULTS

Isokinetic vs MMAS: Kendall Coefficient of passiveresistance torque & MMAS ranges from (r= 0.218-0.240 ) for Quadriceps, (r= 0.274-0.330 ) for

Hamstring & (r= 0.376-0.444 ) for planter flexors.

Isokinetic vs SCAT: Kendall Coefficient of passiveresistance torque & SCATS ranges from (r= 0.080-0.115) passive resistance torque of Quadriceps vsExtensor Spasm, (r= 0.049-0.111) passive resistancetorque of Hamstring vs Flexor Spasm, (r= 0.399 to0.494) passive resistance torque of Planterflexor vsClonus.

Isokinetic vs PSFS (SFS & SSS): Kendall Coefficientbetween Passive resistance torque of Quadriceps,Hamstring & Planterflexor and Frequency of PSFSscale ranges from r= -0.051-0.228. And KendallCoefficient between Passive resistance torque ofQuadriceps, Hamstring & Planter flexor andSeverity of PSFS scale ranges from r= 0.025 - 0.218.

DISCUSSION

ISOKINETIC VS MMAS: Quantification ofspasticity by any clinical tool must be able todistinguish between the neural & non-neuralcomponents, correctly elicit velocity dependentincrease passive resistance & be concerned aboutthe other manifestation of spasticity ( spasms,clonus). Further any tool that measures spinalspasticity have to measure muscle tone (Intrinsictonic spasticity), tendon reflex & clonus (Intrinsicphasic spasticity ) and spasms (Extrinsic spasticity).Hence we used three different scales to measurespasticity; the MMAS, SCATS and PSFS. AS andMAS are criticized for their vulnerability tosubjective interpretation by the examiners as theydo not quantify passive resistance in absolute.Examiners may thus draw biased conclusionsabout the findings and their implications (Pandyanet al., 1999). We chose MMAS as this scale omitsthe ambiguous category +1 and redefines the grade2 (Ansari et al., 2006). Further studies have showngood intra and inter-rater reliability of MMAS inpatients with spinal cord injury.

MMAS scale for the assessment of spasticitymainly concentrates on resistance to passivemovement. MMAS is dependent upon theperception of the examiner. Differentiationbetween neural and non-neural contributions isdifficult. Iso-kinetic measurement is abiomechanical method of measurement ofspasticity. This method of measurement relies onthe resistance to imposed passive movement. Their


clinical relevance seems limited & again theirinability to distinguish between neural and non-neural components of spasticity is questionable.

The poor correlation between MMAS andisokinetic measures can be attributed to thevariable measured in spasticity. Scales based onphysical movement rely on the assumption thatthe linear velocity and range of motion regulatedby the examiner are the same between trials(Pandyan 1999), which in reality is not perfectlyreproducible. The resistance to passive movementas measured by MMAS is a sum total of reflexmuscle activity and non-neural mechanicalcharacteristics. It is influenced by changes in visco-elastic properties of joint structures and soft tissuesafter an upper motor neuron lesion. In addition,changes in mechanical muscle-fibre propertiesmight contribute to spastic muscle tone.

In the present study, Grade 1 was awarded to themajority of the participants of all the muscle groupsfollowed by grade 0, 2, & 3. The mean ± SD for thequadriceps muscle's Average Maximum Torque(AvgMT) = 12.546± 5.90 N*m, mean ± SD for theHamstring muscle's Average Maximum Torque(AvgMT) = 13.826 ± 5.469 N*m & mean ± SD forthe Planterflexors muscle's Average MaximumTorque (AvgMT) = 12.755 ± 15.524 N*m.

Perell et al (1996) studied the quantifying muscletone in spinal cord injury patients using isokineticdynamometric technique found decreased peaktorque in spastic patients in comparison to flaccidand able subjects. They took spastic patients ofashworth grading of 2-4. Their Tmax values are at60°/s the mean ± SD for the spastic group T maxFLX = 8.00 ± 4.35 N*m, the flaccid group Tmax FLX=16.68 ± 6.84 N*m, and the normal group Tmax FLX=16.63 ± 4.10 N*m. At 120°/s, the mean ± SD for thespastic group Tmax FLX= 19.00 ± 7.11 N*m, theflaccid group Tmax FLX = 34.31 ± 9.74 N*m, andthe normal group T max FLX = 36.49 ± 1 3.1 3 N*m.

In 1999, Franzoi et al studied with a group of 12subjects with complete traumatic spinal cord injury& 12 able-bodies to assess spasticity of hamstring& quadriceps and found significantly loweraverage torque in the SCL group with AS score 1-2 compared to the normal group at 60°& 120°/sec.

Pierce et al (2008) didn't found any significant

relationships between quantitative measurementof spasticity (peak passive torque at 15, 90 & 180deg/s) & clinical measurement (AS) scale forspasticity in either group i.e. knee flexors &extensors in children with spinal cord injury.Akman et al (1999) found Ashworth grade 1 of kneeflexors & extensors did not differ from controlgroup in their torque values. And Ashworthgrades 2 were insignificant in respect to controlgroup. Pandyan et al (2001) studying the validityof the modified ashworth scale, showed limitedassociation with the measure of resistance topassive motion. Rabita et al (2005) found theashworth score was significantly correlated withthe normalized passive resistance for each velocitywhereas no correlation was observed with the rawpassive resistance. Alibiglou et al (2008) studyingthe relation between ashworth scores &neuromechanical measurements of spasticityfollowing stroke concludes that MAS does notprovide reliable information about the origin ofthe torque change associated with spasticity. In aanother study Rabita et al (2005) compared thekinematic parameters of imposed anklemobilizations measured by ashworth scale &isokinetic device, concluded that manual test can'tbe simulated by isokinetic device. Limitedassociation between Ashworth & Isokineticmeasurement may be due to different patient'sposition, different repetition of movements anddifferent velocity of performing the movement.

Other factors that might have contributed to thepoor correlation may include the following:

Reliable and comparable measurement ofspasticity, required an exact description of testposition and procedure (Kakebeeke et al, 2002).Muscle spindle activity is linearly related to musclelength, and it's activation threshold is reducedduring passive stretch. Wolf et al stated that initialposition of joint affects muscle length &consequently the degree of depolarization amongmotorneurons that are influenced by spatial &temporal summation of cutaneous &proprioceptive inputs interfering the muscle'sresponse to stretch. While the MMAS wasperformed in appropriate starting positions wherefull range was possible, measurement usingisokinetic machine allowed movements that are


possible only by keeping the other joints in flexionor extension. Further the starting position in whichspasticity was evaluated for both the techniquesdiffered grossly. Another factor that might havecontributed to poor correlation is repetition.Resistance to passive movement is affected byrepetition. Bruke et al has shown reduction ofstretch reflex due to fatigability with repetition.While MMAS necessitated only 1 movement,isokinetic machine necessitated a total of 12movements for a single measurement. MMASrequired testing in one velocity but isokineticmeasurement was calculated with differentvelocities.

ISOKINETIC VS. SCATS

The poor correlation between isokinetic output andSCATS may be hypothesized to the application ofbrief stimuli to evoke forceful, prolongedresponses. The neuro-pathophysiology behindinvoluntary muscle spasms in human SCI stillremains unclear, but one hypothesis is that changesin the intrinsic electrical properties of spinalcircuitry contribute to the spastic syndrome(Bennett et al. 2004; Nielsen et al. 2007). Duringmeasurement of SCATS a stimuli was applied tothe sole of the foot that produced spasmsthroughout muscles in lower extremities lastingfrom a few seconds to tens of seconds (Benz et al.2005). Such stimulus was not applied to isokineticmeasurement. Further SCATS score is dependentupon hip propioceptors and a coordinatedresponse of hip flexion, knee extension, & ankleplanterflexion (Benz 2002) is needed to producespasms. Further a change in position is requiredto elicit spasms, like shifting from a seated tosupine position ( Macht & Kuhn 1984 ) or byextension of legs ( Schmit Benz 2002 ). Such amechanism is not associated with isokinetic testingthat might have resulted in poor correlation.Hornby et al (2004) has observed that prolongedflexion reflexes (i.e., flexor spasms) are triggeredin individuals with SCI using IM TA(intramuscular tibialis anterior) and GS (gastrosoleus)stimulation. Again such mechanism is not possibleduring isokinetic measurement. So from the abovediscussion we can conclude that, spasms mainlyare multi-joint reflexes except clonus but which isalso capable of producing multi-joint response

with appropriate stimulus. As spasms are multi-joint reflexes, its elicitation not only depends onsensory stimulus but also on stretch , position ofthe joint & proprioceptive input, all this results inno correlation between them.

ISOKINETIC Vs PSFS: The study found nocorrelation found between frequency & severityof PSFS and isokinetic measurement of spasticity.PSFS is developed to augment clinical ratings ofspasticity and provide a more comprehensiveunderstanding of an individual's spasticity status.Patients report their perceptions of spasticity withregards to frequency and severity. In general, self-report measures of spasticity correlate onlymoderately with clinical examination suggestingthat the elements of spasticity evaluated in thephysical examination do not represent what isimportant to persons with SCI spasticity. To morefully understand spasticity as experienced by theclient, self-report spasticity measures are animportant adjunct to other clinical measures ofspasticity. Correlation of the PSFS is adequate withthe Ashworth tested on the hip (Spearman'sr=0.43), knee (Spearman's r=0.43) and ankle(Spearman's r=0.51), and the SCATS tested on theclonus (Spearman's r=0.59), flexor (Spearman'sr=0.41) and extensor (Spearman's r=0.40) (Benz etal. 2005, Priebe et al. 1996). Samuel R Pierce et al(2007) found significant relationship between theSPS & passive torque of the knee flexors &extensors with movement at a velocity of 90°/sec.Since they were unable to explain the reason asthere is little EMG activity. As PSFS is a subjectivescale it's score largely depends on the patient'sperception, cognition and mood. So as PSFS is asubjective scale so, it does not correlate withobjective measurement of spasticity i.e. isokinetic.

CONCLUSION, LIMITATION & FUTURERECOMMENDATION

Conclusion: The present study showed there is nocorrelation between isokinetic measurement ofpassive resistance torque & clinical measurementof spasticity. As spasticity following spinal cordinjury is multidimensional nature, a single scalemay not be able to measure all the aspects. MMASis still a good clinical scale to measure spasticitybut ignores the patient's perception of spasticity.


Limitation: Repetition of movement was much inisokinetic measurement. Patient's position was notidentical in all the procedures.

FUTURE RECOMMENDATION

Using single repetition at each velocity duringmeasurement of passive resistance torquethrough isokinetic dynamometer.

Use of identical posture for differentprocedure.

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EFFECT OF DISEASE SPECIFIC CONSERVATIVE TREATMENTON TRUNK MUSCLE STRENGTH IN MALES WITH

CHRONIC LOW BACK PAIN

Biprajit Das 1, Dr. Patitapaban Mohanty2, Mrs. Monalisa Pattnaik3


1- MPT student, 2- Assistant professor in Physiotherapy, 3- Associate Professor in Physiotherapy

ABSTRACT

Low Back Pain is a debilitating condition affecting 80-90% and 5-15% develops chronic low back painwhich is mainly attributed to trunk muscle imbalances. Although many studies have shown positiveinfluence of trunk muscle strengthening in CLBP, this study aimed to prove the effect of disease specificconservative treatment on trunk muscle strength without giving any strengthening exercise in maleswith CLBP. 5o males with CLBP categorized into different categories and disease specific conservativetreatment was planned out for 4 weeks without giving any strengthening exercises. Trunk muscle strengthwas measured in isokinetic dynamometer. Paired t test results have shown improvement in peak andaverage torque and reduction in numeric pain rating score. Hencethe study demonstrates that diseasespecific conventional therapy had positive influence in reduction of pain and improvement in trunk musclestrength

INTRODUCTION

Chronic low back pain is defined as persistent& disabling low back pain lasting more than 3months. During the course of their lives 70-85%of individuals will experience low back pain(LBP).Furthermore, over 80% of such patientsreport recurrent episodes. It is estimated that80-90% of patients will have recovered within6 weeks, regardless of treatment. However, 5-15% will develop chronic low back pain(CLBP>12 weeks): this is more difficult to treatand treatment has variable results

CLBP pain may occur as a result of a stressedor irritated muscle or ligament, a developmentof muscle strain due to prolonged poorposture, weakness and wasting of posturalmuscles. The recognized risk factors for workrelated low back pain are heavy physical workstatic and faulty working posture, prolongedstanding and sitting. Some physical demands,

including manual lifting, bending, twisting andwhole body vibration are associated with anincreased likelihood of postural low backpain.Paraspinal & other trunk muscleweakness has been documented in severe,chronic low back pain

There are various interventions available forthe treatment of CLBP, where most of themfocus mainly on the pain management ratherthan addressing the patho-mechanics behindthe CLBP. Most commonly, the treatmentincludes the use of wide range of electricalmodalities for CLBP, however; their inclusionor exclusion as an intervention has shown poorevidence by the Philadelphia panel.

Hodges and Richardson 1999 added that thefunction and coordination of the stabilizationof low back muscles (mainly the extensors) arereduced in CLBP patients supported byMoffroid et al 2008.This reduction in muscularstrength and coordination contributes to



decreased postural stability and it is found thatthe coordination of postural control may beaffected in subjects with chronic low back pain(CLBP) ( Volpe 2006).

Patients with chronic low back paindemonstrated poorer postural control of thelumbar spine and longer trunk muscleresponse times than healthy control volunteers.Correlation between these two phenomenasuggests a common underlying pathology inthe lumbar spine (Radebold A, 2001).

There are various interventions available forthe treatment of CLBP. There is nowconsiderable evidence documenting theefficacy of exercise in the conservativetreatment of CLBP. However, the choice ofexercise therapy is also fraught with difficultyfor the clinician because aerobic exercises,strengthening exercise, coordination exercisesand specific stability exercises have all shownto be effective in the treatment of thiscoordination. Tulder et al 2001 conducted asystematic review on effectiveness of exercisetherapy for low back pain and found exercisesmay be helpful for patients with chronic lowback pain to increase return to normal dailyactivities and work. However, very little workhas been done to see the direct influence ofreduction of pain and improvement of mobilityon trunk muscle strength.

METHODS

CLBP subjects with mean age (35.88 14) weretaken and their proper assessment was done.Subjects who fulfilled the inclusion andexclusion criteria, were accounted for the study.They were given verbal instructions for thestudy and informed consent was taken fromevery subject before their participation in thestudy. At 0 week isometric strength of trunkflexor and extensor in isokinetic dynamometerand NPRS score was taken to record pain.

Total 50 subjects were selected, disease specificconventional treatment was given. The

treatment was given 5 times a week in a 4 weekprotocol. At the end 4th week the isokineticreadings & NPRS score was measured again.Subjects were instructed not to do any specificstrength training for trunk muscle during thestudy period.

DATA ANALYSIS

The dependent variables were analyzed at 0week & 4th Week using a paired t test. TheSignificance level (p) was taken as 0.05

RESULTS

A total number of 50 male subjects with meanage (35.88 ± 14) were taken. 5 subjects did notfollow up for post measurement. So pre andpost measurement data for 45 subjects datawere analyzed.

Graph1:- illustrates that there was animprovement in strength of both trunk flexornad extensors.

Using a related t test on the data for the trunkflexors ( t = 7.573, df = 45, p=0.000) the resultwere found to be significant. Using a related ttest on the data for trunk extensors ( t= -8.249,df=45,p=0.000), the results were foundsignificant .

Graph 2:- illustrates that there was animprovement in strength of bothtrunk flexorand extensor group. Using a related t test onthe data for trunk flexor (t= -8.885, df=45,p=0.000), the result were significant. Using arelated t test on the data for trunk extensors(t= -8.177, df=45, p=0.000), the results weresignificant.

Graph 3:- illustrates that there was animprovement in Numeric Pain RatingScore(NPRS )score for pain. Using a realated ttest on the data( t = 16.057, p= 0.000) showedsignificant difference in pain from pre to posttest measurement.

DISCUSSION

Although it has already been mentioned in


various studies about the effectiveness ofindividually tailored conservativemanagement in CLBP, but none of the studieshave directly correlated the changes in trunkmuscle strength with mobility and stretchingactivities.In our study no strengthening orstabilization exercises for trunk was taught orprescribed still we have found a difference inthe isometric flexion and extension torque. Thisis supported by (Hodges et al2005) who statedthat there is recruitment of transversesabdominis (TrA) with minimal activity of thesuper?cial abdominal muscles in the earlystages of rehabilitation. This approach is basedon evidence that activity of TrA contributes tospinal control in people with CLBP. Also, inaddition it is seen that that there is animprovement in transverses abdominis controland function following spinal mobilization.The results were also supported by Raney etal., 2007 study where 6 out of 9 patientsdemonstrated an improved ability to increasetransversusabdominis (TrA) musclecontraction following spinal mobilization

Similarly, Janda found that, there is an overalldecrease in activity in the affected muscle,which in extreme cases can result in EMGreadings showing it to be almost completelysilent. This can lead to a misinterpretation thatmuscle strength is totally lacking when in fact,after proper facilitation, it may be capable ofbeing There is an overall decrease in activityin the affected muscle, which in extreme casescan result activated towards more normalfunction. ( Janda calls these changes'pseudoparesis'). Some muscles are more likelyto be affected by hypotonia, loss of strengthand the effects of altered movement patterns.Janda points to tibialis anticus, peronei, vasti,long thigh adductors, the glutei, the abdominalmuscles, the lower stabilisers of the scapulae,the deep neck flexor musles. Among the causesof such changes in mainly phasic muscles arethe effects of reciprocal inhibition by tight

muscles, and in such cases, Janda comments,'Stretching and achievement of normal lengthof the tight muscles disinherits the pseudoparetic muscles and improves their activity'.

(Khalil TM et al 1992) showed that patientsundergoing the multimodal rehabilitationprogram with and without the proposedsystematic stretching maneuver showed asignificant improvement in their functionalabilities as seen from the significant increasein the static strength of the back extensors, withcorresponding significant increase in backmuscle myoelectric signals. The use of thesystematic stretching maneuver enhanced thefunctional gains of chronic low-back painpatients compared to the control group.

Manual therapy has also shown to havepositive effect on muscle recruitment assupported by (Brenner 2007) case report thatdemonstrated a dramatic change in the abilityto activate the multifidus during limb activityimmediately following spinal manipulation.Further, this improvement in multifidusactivation was associated with improvementsin other clinical exam findings.Electromyographic studies have shown themultifidus is more loaded & activecontinuously in upright positions, and it isthought to be active in all anti-gravity activity(Watson 2006).

However, (Mofforoid et al 1993) stated thatthough some improvement in function of backextensors was seen after spinal extensionexercises in prone but we were not able todocument significant physiologic changesaccompanying the increase in the musclefunction.

Physical therapy procedures of active andpassive lumbar movement aid nutrition of thedisks and facet joints, help preserve a full rangeof movement, and ensure strong ligaments andtendons. Lumbar sagittal movements, inparticular, bring about the largest fluid


exchange between the disks and the interstitialfluid surrounding the spine (Adams MA 1989,TyrrellAR,1985). The use of the extensioncomponent of sagittal movement is the mostefficient means of "unloading" the previouslyloaded elements of the spine and ofrehydrating disks, AC, and soft tissues. Thisexplanation provides an understanding of whyextension postures and movements areimportant in the management of low back painand why extension movements are so usefulas a primary form of manual treatment.(Twomey LT 1987)

Various theories have been postulated in manystudies to show a relation between the pain andreduction in strength. The pain-adaptationmodel of ( Lund and colleagues 1991 )stipulates that, in the event of pain, thealteration in motor control serves to limitmovement. During movement, this involves adecrease in agonist muscle activity andincreased antagonist activity to limit thevelocity, force and range of movement(Svensson et al 1995).

Consistent with this proposal, there is evidenceof relative stiffening of the spine in pain.(Nilssen et al 1999) reported reduced trunkmovement during gait during experimentallyinduced pain, and (Henry 2001) showed thattrunk movement following a support surfacetranslation is reduced during pain.Hypothetically, if the general stiffness of thespine is increased, the CNS may perceive thedemand for 'fine-tuning' to be diminished,leading to reduced activity of the deep localspinal muscles despite the potential long-termsequelae of this strategy

This is consistent with data which suggest thatpostural activity of the trunk muscles isreduced or delayed when the perceivedstability of the spine is increased (Hodges et al1997b, Stokes et al 2000). After resolution ofthe pain, this adapted strategy may also resolveor, in the presence of ongoing fear of pain or

other reinforcement, persist to chronicity.

Muscle pain causes no increase inelectromyographic activity at rest and reducesmaximal voluntary contraction and endurancetime during submaximal contractions.Furthermore, muscle pain causes an adaptivechange in the coordination during dynamicexercises. They support an adaptive modelpredicting reduced agonistic muscle activityeventually advanced by changed antagonisticmuscle activity. (Graven-Nielsen T et al 2008)

One study found that higher peak torque ontask of isokinetic trunk extension and flexionwas associated with lower pain related fear(Crombez et al 1999).

CONCLUSION

The study demonstrates that disease specificconventional therapy had positive influence inreduction of pain and improvement in trunkmuscle strength

Images, Graphs and Tables

Physical Diagnosis No. of Patients and treatment protocol

Lumber dearangement syndrome Criteria: Centralization of pain with repetitive extension &Peripheralization with repetitive flexion.R.A. McKenzie 1988

09 Mckenzie extension erercise Susutaied extension Extension mobilisation Stretching of tight structures

Flexion Dysfunction Criteria: Loss of trunk flexion with localized pain before achievement of full normal range of flexion.R.A. McKenzie 1988

06 Flexion exercise Stretching of tight structures

Soft Disc Lesion Criteria: Lower back with radiating pain where leg pain is more than back pain. Pain aggravated with flexion of the trunk. James Cyriax1988

04 Listing correction in supine Continuous traction

Spondylosis Criteria: Limitation and pain in extension, Radiograph shows osteophytes and other degenerative changes.James Cyriax1988

08 Maitlands graded mobilisation Mobility exercise for both flexion and extension Manipulation Stretching of tight structures

Non-Specific Criteria: the problem encountered does not lend itself to a true medical diagnosis. Although clinical presentation of a patient with this condition is fairly easy to recognize, the explanations given for the underlying pathology are controversial and contentious. David J. Magee et al 2009

18 Lumbar mobilisation Thoracic manipulation (R.F. de Oliveira et al 2013) Mobility exercise Stretching of tight structures


b) Conventional Treatment (ConditionSpecific) : -

Indication Exercises

Spinal Flexion

Spinal Extension McKenzie Extension

Increased lumbar lordosis, Flexion dysfunction Reduced lumbar lordosis, Extension dysfunction

Posterior Lumbar Derangement Syndrome

Lumbar Mobilization (Maitland) Central PA Vertebral Pressure

Unilateral PA Vertebral Pressure

Bilaterally disturbed symptoms / Hypomobility

Unilaterally disturbed symptoms / Hypomobility

Traction

Supine

Prone

Radicular signs, unable to centralize symptoms or Muscle spasm If Flexion is pain free, extension is painful

If Extension is pain free, Flexion is painful or if both flexion and extension are painful

Stretching Rectus Femoris

Piriformis

Tightness as determined by Ely’s Test Limited hip external rotation with hip in flexion,

without any associated spasms

RESULT

Graph 1Graph 2

Paired Differences T df Sig. (2-tailed)

Mean Std. Deviation

Std. Error Mean

95% Confidence Interval of the Difference

Lower Upper

PTPREEXT - PTPOSTEXT

-2.37778E1

19.33660 2.88253 -29.58714

-17.96842

-8.249

44 .000

Paired Differences

t df Sig. (2-tailed)

Mean Std. Deviation

Std. Error Mean


Lower Upper

AVGTPREFLX - AVGTPOSTFLX

-1.53778E1

11.60973 1.73068 -

18.86573 -

11.88983 -

8.885 44 .000


Graph 3

Paired Differences

t df Sig. (2-tailed)

Mean Std. Deviation

Std. Error Mean


Lower Upper

NRPS PRE – NRPS POST

2.06667

.86340 .12871 1.80727 2.32606

16.057 44 .000


Posterior Unilateral Vertebral Pressure Posterior Central Vertebral Pressure


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EFFECT OF AUDITORY& VISUAL BIOFEEDBACK WITHELECTRICAL STIMULATION OF THE TIBIALIS ANTERIOR

MUSCLE ON ACTIVE ROM & SELECTIVE MOTOR CONTROLOF ANKLE OF CHILDREN WITH SPASTIC CEREBRAL PALSY

Mayuri Sharma1 , Ms. Monalisa Pattnaik2, Dr. P.P. Mohanty3

Department of Physical Medicine and Rehabilitation, SVNIRTAR1- MPT student, 2-Assistant professor in Physiotherapy, 3-Associate Professor in Physiotherapy

ABSTRACT

Introduction-Cerebral palsy (CP) is the most common cause of movement disability in childhood, with anincidence of 1.5-2.5 per 1000 live born children 1. It is a non-progressive disorder that covers a number of neurologicalconditions, resulting in an abnormal development of movement and postural control.. It is believed that an inabilityto maximally activate their muscles contributed to this weakness.Visual and auditory feedback cues have beenshown to improve ROM & VMC in patients with movement disorders. Aim-The aim of this work was to investigatethe efficacy of using biofeedback and neuromuscular electrical stimulation applied on tibialis anterior in childrenwith cerebral palsy.the present work was designed to compare the effect of treatment with or without biofeedbackapplied to children with diplegic CP. Method-The 30 children with CP were divided in to 2 groups(experimental &control.The control group received NMES on tibialis anterior for 20 min. a day ,6 days in a week for a period of 6weeks.the experimental group received NMES +biofeedback +conventional treatment.pre and post treatmentevaluation included range of motion ,VMC and GMFM scoring. Results-Results showed that There was maineffect for time ,f(1,28;0.05)=4.37.p <0.046 & a main effect for time ,f(1,28;0.05)=1.30 ,p<0.00,however there maineffects were qualified by a group × time interaction ,f (1,28;0.05)=219.37 ,p <0.00.There was main effect for time,f(1,28;0.05)=4.64.p <0.04 & a main effect for group,f(1,28;0.05)=485.96,p<0.00,however there main effects werequalified by a group × time interaction ,f (1,28;0.05)=65.96,p <0.00 in right and left ankle joint.conclusion-Asignificant improvement in range of motion,VMC & GMFM in experimental group as compare to control group.Thestudy determined that biofeedback have positive clinical effects on the ROM & VMC of ankle of spastic diplegic.

INTRODUCTION

Cerebral palsy (CP) is the most common cause ofmovement disability in childhood, with anincidence of 1.5-2.5 per 1000 live born children . Itis a non-progressive disorder that covers a numberof neurological conditions, resulting in anabnormal development of movement and posturalcontrol. Cerebral palsy (CP) is an umbrella termencompassing a group of non-progressive non-contagious motor conditions that cause physicaldisability in human development, chiefly in thevarious areas of body movement.

Muscle weakness has been reported to be acommon symptom in children with cerebral palsy(CP; Brown et al. 1991, Damiano et al. 1995, Toneret al. 1998). It affects some muscles more than

others, often showing greater involvement of thedistal plantar flexors (PF) and dorsiflexors (DF;Brown et al. 1991, Wiley and Damiano 1998,Engsberg et al. 2000). Weakness, as defined byEdwards (1978), implies a failure or inability toproduce or maintain an anticipated level of force.

Neuromuscular electrical stimulation over theagonist or antagonist muscles of spastic muscle isshown to reduce spasticity. There is some evidencethat electrical stimulation of the antagonist musclescan reduce spasticity immediately followingtreatment. It has also been claimed that spasticityreduction by this method is achieved without anymuscle weakness.Biofeedback, a procedurewhereby information about an aspect of bodyfunction is fed back by a visual or an auditorysignal, is a noninvasive technique that has been



implemented to increase strength and improvemotor control in patients with cerebral palsy .

METHODS

30 Spastic CP diplegics with age group 4-10 yrs from SVNIRTAR who fulfilled the criteriawere randomly assigned in to experimental group(n=15) and control group (n=15). Children weregiven therapy for 6 weeks, 5 days/week. 15 minutesof feedback via fabricated goniometer & electricalstimulation was be given to Tibialis anterior musclefor 20 mins/day.

Position- (for feedback viaelectrogoniometer)-high sitting position withhip&knee 900 flexed. (for electrical stimulation)-high sitting with back & foot supported. Thestimulation was applied using surface electrodesadapted on the size of child's muscle belly, so onlythe tibialis anterior was stimulated and thusoverflow was eliminated. Equipment:-

Visual and auditory biofeedback(electrogoniometer)

Electrical stimulato

Universal goniometer

MATERIALS AND METHOD

electrogoniometer

The device was designed and fabricated for theANKLE joints

It comprised of:

(a) ankle unit.

(b) Audio - visual feedback unit.

ankle unit comprised of a protractor with astationary and movabl arm.

Audio- visual feedback unit comprised of a:

- potentiometer, the shaft of which is rotatedby the movable arm of the ANKLE unit, therebychanging the amout of resistance the potentiometeroffers to electricity in the circuit, which in turnchanges the frequency of the,

- frequency generator, resulting in outputwhich is through a, speaker and LED bar.

- step- down transformer converts AC to DCfrom the mains.


The monitoring of dorsiflexion was done on6 digit 7-segment based display system.4MHzcrystal oscillator along with IC for frequency scaledown by factor of 222is used to get high precision1Hz time base for our electronic logic circuit. Thesensor for measuring the ankle movement isconnected to the oscillator circuit, in which thechange in frequency as well as duty cyclecorresponds to the ankle ROM.

Data collection

Measurements of active ankle dorsiflexionrange of motion,voluntary motor control of DF andgross motor function score were taken for eachsubject after completion of 6 weeks of therapy. Thedata collected were taken for analysis.

Data analysis

Data were analysed using 2×2 ANOVA withone between factor (group) with two levels andone within factor (time) with two levels for rangeof motion of ankle joint. Between group differencesfor GMFM and VMC was done by Mann WhitneyU test .An alpha level of 0.05 of significance wasset.

Analysis was performed using SPSS package16 version.

Results

Range of motion(left ankle joint

There was main effect for time,f(1,28;0.05)=4.64.p <0.05 & a main effect forgroup,f(1,28;0.05)=485.96,p<0.05,however thesemain effects were qualified by a group × timeinteraction ,f (1,28;0.05)=65.96,p <0.05.

Post-hoc analysis showed that both thegroups improved significantly however at the endof the treatment experimental group showedsignificantly more improvement.

Range of motion(right ankle joint

There was main effect for time,f(1,28;0.05)=4.37.p <0.046 & a main effect for time,f(1,28;0.05)=1.30 ,p<0.05,however there maineffects were qualified by a group × time interaction,f (1,28;0.05)=219.37 ,p <0.05.

Post-hoc analysis showed that both thegroups improved significantly however at the endof the treatment experimental group showedsignificantly more improvement .

Voluntary motor control(left ankle joint)

Graph 3 illustrates that there was significantimprovement in voluntary motor control of leftankle dorsiflexion in the experimental group thanthe control group with the score of mann whitneyU 45.00, Z score-3.52 & significance level of p <0.05.

Voluntary motor control(right ankle joint)

Graph 4 illustrates that there wassignificant improvement in voluntary motorcontrol of right ankle dorsiflexion in theexperimental group than the control group withthe score of mann whitney U 37.00,Z score-3.59 &significance level of0.001.


Gross motor function (gmfm)-

Graph demonstrates the subjects in theexperimental group showed more significantchange than control group in their gross motorfunction .Table 9 shows there is statisticallysignificant difference in dimension D (standing)of the gross motor function measure between theexperimental group with the significance level of0.00,mann whitney U score -0.00 & Z score -4.73.

Discussion-

Active ankle dorsiflexion range of motion-

The present study shows that there wassignificant improvement in active range of motionwith time in both the groups but the subject whohad undergone biofeedback and NMES(experimental group) improved to a greater extentthan the subject who received NMES andconventional exercises (control group). Theremight have occurred improvement in antagonistmuscle strength due to electrical stimulation whichcould help to overcome the spasticity of the agonistmuscle. Increased dorsiflexion strength-with theapplication of biofeedback recruitment of highernumber of motor units or higher firing frequenciescan best explain the strength increase.

Voluntary motor control of ankle joint-There was increase in VMC of ankle joint

found on the modified selective motor control teston both groups but the subjects who hadundergone biofeedback and electrical stimulationimproved to a greater extent than the subjects whoreceived conventional therapy .

Repeated contraction of dorsiflexors usingelectrical stimulation may cause planter flexors tostretch slightly leading to stretch reflex inhibitionand thus unmasking the voluntary movement.Training with the use of feedback process isgenerally not a passive process ,it requires theactive participation of the patient by doingvoluntary contraction & it causes recruitment oftype 1 muscle fibres. During voluntary contractionof muscle there is an asynchronous firing of motorneuron resulting in a smooth contraction as moremotor units become involved, further increase inmuscle force is largely achieved by increase rateof nerve impulse firing (milner-brown&stein,1975).Mulder et.al., reported improvement of voluntarycontrol in hemiparetic patient with the use ofEMG biofeedback.Gross motor function -

There was improvement of gross motorfunction in both the group ,but the biofeedbackand NMES group improved with a significantdifference from the conventional group.

Subjects with cerebral palsy were examinedusing the gross motor function measure -66(GMFM-66) the GMFM-66 is a test used forassessing motor function in children with cerebralpalsy & it has been a useful measure to detectchanges in motor function in intervention studies(Rusell et.al. 1989). The GMFM-66 is chosenbecause it has been shown to be more reliable thanthe original test (now called the GMFM-88) as wellas more sensitive to changes infunction(Rusell.et.al., Wang & Yang,2006. factorswhich were responsible for improvement in motorfunction included improved strength of pretibials.However it must be considered that there is alwaysan impact of altered body mechanics on theperformance of functional tasks. Achievingdosiflexion range in ankle or at least plantigradeposition can influence the patient's ability to usehis/her recovering control of volitionalmovement.(Barbara et.al. 2003)


Conclusion- Over the years NMES is being used for

improving the strength and function in case ofupper motor neuron lesion. Recent advancementin clinical medicine and biomedical engineeringalso proved the implementation of biofeedback forimproving range of motion and mobility function.The findings of the study show that a combinedprogram of biofeedback, NMES for pretibials &conventional therapy for 6 weeks durationsimproves the ankle ROM & VMC. Results alsoshow the significant improvements in gross motorfunction. The improvement confirms thetherapeutic benefits of combined biofeedback &NMES regimen in CP.

Liitation-

1 . Small sample size

2. Short duration of the study

3. Carryover effect of the combined regimen ofbiofeedback and NMES to pretibials was notobserved.

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COMPARISON BETWEEN THE EFFECTS OF TWO CORE STABILIZATION-DIRECTED TO TRUNK MUSCLE VS ARM EXERCISES WITH BREATHING

IN TREATMENT OF CHRONIC LOW BACK PAIN

Megha Bandawde 1, Mrs. Monalisa Pattnaik 2, Dr. Patitapaban Mohanty3

Department of Physical Medicine and Rehabilitation, SVNIRTAR1- MPT student, 2-Assistant professor in Physiotherapy, 3-Associate Professor in Physiotherapy

ABSTRACT

Low back pain is a debilitating condition affecting 80-90% and 5-15% develop chronic low back pain which isattributed to trunk muscle imbalances and affecting feedforward activity of Transverse abdominis muscle. So, thisstudy aimed to compare the effect of two core stabilization-directed to trunk muscle vs arm exercises with breathingin treatment of chronic low back pain 30 patients were selected divided into two groups (n = 15), Group 1 (whoreceived core strengthening specific to trunk along with the conventional treatment) and Group 2(who receivedarm exercises with breathing along with the conventional treatment). Both groups improved in pain, strength,endurance and function with treatment given however group 2 had a significantly more improvement in TrAmuscle strength endurance. 2X2 ANOVA revealed that there was a main effect for time and group, also the maineffect qualified to the interaction of time group. Post Hoc analysis revealed that the group 2 had a significantimprovement in strength & endurance of Transsversus Abdominis, ODI and VAS. So, it can be concluded thatcore strengthening specific to trunk and arm exercises with breathing along with the conventional treatment hasrole in improvement in pain, strength, endurance and function in chronic low back pain patients. However armexercises with breathing has additional effects in improvement in pain, strength, endurance in chronic low backpain patients.Key words; Low back pain, core stabilization directed to trunk,arm exercises with breathing, feedforward action, transeverse abdominis muscle.

INTRODUCTION

Back pain is the primary reason to seek medicaladvice; it is second only to upper respiratoryinfection as reasons for GP consultation. Back painis the fifth ranking cause of admission to hospitaland 3rd most common cause of surgical procedure.It also define as pain that last beyond expectedperiod of healing and acknowledge that chronicpain since it intermittently affect an individual overlong period.

Three systems contribute to the stabilization of thespine:

a] The passive musculoskeletal subsystem.

b] The active musculoskeletal subsystem, and

c] The neural and feedback subsystem (Panjabi,1992).

The active subsystem consists of muscles Lumbarand abdominal muscles which stabilize the spinemay be classified as either local stabilizers, orglobal stabilizers (Richardson et al., 2002).

Tendons which stabilize the spine and generateforce (Panjabi, 1992). TrA is important componentsof the local stability system, in which a number ofstudies have reported on the anatomical,biomechanical or neurophysiologic characteristics,in the context of spinal stability (McGill, 1991;Wilke et al. 1995; Anderson et al. 1996; Hodges,1999; Penning, 2000; Hodges et al. 2003).EMGstudies have revealed that the TrA is the onlymuscles active during all trunk movements(Cresswell et al. 1994; Wilke et al. 1995). There issignificant reduction of cross section area of TrAmuscle analyzed by MRI, and CT SCAN (14). The

The author can be contacted [email protected] 09595131749


focus on exercise include parameter ranging fromstrength and endurance specific training of musclecoordination and function improved control and

stability would reduce mechanical irritation and

lead to pain relief.20, 21 Rehabili tation or

performance enhancement training should be

based on principle that specific imposed demands

on the musculoskeletal system will produce

specific adaptation within the system. . Core

stabilization is an established a specific exercise

program that include optimal exercise position to

target specific identified muscular performance

deficits. Specific exercise program such as in-

drawing manure is generally used in our clinical

setting in treatment of chronic low back pain

treatment for increasing strength and endurance

of transverse abdominals, which become weaker

in chronic low back pain condition.22

Neurochemical ,structural and functional changes

in the cortical area of brain has been reported in

patients with chronic low back pain in various

studies. As the Transversus Abdominis contract

before any other trunk muscle or the prime movers

(Hodges & Richardson, 1997) , it prepares the body

for disturbances caused by movement (1997) in a

feed forward manner. Rapid flexion of upper limb

produce a brief challenge to postural stability of

trunk as a result of reactive force acting equal and

opposite to those producing the movement.25 This

is associated with activation of Transverse

Abdominis preceding the activation of deltoid. The

influence of respiratory activity of abdominal

muscle increases reaction time in postural task .

During forced breathing there is activation of

diaphragm and TrA.

Thus complete core stabilization program would

optimize spinal stabilization. So other group of

exercise in which upper limb movement along

with breathing are added to enhance

neuromuscular facilitation of core muscle are

proposed to increase the strength and endurance

of core muscle by increasing perturbation.24

Combining tonic and phasic activity of this muscle

provide mechanical assistance to CNS for

coordination of respiration and control of spine

during limb movements.26, 27, 28, 29, 30, 31

Methods: Subjects; 30 subjects diagnosed clinicallyas chronic low back pain who met inclusion andexclusion criteria was recruited from outpatientdepartment of SVNIRTAR. Inclusion criteria wereadult population: <55 yr age, complain of low backpain >90 days, radiating or non radiating, male andfemale patient and hypomobility of lumbar spine.Exclusion criteria were direct trauma, vertebralfacture, neurological deficit, above 55 year ofage, infection of spine, tumors / malignancy,spinal surgery, shoulder pathology,cardiopulmonary disease, neurological disorder,active systemic disease, CNS involvement. At 0week Pressure Biofeedback readings of abdominalmuscles were evaluated for strength & enduranceand ODI score was taken to quantify disability/function ,pain on VAS.

PROCEDURE : Two groups were divided with 15subjects in each group, namely Group 1 (whoreceived core strengthening specific to trunk alongwith the conventional treatment) and in Group2(who received arm exercises with breathing alongwith the conventional treatment). The treatmentwas given 5 times a week in a 4 week protocol. Atthe end of 4th week the PBU readings, ODI score& pain vas was measured again. The exercises wereperformed by doing 2 or 3 sets of 10 to 15repetitions for each exercise, with 30 seconds to 1-minute rest between each set. The patients weretold not to provoke pain during the exercises.Strengthening and stabilizing exercises for thetrunk muscles, suiting to the clinical findings, areallowed. A protocol of 4 weeks strengtheningprogramme was followed. Each week higher levelof exercises were given & patient were allowed tomove next higher level if he/she is acquainted withthe previous level.

GROUP 1. Phase 1- Patient in crook lying, askedto hollow the lower abdomen & hold it for 10seconds. Phase 2-.Patient seated stable on a stoolmaintaining lumbar spine stability was asked tohollow the lower abdomen & hold it for 10 seconds.Phase 3- Patient in quadripod position was askedto hollow the lower abdomen & hold it for 10seconds. Phase 4- Patient in standing was asked tohollow the lower abdomen & hold it for 10seconds10seconds.


GROUP 2

Phase 1.Patient sitting on a stool with feet on floor,asked the patient to do 2 to 3sets of 10 to 15repetition of arm movement on in direction flexion.Phase 2.Patient sitting on a stool with feet on floorwere asked to do 2 to 3sets of 10 to 15 repetition ofarm movement onin direction of flexion duringforceful expiration with low resistance theraband.Phase 3. Patient standing with feet shoulder widthapart, were asked to do 2 to 3sets of 10 to 15repetition of arm movement against low resistance

theraband in direction of flexion during forcefulexpiration. Phase 4. Patient standing with feetshoulder width apart were asked to do 2 to 3setsof 10 to 15 repetition of arm movement againstprogressive increasing resistance of theraband orincreasing intensity in direction flexion duringforceful expiration maneuver

Conventional treatment for both groups wastraction, stretching of tight muscles and spinalmobilization.

DATA COLLECTION

Measurements of all dependent variable for eachpatient were taken prior to the beginning oftherapy (Pre test) on the same day before startingthe intervention. Immediately after the last sessionof intervention i.e. after four weeks of therapy (posttest) final measurement were taken

Data Analysis:

The dependent variables were analyzed using a 22 ANOVA, with repeated measures as a secondfactor. There was one between factor (group) withtwo levels (groups: Experimental and Control) andone within factor (time) with two levels (time: Preand Post). All pair wise post - hoc comparisonswere analyzed using a 0.05 level of significance.

Result:

The 2X2 ANOVA revealed that there was a maineffect for time and group, also the main effectqualified to the interaction of time group inTranssversus Abdominis [time (Fstr=570.182,Fend=454.545, p = 0.00), group (Fstr= 10.790,p0.003,Fend=15.265, p = 0.01), time group (Fstr=18.182,Fend=22.00, p=0.00) Pain on vas(Ft=1.84,p=0.00,Fg=.969,p=0.3, Ftxg=5.091, p=0.03) as well asimproved function on ODI (Ft=306.014,p=0.00,Fg=5.545,p=0.026, Ftxg=.012, p=0.913).

Post Hoc analysis revealed that both thegroup had a significant improvement in strength, endurance of Transsversus Abdominis, pain onVAS and function on ODI. However, group 2


showed more improvement than group 1 instrength endurance of TrA muscle and pain on vasthan group 1.

VAS

STRENGTH

ENDURENCE

ODI

Discussion:

Overall results of the study shows that both theGroup 1(who received core strengthening specificto trunk along with the conventional treatment)and Group 2(who received arm exercises withbreathing along with the conventional treatment)improved in pain, strength, endurance andfunction with treatment given however group 2had a significantly more improvement in TrAmuscle strength endurance

PAIN;

In both groups significant reduction of pain maybe due to conventional treatment such asstretching, mobilization and traction. Thereduction in pain in both the groups may beattributed to the role of TrA muscle strengtheningprogram incorporated in the study. HoweverGroup 2 showed more improvement than Group1 due to overhead arm movement that lead tocontraction of transvers abdominis muscle beforethe arm movement. Hodge et al also concludedthat rapid flexion of the upper limb produces abrief challenge to postural stability of the trunk asa result of reactive forces acting equal and oppositeto those producing the movement. Forcefulexpiration require greater recruitment of TrAmuscle

TRANSVERSABDOMINIS MUSCLESTRENGTH AND ENDURANCE

Both groups showed improvement in strength andendurance. This may be because in both the groupscore stabilization exercises were performed for 2or 3 sets of 15 to 20 repetitions with 30 seconds to1-minute rest between each set 5 days of a weekfor 4 weeks .TrA muscle comprised of type I fibers.This means that TrA muscle is highly specific toresistance to fatigue as per the fiber composition.Further repeated contraction of TrA muscle duringtreatment may be the cause of improvement inmuscle strength, as well as endurance in both thegroups (Huczel 1992). Group 2 showed significantgreater improvement in than Group 1 may bebecause arm exercises with breathing involved inanticipatory action of TrA muscle and this feedforward activity which is based upon the SAIDprinciple (Specific Adaptation to ImposedDemands) suggested greater improvement. By


adding resistance by theraband in later phases ofexercises increases overload on TrA muscle during

postural task of arm movement may be the causes

of greater improvement in TrA muscle strength in

group 2 than group 1.

FUNCTION

Both the groups from pre to post (4 weeks) may be

attributed to conventional treatment such as

stretching, mobilization and traction causing

reduction in pain and core stabilization exercises

causing improvement in pain, strength and

endurance of TrA muscle contributing to decreased

percentage of disability in ODI score. Strength and

endurance are important elements of muscle

performance and they have important role to play

in lifting heavy weight and other functional task

without excessive fatigue or potential injury. In

group 2 in which arm exercises with breathingwere given, improvement in function may be

because of the repeated movement of upper limb

added by expiration enhancing the recruitment of

TrA muscle. This is supported by various studies.

Feedforward activity lead to TrA muscle

contractions which are initiated without feedback

from limb movement increases lumbopelvic

stability (Enoka, 2002; Hodges & Richardson, 1997).

CNS predicts the effect that this movement will

have on body and plans sequence of muscle

activity to overcome this perturbation .Repetitive

limb movement challenging stability of spine, tonic

activity of the diaphragm and TrA is sustained butmodulated with respiration to meet respiratory

demands with postural task during the limb

movement such as locomotion

CONCLUSION

This study shows that core strengthening specific

to trunk and arm exercises with breathing alongwith the conventional treatment has role in

improvement in pain, strength, endurance and

function in chronic low back pain patients.

However arm exercises with breathing hasadditional effects in improvement in pain,strength, endurance in chronic low back painpatients.

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UTILITY OF ICF CHECKLIST IN IDENTIFYING MOST COMMON

PROBLEMS IN FUNCTIONING IN PARAPLEGIC PATIENTS IN POST

Ms. Aswini N.S1, Mrs. Pragyan Singh2

Department of Physical Medicine and Rehabilitation, SVNIRTAR1-MPT student, 2-Lecturer in Occupational Therapy

ABSTRACTSAIM OF THE STUDY: To find out the utility of the ICF checklist in identifying the most common problems infunctioning in paraplegic patients in post-acute phase of rehabilitation.METHODOLOGY: A cross sectional study was undertaken involving 80 patients with Traumatic Spinal CordInjury(SCI) below the level of T1 in post-acute phase of rehabilitation and were assessed using ICF Checklist.RESULTS: A dichotomized qualifier was used. Descriptive analysis (prevalence of problems in percentage) wasused to calculate the problems in each category. It was found that there are other categories which are not in thechecklist that has to be included in identifying the problems in functioning of a paraplegic patient in post-acutephase of rehabilitation.CONCLUSION: ICF checklist potentially facilitate the description and classification of all aspects of function andhealth in individuals independent of specific instruments. A few ICF categories which are not there in the checklistbut important in paraplegic assessment like b455, b810, b820 and b830, d240, d415, d420 and personal factorsshould be included during assessment of paraplegia.

Key Words: Spinal Cord Injury, Post-acute Phase, ICF Checklist.

INTRODUCTION

The International Classification of Functioning,Disability and Health (ICF) belong to the "family"of international classifications developed by theWorld Health Organization (WHO). ICF providesa framework for functioning and health as well asa universal and standard language to be used bydifferent professionals in different countries andsettings (1). It is the most recently developeddisability model. The model has many potentialapplications in the area of rehabilitation and publichealth. As a research tool, the ICF serves tomeasure outcomes, focusing not only on functionaloutcomes, but also on the overall quality of life.(1). In the clinical context the ICF is intended foruse in needs assessment, matching interventionsto specific health states, rehabilitation, andoutcome evaluation. In order to facilitate the useof the ICF in clinical encounters, the WHO hasdeveloped the ICF checklist. The checklist


comprises 128 categories out of more than 1400categories of the whole ICF classification system.The checklist makes it possible to generate a profileof the patient using the most important ICFcategories (2)


RATIONALE OF THE STUDY:

ICF has been used on various disease conditions

and core sets have been formed. ICF checklist and

ICF core sets is the practical tool to use ICF. A few

studies have focused on the application of the ICF

on spinal cord injury patients however utility of

the ICF checklist on paraplegia patients has not

been reported. So here an attempt was made to

find out the utility of the ICF checklist in

identifying common problems in functioning in

paraplegic patients during the post - acute phase

of rehabilitation.

AIM OF THE STUDY: To find out the utility of

the ICF checklist in identifying the most common

problems in functioning in paraplegic patients in

post acute phase of rehabilitation.

METHODOLOGY: A cross-sectional study design

was used and participants were selected by

convenient sampling. A total of 80 patients with

Traumatic Spinal Cord Injury below the level of

T1 in post-acute phase of rehabilitation between

the age 18 to 65 years, both complete and

incomplete SCI who were medically stable after

obtaining informed consent were recruited for the

study. Any other traumatic condition in past along

with the present condition like peripheral nerve

injury, TBI which have impact on the functioning

of the client were excluded from the study.

RESULTS:

A total of 80 patients were included in the study.

Table I shows the number of patients in different

level of spinal cord injury.

Table I: showing the number of patients in different

level of spinal lesion

S. No Level No. of patients Mean Age

1. T1 – T6 20 38.65

2. T7-T12 20 44.2

3. L1-L5 20 34.95

4. Below L5 20 33.6

The ICF provides qualifiers which range from 0-4

for each category. Because the metric properties

of this scale are not yet evaluated sufficiently, a

dichotomized qualifier was used. Each category

of the components Body Function, Body Structure

and Activity and Participation was graded with the

qualifier 0 for 'no impairment/limitation', 1 for

'impairment/limitation'. The categories of the

component Environmental Factors were graded

with +0 or -0 for 'no facilitator/no barrier', +1 for

'facilitator' and -1 for 'barrier'. Additionally

qualifier '8' is used if the available information was

not sufficient and '9' if the category was not

applicable.

Descriptive analysis (prevalence of problems

in percentage) was used to calculate the problems

in each category.

Table II to IV shows the prevalence of

limitation in categories of the components of Body

Function and Body Structures and Activity and

Participation

Table V shows the categories of the component

Environmental Factors experienced as barrier.


ICF Code

ICF Code Description

Descriptive Analysis: prevalence of problems %

T1-T6

n=20(%)

T7-T12

n=20(%)

L1-L5

n=20(%)

Below L5

n=20(%)

b710 Mobility of joint 100 100 100 100

b730 Muscle power 100 100 100 100

b735 Muscle tone 100 100 100 100

b525 Defecation 90 80 80 65

b620 Urination function 90 80 80 65

b235 Vestibular function 85 85 50 35

b640 Sexual function 80 65 75 60

b8 Function of skin 70 75 60 30

b134 Sleep 60 55 55 40

b130 Energy and drive functions 60 55 35 25

b280 Pain 50 60 35 25

b152 Emotional functions 50 55 25 25

b420 Blood pressure 40 25 30 25

b530 Weight maintenance 40 40 35 30

Table III. ICF - prevalence of limitations in categories of the component Body Structure

Table II. ICF - prevalence of limitations in categories of the component Body Function.

ICF Code



T1-T6

n=20(%)

T7-T12

n=20(%)

L1-L5

n=20(%)

Below L5

n=20(%)

s120 Spinal cord and peripheral nerves 100 100 100 100

s750 Lower extremity 70 60 40 20

s760 Trunk 65 60 55 20

s8 Skin and related structures 40 40 20 0

s740 Pelvis 20 15 15 0


Table IV. ICF - prevalence of limitations in categories of the component Activity limitations andParticipation restrictions

ICF

Code



T1-T6

n=20(%)

T7-T12

n=20(%)

L1-L5

n=20(%)

Below L5

n=20(%)

PQ* CQ* PQ* CQ* PQ* CQ* PQ* CQ*

d450 Walking 100 100 100 100 100 100 55 75

d470 Using transportation 100 100 100 100 100 100 90 80

d475 Driving 100 100 100 100 100 100 100 100

d570 Looking after one’s health 100 100 100 100 100 100 100 100

d620 Acquisition of goods and

services 100 100 100 100 100 100 70 70

d660 Assisting others 100 100 100 100 100 100 70 70

d850 Remunerative employment 100 100 100 100 85 100 85 65

d870 Economic self-sufficiency 100 100 100 100 80 100 80 65

d910 Community life 100 100 100 100 100 100 85 70

d930 Religion and spirituality 100 100 100 100 100 100 85 75

d950 Political life and citizenship 100 100 100 100 100 100 40 75

d220 Undertaking a multiple task 65 95 70 95 55 85 40 70

d530 Toileting 80 90 80 90 80 90 55 75

d430 Lifting and carrying objects 35 85 35 85 25 50 25 35

d510 Washing oneself 70 85 70 80 65 70 55 55

d540 Dressing 80 90 80 90 75 85 50 75

d465 Moving around using equipment 70 70 70 75 65 65 40 50

d920 Recreation and leisure 80 60 65 60 80 75 40 70

d520 Caring of body parts (brushing,

shaving) 70 55 50 55 45 45 10 20

d210 Undertaking a single task 30 20 20 20 35 25 30 15

d830 Higher education 15 15 15 15 25 25 20 25


PQ* - Performance Qualifier; CQ* - Capacity Qualifier

Table V. ICF - categories of the component of Environmental Factors experienced as barrier

ICF

Code



T1-T6

n=20(%)

T7-T12

n=20(%)

L1-L5

n=20(%)

Below L5

n=20(%)

e120 For personal indoor and outdoor

mobility and transport

90 85 85 80

e150 Design, construction and building

products and technology of buildings

for public use

90 95 90 70

e155 Design, construction and building

products and technology of buildings

for private use

90 95 90 75

e115 For personal use in daily living 80 80 80 80

e225 Climate 20 20 20 20

Table II, III, IV shows the impairments of body functions, body structures and activity limitationand participation restriction respectively. Table V shows the component of Environmental factors asexperienced as barrier.

Graph 1: percentage of prevalence of limitation of the patients injured in the level T1-T6


Graph 2: percentage of prevalence of limitation of the patients injured in the level T1-T6 (Activityand participation Component's Performance qualifier)


Graph 3: percentage of prevalence of limitation of the patients injured in the level T7-T12



Graph 5: percentage of prevalence of limitation of the patients injured in the level L1-L5

Graph 6: percentage of prevalence of limitation of the patients injured in the level L1-L5 (Activityand participation Component's Performance qualifier)

Graph 7: percentage of prevalence of limitation of the patients injured in the level Below L5

Graph 8: percentage of prevalence of limitation of the patients injured in the level Below L5 (Activityand participation Component's Performance qualifier)


DISCUSSION

The aim of this cross-sectional study was tofind the utility of the ICF checklist in identifyingthe most common problems in functioning inparaplegic patients in post-acute phase ofrehabilitation. First, the most common problemsin functioning in paraplegic patients in post-acutephase of rehabilitation were identified using theICF checklist.

According to the study results, of the 29 Ilevel chapters 19 (65.5%) chapters were found tohave problems for all paraplegic patients atdifferent level of injury. The most commonchapters in which the patients had problems wereb2: sensory function and pain, b5: functions ofdigestive, metabolic and endocrine system, b6:genitourinary and reproductive functions, b7:neuromusculoskeletal and movement relatedstructures, b8: functions of the skin and relatedstructures, s1: structure of the nervous system, s7:structures related to movement, d4: mobility, d5:self care, d6: domestic life, d8: major life area, d9:community, social and civic life, e1: products andtechnology.

46 (40%) different II level categories out of128categories in the checklist were identified asproblems for all the paraplegic patients at differentlevel of injury. In the component of Body Functionsb710 (mobility of joints), b730 (muscle power), b735(muscle tone) were the areas in which all the levelof paraplegic patients had 100% problem.

In the component Activity Limitation andParticipation Restriction 22 (45.8%) of 48 categoriesin the checklist were found to be problem for allparaplegic patients at different level. Most of thepatients had problem in d4 (mobility), d5 (selfcare), d8 (major life areas), d9 (community, socialand civic life).

The most problematic area in Activity Limitationand Participation Restriction were d450 (walking),d420 (using transportation), d475 (driving) andd850 (remunerative employment). There arevarious studies conducted on employment afterspinal cord injury (3). During the post-acute phaseof rehabilitation due to various other physical andpsychological problems employment is affected.Several predictive factors influence the return to

gainful employment. Completeness of injury,gender, impairment type, motivation to work,social support have been considered as predictivefactors (4). Participation Restriction were foundin d910 (community life), d920 (recreation andleisure). Involvement in recreation and leisuremay be limited by motor function after injury aswell as changes in autonomic functions (5).

In component of Environmental Factors e120 (Forpersonal indoor and outdoor mobility andtransportation, e150 and e155 (Design constructionand building products and technology of buildingfor public and private use) respectively were foundto be barrier for paraplegic patients. whenassessing e5 (Services, systems and policies), it wasnoted that majority of the patients were not awareabout the services and the policies that areavailable for the disabled persons which is alsomentioned in Indian Country Report aboutDisabled People in development (6). As most ofthem were not aware about the services, systemand policies for the disabled, it was not possible toknow whether the services, system and policiesfor disabled in our country were a facilitator or abarrier to them.

The many measures used for neurologicalconditions differ because they cover differentaspects of functioning or because they havedifferent purposes. However, a number ofmeasures cover the same or over lapping aspectsof function and vary with respect to underlyingdimensions and constructs (8). The ICF categoriespotentially facilitated the description andclassification of all aspects of function and healthin individuals independent of specific instruments(8).

Universal design represents a broad focusconsidering a large range of abilities (hearing andvisual disabilities, people of short stature, forexample) and ages in broad range of contextsincluding public buildings, such as schools,museums, hotel, parks and public rights of way inurban area (9). It relates to the areas ofparticipation and environmental factors in ICF (10).The ICF checklist also covers a wide range of theEnvironmental factors. Paraplegia being a longterm disability, the universal design relating to thearea of participation and environmental factors can


be assessed using the ICF checklist.

The ICF checklist is not disease/condition specific.During the assessment, the participants were madeto give additional comments. With thesecomments and from literature there were fewcategories which were very much important forthe paraplegic patients were noted.

In body function component other categories apartfrom the categories which were mention in thechecklist were b455 (exercise tolerance functions)and b810 (protective function of skin), b820 (repairfunction of skin) and b830 (other function of skin)were considered important. A study by Bauman(11) reported that cardiovascular disease was theunderlying cause of death in individuals with SCI.The importance of exercise tolerance function isemphasized by Sandee Melton Rogers (12). Theloss of functional skeletal muscle and thediminished or nonexistent cardiovascular reflexduring exercise can result in high fatigability ofthe active muscles of the arms. All the above-statedfactors discourage many individuals with SCI fromengaging in a regular physical fitness program.Normal daily wheelchair activity is probably notsufficient to train the cardiopulmonary system orimprove physical fitness. A sedentary individualwith SCI becomes de conditioned, leading tofunctional deterioration. Exercise is necessary tobreak this cycle, decrease cardiovascular riskfactors, and maximize functional independenceand to decrease the risk of heart disease,respiratory disorders, and coronary artery disease.Middleton JW, K Lim et al (13) in their study onpatterns of morbidity and re hospitalisationfollowing spinal cord injury found out thatpressure sore was one of the leading causes for rehospitalization following SCI.

In Activity Limitation and Participation Restrictioncomponent, the other categories which wereconsidered important were d240 (handling stressand other psychological demands), d415(maintaining a body position) and d420(transferring oneself). Spinal cord injury is one ofthe most devastating events that can occur toindividuals and their families. The many physicalchanges are immediate, unanticipated and oftenpermanent. Contending with altered mobility,adaptive equipment, accessibility concerns, bowel

and bladder programs, disrupted sexualfunctioning, added dependency on others forassistance, limitations and loss of spontaneity inmany areas of functioning can tax a person's copingskills and psychological adjustments (14). Personwith SCI experience higher level of distress isassociated with abnormal level of psychologicalmorbidity, substance abuse and risk of suicide.Consequently, psychosocial issues have becomeprominent in SCI (15).

d420 (transferring oneself) is the most importantas the paraplegic needs to learn a number oftransfers like transfer from bed to wheel chair andvice versa; transfer from toilet stool to wheel chairand vice versa and direct transfers (sit to stand withKnee Ankle Foot Orthosis with walker/crutchesand floor transfers are very important which hasto be included in the assessment (16).

Personal Factors (PF) is also a component ofContextual Factors in ICF but they are not classifiedbecause of the large social and cultural varianceassociated with them and so the ICF checklist alsodoes not cover the personal factors. PF are theparticular background of an individual's life andliving, and comprise features of the individual thatare not part of a health condition or health states.These factors may include gender, race, age, otherhealth conditions, fitness, lifestyle, habits,upbringing, coping styles, social background,education, profession, past and current experience(past life events and concurrent events), overallbehaviour pattern and character style, individualpsychological assets and other characteristics, allor any of which may play a role in disability atany level (10). The World Health Organization(WHO) has recognized the relevance of PersonalFactors (PF) in the context of functioning anddisability and included them in the framework ofICF. However, PF are not implemented in theclassification, yet, and their understanding and rolerequires further clarification. Research is nowgoing on to include PF in ICF. The Personal FactorResearch Project aims (1) to explore the possibilitiesof developing the ICF classification of PF incollaboration with the WHO, and (2) to explorethe role of PF with special reference to people withspinal cord injury (SCI).

As the ICF checklist is not disease/condition,


specific categories which are relevant to paraplegicand personal factors which are relevant to theindividual subjects can be added so that the overallfunctioning of the clients can be assessed throughthe ICF checklist.

CONCLUSION

The ICF categories in the ICF checklist potentiallyfacilitate the description and classification of allaspects of function and health in individualsindependent of specific instruments. ICF checklisthelps in identifying common problems infunctioning in paraplegic patients during post-acute phase of rehabilitation. But a few ICFcategories which are not there in the checklist butimportant in paraplegic assessment like b455(exercise tolerance), b810 (protective function ofskin), b820 (repair function of skin) and b830 (otherfunction of skin), d240 (handling stress and otherpsychological demands), d415 (maintaining a bodyposition), d420 (transferring oneself) and personalfactors should be included during assessment ofparaplegia. ICF can be advocated as a tool tostructure rehabilitation and universal language toaid communication within multi-disciplinaryteam.

REFERENCES:

1. International Classification of Functioning,Disability and Health, ICF. Geneva : World HealthOrganization, 2001.

2. Identification of the most common patientproblems in patients with chronic conditionsusing the ICF checklist. Ewert T, Fuessel M, CiezaA, Andersen C, Chatterji S, Kostanjsek N, Stucki.2004, Vol. 36 suppl 44.

3. Employment after spinal cord injury. DeVivo MJ,Rutt RD, Stover SL. 1987, Archives of PhysicalMedicine and Rehabilitation, Vol. 68, pp. 494-498.

4. Return to work after spinal cord injury. PCDTobeckmassen, MWM Post and FWA van As. 2000,Spinal cord , Vol. 38, pp. 51-55.

5. Mark S. Nash, John A. Horton. Recreational andTherapeutic exercise after SCI. [book auth.] M. DDenise I. Campagnolo M.D Steven Kirshblum.Spinal cord medicine. s.l. : Lippincott Williamsand Wilkins, 2002.

6. Disabled people in development India countryReport. Foundation for International training andRegional and Sustainable DeveloopmentDepartment. June 2005.

7. Outcome measure for clinical rehabilitation trialsimpairment, fucntion, quality of life, or value? DT,Wade. 2003, American Journal of Physicalmedicine and rehabilitation, Vol. 82, pp. S26-S31.

8. Value and application of the ICF in rehabilitationmedicine. Stucki G, Ewert T, Cieza A. 17, 2002,Disability and rehabilitation, Vol. 24, pp. 932-938.

9. Ringaer, Laurie. Universal design of the builtenvironment to enable occupational performance.[book auth.] Patty Rigby, Debra Stewart LorisLetts. Using environments to enable occupationalperformance. s.l. : Slack, 2003, 7, p. 97.

10. WHO. International classification of functioning,disability and health: ICF. Geneva : s.n., 2001.

11. Depressed serum high density lipo proteincholestrol level in veterans with spinal cordinjured patients. Bauman WA, Spungen AM,Shong YG, Rothstein JL, Petry C, Gordon SK. 1986,Archieves of physical medicine and rehabilitation,Vol. 67, pp. 445-50.

12. Rogers, Sandee Melton. Factors that influenceexercise tolerance. RRDS Physical fitness: A guidefor individual with SCI. pp. 25-32.

13. Patterns of morbidity and rehospitalizationfollowing SCI. Middleton JW, K Lim, L Taylor, RSoden, S Rutkowski. 2000, Spinal cord, Vol. 42,pp. 359-367.

14. Joyce Fichtenbaum, Steven Kirshblum.Psychological adaptation to SCI. [book auth.] M.D., Denise I. Campagnolo, M. D StevenKirshblum. Spinal cord medicine. s.l. : LippincottWilliams and w, 2002, p. 299.

15. Psychosocial issues in SCI: wat do we (not) know?Marcel W. M. Post, Christel M C. Van Leeuwen.Preconference draft- to be published in spinalcord special issue, spring 2012.

16. Guidelines for care of persons with SCI in thecommunity. Department of Physical Medicineand Rehabilitation and Low Cost effective unit,Christian Medical College, Vellore, India. 2008-09. Developed under the Government of India -WHO collaborative programme.

17. Results of the NIH consensus conference on"Rehabilitation of Persons with Traumatic BrainInjury". KT, Ragnarsson. 2002, Vol. 20.


18. Epidemiology of spasticity following traumaticspinal cord injury. Maynard FM, Karunas R,Waring WW. 1990, Archives of Physical Medicineand Rehabilitation, Vol. 71.

19. The Stockhom spinal cord injury study. 2.Associations between clinical patientcharacteristics and post-acute medical problems.Levi R, Hultling C, Seiger A. 1999, Paraplegia, Vol.33, pp. 585-594.

20. Neurogenic bladder, neurogenic bowel andsexual dysfunction in people with spinal cordinjury. Barbara T Benevento, Marco L Spiski. 6,June 2002, Physical Therapy, Vol. 82, pp. 601-612.

21. Bowel dysfunction in spinal cord injury patients.Gabriele Bazzocchi, Christoffel Schuijt, RobertoPederzini. 2007, Journal of Pelviperineology, Vol.26, pp. 84-87.

22. Profile of spinal injuries in Lagos, Nigeria.Obalum DC, Giwa SO, Adekoya-Cole TO,Enweluzo GO. 2009, Spinal Cord, Vol. 47, pp. 134-137.

23. A study on emotional aspects of spinal cord injury.N. M.Rath, S. Bag, P. Sarojini Dash. 1, 1993, Indianjournal of psychiatry, Vol. 35, pp. 51-53.

24. Nursing diagnoses in patients with SCI accordingto Horta's conceptual model and taxonomy II ofNANDA/ Nursing diagnosis in SCI patientsaccording to Horta's conceptual model andNANDA Taxonomy I. Neves, Rinaldo de Souza.Presented at Brazilia university. Faculty of Health

Sciences to obtain a Master's degree : s.n.


THE EFFECT OF WRIST AND THUMB KINESIO TAPING ONFUNCTIONAL GRASP IN CHILDREN WITH SPASTIC HEMIPLEGIC

CEREBRAL PALSY PRESENTING THUMB IN PALM POSITION

Ms. Bidyutprava Behera, Ms. Pragyan Singh, , Ms. Anurupa Senapati,

Dr Jaganath Sahoo2, Dr Swati Sinha3, Dr R N Mohanty4

Department of Occupational Therapy1-MPT student, 2-Lecturer in Occupational Therapy, 3-Assistant Professor and HOD

ABSTRACT

AIM :The effect of wrist and thumb kinesio taping on functional grasp in children with spastic hemiplegic cerebralpalsy presenting thumb in palm position

METHODS ; 30 spastic hemiplegic cerebral palsy children who fulfill the inclusion criteria were selected for thestudy. Selection of the subjects was done by convenient sampling and consecutively assigned into 2 groups. Kinesiotaping was done for 6 weeks to the subjects of experimental group and micro pore taping was given to the controlgroup as a placebo. Both groups were given occupational therapy focusing on activities for improvement of grasp.

RESULT AND CONCLUSION : Group with kinesiotaping showed significantly higher improvement over thecontrol group (p < .000). Within the group (both experimental and control) there was a significant improvement.Experimental group significant at p< .001 and control group was significant at p < .002. Hence from it can beconcluded that wrist and thumb kinesio taping improve hand grasp in spastic hemiplegic cerebral palsy presentingthumb in palm position.

KEY WORD : Functional grasp, kinesiotaping, spastic hemiplegic cerebral palsy, thumb in palm.

INTRODUCTION

In comparison with most types of cerebral palsy,hemiplegic cerebral palsy is characterized by anuncomplicated natural history and the affectedchild has reasonable prospects of leading a morefulfilled adult life. Impaired arm and handfunctions are the main problems in about half ofthe affected children and are the main factorscontributing to disability in activities of daily living(Fedrizzi et al, 2003).

Some children with hemiplegic cerebral palsy maydevelop a thumb - in - palm position, affecting arm-hand function. If thumb opposition and abductionare limited in anyway, the role and movementpatterns of the finger and hypothenar area aregreatly affected. The thumb is their essentialopposing force and their partner in action of pinchand grasp (case - smith, 4th edition). In flexion, itacts as a block by occupying space in the palm and

The author can be contacted [email protected] 9538648490.

a lack of active movement for pinch and grasplimits the usefulness of the hand, specifically inthe type and quality of prehension patterns usedand in the coordination of release. If unattended,the web space may eventually shorten and acontracture may develop, causing significantlimitations in hand function and potentialproblems in hygiene and skin integrity.

To improve hand function occupational therapistsstimulate use of the affected hand by challengingthe child to perform bimanual activities of dailyliving (ADL). Different kinds of splints have beendesigned and used to minimize tightness in thumbadduction. The short thumb opponense splint isintended for those children with moderate tosevere hyper tonicity, whereas both the soft-splintand thumb-loop splint are intended for thosedisplaying minimal to moderate hyper tonicity(Boehme, 1988).

Taping can be used as an adjunct during therehabilitation programme to enhance functional


recovery by reducing pain, improving alignment,and stimulating or inhibiting muscle function andimproving proprioceptive function of the jointstructure (Ewa Jaraczewska et al 2006).

Kinesio Taping, when applied properly, cantheoretically improve the following: strengthenweakened muscles, control joint instability, assistwith postural alignment, and relax an over-usedmuscle (Jacob M and Aution N. 2003).

Kinesio Tex™ is the brand name of the tape. TheKinesio Tex tape is more elastic compared toconventional rigid tape. With the Kinesio Tapeapplied, patients often report symptom relief,improved comfort level, or stability of the involvedjoint. The elasticity of Kinesio Tape conforms tothe body, allowing for movement. The tape is latex-free, very thin, and stretches in the longitudinalplane. Kinesio Tape has been suggested to provideproprioceptive input in the acute phase of theinjury process for lateral ankle sprain (Murray &Husk, 2001).

According to the Kinesio Taping website:

This taping Method is a definitive rehabilitativetaping technique that is designed to facilitate thebody's natural healing process while providingsupport and stability to muscles and joints withoutrestricting the body's range of motion as well asproviding extended soft tissue manipulation toprolong the benefits of manual therapyadministered within the clinical setting.

Kinesio tape is highly elastic, thickness and weightof the tape are approximately the same as skin, andwhen applied rarely perceived by the patient. Itstretches the skin in the longitudinal axis up to 40%of its resting length. It is made up of 100% cottonfabric and there is no latex or medicinal propertiesin the tape. Proper application of this tape doesnot restrict soft tissue movement but rather relieson the on the movement of the skin for multileveleffects. The elastic recoil of the tape is used toprovide support weak muscle and encourage fullrange of movements.

Andrey Yasukawa et al. (2006) conducted a studyfor 13 patients, following an acquired disabilitywhich included encephalitis, brain tumour, CVA,TBI, and SCI. the Melbourne assessment of

unilateral upper limb function was used tomeasure upper limb functional change prior to useof Kinesio tape, immediately after application ofthe tape and 3 days after wearing the tape. It isshowed Kinesio tape appeared to have improvedpurposeful movement, provided stability of theshoulder and/or hand alignment to perform thetask for reach, grasp, release, and manipulation.

O'Mahony and Spritos (2010) evaluated theeffectiveness of Kinesio taping at the thumb andwrist fourteen hemiplegic cerebral palsy children.They were measured before and after applicationof the kinesio tape for 6 weeks. They concludedfrom their study that Kinesio taping combinedwith functional training would be useful. Thismethod has not consistently proven successful inall pediatrics settings, which may be due to ashortage of thorough research.

Hence, in this study an attempt has been made tosee the effect of wrist and thumb Kinesio tapingon functional grasp in children with hemiplegiccerebral palsy presenting thumb in palm position.

AIM

The effect of wrist and thumb kinesio taping onfunctional grasp in children with spastichemiplegic cerebral palsy presenting thumb inpalm position.

METHODS

STUDY DESIGN :

Pre- test and post test control group design.

INSTRUMENTATION:

Quality Of Upper Extremity Skill Tests (QUEST) -It is used to measure the quality of grasp pattern

Modified Modified Ashworth Scale (MMAS) -Spasticity of wrist was measured by using MMAS.

House classification of Thumb in palm Deformity-it was used to screen out type 1 and 2 deformities.

OUTCOME MEASURES :

MODIFIED MODIFIED ASHWORTH SCALE(MMAS): It is a clinical tool used measurespasticity. The inter rater reliability formeasurement of spasticity is very good.

QUALITY OF UPPER EXTREMITY SKILLS TEST


(QUEST):It is an outcome measure designed toevaluate movement patterns and hand function inchildren with cerebral palsy. It is designed to beused with children who have neuromotordysfunction with spasticity and has been validatedwith children from 18 months to 8 years of age.

COMPONENTS - QUEST evaluates quality ofupper extremity function in 4 domains

" Dissociated movement" Grasp" Protective extension" Weight bearing

PROCEDURE:

The study was conducted over a period from april2012 to may 2013, in the department ofoccupational therapy, SVNIRTAR, Cuttack. 30children with spastic hemiplegic cerebral palsypresenting thumb in palm position between theage group of 4-6 years, having UE tone 1,2(MMAS), both male & female subjects who wereable to follow instruction were selected for thestudy that had been followed up at SVNIRTAR,department of OT. Children having any surgeryor fracture of the hand, having self injuriousbehavior or associated epilepsy or MR wereexcluded from the study. The subjects wereselected according to inclusion, exclusion criteriaafter obtaining informed consent from the parentsand consecutively assigned to both the groups. Thescreening was done using House classification ofthumb in palm deformity. Each group(experimental and control) were assigned with 15children. General information of the individual'smedical condition was collected. All the subjectswere tested by using scale of QUEST, MMAS tofind out the base line score. Once the subjects metthe aforementioned inclusion criteria, theyparticipated in 5 days skin check to rule out raretoxic responses to adhesive tapes before fullinclusion in the study. Control group was givenoccupational therapy focusing on activities forimprovement of grasp along with ordinary micropore taping to provide placebo effect. Kinesiotaping with scientific manner was applied only inexperimental group along with Occupationaltherapy focusing on activities for improvement ofgrasp for 6 weeks. . Skin preparation was donebefore the application. The tape applied to the

subjects by same therapist. The tape was left dayand night and changed after 2-3 days by the sametherapist. The improvement of subjects wasreassessed by using the same scale. The base linedata and post data were taken for statisticalanalysis.

DATA ANALYSIS AND RESULTS

Analysis was performed with SPSS version 16.0package. Statistical significance was consideredsignificant at p<0.05. To know the improvementbetween groups Mann Whitney U test was used.To know the improvement within group Wilcoxnsigned Rank test was used.

TABLE -1 showing results of Wilcoxon signed Ranktest for QUEST -GRASP score before and after 6weeks of intervention with in groups

Groups Mean difference z (2-tailed) p (2-tailed)

Experimental 5.43 -3.416 .001

Control 1.73 -3.064 .002

GRAPH 1: Bar graph showing mean score changesin QUEST - GRASP of both groups.

Table -2: Results of Wilcoxon Sign Rank Test forMMAS of wrist within the groups.

Groups Mean rank z(2-tailed) p(2- tailed)

Experimental 8 -3.542 0.000

Control 4.50 -2.828 0.005


Graph-2: Bar graph showing the mean score changes in MMAS score of the wrist.

TABLE - 3 showing results of improvement through Mann Whitney U test between groups after6 week of intervention for QUEST-GRASP

Group Mean rank Sum of ranks U P

Experimental 21.43 321.50 23 0.000

Control 9.57 143.50

Graph-3 Mean Change Score of QUEST- GRASP


Table - 4 Mann Whitney U test between the groups for MMAS score of wrist

Group Mean rank Sum of rank u P

Experimental 20.33 305.00 40 0.001

Control 10.67 160.00

Graph - 4: Mean change of MMAS score of wrist

Discussion

The present study the group with wrist and thumbkinesio taping showed significantly betterimprovement over the control group (p < .000),within the group (both experimental p< .001 andcontrol p < .002) there was a significantimprovement. This finding is in agreement withthe study done by Ahmed M. Azzam on 2012. Inthis study data analysis were available on 30 spastichemiplegic cerebral palsy children and mean valueof hand grip strength in study group pre and posttreatment had highly significant difference at p<0.001 while mean value of hand grip strength in

control group pre and post treatment hadsignificant difference at p<0.05.

It was also observed there was a significantimprovement in experimental group, suggestingthat Kinesio taping is an effective adjunct toconventional therapy in improving grasping skills.This result is consistent with the previous studiesshowing that the Kinesio taping has a positiveeffect on upper extremity function (Ewajaraczewska and Carol Long 2006, Kim KS, SeoHM, Lee HD 2002, Yasukawa A, Patel P, SIsung C2006, o' mahony and Spirots 2010).

O Mahony and Spritos (2010) evaluated theeffectiveness of Kinesio taping at the thumb and


wrist of children. The data in this study showedthat there was no significant difference in theoverall body functions and active range of motion

after using Kinesio tape. However, the data didillustrate that this technique had a significantimpact on the subject's ability to perform self care.

It was further observed in the present study that,there was an improvement in muscle tone at thewrist as observed in the score of Modified modifiedashworth scale. This finding is supported with theprevious studies (Silwinski Z, Halat B(2007), SlupikA, Dwornik M et al (2007), Kouhzard MohammodiH, Pooretezedm, Shokri E et al 2010) , SadeghiMoghaddam R, Lajvardi L, Amiri A et al(2012),Greve P, Perez VJ, Yoshizumi LM et al (2008).

By varying muscle tone, one can execute fine andgross motor skills efficiently. The effects provokedby an improvement in muscle have severalbeneficial effects in improving function (ElisabethGraham 2006). The decrease in tone positivelycorrelates with improvement in hand grasp, was

clearly observed in the present study. However,no statistical analysis on this regard was done.

In this study it is suggested to persue Kinesio

taping as a treatment adjunct over othertherapeutic activities because training toimproving grasp can be conducted with Kinesiotaping which cannot be achieved with rigidsplinting., when Kinesio taping is applied correctly.

It was seen that there was significant improvementin the control group this may be due to the handfunction training programme that they receivedat the department & continued the same at homeas home exercise programme. Out of the 15children in control group 4 children did not showany improvement in grasp patterns. Thereforebased on this study and taking view of previousstudies it is possible to suggest that Kinesio taping

along with occupational therapy focusing ongrasping activities, can significantly improvefunctional grasp in spastic hemiplegic cerebralpalsy presenting thumb in palm position.

CONCLUSION

From this study it can be concluded that aparticular method of wrist and thumb Kinesio

taping along with functional activities for grasp inspastic hemiplegic cerebral palsy improve handgrasp. As well as Kinesio taping is effective inreducing muscle tone. Hand function training isvital in improving functional grasp. Thus Kinesiotaping is effective adjunctive therapy in improvinghand grasp when applied in proper manner.

Parental motivation and compliance to therapyprogram has its own value.

LIMITATION & FUTURERECOMMENDATIONS

Sample size was small & follows up effects ofKinesio taping was not documented. Though thereis indirect observation of the muscle tone due toKinesio taping and improvement there to in handgrasp. The statistical correlation between tone andhand grasp not documented; hence it isrecommended that to find out the correlation.Further investigations' to examine that repeatedcarry over effect of Kinesio taping.

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www.kinesiotaping.com/kinesio/method. Html


INFLUENCE OF DEVELOPMENTAL COORDINATIONDISORDER COMORBIDITY IN ADHD CHILDREN WHO

RECEIVED VISUAL PERCEPTUAL SKILL TRAINING

S.Kurinji Chelvan1, Mrs. Anurupa Senapati 2, Mr. Ram Kumar Sahoo3,

Department of Occupational Therapy, SVNIRTAR1- MPT student, 2-Assistant Professor and HOD, 3-Senior Occupational therapist cum junior lecturer

ABSTRACT

Objective : Attention-deficit Hyperactivity disorder often co-occur and share genetic risks with Developmentalcoordination Disorder. The aim of this study was to determine and estimate the impact of DCD co morbidity onADHD, through visual perceptual skill training.

Method : Twenty two pure ADHD children and twenty two ADHD children with DCD co morbidity participatedin this study. Visual Perceptual Skill training was given for two months to both groups children. Then thePrognosis was evaluated by Pre and Post-treatment Visual Perceptual Skill (TVPS).

Results : The TVPS pre and post-test results showed that there was a significant difference between the ADHDwith and without DCD co morbidity.

Conclusion : The result of this study demonstrated that the DCD co morbidity influences the prognosis aftervisual perceptual skill training in children with ADHD. It is proved here that co morbidity in ADHD impacts onthe treatment outcomes. So while assessing and planning for intervention consideration must be given towards comorbidity conditions.

Key words : ADHD, DCD, Co morbidity, Visual Perceptual Skill training

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD)is the most common behavioral disorder ofchildhood, and is marked by a constellation ofsymptoms including immature levels ofimpulsivity, inattention, and hyperactivity (1). Itwas declared as a "severe public health problem".(2) The prevalence of ADHD is 3-5% of school agedchildren in the population. (1) (3) (4)

The children who presented with the features ofADHD were mostly being seen by Occupationaltherapists in community settings as children witha specific developmental disorder that is havingdeficits in different sensory, perceptual, motor andfunctional performance areas. (4)

DCD is currently used to define a group of childrenwho have a serious and persistent impairment inthe development of motor coordination, which

The author can be contacted at [email protected] and 91 9597254353

impedes functional performance and which is notexplained by Intellectual Retardation, PervasiveDevelopment Disorder (PDD) or congenital oracquired neurological disorder. (1) (7) WatembergM.D. (2007) (8) stated that DCD is defined by theAmerican Psychiatry Association as a markedimpairment in the development of motor co-ordination that significantly interferes withacademic achievement or activities of daily living.

The prevalence of Developmental CoordinationDisorder is 5-8% children among school-agedchildren. (11) (12) (9) (1) the children born withDCD depict a high prevalence of attention deficits,and that individuals with ADHD demonstratemotor coordination disabilities consistent with adiagnosis of DCD. (13) DCD was detected in 55.2%of 96 consecutive children with ADHD (81 males,15 females). In conclusion, DCD is common inchildren with ADHD, particularly of theinattentive type. (Nathan Watmberg, 2007) (14).


Because of the complexity of the visual system, itis difficult to imagine the impact of a visualperceptual deficit on daily living. Functionalproblems that may result from a visual perceptualdeficit include difficulties with eating, dressing,reading, writing, locating objects and many more

activities necessary for functional independence.

(16) (17)

Visual Perception is the total process responsible

for the reception and cognition of visual stimuli.

(18) The combined impact of visual experience,

inter sensory communication and cognitive growth

influence the development of visual perceptualabilities. It is a cognitive process that changes in

relation to learning, labeling and experience. (19)

It is important for classroom learning is. A child

with even mild visual-perceptual difficulties will

struggle with learning in the classroom and often

in other areas of life. (20)

Tarter & Hegedus (26) gave evidences which were

demonstrating high correlations between rates of

perceptual problems, learning disabilities,antisocial behavior, and delinquency.

Occupational therapists have long been committed

to the assessment and treatment of visual-

perception dysfunction because of the importance

of visual perception for competent occupational

performance. (27) Schneck (28) contended that

visual-perception deficits negatively impact on

children's self-care, work and leisure performance.

ADHD children have high co morbidity with

Developmental Coordination Disorder children.

As per the literatures, the DCD co morbidity makes

influence in the treatment and prognosis. So I owe

to find how much impact DCD co morbidity makes

in ADHD children's prognosis.

AIM: To determine and estimate the impact of

DCD co morbidity on ADHD children.

METHODOLOGY

STUDY DESIGN:

Pre-test, post-test Experimental study was used.

SUBJECT AND SETTING

For this study Forty four ADHD Children with &

without DCD between the ages 5-12 years, both

male & female, who were able to follow & respondto simple commands & with minimum sitting

tolerance for 15- 20 minutes were taken for the

study by consecutive sampling after obtaining the

informed consent from the parent or the caregiver

of the children. The children having autism,

Epilepsy, Infantile hemiplegia, any other comorbid

conditions were excluded from the study. The

independent variable was Visual perceptual skill

training & the dependent variable was TVPS R.

PROCEDURE:

Children were screened with ADHD Rating scale

questionnaire. Then they were assessed

usingTVPS-R. Visual perceptual deficit ADHD

children were detected. These children were then

screened with DCD-Q to find the Developmental

coordination disorder co morbid children in

ADHD population. Two groups were formed as

pure ADHD children and ADHD children with

DCD comorbidity. Visual perceptual skill training

was given to these children; each session carried

fifty minutes; six weeks, five days per week. At

the end of sixth week, all subjects were reassessed

and post treatment score were obtained and

statistically analyzed.

DATA ANALYSIS:

Pre and Post scores of TVPS-R of ADHD and

ADHD with DCD were taken for data analysis.

Collected data were analyzed using two tailed

Statistical Package of Social Sciences version 16.0.

An alpha level of P < 0.05 was set for test of

significance.

Independent 't' test was done to determine the

change in scores of Test for Visual Perceptual Skill

(TVPS-R) between groups.

The mean difference was compared between two

groups to find the influence of DCD comorbidity

in ADHD children group.

RESULTS

The study population comprised 44 subjects, 22


TABLE 1

The Raw scores of TVPS-R were collected forboth groups.

S.No ADHD ADHD WITH DCD

Pre test Post test Pre test Post test

1 18 43 16 33

2 13 35 11 24

3 17 44 16 29

4 21 51 19 34

5 18 38 9 22

6 12 32 4 15

7 26 57 20 34

8 26 56 15 30

9 16 33 8 16

10 16 33 9 22

11 16 34 15 27

12 23 47 12 23

13 18 38 24 40

14 26 45 14 30

15 30 47 22 40

16 20 37 22 41

17 26 43 18 36

18 34 55 19 31

19 12 29 11 27

TABLE 2

The mean was calculated from pre and post-tests of TVPS-R.

GROUP PRE TEST MEAN POST TEST MEAN

ADHD 20.409 41.455

ADHD WITH DCD 15.682 30.455

GRAPH 1

Graph 1 is the representation of pre and post scoresmean of TVPS-R Test between the Groups

TABLE 3

GROUP NUMBER

MEAN

DIFFERENCE

Std

Deviation

Sig. (2-

tailed)

1 22 21.04 4.695 .000

2 22 14.77 3.006 .000

The mean difference & Standard deviation of thepre and post-test of ADHD group is 21.04 & 4.695respectively. The mean difference & Standarddeviation of pre and post-test of ADHD with DCDis 14.77 & 3.006 respectively. Independent t test wasused to find out the changes in the pre and postscored of TVPS-R between the groups and the tvalue is 5.277. The mean difference in the


Independence t test is 6.27 and the standard ErrorDifference is 1.188. The 2 tailed significant valuesare 0.000. Paired 't' test was used to find out thestatistical difference between post and pre scoresof TVPS-R within the groups.

The result shows that the ADHD Children gotmore prognosis than the ADHD Children withDCD co morbidity group.

DISCUSSION

The purpose of this study was to find out theInfluence of Developmental CoordinationDisorder co morbidity in ADHD ChildrenReceiving Visual Perceptual Skill Training. Theresult of this study showed that there wassignificant difference between the ADHD andADHD with DCD co morbidity children.

Both groups scored better after visual perceptualskill training. There is significant improvement inpost test scores. The ADHD children performedsignificantly better than ADHD with DCD comorbid group.

The visual perceptual training used in this studymight provide opportunities for learning visualperceptual skills in ADHD children. This may bedue to enhancement of processing of visualinformation and strengthening of the synapticconnections with increase in number ofconnections among neurons in cortico-limbo-thalmo cortical pathway (Mishkin et al., 1983) (122).Apart from this, visual perceptual trainingdecreases the reaction time and improves the speedof visual perception (Ding Y et al., 2003) (123).

In normal brain function the dorsolateralprefrontal cortex is thought to be critical for themost complex cognitive abilities, whereas thecerebellum has been considered critical primarilyfor motor skills. These two areas are much relatedwith each other while doing work. When one seesdecreased dorsolateral prefrontal cortex activation(e.g.., when task has been practiced and requiresless concentration) one also sees a concomitantdecrease in cerebellar activation. Activation inthese two regions is strikingly correlated andclosely coupled.

Lesions of prefrontal cortex can causehypometabolism in the contralateral cerebellum

(Fuham, brooks, Hallett & DiChiro 1992; Muira etal., 1994; Tanaka et al., 1992). Similarly, cerebellardamage can cause frontal hypometabolism (Boniet al., 1992). To give close attention andconcentrate, or learn something new for cognitiveor motor performance, the cerebellum is recruitedmost heavily.

The basal ganglia, and the caudate specifically, isimportant for movement control, such as selectingthe proper movement, the appropriate muscles toperform a movement, or the appropriate force withwhich to execute the movement (e.g., De Long &Georgopoulous 1981; Groves 1983)

In addition the children with motor dysfunction(DCD) seem to be at greater risk of having a severeand co morbid ADHD.

In ADHD children the prefrontal and temporalareas of brain are affected. In children with motorcoordination disorder the cerebellum, basalganglia and caudate nucleus are involved. Whenthe Developmental coordination disorder comorbid with ADHD children the severity of theADHD and the brain structure involvement willbe more than the ADHD children. Children witha severe degree of ADHD usually have poorermotor function than children with a mild degreeof ADHD with cerebellar dysfunction (eg.,problems with balance, with rapid alternativemovement, and with consistently producingmovements of the correct distance or correcttiming) as well as motor problems with less specificcauses (e.g., poor handwriting).

The presence of DCD in ADHD predicts moreacademic and autistic-type problems than aregenerally encountered in ADHD without DCD.There is evidence to support the rationale formotor difficulties in ADHD. Tervo et al (2002)showed that children with ADHD anddevelopmental coordination disorder were morelikely to have the severe combined type of ADHDand other neurodevelopmental and behaviouralproblems than children with ADHD alone.

ADHD patients with comorbid problemscompared to ADHD patients without comorbidproblems appear to have a more severe form ofADHD, are often more impaired in their dailyfunctioning, and have a poorer long term


prognosis (Bauermeister et al. 2007; Biederman etal. 1996; Connor et al. 2003; Gillberg et al. 2004).This may have implications for diagnosis andtreatment of ADHD, like broad assessmentscovering multiple childhood psychiatric disordersand not only ADHD and interventions that alsoaddress the comorbid problems (Biederman et al1991; Gillberg et al. 2004; Hechtman et al. 2005;Jensen et al. 2001).

In addition, Hellgren et al (1993) in a long-termfollow-up study showed that patients with thecombination of ADHD and developmentalcoordination disorder had a greater risk of long-term psychiatric morbidity than those withdevelopmental coordination disorder alone.Recognising the combination of ADHD anddevelopmental coordination disorder might alsobe important in terms of responsiveness todifferent treatment approaches.

In this study the result showed that the DCD comorbid condition influenced the prognosis ofvisual perceptual skill training in children withADHD. The study result suggested that inpaediatric psychiatry field we have to focus on theco morbid conditions and it's severity of thatcondition.

The knowledge of the co morbid conditions willhelp to identify the problems of the child, to givean effective treatment, and appropriate advice orcounseling to the caretakers. This is supported byBlondis (1999) who recommended that in order forthe needs of children with ADHD to be addressed,clinicians must be able to recognize motorcoordination deficits and give appropriate adviceto caregivers. Ingram had stated that the child'sprognosis is influenced by the severity ofSymptoms, Co morbidity, IQ, Family situation,Parental pathology, Family adversity, SocioEconomic status and Treatment received. (38)Therefore it would be a reasonable to consider theco morbidity conditions during our assessment,treatment planning and intervention.

CONCLUSION

The result of this study demonstrated that the DCDco morbidity influences the prognosis after visualperceptual skill training in children with ADHD.It is proved here that co morbidity in ADHD

impacts on the treatment outcomes. DCD and LDconditions are having high percentage of comorbidity with ADHD children. So whileassessing and planning for interventionconsideration must be given towards co morbidityin ADHD. So that interventions can be modifiedat the initial stage.

LIMITATION

This study was conducted in a short duration, withsmall group of children, so it is not possible togeneralize the study result. In addition, this studywas conducted with only one comorbidityconditions.

RECOMMENDATION FOR FUTURE STUDY

Learning Disability is also having comorbidity withADHD children. To find the impact of learningdisability in ADHD children's prognosis.

Further study with a large sample with longduration.

BIBLIOGRAPHY

American Psychiatric Assocation. 1994.

s.l. : National Institutes of Health, 1998. consensusconference on ADHD.

Attention-deficit hyperactivity disorder as afrontal-subcortical disorder. . Voeller. May 2003,BJOT, Vol. 66(5), pp. 209-218.

et, Sidney Chu. September 2007, BJOT, Vol. 70(9),pp. 372-383.

Children and clumsiness: A disability in search ofdefinition. Polatajko HJ, Fox AM (1995). LondonON; : s.n., 1995.

Watmberg, Nathan. 2007, Developmental Medicine& Child Neurology, Vol. 49, pp. 920-925.

SS, Gubbay. The clumsy Child. London : W.B.Saunders, 1975.

Caring for the developmentally dyspraxic child.SC, Dawdy. 1981, International Jounal of ClinicalNeuropsychiatry, Vol. 3, pp. 30-37.

Concomitants of clumsiness in young schoolchildren. SE, Henderson. 1982, Dev. Med. Child.Neurol. , Vol. 24, pp. 448-460.

HendersonSE, Barnett AL. Perspectives on theclassification of specific developmental disorders.Developmental movement disorders. pp. 209-230.


Developmental Coordination Disorder: associatedproblems in attention, learning and psychosocialadjustments. Dewey D, Kaplan BJ. 2002, HumanMovement Science, Vol. 21, pp. 131-144.

Mckinley, Gordon &. Helping Clumsy children.1980.

Bouska, M.J., Kauffman, N.A., & Marcus, S.E.Disorder of Visal Perceptual system. NeurologicalRehabilitation (2nd ed.) . 1990, pp. 705-740.

R.A, Asarnow. Schizophrenia . [book auth.] R.E.Tartar (Ed.). The child at psychiatric risk. New York,Oxford University. : s.n., 1983, pp. 150-194.

Burnell, S.H. Children with severe emotional orbehavioural disorders. . 1985.

Tarter&Hegedus. The child at psychiatric risk. 1983,pp. 108-127.

al, Phoebe L et. August 2005, The American Journalof Occuaptional Therapy, Vol. 59(4).

Schneck. Visual Perception. [book auth.] J. CaseSmith. In Occupational therapy for children. 2001,pp. 382-412.

"Brain development and ADHD". Krain, Amy andCastellanos, Xavier. 4, 2006, Clinical PsychologyReview , Vol. 26, pp. 433-444.

Barkley. A Hand book for Diagnosis and Treatment.1990.

Motor coordination and kinaesthesis in boys withattention deficit-hyperactivity disorder. Piek, J.P.,Pitcher, T.M. and Hay, D.A.,. 1999, DevelopmentalMedicine and Child Neurology , Vol. 41, pp. 159-165.

The comorbidity of ADHD in the generalpopulation of Swedish School-age children. al,Kadesjo et. 4, 2001, Journal of Child Psychologyand Psychiatry, Vol. 42, pp. 487-492.

Natural outcome of ADHD with DCD . al,Ramussen P et, [ed.]. 11, 2000, Journal of AmericanAcademy of Child and Adolescent Psychiatry, Vol.39, pp. 1424-31.

al, Gillberg et. ADHD and comorbidities inchildren, adolescents and adults. ADHD and DCD.2000.

al, Deborah Dewey et. 2/3, 2001, Physical &occupational therapy in pediatrics , Vol. 20, pp. 5-27.

Gillberg. o Gillberg, G. (1992). Deficits in attention,motor control and perception, and othersyndromes attributed to minimal braindysfunction. . [book auth.] J. Aicardi (Ed.). Diseasesof the nervous system in children. Clinics indevelopmental medicine. pp. 138-172.

The term 'co-morbidity' is of questionable value inreference to developmental disorders:. al, Kaplanet. 2001, Journal of Learning Disabilities, Vol. 34,

pp. 555-565.


EFFECT OF VERBAL AND VIDEOTAPE FEEDBACK ON UPPERBODY DRESSING SKILL OF MALE STROKE SURVIVORS

Dr Vandna Sinha1, Mr. Subrata Kumar Halder2

Department of Department of Occupational Therapy, SVNIRTAR1-MOT student, 2-Senior Occupational Therapist cum Junior Lecturer

INTRODUCTION

A stroke is caused by an interruption of the bloodsupply to the brain, usually due to a rupturedblood vessel or a blockage caused by a clot (WHO2008).

Legg et al 2006 investigate that after stroke deficitin motor, sensory, cognitive; communication skillscan profoundly affect an individual's occupationalperformance in activities of daily living. Dressingis an important activity of daily living which thestroke patients is dependent even after many yearsof onset. So it is a relevant activity in which toengage patients in their rehabilitation.Occupational therapists commonly use thefunctional approach in dressing practice (Walkeret al 2003). But the functional approach doesn't seekto analyze and treat the root cause of the problem,rather it compensates for the deficit by findingalternative methods of performing tasks. Motorlearning theories have been applied to therehabilitation of people who have had a cerebralvascular event. Stroke can damage motorprogrammes and cause an inability to form orimplement schema/ internal models, the sensorymotor mappings used by the nervous system toanticipate the force requirements of a movementfor a given task (Beer et al. 2004; Beer, Dewald, &Rymer 2000;Mercier et al. 2004).Without the abilityto form or use internal representations, a personwith stroke will struggle to learn to perform tasksefficiently. Another common problem after strokeis the use of compensatory movements which oftendevelop due to muscle imbalances. Feedbackenhances learning a new task, improvesperformance tasks that have been acquired, anddecreases reports that tasks are tiring. Previouslythere were many studies has been done on effect

of different types of feedback on different skills instroke. There has been very few numbers ofstudies on effect of feedback on activities of dailyliving on stroke survivors. Dressing task haschosen because literature supports the use of goaldirected activity and purposeful occupations toenhance motor leaning.

AIM:-

To study and compare the effect of verbal andvideotape feedback on upper body dressing skillsof male stroke survivor.

HYPOTHESIS ALTERNATIVE HYPOTHESIS:-

o Videotape feedback is more effective thanverbal feedback in upper body dressing skillsof male stroke survivor.

o Verbal feedback is more effective than visualfeedback in upper body dressing skill of malestroke survivor

NULL HYPOTHESIS:-

o Both verbal and videotape feedback areequally effective in upper body dressingskills of male stroke survivor

o Both verbal and visual feedback are noteffective in upper body dressing skill of malestroke survivor

LITERATURE REVIEW

Sandeep K. Subramanian, Crystal L. Massie,Matthew P. Malcolm et al (2010) examined theprovision of extrinsic feedback result in improvedmotor learning in the upper limb post stroke,focusing on upper limb movement and functionalrecovery. The result suggested that people withstroke may be capable of using extrinsic feedbackfor explicit motor learning and improving upperlimb motor recovery.

Paula E. Gilmore and Sandi J. Spaulding(2007) did

The author can be contacted at

[email protected] and 9711274570


two-group research study attempted to determinethe effectiveness of an experimental therapycombining videotape feedback with occupationaltherapy compared to only occupational therapy inlearning the motor skill of donning socks and shoesafter stroke, the group that received videotapefeedback thought they performed better and weremore satisfied with their ability to don shoes,lending support for the use of videotape feedbackpost stroke to improve satisfaction withperformance.

Katherine F. Durham (2011) examines effect ofextrinsic feedback in the retraining of reach tograsp after stroke. Findings from this study weresays that Inducing an external focus of attentionhas the potential to improve performance of reachto grasp.

Sackley CM, BaguleyBI (1993) studied the effectof visual feedback after stroke with the balanceperformance monitor. . The results indicated largeimprovement in symmetry.

Christie Lauren, Rebecca Bedford,AnnieMcCluskey (2011) investigate the feasibility andoutcomes of a group-based, task-specific dressingretraining programme for inpatients post-stroke.They concluded that Task-specific practice ofdressing tasks in a group setting was feasible andmade clinically significant differences to dressingperformance during inpatient rehabilitation.

METHODOLOGY STUDY DESIGN:-

A Pre test- post test experimental group design wasused. The study was conducted, between July 2012to May 2013 in DEPARTMENT OFOCCUPATIONAL THERAPY, SVNIRTAR,Cuttack.

SUBJECT AND SETTING:-

A total number of 30 stroke patients were selectedfor the study. All the patients wererecruited from the department of occupationaltherapy, SVNIRTAR, Cuttack.

INCLUSION CRITERIA:-

Subjects diagnosed as stroke by thephysician.

Age: 35-60

First stroke resulting hemiplegia at least 3months ago

Only male adult stroke patients

MMSE 21 and above

Brunnstorm stage more than 3 for arm andhand

Functional balance grade for sitting shouldbe good

EXCLUSION CRITERIA:-

o Hemiplegia due to other causes like braininjury.

o Severe cardiopulmonary or respiratoryinsufficiency

o Shoulder dislocation

o Post stroke epilepsy or associatedneurological conditions

o Previous training of dressing skills

o Difficulty in comprehension of verbalcommand and simple instructions

o Serious visual perceptual deficits andunilateral neglect

VARIABLES:- INDEPENDENT VARIABLES:

Verbal feedback

Videotape feedback

DEPENDENT VARIABLES:

Dressing skill

OUTCOME MEASURE:-

Klein-bell Activities of daily living scale (KB- ADL)

MATERIALS USED IN THE STUDY:-

Stool or chair without arm support

Buttoned shirt and pullover

Laptop

Video camera

PROCEDURE:-

After screening by using MMSE and starcancellation task, the subjects were selectedaccording to inclusion and exclusion criteria andconsecutively assigned to both the groups (verbal


and videotape feedback). The purpose of this studywas explained to the patients and informedconsent was obtained.30 adult male stroke patients

included in this study. General information of the

individual's medical condition was collected.

All the subjects were told briefly how to dress

pullover and buttoned shirt. Only two subtests of

KB-ADL scale were used for the scoring: the

pullover and buttoned shirt. Scale was

administered to the patients. After the pretesttherapy was began for the patients.

1. Experimental group A- verbal feedback (15

subject)

2. Experimental group B - videotape feedback

(15 subject)

Group A receive dressing training with verbal

feedback and group B receive dressing training

with videotape feedback. Intervention was

continued consecutively for 15 sessions. Treatment

stopped if the participant was able to

independently don his shirt and pullover prior to

the 15 session maximum. If the skill was not

acquired in 15 sessions, the 15th session was the

post test. Full score on the KB-ADL in three

consecutive session indicated, for the purpose of

this study, that the participant was able toindependently don his shirt and pullover.

During each intervention session, the

demonstration of the whole task of donning the

shirt and pullover had given to both the groups,

while the participant watched. Then both group

participants practiced donning shirt and pullover

three times per session. The starting position for

dressing training was the patient grasping the shirt

collar.

Group A receive verbal feedback without the use

of videotape replay. Dressing training begins with

verbal instructions. Knowledge of performance

(KP) during performance and knowledge of result

(KR) after the each performance were provided.

Content of feedback was prescriptive type

(describe errors and suggesting how to correct

them). Group A who receive verbal feedback

during training, receives cues from therapist about

incorrect movement and how to correct the

movement in each steps and end of the session also.

Group B receive videotape feedback. The Dressingprocedure for normal individual was videotaped

and during treatment session shown to the

subjects. Subjects saw dressing procedure and tried

to dress shirt/pullover in similar manner. Each

treatment session was videotaped, again shown to

the subjects. They saw him in video and interpret

the behaviour of the task and compare his

performance with actual performance and in next

session try to correct his performance.

COMPONENTS FOR THE PROCESS OF BUTTONED

SHIRT: (Suzuki M, Omori M, Hatakeyama M, Yamada S,

Matsushita K, Iijima S (2006)

The paralyzed upper extremity is inserted

into the sleeve

The sleeve is pulled up beyond elbow joint

The sleeve is pulled up beyond the shoulder

joint

The shirt is pulled across the back to the

opposite shoulder joint

The intact upper extremity is inserted into

the sleeve

Collar is arranged

Fasten the first button to fourth button

Fasten the cuff

Tuck shirt into the pant

COMPONENTS FOR THE PROCESS OF

PULLOVER SHIRT:-

The paralyzed upper extremity is inserted

into the sleeve

The sleeve is pulled up beyond elbow joint

Put the unaffected extremity into the sleeve

Sleeve pulled up beyond elbow

Reach shirt to top of head

Pull head through neck hole

Pull shirt down over trunk


Fig 1. - Participant practicing to put uninvolvedlimb into sleeve with videotape feedback Fig. 2- participant practicing dressing task

with verbal feedback

DATA ANALYSIS

After the completion of post treatmentassessments, results were collected and data wasanalyzed. Statistical calculations were performedwith statistical package for social science (SPSS)version 16.0 package. Statistical tests were carriedwith the level of significance set at p?0.005.As thiswas 2-tailed, non parametric study, the changes inoutcome measures within verbal feedback andvideotape feedback groups were analyzed usingWilcoxon Sign Rank Test. Mann- Whitney U Testwas performed for the knowing the significancebetween the groups.

S.No. Baselines

Characteristics

Group A (verbal

feedback)

Group B (videotape

feedback)

1. No. of subject(male) 15 15

2. Age range (years) 35-60 35-60

3. Mean age (Std Dev.) 49.8(±7.61) 49.26(±7.32)

4. MMSE score (mean) 27.13 26.26

5. Time post stroke

(mean)

11.4 months 11.06 months

6.

Right/left hemiplegia 10/5 10/5

RESULT

The analysis of data gives the following tablesshowing the demographic characteristics and testresults. The individual characteristics of verbal andvideotape feedback groups are given in table 1.

TABLE-1: DEMOGRAPHIC CHARACTERISTICS OF SUBJECTS:


Table -2 : Descriptive statistic of outcome measure:-

Outcome

measure (Klein

bell ADL scale)

Verbal feedback ( group A) (N=15) videotape feedback (group B)

(N=15)

Mean test score Standard

deviation(SD)

Mean test score

Standard

Deviation

Pre test Post

pest

Pre

test

Post

test

Pre test Post

test

Pre

test

Post

test

Pullover score

5.2 10.93 1.26 2.05 4.9 10.66 0.99 1.88

Buttoned shirt

score

7.6 17.2 2.21 3.24 6 15.86 1.45 3.22

Table – 3: showing the results of Wilcoxon Sign Rank Test for KB- ADL scale (pullover score)

within the groups.

Groups Mean difference z P ( 2- tailed)

VERBAL FEEDBACK 6.66 -3.462 0.001

VEDIOTAPE

FEEDBACK

5.73 -3.446 0.001

Graph 1: showing mean score changes in the pullover score in KB- ADL scale of both the groups.


Table-4: showing results of Wilcoxon Sign Rank Test for buttoned shirt score in KB ADL scale

within the groups.

Groups Mean difference z P(2-tailed)

VERBAL FEEDBACK 9.6 -3.430 0.001

VEDIOTAPE

FEEDBACK

10 -3.436 0.001

Graph 2: showing mean score changes in the buttoned shirt score in K B ADL scale of both the

groups.

Table 5: Mann-Whitney U tests results between the groups showing mean and sum of rank:

Pullover shirt Buttoned shirt

Groups N

Mean Rank Sum of Rank Mean Rank Sum of Rank

A 15 16.50 247.50 14.77 221.50

B 15 14.50 217.80 16.23 243.50


Table 6: Mann-Whitney U test results between the group showing z and p value:

Outcome

measures(KB -ADL)

Mean difference Z P (2-tailed)

Pullover score 0.93 -0.662 0.508

Buttoned shirt score 0.4 -0.469 0.639

Result shows that clinically there was moreimprovement in Group A (verbal feedback) bothin pullover and buttoned shirt than Group B. Butthe mean pre test score of Group A was more thanGroup B. Mann-Whitney U tests result shows therewas not statistically significant difference in bothpullover and buttoned shirt score in betweenverbal and videotape feedback groups as shownin Table-5 of Mann Whitney U Test at the p value0.508 and 0.639 respectively.

DISCUSSION:

"It is degrading to have to be dressed by someoneelse." Mulley (1985)

Dressing independently gives stroke patients asense of dignity, self respect and achievement.Hence intervention that can improve dressingability is important part of rehabilitation. In stroke,lesions of the sensorimotor areas of the brain cancause damage to intrinsic feedback mechanisms(Fisher et al. 2000). This reduces individual's abilityto make ongoing movement adjustments which arenecessary for effective movements. So that the roleof extrinsic feedback for skill acquisition andlearning is very important, even more compellingafter stroke.

The present study was designed to compare theeffect of verbal and visual feedback on dressingskill of stroke survivors. All subjects in presentstudy said that their ability to don pullover andbuttoned shirt independently is very important forthem. The finding of the study suggests that bothverbal and videotape feedback groups showssignificant improvement in dressing ability.Another similar study was found Sandeep K.Subramanian, Crystal L. Massie (2010) theyexamined the provision of extrinsic feedback result

in improved motor learning in the upper limb poststroke, focusing on upper limb movement andfunctional recovery.

Effect of verbal feedback on upper body dressingability of stroke patients:

Verbal feedback can be an effective tool anderroneous verbal feedback can even override theperson's own correct visual feedback in somesituations. In a study by Beukers et al. subjectspracticed an anticipation timing task. When givenerroneous verbal feedback, it had the effect ofoverriding the person's own visual feedback, suchthat subjects adjusted their response to theincorrect verbal feedback. Kawashima R., TajimaN. (2000) who investigates brain mechanismsunderlying feedback effects on motor learning. Theresults indicate that these brain areas may play animportant role in representing knowledge ofresults during motor learning and the appropriatefeedback may facilitate motor learning. Anotherstudy by Alexander S. Aruin, Timothy A. Hanke,and Asha Sharma (2003) suggest that extrinsicverbal feedback information about base of supportimprove gait in stroke patients. Barclay-GoddardRE et al (2009) also find out that auditory forceplatform feedback improves the standing balanceoutcomes in stroke patients.

Effect of videotape feedback on upper bodydressing ability of stroke patients:

Videotape provides feedback about theperformance quickly and can replay the dynamicsof movement in detail. Darden reviewed theliterature and found positive outcomes resultingfrom using videotape. Schmidt and Wrisberg (ascited in Darden, 1999) found that videotape replay


highlights the difficult aspects of movement.Videotape feedback can promote cognitive effortin the learning process. Research involvingvideotape modeling has shown it to be an effectiveinstructional method for enhancing motor skillacquisition.

Marian E. Michielsen, Ruud W. Selles (2010) didstudy on effect of visual feedback on balance andfound that shift in activation balance with in theprimary cortex area towards the affectedhemisphere in the visual feedback group becauseChange in the neural activation pattern were foundin the functional magnetic resonance imaging(Fmri) in their study so that balance is improve. Soit has been proved that cortical reorganizationoccurs in the brain with visual feedback in strokesurvivors.Another study is which supportedpresent study is chun chen et al (2002) who found,visual feedback training improve dynamic balancein stroke and there is also significant improvementin self care abilities. Bambi Roberts Brewer (2006)studied the Visual Feedback Manipulation forHand Rehabilitation in a robotic environment instroke and found that all patients showedfunctional improvements (in arm motor mobilitytest) after participation in the study.

Though there was significant improvementoccurred in both the groups. No significantdifference was seen between the groups in upperbody dressing skills. The reason could be smallsample size, task was complex, and the scale maylack sensitivity to improvements.

CONCLUSION

Dressing is an important activity of daily livingwhich the stroke patients is dependent even aftermany years of onset.

The result of the present study suggest that therewas a significant improvement in upper bodydressing skill in stroke survivors (verbal andvideotape feedback) in the both the groups. Thereis no statistical significant difference between thegroups. This study gives evidence that verbal andvideotape feedback enhances dressing abilities.The finding provides support for the research thatrecommended using goal directed activity andmeaningful occupations with feedback to enhancemotor learning. This result supports the need foroccupational therapy intervention.

LIMITATIONS

The study had small number of sample size

Only upper body dressing task was includedin the study

Follow up for the effect of intervention wasnot done

The subjects received other interventionssuch as physiotherapy that could contaminatethe treatment effect

Included only those subjects whose cognitionperception were good

FUTURE RECOMMENDATION:

Future study can be done with large samplesize

Future study can be done lower bodydressing skill

Study can be performed with different typeof tasks with different types of feedback

Combine effect of different types of feedbackon different tasks can also be assessed.

Study on Dressing skill can be performedwith different type of feedback

Study can be done on females and cognitivelyimpaired patients.

REFERENCES:

1. Carr Janet H. and Shepherd B. Roberta: A MotorLearning Model for Stroke Rehabilitation:physiotherapy rehabilitation. 1989; vol.-75, issue-7: 372-380.

2. Chan YL Dora, Chan CH Chetwyn and Au KSDerrick: motor relearning programme for strokepatients: a randomized controlled trial; Clinicalrehabilitation. 2006; 20: 191-200.

3. Christie Lauren, Bedford Rebecca, Cluskey McAnnie : Task-specific practice of dressing tasks ina hospital setting improved dressing performancepost-stroke: A feasibility study: AustralianOccupational Therapy Journal. October2011;Volume 58, Issue 5, 364-369

4. Chouhan, Swati; Kumar, Sanjiv: Comparing theeffects of rhythmic auditory cueing and visualcueing in acute hemiparetic stroke: InternationalJournal of Therapy & Rehabilitation. June 2012;Vol. 19 Issue 6:344.


5. Cirstea M. C. and Levin M. F. : Feedback andCognition in Arm Motor Skill Reacquisition afterStroke: Stroke rehabilitation. 2006;vol- 37: 1237-1242.

6. Dahlgren Annika, Åsa Sand, Åsa Larsson et al:Linking the Klein-Bell Activities of daily LivingScale to the International Classification ofFunctioning, Disability and Health; J Rehabil Med.2013; ISSN 1650-1977

7. Darden GF. Videotape feedback for studentlearning and performance: a learning-stagesapproach. J Phys Education Recreation Dance.1999;70:40-45

8. Dijk Van Henk :motor skill learning , age andaugmented feedback: ISBN 90-365-2302-8:2009.

9. Dimyan A. Michael and Cohen G. Leonardo :Neuroplastic ity in the context of motorrehabilitation after stroke: Nature ReviewsNeurology 7, 76-85 (February 2011) | doi:10.1038/nrneurol.2010.

10. Durham F. Katherine : Effect of extrinsic feedbackin the retraining of reach to grasp after stroke, andin particular the effect of directing attention toeither the body movements or the task:2011.

11. Klein RW, Bell BJ. Self-care skills: behavioralmanagement with Klein-Bell ADL Scale. ArchPhys Med Rehabil. 1982;63:335-338. 26.

12. Ezekiel HJ, Lehto NK, Marley TL, Wishart LR, LeeTD. Application of motor learning principles: Thephysiotherapy client as a problem-solver.III:Augmented feedback. Physiotherapy Can 2001;53(1):33 - 39. 65.

13. Fasoli SE, Trombly CA, Ticle-Degned L, VerfaellieMH. Effect of instructions on functional reach inpersons with and without cerebrovascularaccident. American journal OccupationalTherapy. 2002; 56(4):380 - 390.

14. Ferracioli Irana Junqueira and Ferracioli Marcela: Breaststroke learning through the use ofvideotape feedback. Brazilian journal ofkinanthropometry and human performance:2013;15(2):204-214

15. Fletcher-Smith, Joanna C. : Recovery of dressingability after stroke: MPhil thesis, University ofNottingham ;2011.

16. Fowler V, Carr J. Auditory feedback: Effects onvertical force production during standing upfollowing stroke: Int J Rehab Res. 1996;19:265 -269

17. Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State": a practical method for grading thecognitive state of patients for the clinician. JPsychiatric Residency. 1975; 12:189-198. 25.

18. Fredericks M. Christopher and Saladin K. Lisa:Pathophysiology of motor system

19. Gengel W. Roy and Hirsh J. Ira:Temporal order:The effect of single versus repeated presentations,practice, and verbal feedback : Perception &Psychophysics:1970;Vol. 7 (4)

20. Gilmore E. Paula and Spaulding J. Sandi :MotorLearning and the Use of Videotape Feedback AfterStroke: TOPICS IN STROKE REHABILITATION/SEPT-OCT. 2007; vol-14(5):28-36

21. Gray SW.: Effect of visuomotor rehearsal withvideotaped modeling on racquetball performanceof beginning players. Percept Motor Skills. 1990;70:379- 385.

22. Hanlon RE. Motor learning following unilateralstroke. Archive Physical Medicine Rehab.1996;77:811 - 815.v52

23. Herbert E, Landin D, Menickelli J. Videotapefeedback: What learners see and how they use it.J Sport Pedagogy. 1998;4: 12 - 28.

24. Khan , Anwar ulla Mohammad : Effect Of PhysicalTherapy Intervention With And Without VisualAnd Verbal Cues On Balance Training In TheRecovery Stage Of Stroke:2005.

25. Kawashima R, Tajima N, Yoshida H, Okita K,Sasaki T, Schormann T, Ogawa A, Fukuda H,Zilles K: The effect of verbal feedback on motorlearning a PET study: Positron emissiontomography.: neuroimaging . 2000 ;Dec;12(6):698-706.


MODULAR POST-OPERATIVE BK PROSTHETICS

Mr. Lagnajit Behera1, Aparna Sahoo2

Department of prosthetics and Orthotics, SVNIRTAR1-Demonstrator (P & O), 2-BPO Internee

ABSTRACT

The goal of post operative management in patients with transtibial amputation is to ensure primary wound healingand pain control to prevent oedema, shape the residual limb for prosthetic fit to extent possible, and prepare thepatient for restoration of function and restoration of life. A new design of light weight prosthesis having no metalparts that will help the amputee to ambulate as soon as possible. This prosthesis has prescribed for geriatric patients,women and child cases as it is very light in weight. The different segments must fabricate in polypropylene sheet toreduce the weight. The use of modular IPOP jig is of great psychological benefit to the patient and allows for earlyambulation and rehabilitation. It should be considered for all appropriate candidates undergoing trans-tibialamputation.Key words: Post Operative prosthesis, preparatory prosthesis, prosthetics jig

INTRODUCTION

The immediate approach of prosthetics to a newamputee definitely creates a physical andpsychological advantage as it has provided alimbless interval between the amputation andfitting of the definitive prosthesis. The primemotive of immediate post operative prosthesis isto preserve some degree of functional restoration.Also it offers all the benefits of rigid dressings andpermit limited weight bearing and supervisedearly ambulation. The time for limb maturationand overall amputee rehabilitation, includinghospitalization, is reported to be considerablyshorter.

This short term temporary prosthesis, alsoknown as Immediate Post-OperativeProsthesis(IPOP) are commonly utilized as anexternal semirigid protective device to promoteresidual limb healing, reduce limb contracturesand minimize post operative oedema. Postoperative prosthesis were introduced by MarianA. Wiss, PhD, of Poland and further refined in theUnited States By Ernest Burgess, MD in the 1960s.Recently, more options of IPOPs are come out withadvancing material technology and variable choice

of clinical team & patient. A preparatory prosthesisis generally constructed on an endoskeletal pylon,permitting alignment changes at any time. This isa considerable advantage because the needs of thepatient can be constantly reassessed andaccommodated as the ability to use the prosthesisimprove.

Fig.1: Plaster removable rigid dressing

Apart from that the psychological reasonelucidates the necessity of IPOP for a positive outcome. When a patient wakes from a transtibialamputation with an IPOP and foot attachment inplace, the patient does not experience a period of"limblessness" with attendant neurological andpsychological ramifications. Although, the patienthas endured a life altering procedure,he/she hasThe author can be contacted at

[email protected] and 09439192040


awakened in the recovery room with two legsbeneath the sheets. Feeling of being "disabled" orless than whole are often replaced with sense ofhope and encouragement.

Post amputation management is animportant determinant of recovery fromamputation. Definitely the temporary prosthesishas a rigid dressing which addresses the need tocleanly cover a fresh surgical wound to facilitatethe strategic goals of preventing knee contractures,reducing oedema, protecting from internal traumaand facilitating early weight bearing. It is a totalcontact system encapsulating the amputated limb,including the patella and extending to the midthigh. The knee is maintained five to ten degreesflexion. Generally ttghe suspension is by totalcontact, in addition to attach waist belt for moresecurity. This design assists in sharing weightbearing over a larger surface area which reducesthe load on the amputation side itself.

The fitment of IPOPs are based on thecurrent protocols and decisions made by localpractice, skill and intuition.Mostly in our countrythe use of IPOPs are limited due to lacking ofawareness, unavailability of materials and theconstraints of the components for all the amputees.

We, thus, initiated to design an IPOP forencouraging the patient as it is a light weightprosthesis constructed by a rigid cast socket, shankpiece and foot. The most important factor is thefoot and shank piece designed from plasticinsteadof the conventional pylon and SACH footwhich ultimately reduce the weight for consideringthe geriatric, women and child cases.

AIM & OBJECTIVES:

The aim of this design to make a light weightprosthesis having elimination of conventionalSACH foot and pylon system for the geriatric,women & child patients. The objectives aredescribed as follows:

- To initiate early weight bearing and indoorambulation

- Easily replaceable rigid cast in time

- Prevention of residual limb trauma

- Reduction of wound pain

- To provide a psychological boost to thepatient and to encourage their participation in therehabilitation process.

METHODOLOGY:

Design concept:

To fabricate this type of IPOP, it wasplanned to make a layout as it helps to give anappropriate format. Although it will make fromlight weight components, the cost effectivenessmust not be ignored. A blueprint (fig.2) of thisdesign has been made to lead the project further.

MATERIALS REQUIRED: (fig.3)

Polypropylene sheet(16mm)

Nut and bolt(10mm)

Canvas belt

Copper rivet with washer(4mm)

Ethaflex

Rubber sole

FABRICATION PROCEDURE:

In this project one patient was participatedto check the effectiveness of the prosthesis. Thisprosthesis is made out of three components; onenegative cast type of socket, and one Y shape shankpiece and foot attachment. Both Shank piece andfoot are made out of polypropylene.

FOOT:

Correct dynamic alignment is determinedby the prosthetist as the patient ambulates on anadjustable alignment unit. This unit allows antero-posterior foot positioning. Proper anteroposteriorpositioning of the prosthetic foot will distributeweight evenly between the heel and toe portion.This will result in a smooth energy efficient gait,including controlled knee flexion after the heelstrike, smooth rollover without recur vatum andheel of before initial heel contact on the contralateral foot.

At the normal side foot, a cast was taken. Afterthat it was poured by plaster of paris liquid. Whenit was hard the modification procedure was doneand smoothed by the wire mesh. A 10mmpolypropylene sheet was put into the oven at last


moulding was done. A canvas belt (4 mm thicknessand 4 inch wide) is attached at the proximal thirdof the foot for toe break. At the heel portion ethaflexpadding was given and also a rubber sole isattached to prevent slippage and backward falling(fig 4). 1 cm toe space was given to prevent heel totoe gait.

Fig.4: Foot design

Attachment of the ankle complex:

The fo ot measurement was taken for todetermine the ankle joint. The foot length wasdivided into three parts and the proximal onethird was considered as the ankle axis. A polypropylene sheet of 16 mm was cut accordingto the design shown in the figure that attachedwith the foot piece and the shank piece. Itsdimension was described as length of 6cm(lower part) which was attached to the foot andupper part was a semi circle like structure. It'sdiameter was 3cm along with the 10 mmdiameter of inner hole that attached to thelower part of the shank piece.(fig 5)

SHANK PIECE :

This is made out of 16 mm of polypropylene sheet.There are two polypropylene sheet attached toeach other (fig.5). The upper part of the shank pieceis a curved shaped to match the calf area and thelower part is straight which is attached to eachother by rivet. So it is look like a y shaped shankpiece where, the ankle complex was fastened withnut and bolt. Length of the shank piece is 39cmaccording to the normal side measurement of thepatient i.e. from mid patella tendon to lateralmalleolus of the foot. An attachment bar is attachedwith both shank piece and foot plate to preventthe unwanted movement of the ankle joint andprovide stability (.Fig.5)

CAST SOCKET :

In traditional amputation management thedressing typically applied to the fresh surgicalwound has been comprised essentially of gaugepads and a gauge bandage.

Fig.2: Sketch of the IPOP design

Fig.3: Materials required


The limitation of fluid accumulation (stumpoedema) with consequent reduction in pain andaccelerated wound healing; andThe provision of afoundation on which, either immediately or soon,the patient could stand and bear at least part of hisweight, or even ambulate, by means of a simpleimmediate post operative prosthesis attached tothe cast. In this way fitting of the definitiveprosthesis could be expedited subsequentmanagement.

MEASUREMENTS:

At normal side

¢ Heights from mid patella tendon to floor.

¢ Foot size (length).

¢ Diameter of the foot.

¢ Minimum ankle circumference.

¢ Heel height.

PATIENT TRIAL :

After all fabrication procedure complete(fig 7 & 8)the patient was trial with the prosthesis (fig.10).Thegait pattern of the patient was smooth running andlooks like a definitive prosthesis.

Again typically this type of dressing has beenmaintained, until the wound has healed. With theadvent of "immediate postoperative fittingprocedures," considerable emphasis was placed onthe application of a rigid plaster-of-Paris cast (fig6) immediately after amputation. This cast,carefully applied to provide "total contact" or "totaltissue support," was considered to have two primefunctions:

Fig.5: Total Jig Frame work

Fig. 6: Cast socket Fig.7 : Final finishing of prosthesis

Ankle complex

Attachment Bar

Shank Piece

Reinforcingplate


Fig.8: Final finishing of prosthesis

RESULT

During this study, patients with stumps werefitted with temporary cast socket prosthesis.Postoperatively patients managed immediate rigiddressing with dynamic alignment unit, shank pieceand foot prior to the temporary prosthesis.

Advantages

Affordable cost.

Good cosmoses.

Light in weight to the structural strength atthe periphery of the prosthesis

Rapid application of the prosthesis

Water resistance.

Disadvantages

If the cast is not applied correctly or if thereare subsequent changes in stumpdimensions, localized high-pressure areasmay develop

Fig 9: side view of prosthesis with the patient

Plaster casts provide limited protectionagainst bacterial infection and little or nocontrol of temperature and relative humidityin the immediate environment of the stump.

DISCUSSION

Return of function to an attainable rehabilitationlevel is the primary goal of treatment for IPOPs.Especially for the below-knee level it is hoped thata high degree of restoration of function will beachieved particularly with the use of the modularimmediate post operative prosthesis jig. It is reallyconcerned that the patients such as women childand geriatric have got the maximum advantage towear this prosthesis. It helps in early ambulationdecrease in pain, provides a great psychologicalboost. Apart from that no sophisticated equipmentis used and it is cost effective and the significantof this IPOP is a modular frame with adjustmentfacilities.


CONCLUSION

For the past 7 years, the removable IPOP hasproven to be an effective adaptation to the originalIPOP concept. The initial goal of the design was tomeet the needs of the surgeon, which was to allowfor easy wound inspection. The design later provedto be beneficial in the area of physical therapy toallow for strengthening and range of motion. Inaddition, the prosthetist is aided by the ability toadjust for residual limb volume loss and assist inlimb shaping. All lead to a more cohesive clinicalteam approach with a better understanding of thechallenges of postoperative management. Patientsundergoing IPOP had similar complication ratesas those undergoing the traditional method butwere less likely to require surgical revision. Theuse of modular IPOP jig is of great psychologicalbenefit to the patient and allows for earlyambulation and rehabilitation. It should beconsidered for all appropriate candidatesundergoing trans-tibial amputation.

REFERENCES

1. Kihn RB, Golbranson FL, Hutchinson RH,Moore WS, Premer RF. The immediatepostoperative prosthesis. Arch Surg1970;101:40-44

2. Warren R, Moseley RV. Immediatepostoperative prostheses for below the kneeamputations. Am J Surg 1968;116: 429-32

3. Moore TJ, Barron J, Hutchinson F, Golden C,Ellis C, Humphries D. Prosthetic usagefollowing major lower extremityamputation. ClinOrthopRel Res 1989;238:219-24.

4. 30. Baker WH, Barnes RW, Shutt DG. Thehealing of below-knee amputations. Acomparison of soft and plaster dressings. AmJ Surg 1977;133:716-18

5. . Wilson PD. Early weight-bearing in thetreatment of amputations of the lower limbs.J Bone Joint Surg Am 1922; 4(2):224-47.

6. Schon LC, Short KW, Soupiou O, Noll K,Rheinstein J. Benefits of early prostheticmanagement of transtibial amputees: aprospective clinical study of a prefabricatedprosthesis. Foot Ankle Int 2002; 23:509-14.

7. -A: 241- Mooney V, Harvey JP, McBride E,Snelson R. Comparison of postoperativestump management: plaster vs. softdressings. J Bone Joint Surg Am 1971;5349.

8. Dederich R.Amputationen derunterenExtremitat. Operationstechnik undprothetischeSofortversorgung. Stuttgart,Thieme, 1970.

9. Berlemont M. Notre experience del'appareillageprecoce des amputees desmembresinferieurs aux establissmentsHelio-Marins de Berck. Ann Med Phys. 1961; 4:4.

10. Berlemont M, Weber R, Willot JP. Ten yearsof experience with immediate application ofprosthetic devices to amputees of the lowerextremities on the operating table.ProsthetOrthot Int. 1969; 3:8.

11. Burgess EM. Immediate postsurgicalprosthetic fitting: A system of amputeemanagement. Am J PhysTher. 1971; 51:139-143.

12. Moore WS. Below-knee amputation. In:Moore WS, Malone JM, eds. Lower ExtremityAmputation. Philadelphia: WB SaundersCompany; 1989:118-131.

13. Wu Y, Krick H. Removable Rigid Dressingfor Below-knee Amputees.ClinProsthetOrthot. 1987; 11:33-44.7.Zettl,JH. Immediate Postoperative Prostheses andTemporary Prosthetics. In: Moore WS,Malone JM, Eds Lower ExtremityAmputation. Philadelphia: WB SaundersCompany; 1989:177-207.8.Barr J, Brown P,Perry G. Risk factors associated with falls inthe elderly rehabilitation client. Austral as JAgeing. 1999;18:27-31.

14. Gailey RS. Preparing for a prosthetic fitting.


First Step 2001; 2:111-128.

15. Nasser E. Amputation rehabilitation. In: O'Young B, Young MA, and StiensSA (Eds).Physical Medicine and RehabilitationSecrets. Philadelphia: Hanley and Belvis;2003: 553-561.

16. Walsh TM. Custom removable immediatepostoperative prosthesis. JPO 2003; 15:161-8.

17. Smith DG, McFarland LV, Sangeorzan BJ,Reiber GE, Czerniecki JM. Postoperativedressing and management strategies fortranstibial amputations: A critical review.JPO 2004; 16:15-26.

18. Tang P. Let them walk! Current prosthesisoptions for leg and foot amputees. JACS2008; 206:548-60.

19. Seymour R. Immediate PostoperativeProsthesis (IPOP) Protocols. In: Prostheticsand Orthotics: Lower limb and spine.Philadelphia: Lippincott & Williams; 2002:161-163.

20. Sindhu V, Singh U, Wadhwa S, Yadav SL.Advantages of ischial weight bearingimmediate postoperative prosthesis. IJPMR2002; 13:5-11.

21. Vigier S. Healing of open stump woundsafter vascular below-knee amputation:plaster cast socket with silicone sleeve versuselastic compression. Arch PhysMdRehabil1999; 80:1327-30.


KAFO FOR FIXED FLEXION CONTRACTURE

Mr. Sanket Kumar Rout1, Mr. Bapina Kumar Rout2

Department of prosthetics and Orthotics, SVNIRTAR1-Demonstrator (P & O), 2-BPO Internee

ABSTRACT

Contractures associated with neurological conditions like paraplegia, hemiplegia and cerebral palsy adds morechallenges to a already physically challenged person. Unlike fixed contractures, a lot of research has been carriedout in the field of P & O, on successful management of flexible contractures. A simple theorem in rehabilitation is?orthosis for functional deformity and surgery for structural one". In case of patients suffering from diabetesmellitus and clotting disorders, surgery cannot be carried out. In such cases the only way of rehabilitation isaccommodation of deformity. This article is about the accommodation of fixed knee flexion deformity by a co-polymer KAFO with drop ring lock and subsequent ambulation.

Key words: Fixed flexion contracture, KAFO

INTRODUCTION

Contractures are secondary to any locomotordisorders observed most often. Surprisingly mostresearch has been carried out on flexiblecontractures in P&O. Fixed contractures create aapparent shortening which otherwise hampers themobility. Flexion contracture introduces a constantlimitation to extension. With 30 degree kneecontracture, all phases of gait cycle will beabnormal except initial swing. In 15 degree of kneecontracture, loading response and preswing willbe normal but knee extension in terminal swing,initial contact, and mid and terminal stance willbe in adequate. Thus, penalty for loss of extensionin terminal swing will be shortening of step length.Inability to appropriately extend the knee in midand terminal stance will increase the energydemand on quadriceps. So, this KAFO willaccommodate the deformity and apparentshortening will be managed by shoe compensation.Thus the extra demand on quadriceps will be takenby uprights during mid and terminal stance. Alsothe step length will be managed to some extent.The major implication of this orthosis will be seenby inhibiting postural scoliosis.

Design concept:

Whole notion is centered on accommodation offixed knee flexion contracture, direct load bearingby orthosis, hence relaxation of protagonisticmuscle (quadriceps).

It is practically impossible for an orthotistto prescribe and fit knee ankle foot orthosis (KAFO)to neuromuscular conditions like paraplegia,hemiplegia and Cerebral Palsy having associatedfixed knee flexion contracture of more than 35degree. So, this innovative KAFO found a way toaccommodate fixed knee contractures in abovementioned conditions.

In this particular KAFO there are matching holeson both male and female counterpart of the specialknee joint. In order to accommodate the anatomicalknee joint in desired angulations, locking pins areengaged in graduated holes and lockedaccordingly. The apparent shortening on affectedside due to contracture is managed by giving shoecompensation.

After casting and modification, mouldingwas done by using polypropylene sheets of 4mmthickness. Both calf and thigh shell are moldedseparately.



The specially designed knee joint consistsof a drop lock and several matching holes foradjustment in different angulations. Knee jointwith uprights are aligned with thigh and calf shells.

Both anatomical and mechanical knee joints arekept in same axis. During alignment the kneeflexion angle was maintained by locking the KAFOat desired angle.

FIG.1: SPECIAL ORTHOTIC KNEE JOINT

RESULTS

The innovative KAFO with drop lock mechanismfor accommodating the fixed knee contractureangle was found to be very successful inrehabilitation programme. This orthosis can beapplied with equal success to many other patientswith fixed knee contracture.

FIG 2: KAFO FOR FIXED FLEXION

CONTRACTURE (SIDE VIEW)

ADVANTAGES:

" Simple in construction, but effective in action.

" Successful accommodation of fixed kneeflexion contracture.

" Optimum retainment of the alignment.

" Effective management of apparentshortening by compensation.

" Successful ambulation with minimaldisplacement of CG


DISADVANTAGE

Rachet mechanism instead of locking pins, wouldhave improve the function of knee joints.

DISCUSSION

After fitment a more efficient patient was seen dueto less stress on quadriceps during mid andterminal stance. Step length was preserved by 92%with respect to normal side step length. Duringsingle limb support most of loads were borne byuprights. Sitting with 90degree knee flexion waspermitted due to incorporation of drop ring lock.

The orthosis has helped to find a way out forpatients with fixed contracture who are reluctantto go for surgery. Incorporation of RACHETmechanism would have improved the function ofjoint.

CONCLUSION

Once a great philosopher said ?we are born freebut everywhere in chains ?. Today's society doesnot possess the word LIMIT in its word bank.Contractures are that limitations which is limitinghuman being to get its quality of life. Theprevention, correction and accommodation ofcontractures play a definite role in the achievementof optimum mobility and dignity.

REFERENCES

1. Fergusson D, Hutton B, Drodge A.Theepidemiology of major joint contractures: asystematic review of the literature. ClinorthopRelat Res. 2007;456:22-29

2. Liber RL, Steinman S, Barash IA, ChambersH.Structural and functional changes in spasticskeletal muscle. Muscle Nerve.2004;29:615-627.

3. Katalinic OM, Harvey LA, Hebert RD.Effectiveness of stretch for the treatment andprevention of contractures in

4. Jansen CM,Windau JE,Bonutti PM,BrillhartMV.Treatment of knee contracture using aknee orthosis incorporating stress-relaxationtechniques.Phys Ther.1996;76:182-186.

5. Hepburn GR. Case studies: contracture and stiffjoint management with dynasplint.J Orthopsports phys ther.1987; 8:498-504.

6. Kenton R. Kaufman, PE Steven E, Irby. MS.Ambulatory KAFOs: A BiomechanicalEngineering Perspective Journal of Prostheticsand Orthotics 2006;18(3):175.

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