Vol 4 | Issue 1 | Jan - Apr 2016 | page: 31-36 | Bipul Borthakur[1], Birseek Hanse[2], Russel Haque[3], Saurabh Jindal[4], Manabjyoti Talukdar[5].

Author: Bipul Borthakur[1], Birseek Hanse[2], Russel Haque[3], Saurabh Jindal[4], Manabjyoti Talukdar[5].

[1] Department of Orthopaedics, Assam Medical College, Barbari, Dibrugarh,  PIN - 786 002, Assam, India.
Institute Where Research Was Conducted: Assam Medical College, Dibrugarh, Assam.
University Affiliation: Srimanta Sankaradeva University of Health Sciences, Guwahati.
Year Of Acceptance Of Thesis: 2013.

Address of Correspondence
Dr. Russel Haque
Department of Orthopaedics, Assam Medical College, Barbari, Dibrugarh,
PIN - 786 002, Assam, India.
Email- russelhaq@gmail.com

 Abstract

Background: Distal femoral fractures represents a challenging problem in orthopaedic practice. Open reduction with Internal fixation replaces previous trend of closed conservative management and external fixation. Distal femoral locking compression plate (DF-LCP) requires both locking and compression screw fixation of the femur shaft. This study was conducted to examine the short-term results, early complications and healing rate of distal femoral fractures treated with the DF-LCP.
Materials and Method: 32 patients were included in the study. Lateral approach was performed as standard surgical technique. Functional results evaluated using knee society score.
Results: There were 24 males and 8 female patients of mean age 48.84 years. Road traffic Accident (59.38%) was the commonest mode of injury and 33A3 was the commonest fracture type (25%). Most were closed fractures (78.12%). Late complications seen in 4 cases of implant failure (broken plate and screw breakage) and 2 wound infections. 100% union rate seen with an average union time 14.40 weeks. Knee society score was Excellent in 13 (40.63%), good in 17 (53.12%) and failure in 2 (6.25 %) patients.
Conclusion: DF-LCP is an important armamentarium in treatment of Distal femur fractures especially when fracture is closed, severely comminuted and in situations of osteoporosis.

Introduction

The incidence of distal femoral fractures is 4-7% of all femur fractures. Distal femoral fractures, especially AO Type C fractures are difficult to treat as diastasis of 3 or more millimetres cause Osteoarthritis. The problems associated with conservative management as was done previously are the limitation of reduction and difficulty of maintaining reduction with associated complications of prolonged immobilisation and economic considerations of increased hospital stay. Pin tract infections and joint contractures are common complications with external fixation with devices such as the hybrid external fixator and the Ilizarov external fixator. Internal fixation devices used earlier such as 95° angled blade plate, dynamic condylar screw plate, condylar buttress plate and retrograde supra-condylar inter-locking nail etc. but these implants may not be ideal for complex inter-condylar and metaphyseal comminuted fracture types. Distal femoral locking compression plate (DF-LCP) has a smaller application device and allows both locking and compression screw fixation of the femur shaft. This study was conducted to examine the short term results, early complications and healing rate of distal femoral fractures treated with the distal femoral locking compression plate.

Aim and Objectives
Aim: To study and analyse the results of Locking compression plate (LCP) in Distal Femur Fracture.

Objectives:
1) To Analyse the clinical profile of the patient in regards to age, sex, mode of injury and any other relevant features.
2) To evaluate the Radiological union in treated patients.
3) To evaluate the complications.
4) To evaluate the functional outcome in treated patient based on knee findings.
5) To Assess any factors influencing the results.

Materials And Method
This study was petrformed in Assam Medical College & Hospital, Dibrugarh from July, 2012 to June, 2013 and 32 patients eligible for inclusion were selected who were admitted either through the Outpatient Department (OPD) or the Emergency Department (Casualty). All the fractures were post-traumatic. No pathological fracture was included in the study Patients with distal neurovascular injury is not included in this study. Inclusion Criteria: were Fresh cases of Closed fractures or Type1 open (Gustilo and Anderson) in skeletally mature patients. Exclusion Criteria: were who do not gave consent, unable to take part in post- operative rehabilitation. Open infected wound like Compound fracture(type 2 or 3), Pathological Fractures and Malunited fractures or Long standing cases(>3wks) or patients with Definite major illness like malignancy,chronic major system illness etc. Drug or alcohol abuse were also excluded. After admission into the hospital general and systemic examination as well as local examination along with thorough assessment of patient to rule out other systemic injuries was done followed by evaluation of patients in terms of age ,sex , mode of trauma and period between injury and arrival. Thereafter patient is stabilized with intravenous fluids, oxygen and blood transfusion as and when required. Careful assessment of injured limb as regards to neurovascular status was noted. Primary immobilization done with a Thomas splint and Antero-posterior and true lateral views of injured limb including Hip joint and Knee joint were done. CT scan was done as and when required. Traction given over Thomas splint for complex fractures. Analgesics were administered as required. Preoperative preparation include prophylactic antibiotics (3rd generation cephalosporin) on the evening before surgery and just before skin incision. Either Spinal aneasthesia or General anesthesia were used. Operating field washed with savlon , povidone iodine and was draped separately. PROCEDURE: Lateral approach as standard surgical technique was followed in all patients. The incision should start as proximal as necessary and distally, should extend across the midpoint of the lateral condyle anterior to the fibular collateral ligament, across the knee joint, and then gently curve anteriorly to end distal and lateral to the tibial tubercle. The fascia lata is incised in line with the skin incision. At the knee, the iliotibial tract will need to be incised, and the incision will continue down through the joint capsule and synovium to expose the lateral femoral condyle. The superior geniculate artery will need to be identified and ligated. Care was taken not to incise the lateral meniscus at the lateral joint margin. The vastus lateralis muscle is carefully elevated from the intermuscular septum and is retracted anteriorly and medially. Fractures were reduced under direct vision using manual traction. A knee roll assisted the procurement and maintenance of reduction. The plate length, axial and rotational alignment were checked under image intensifier (IITV).Temporary fixation was achieved through the use of Kirschner- wires. Inter-condylar type fractures were converted to a single condylar block before DF-LCP. Appropriate lengths of the plates were selected intra-operatively. Fixation of plates done. In minimally invasive technique, of selected distal femur fractures,a5-6cm lateral incision limited to the area of the lateral condyle and distal metaphysis was used. The incision was placed more distal to allow for retrograde sub-muscular plate insertion. Condylar screws are placed through the incision used for plate insertion. Adequate length of LCP was taken and placed on distal femur and temporarily fixed with k-wires. Locking compression screws were applied sequentially, followed by proximal screws. Reduction was viewed under IITV. Wound was washed thoroughly with normal saline. Drain was given to every patient. Closure was done in layers after Haemostasis was achieved, followed by Dressing. Posterior plaster slab above knee was applied. Considering the patient's condition and the stability of the internal fixation, mobilization using a walker was done as soon as possible with the help of supervised physiotherapy. Crutch walking given but weight bearing was not allowed. . In case of unstable fracture immobilization was upto 3 weeks. Weight bearing was allowed only after clinical and functional assessment. Patients were followed up clinically at 2, 6, 12 and 24 weeks and radiologically at 6,12 and 24 weeks. Further radiological assessment was done at 6 weeks,3 months, 6 months and 12 months.

Results
Among 32 patients the mean age was 48.84 years ( youngest 18 years and oldest 78 years ), 24 males and 8 females were among the subjects. Slight preponderance of Left side was noted. Road traffic Accident (RTA) (59.38%) was the Commonest mode of injury. Five cases had fractures in other parts of the body. One case had Associated head injury with other parts fracture. Most of the patient were closed fracture 25 Patients (78.12%) and 7 patients (21.88%) were open fractures. Majority (87.50%) were operated in 8–14 days following injury. There were no intraoperative and immediate post-operative complications. Late complications encountered were 2 cases of implant failure (broken locking plate and screw breakage) and 2 wound infections. Broken implants were safely removed and treated with other method. The union rate was 100% in the study group with average union rate 14.40 weeks, with no delayed or non-unions in the study, except 2 failure case treated with other implants. The union rate was 100% in our study group with average union time of 14.40 weeks, with no delayed or non-unions in the study, except 2 failure case treated with other implants. Based on the assessment criteria of knee society score for the present study, the final outcome for all cases was Excellent in 13 (40.63%) patients, good in 17 (53.12%) patients and failure in 2 (6.25 %).

Conclusion
The final outcome of the study based on the assessment criteria of knee society score was Excellent in 13 (40.63%) patients, good in 17 (53.12%) patients and failure in 2 (6.25 %). Thus, Locking Compression Plate is an important armamentarium in treatment of the Distal femur fractures especially when fracture is closed, severely comminuted and in situations of osteoporosis. Further study in large number of patients is required to comment regarding disadvantages and complications.

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116. Mongkon Luechoowong. The Locking Compression Plate (LCP) for Distal Femoral Fractures. Buddhachinaraj Medical Journal Volume 25 (Supplement 1) January–April 2008.
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Vol 4 | Issue 1 | Jan - Apr 2016 | page: 26-30 | Abhishek Vaish[1],  Sandeep Patwardhan[1], Ashok Shyam[1], Parag Sancheti[1].

Author: Abhishek Vaish[1],  Sandeep Patwardhan[1], Ashok Shyam[1], Parag Sancheti[1].

[1] Sancheti Institute for Orthopedics and Rehabilitation, Shivajinagar, Pune.
Institute Where Research Was Conducted: Sancheti Institute for Orthopedics and Rehabilitation, Shivajinagar, Pune 411005.
University Affiliation: MUHS(Maharashtra university of health sciences),Nashik.
Year Of Acceptance Of Thesis: 2015.

Address of Correspondence
Dr. Abhishek Vaish
Healing Touch Clinic, 94 Sukhdev Vihar
New delhi 110025.
Email: drabhishekvaish@gmail.com

 Abstract

Background: Titanium elastic nail (TEN) fixation was originally meant as an ideal treatment method for femoral fractures, but was gradually applied to other long bone fractures in children. We assessed outcomes in 50 Indian patients.
Material and Methods: Children with long bones fractures between 3-16 years were included and patients pathological fractures excluded. Functional outcome was assessed by using LEFS and DASH scoring and clinical by Flynn and Daruwala scoring. Radiological union was assessed by Anthony score. All patients were assessed upto 1 year or till implant removal .
Results: Excellent in 73%, satisfactory in 27% cases based on Flynn score. Based on Daruwala forearm score Excellent in 53%,Good in 27% and Fair in 20% cases.Percentage of functionality based on LEFS Score was 89.15% and Percentage of disability according to Quick DASH was 6.6 for both bones and 7.4 for humerus. Grade 3 callus formation according to Anthony et al scale was seen at 6 weeks in 70% and 28% cases at 12 weeks.
Conclusion: Based on our results, we conclude that flexible intramedullary nailing is an effective way of fixation with excellent functional results and minimal complications in diaphyseal fractures in skeletally immature patients.
Keywords: ESIN, TEN, Diaphyseal Fracture, Flynn.
Thesis Question: Is flexible elastic nailing an effective treatment modality in skeletally immature children?
Thesis Answer: Based on our results, we conclude that flexible intramedullary nailing is an effective way of fixation with excellent functional results and minimal complications in diaphyseal fractures in skeletally immature patients.

Introduction

Treatment of paediatric fractures dramatically changed in 1982, when Métaizeau and the team from Nancy( France), developed the technique of flexible stable intramedullary pinning (FSIMP) using titanium pins [1,2].Since then there have been tremendous advances in the surgical options available to treat paediatric fractures. Pediatric orthopedists have increasingly recognized the advantages of fixation and rapid mobilization.
Between 6 to 16 years, there are several available treatment options like traction followed by hip spica, external fixation, flexible stable intramedullary nails (ender or titanium), plate fixation, and locked intramedullary nailing[3,4,5,6,7] . Systematic review of literature provides little evidence to support one method of treatment over the other [8]. The treatment of long bone fractures in children less than 6 years and adolescents older than 16 years is straight forward. Titanium elastic nail (TEN) fixation was originally meant as a gold standard treatment method for femoral fractures[9], but was gradually applied to other long bone fractures in children, as it represents a midpath between conservative and surgical modality with satisfactory results and minimal complications.[10,11,12,13]. Much of the indexed publications and literature available on titanium elastic nailing is based on studies conducted outside the Indian subcontinent where the demographics like body weight on an average is different. The aim of this study is to evaluate the results of operative treatment of paediatric diaphyseal fractures in the age group between 6 to 16 years using titanium elastic nailing system (TENS).

Aims and Objectives
1. To study the surgical and functional outcomes of titanium elastic nailing in diaphyseal fractures in children between the age of 6-16 years.
2. To study the complications associated with titanium elastic nailing.

Material and Methods
Type of Study: Prospective study.

Duration of Study: May 2012 to November 2014
Case Selection Criteria: During this period all patients posted for titanium elastic nailing were screened using the inclusion and exclusion criteria. Informed consent was taken from all patients that fit the inclusion criteria and all patients willing to undergo the study were included after approval from the ethics committee.

Inclusion Criteria:
• Children with diaphyseal fractures of long bones.
• Age between 6-16 years.

Exclusion criteria:
• Congenital disorders.
• Patients with pathological fractures.

Study Method
All patients diagnosed with fractures of long bones were assessed clinically and radiographs were taken. Patients who fell into the eligibility criteria were included in the study and followed up at 2 weeks, 6 weeks, 12 weeks and till maximum 1 year or till implant removal whichever was earlier. They were assessed clinically, radiographically and functionally using Flynn outcome scoring65(Table 1- Annexure), Daruwala scoring66 (Table 2-Annexure)for forearm fractures. Radiographs were analysed in which the Limb alignment, delayed or non union(using Anthony scoring67-Table 5 annexure) were seen. Functional outcome was assessed by using quick Disability Arm, Shoulder, Hand scoring(Table 3-Annexure) for upper limbs and Lower Extremity Functional Score (Table 4-Annexure) for lower limbs at final follow up. Protocol was approved by Institutional review board. All patients were consented prior to inclusion in the study. Displaced fractures were immobilized using skin traction with Thomas splint (femur / tibia) or slab support till the day of surgery. Various demographic, clinical, investigative and operative findings were recorded from the hospital case file. Postoperative data collected was number of nails, postoperative immobilization, period of hospital stay, period of radiological union , return to normal work/daily activities, any complication , time to nail removal. Radiographs were evaluated for alignment, callus formation, nail position, and measurement of fracture location. Final outcome was graded excellent, satisfactory or poor based on criteria described by Flynn et al.

Results
Excellent in 73%, satisfactory in 27% cases based on Flynn score. Based on Daruwala forearm score Excellent in 53%,Good in 27% and Fair in 20% cases.Percentage of functionality based on LEFS Score was 89.15% and Percentage of disability according to Quick DASH was 6.6 for both bones and 7.4 for humerus. Grade 3 callus formation according to Anthony et al scale was seen at 6 weeks in 70% and 28% cases at 12 weeks.

Conclusion
Based on our results, we conclude that flexible intramedullary nailing is an effective way of fixation with excellent functional results and minimal complications in diaphyseal fractures in skeletally immature patients.

Clinical message
Titanium elastic nailing is a good modality of treatment with excellent results in the hands of experience surgeons with good surgical skills.
Hence this should be undertaken after proper training as the learning curve is high.
Keywords: ESIN, TEN, diaphyseal fracture,Flynn

Reference
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Vol 4 | Issue 1 | Jan - Apr 2016 | page:3-6 | Dr Shimpi Apurv P (PT).

Author: Dr Shimpi Apurv P (PT).

Associate Professor and Head Department of Community Physiotherapy, Sancheti Institute College of Physiotherapy, Pune.
Email: apurvshimpi@sha.edu.in

Introduction to Physiotherapy Research
Physiotherapy is a Health care profession concerned with human function & movement aimed at maximizing its potential. It uses physical approaches to promote, maintain & restore physical, psychological & social wellbeing, taking account of variations in health status. The role of a Physiotherapist involves administration and interpretation of tests related to bodily functions and structures, and the provision of a range of therapeutic and preventive measures to patients suffering from disabilities, dysfunctions and pain. But by large, Physiotherapy is still a non-dosage specific field where still lot of researches are being done to understand the exact or specific dosages required in the treatments/ restoration/ prevention of various conditions.

Challenges faced by the novice researcher
New PG Physiotherapy candidates are full of concerns regarding the application of research knowledge in practice for their PG thesis. Although few of the universities in India have incorporated research at an under-graduation level, this is expected to be an observational research, more or less limited to a retrospective study. Thus, many times, they may neither be exposed to, nor be interested in research. Although the thesis in PG is mandatory, most of the young learners consider clinical learning devoid of research and Evidence Based Physical Therapy (EBPT). EBPT incorporates the application of the learners' clinical Physiotherapy knowledge backed by latest evidences favouring the same considering the patients' needs and necessities. This requires a thorough knowledge of the client's functional aspects backed by the latest trends in the practice of that condition at a global level. This also necessitates the formulation of a clinical research question in current practice.

The Research Question
The Research Question is the soul of every thesis. It not only directs the end point of the thesis, but also marks the pathway to be taken towards completion of the thesis. Research question helps to understand contents of the thesis, including the methodology, tools, outcome measures and statistical tests that may be used in the particular thesis. It helps choose an appropriate protocol to be followed in completion of the thesis and let the researcher understand the need for the study. A good research question should guide towards appropriate references; explain about the condition to be studied and treatments currently available. It should note the gaps present in the current chain of evidences and the specific treatment to be studied and guide towards collection of preliminary data in the condition to be studied. It should also help the researcher anticipate results and potential pitfalls and describe the significance of the research including potential benefit for individual subjects or society at large.

Hypothesis
The hypothesis directs the methodology which considers the measures of exposure and outcome. It should be tested by making a comparison between the two or more groups. It guides the authors to develop a plan for data collection and management, determine the statistical methods for analysis and also estimate the magnitude of the expected difference between the two groups, as a basis for determining sample size (power calculation). This will guide to assess study feasibility, sample recruitments and analysis.

Study Title
This is the most important part of every research as the title forms the face of the study. An improper title will be a deterrent for any study and shall not arouse interest in the readers. The title should be descriptive of the study and should be concise, clear and non-ambiguous.

Challenges in writing Introduction
The introduction is the prima facia of the research. The introduction should be of the current study, rather than about the known knowledge of the conditions and diseases. It should always be in the funnel format, i.e. from broad global concerns to small local concern. Many times, the young researcher writes in great lengths about everything else other than their own study which may turn down the review board and readers. Introduction should be short and specific incorporating the need for conducting the present research in around 2–3 pages maximum. Bold statements like “such evidences do not exist” or “there have been no studies on this topic” etc. should be avoided.

Conducting the Review
The next challenge faced is collecting literature for reviewing. Although textbooks do give some baseline information, they can only answer background questions. For understanding research in its better aspect, answers to the foreground questions must be sought for which reading latest literature is mandatory. This can be obtained by subscribing to various peer reviewed, indexed journals or going through online databases. Database like the Google scholar may be useful to find articles, but specific databases like Pubmed, Cochrane, PEDro and CINAHL are also useful in Physiotherapy thesis. But the reader should be clear in understanding methods to navigate through them e.g., using the key words, filters, bullions, truncation symbols, MeSH terms etc. Documentation of the reviewed literature is also an art. A review should always have a story and a flow to it. This may be from the historical to the newer perspectives or may be compartmentalised based on the research question/s. Writing briefly about the authors, their study, design, results, conclusion and applicability is desired.

Aim and Objectives
Generally PG thesis may have a single aim to answer to a specific research question. The study objectives should be clearly and precisely stated. They should be simple, specific, and stated in advance to performing the research and should be attainable, measurable and realistic.

Research design and Statistics
The research design should be identified and should be appropriate to answer the research question/s under study. The researcher may describe the type of research proposed (e.g. experimental, correlational, survey, qualitative) and specific study design that will be used (e.g. pre-posttest, control group, cross-sectional; prospective longitudinal, cohort; blinded randomized control). The research design, methods and procedures should help answer the specific research question/s as mentioned in the study objectives. The sampling procedures should be specific and scientific. The researcher should always describe the sampling approach including determination and justification for sample size. A larger sample size may increase the cost and duration of the study and will be unethical to expose human subjects to any potential unnecessary risk without additional benefit. A smaller sample size can also be unethical if it exposes human subjects to risk with no benefit to scientific knowledge. Calculation of sample size has been made easy by computer software programs. The principles underlying the estimation of the software sample size should be well understood. The researchers have to identify the procedures that will be used to recruit, screen and follow study volunteers as well as specifically define the study sample (number and characteristics of subjects to be included and excluded). In intervention studies, clarification of subject allocation to treatment and comparison groups and criteria for discontinuation should be defined. Another challenge faced is on statistics which is considered as a huge hurdle. Thus, involving the statistician from the earliest part of the research is an excellent idea. Statisticians can help in understanding the basis of statistical tools, data variables and tests before actual exploration of data. Choosing good and appropriate, valid and reliable outcome measures is also an important step to a successful thesis.

Why conduct the Pilot Study?
Before the actual research, performing the pilot study is another crucial step in Physiotherapy thesis. It is useful in multiple ways. In observational studies, it may help understand the outcome measure or may help in validating the research tools. In experimental studies, it may help in rectification and finalization of the processes and the procedures which may be used in the study. Pilot study is never meant to analyse the end results. It will help the researcher understand if he is on the right track. This also helps rectify any lacunae that may weaken the study as well as prevent any potential confounders that may cause bias in the study. Permissions for obtaining/ using outcome measures can also be done in this phase.

Materials and Methods
The methodology should be elaborate to explain every procedural detail to the level of replication of the entire study in the similar given environment. Processes of sampling, consent, measures, tests, and data entry need to be provided in elaborate details. A very important consideration in the thesis methodology is following the universal guidelines for the procedure documentation. Researchers are advised to go through CONSORT guidelines (CONsolidated Standards Of Reporting Trials) for experimental, STROBE guidelines (STrengthening the Reporting of OBservational studies in Epidemiology) for observational and STARD guidelines (STAtement for Reporting studies of Diagnostic accuracy) for diagnostic studies.

Ethical Clearance and Research Registration
Another important step, before actual initiation of the study, is getting clearance from the Ethics Committee. This is mandatory for any medical research, including Physiotherapy research to ensure that the researcher shall not violate the rights and dignity of their subjects. It is advisable for every researcher to be certified in Good Clinical Practices, in order to ensure safeguarding of their subjects. Methods for data collection and for avoiding/ minimizing subject risks should be included. Always include a timeline for subject evaluations, duration of intervention and tentative budget for the project. The researcher should document the methods for maintaining subject confidentiality (plans for coding data and for securing written and electronic subject records) and should indicate duration of storage of personal information post study completion. These methods will vary with the research type (qualitative, quantitative) and thus should sufficiently describe justification of the approach for answering the defined research question. Methods should also be described in adequate detail so that IEC members may assess the potential study risks and benefits. Also it is important to register the study with national clinical trials registry (Clinical Trials Registry of India, CTRI). Many Physiotherapy researchers are still unaware of the importance of registering their studies to safeguard their intellectual rights. CTRI does register Post graduation Physiotherapy thesis and also observational studies. Also, it is advantageous to publish of your hypothesis as a defensive publications. Journals like 'Journal of Medical Thesis' does publish Research Hypothesis which helps protect intellectual property of the researchers.

The master chart and Scientific Misconduct
Although the master chart seems to be the last and inconspicuous part of the research, fact is that it is the most important piece of evidence in every research. The basic analysis of the entire study data is done from the master chart and thus, it should be created properly without any fallacies. The PG candidate should be clear with the data being analysed and should make the master chart elaborately. Avoid making single headings for multiple components. E.g., for male/ female, yes/ no options, make 2 different columns rather than a single column and enter '1' for every 'yes' or 'no'. This is extremely important in summation and averaging. In experimental studies, it is advised to make different sheets for control and experimental groups. MS Excel has multiple, user friendly options and tools which should be learnt before making the master chart. Also, many statistical tests for parametric data can be performed in Excel, including descriptive statistics, paired and unpaired t test, ANOVA, Correlations, covariance etc. For all other tests, including non-parametric tests and Correlations etc., using statistical packages like the SPSS is beneficial. Taking guidance from a good statistician always helps but learn your own basic test procedures as well. Few of the researchers tend to indulge in research malpractices during this phase by falsification and fabrication of their data. This is strongly condemned and the researchers have to understand that such malpractices can easily be detected by basic analysis of the master-chart. Also ensure that the master chart does not disclose the identity of the subjects in any way as this is considered as breach of confidentiality. Hence, coding of the case report forms before making the master chart is a good practice.

Results, Discussion and Conclusion of the Study
This is another crucial part of any Physiotherapy thesis. Often good studies lose their value due to improperly interpreted and explained results. The PG candidate should choose appropriate, self-explanatory graphs and tables for explanation of their results. The discussion should focus on the important findings and rationalisation of these findings and should avoid repetition of results. Utilising a good reviewed literature is extremely helpful in this stage. Also, the confounders of the study should be well identified and expressed in the discussion (unless they are being written separately as limitations). The conclusion should be a good amalgamation of the aim, objectives, research question and hypothesis. Any conclusion, whether it accepts or rejects the null hypothesis, is an important contribution to Physiotherapy research. Conclusion should only be based on the results obtained and should not have any comments outside the preview of the study, including indirect study implications. Any suggestions or added information can be written as a scope for further study.

References Guidelines
References should always be recent, complete and preferably in the Vancouver format. The details can be found in most of the standard journal and sites. References should be given to all the published articles, books, websites (mentioning the date of viewing them), and even to unpublished but accepted works.

Summary
Thesis has been an integral part of every Post Graduate Physiotherapy candidate and is associated with them for a lifetime. In today's electronic era, every published or unpublished thesis can utilised by future researchers as a reference. But it should be remembered that every research is completed only when published in a good peer reviewed indexed journal. Thus, it becomes not only important and ethical, but even legal to lay down all the facts associated with the study in a truthful and honest manner. Malpractices like plagiarism, although may seem easy, but are deterrents in the future prospects of the candidate. Almost all of the universities and journals run anti-plagiarism software's and getting indulged in such act may not only cause rejection of this wonderful piece of literature, but may also blacklist the candidate for life. Research is all about a bit of dedication, understanding, honesty and hard work on the researchers' side and about a lot of truth, facts and probabilities of the findings for verification of these facts, which under any costs, must not be altered, but be expressed with all its integrity. Only then can the candidate truly contribute to his professions growth and stability in a noble way.

References

1. Nicholls DA, Gibson BE. The body and Physiotherapy. Physiother Theory Pract. 2010 Nov;26(8):497-509.
2. Shimpi A, Writer H, Shyam A, Dabadghav R. Role of Physiotherapy in India – A Cross-sectional Survey to Study the Awareness and Perspective among Referring Doctors. Journal of Medical Thesis 2014 May-Aug; 2(2) : 11-15.
3. Portney LG. Evidence-based practice and clinical decision making: It's not just the research course anymore. Journal of Physical Therapy Education. 2004;18(3):46-51.
4. Kaplan SL. Developing Evidence-Based Physical Therapy Clinical Practice Guidelines. Pediatric Physical Therapy. 2013; 257-70.
5. Fathalla MF. A Practical Guide for Health Researchers. WHO Regional Publications Eastern Mediterranean Series 30.
6.Writing a Research Policy – WHO. Recommended format for a Research Protocol. Available at http:// www.who.int/rpc/research_ethics/format_rp/en/ [Viewed on February 22, 2016].
7. Indrayan A. Statistical fallacies in orthopedic research. Indian J Orthop. 2007 Jan;41(1):37-46.
8. Amezcua M. [Myths, challenges, and fallacies in nursing research]. Rev Enferm. 2003 Sep;26(9):36-44. Spanish.
9. Babu AS, Veluswamy SK, Rao PT, Maiya AG. Clinical trial registration in physical therapy journals: a cross-sectional study. Phys Ther. 2014 Jan;94(1):83-90.
10. Shyam AK. Editorial: Hypothesis, Intellectual Property and Journal of Medical Thesis: Concept of Defensive Publication. Journal Medical Thesis 2014 Jan- April: 2(1); 1-2.

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Vol 4 | Issue 1 | Jan - Apr 2016 | page 1-2 | Shyam AK.

Author: Dr. Ashok K Shyam

MS Orthopaedics
Editor - Journal of Medical Thesis
Email: drashokshyam@yahoo.co.uk

Journal of Medical thesis (JMT) has entered in its fourth year of publication. This is a significant achievement in a country where thesis is something of a burden to most medical students. The aim of the journal was to increase the value of thesis and to provide an opportunity to students and medical faculty to publish their research. I believe JMT has definitely taken in steps in right direction to achieve these goals. We are now receiving submission from many countries and many contributors have shown great interest in publishing their thesis in entirety.
Thesis have been published in various other formats but mostly as part of a university repository where due credit in form of citations is mostly not credited to the thesis. Publishing the thesis is JMT has this significant advantage. All articles are indexed in google scholar and index Copernicus and citations can be received for the thesis. This adds academic value to the thesis and to contributors too, which repositories can't provide. Another advantage of publishing in JMT is that the articles have a wide outreach. The number of readers at JMT website has increased exponentially and now includes readers from more than fifty countries. We also have increased submissions from different faculties of medicine and in short time we will be looking at becoming a comprehensive medical journal which will include thesis from all faculties. We also aim to include the para-medical and para-clinical thesis in the purview of JMT to improve the comprehensiveness. Even with such large scope, there are strict criteria for inclusion into JMT and not many articles are published by us. In fact last year we published only one issue which is testament of our commitment to uphold quality of the journal.
We are planning a more organised approach for JMT in year 2016. We will be formulating a speciality based editorial board by the end of this year. We wish to invite readers who are interested to join JMT to write to us. This will help us get good peer review for subject wise thesis and improve the quality of the Journal. We have also submitted JMT to leading indexing bodies and will be indexed in all of them by the end of this year. We will also be printing every issue of JMT and will be distributing it to all medical colleges. Print copies of JMT will be available to all colleges on subscription basis however access to online version will remain open access. JMT fulfils the current requirement of MCI as it is available in print version and is indexed with Index Copernicus. But this it is not the main purpose of JMT to simply publish to help people get accreditation from MCI. The main aim remain to publish quality thesis which will serve as template to improve the quality of thesis in future.
Recently medical education in our country has come under lot of criticism specifically in terms of research and publications. We hope JMT will provide a good platform for student to read and publish quality material and in turn will improve the understanding of research and publications. With this is mind we are planning to introduce certain new features in JMT. We have already introduced the hypothesis section which will publish the hypothesis of thesis that have been approved by a medical university. This will help students get a publication to begin with and the literature review will help in improving their understanding about the subject. The hypothesis also undergo peer review and students may get new insights in their research from comment of the reviewers. Along with hypothesis we are planning to start a subject specific section where difficulties in thesis writing and publications will be discussed by teachers and researchers. Another permanent feature we are introducing is a 'Statistic article'. This will be a featured article preferable written by a research person or a statistician. These articles will be present complex statistical concepts in easier way for understanding of our students and new researchers. We are hopeful that these new feature will help in making JMT a more complete Journal. We are also open to suggestions from our readers about what more we can include in JMT.
The journey of four years for JMT is not been easy. The editorial team had to do lot of hard work and many thesis were rejected in peer review. The indexing was difficult to obtain and quality articles were even difficult. However the future of JMT looks really bright with many more submissions this year. The print version will help improve the outreach of the journal much more. The Journal of Medical Thesis still hold the status of being the only Journal in the world that is dedicated to publishing medical thesis and this fact has been acknowledged by increased visits to our website from all across the globe. We invite all researchers to publish their thesis in entirety with JMT and showcase their work on our platform. I sincerely thank our editorial board that has supported the journal I all these years.

Best Wishes
Dr Ashok Shyam
Editor- Journal of Medical thesis.

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Vol 3 | Issue 1 | Jan - Apr 2015 | page:15-18 | Biplab Nandi, Sucheta Mishra, Ujwal Yeole, Pravin Gawali, Roshan Adkitte.

Author: Biplab Nandi[1], Sucheta Mishra[1], Ujwal Yeole[1], Pravin Gawali[1], Roshan Adkitte[1].

[1] Tilak Maharashtra Vidyapeeth, Department of Physiotherapy, Pune, Maharashtra, India.
Institute at which research was conducted: Tilak Maharashtra Vidyapeeth, Department of Physiotherapy, Pune, Maharashtra, India.
Year of Acceptance: 2015.

Address of Correspondence
Dr. Biplab Nandi
5th floor, Department of Physiotherapy
Tilak Maharashtra Vidyapeeth
Mukundnagar, Pune, 37.
Email: bips1303@gmail.com

 Abstract

Background: Incentive Spirometry is widely used in prevention and treatment of postoperative pulmonary complications after major surgeries. This study was aimed to evaluate the efficacy of incentive spirometer in improving the Peak Expiratory Flow Rate in abdominal surgery patients.
Methodology: A total of 40 patients were selected between 25-55 age group and put in two groups through random sampling. Patients in group B were given IS for 5 days and patients in group A were taught Diaphragmatic Breathing Exercise and both groups were encouraged to perform this every waking hour. PEFR measurements of day 1 and day 5 of both groups were taken.
Conclusions: The PEFR measurement exhibited significantly higher values in IS group. There was a major difference in the improvement among the two groups. The difference in the mean value for Group A and Group B on day 1 and day 5 was 24.00 and 41.25 respectively using statistical test (Two independent t-test) showing p value of 0.021.                                                                                                                                                                                 Keywords: IS- Incentive Spirometer, PEFR- Peak Expiratory Flow Rate, Abdominal surgery, Diaphragmatic Breathing Exercise.
Thesis Question: Is Incentive Spirometry effective in improving peak expiratory flow rate in abdominal surgery patients?
Thesis Answer: Incentive Spirometry is effective in improving peak expiratory flow rate in abdominal surgery patients.

Introduction

Upper abdominal surgical procedures are associated with a high risk of postoperative pulmonary complications. These are defined as pulmonary abnormalities occurring in the postoperative period which produce clinically significant identifiable diseases or dysfunction that adversely affect the patient's clinical course[1]. Pulmonary complications include atelectasis, pneumonia, respiratory failure and tracheobronchial infection. Pulmonary complications are the most frequently occurring complications following upper abdominal surgeries with reported frequency of up to 75% of all patients[2]. Upper abdominal surgeries are associated with decreased lung volumes, adoption of rapid shallow pattern of breathing. Rapid shallow breathing causes uneven ventilation of lungs and this may lead to development of micro atelectasis and if sustained for long enough it may be the starting mechanism for pulmonary inefficiency[3]. It is particularly important to identify patients at risk of postoperative pulmonary complication as this is the most frequently reported cause of morbidity and mortality in the postoperative period[1]. The risk and severity of complication can be reduced by the use of therapeutic maneuvers that increase lung volume[4]. Physiotherapy is designed to enhance inspiration and is aimed at increasing the abnormally low postoperative functional residual capacity[1]. Incentive spirometry has been routinely considered a part of the perioperative respiratory therapy strategies to prevent or treat these complications. The spirometer is designed to imitate maximum deep inspirations and encourages the patient to take long, deep, slow breathes that increases lung inflation[1]. This promotes increased lung expansion and better gas exchange. When this procedure is repeated on a regular basis, pulmonary complications may be prevented[4].
Objective: To assess the effect of incentive spirometry in improving peak expiratory flow rate in abdominal surgery patients.
There are limited studies that have been done on clinical efficacy of incentive spirometry after abdominal surgery in Indian set up. With this objective in mind this study is planned to evaluate the efficacy of Incentive Spirometry in abdominal surgery patients[3].

Material and Method

This is an experimental study. The study was approved by the ethical committee and faculty of physiotherapy department of Tilak Maharashtra Vidyapeeth, Pune. Forty patients were selected through convenient sampling based on inclusion and exclusion criteria and put into one of the two groups through randomisation. The study was conducted in Pune city, Maharashtra. Patients having any type of abdominal surgery both male and female between the ages of 25-55 were included in this study. Neurological patients or patients below the age 25 or above 55 were not included in the study.

Outcome Measure: Peak Expiratory Flow Rate
Procedure:
Patients posted for abdominal surgery were selected and who fulfilled inclusion and exclusion criteria were included in the group. Patients were divided into two groups of Group A – Diaphragmatic Breathing Exercise and Group B – Incentive Spirometry. There were 20 patients in each group. Detailed assessment was done and written consent was taken. The technique and need of this study was explained to every patient.
Group A- Diaphragmatic Breathing Exercise Group (control group)
Patients in group A were taught Diaphragmatic Breathing Exercise in crook lying position. Patients were asked to take deep breath through their nose and exhale through their mouth. During this procedure they were asked to relax their shoulders and upper chest and then inhale. This technique was repeated for 10 times. Patients were then asked to repeat the procedure 10 times during each waking hour.
Group B- Incentive Spirometry Group
Patients in group B were given Incentive Spirometry in crook lying position. They were asked to seal their lips around the mouth piece and inhale as deeply as they can and hold the inhalation for 3 seconds. This was repeated for 10 times. Patients were asked to repeat the technique 10 times during each waking hour.
Postoperative day 1 and day 5 three PEFR measurements were taken of both the groups and highest of the three measurements were recorded.

Result

Data and statistical analysis were performed by using SPSS Software. The result of this study shows that there is no statistical difference for the values of PEFR on Day 1 after surgery in between Group A and Group B. Whereas, there is significant difference for the values of PEFR on Day 5 between Group A and Group B. The improvement in mean PEFR value for Group A during Day 1 and Day 5 is 26% and improvement in mean PEFR value for Group B during Day 1 and Day 5 is 44%.

Discussion

It is well documented that the functions of the respiratory muscles are affected during and after the abdominal surgery. It has been suggested that respiratory muscles dysfunction may be responsible for a number of pulmonary complications including atelectasis and pneumonia. The site of the operation as well as the type of the operation are the most important factors affecting respiratory muscles[5].
There is significant difference in the values of PEFR on Day 1 and Day 5 in between Group A and Group B. The Incentive Spirometer group shows better result.
Table no.1 and figure 1 and 2 describes the Mean PEFR at day 1 of the Group A which is 91.50 and of the Group B which is 94.00 with a p value of 0.644. The mean PEFR at day 5 of the Group A was 115.50 and of Group B was 135.25 with a p value of 0.009. It also shows the Mean difference of the PEFR of both the group at day 1 and day 5 with Group A with a Mean difference of 24.00 and Group B with 41.25 and the p value being 0.021. Two independent t-test used for both the values. The graph describes that there was no significant difference at day 1 in Group A and Group B but as the treatment progressed there is significant difference in the PEFR of both the groups at day 5.
The findings of our study are consistent with various previous studies by Dr. Sanjeev Kumar Khanna in Indian Journal of Basic and Applied Medical Research, December 2013 Vol-3; Paula Agostini et al in Interactive Cardiovascular and Thoracic Surgery 7; Jackie A Thomas in Physical Therapy Journal of the American Physical Therapy Association which confirm the role of Incentive Spirometer in prevention of postoperative pulmonary complications following abdominal surgeries. Hence, the result of this study are supported by previous studies.
Further Scope: This study can be further extended with large sample size and including other major surgeries that affect the pulmonary function of the patients postoperatively. Further study can be done including different age group patients to differentiate the complication and improvement at different age group.
Limitations:
i.The sample size is small.
ii.Only one outcome measure ie PEFR
iii.Only abdominal surgery patients included.
We suggest that incentive spirometry should be used widely for abdominal surgery patients under the supervision of the physiotherapist.

Conclusion

The conclusion  of this study is that there is a significant difference in the PEFR values of both groups and Incentive Spirometer shows better  result in improving PEFR for abdominal surgery patients.

Clinical Importance

Incentive spirometry is effective in improving peak expiratory flow rate in abdominal surgery patients thus improves pulmonary functions after surgery. It can be used prophylactically to prevent pulmonary complications.

Keywords

Peak Expiratory Flow Rate, Abdominal Surgery, Pulmonary Complications, Diaphragmatic Breathing Exercise, Incentive Spirometry.

Acknowledgement

Author acknowledges Jehangir hospital for support to conduct the study. We extend our gratitude towards patients for their consent and cooperation of the study. We would also like to thank Tilak MaharashtraVidyapeeth for their support in the study.
Funding: This study is not funded or Sponsored by any financial resources.

Bibliography

1. Guimaraes MMF, El Dib R, Smith AF, Matos D. Incentive Spirometry for Prevention of Postoperative Pulmonary Complications in Upper Abdominal Surgery; The Cochrane Collaboration; 2009 Issue 3.
2. Joannel.Thanavaro , Barbara J. Postoperative Pulmonary Complication: Reducing Risks for Non-Cardiac Surgery; Lippincott Nursing Center.com; July 2013; Vol 38.
3. Don D Sin. Postoperative Pulmonary Complication: What Every General Practioner Ought To Know; BCMJ; April 2008; Vol 50.
4. Dr. Sanjeev Khanna; Efficacy of Incentive Spirometer In Improving Pulmonary Functions After Upper Abdominal Surgery; Indian Journal of Basic and Applied Medical Research; Dec 2013; Vol-3; Issue-1.
5. Medical Dictionary; The Free Dictionary By Farlex.
6. Warren G Magnuson; Critical Care Therapy and Respiratory Care Section; National Institute of Health.
7. Lung Expansion Therapy www.ceu.org/cecourses.
8. Ruben D Restrepo, Richard Wettstien, Leo Wittnebell, Michael Tracy; Incentive Spirometry; AARC Clinical Practice Guideline; 2011; Vol 56.
9. Wikipedia, The Free Encyclopedia.
10. Paulo Do Nascimento, Norma SP Modolo, Silvia Andrade; Incentive Spirometry For Prevention of Postoperative Pulmonary Complication In Upper Abdominal Surgery; NCBI; Pub Med; 2013.
11.Freitas ER, Seares BG, Cardoso JR; Incentive Spirometry For Preventing Pulmonary Complication After CABG; Cochrane Database Systemic Review; 2012.
12.Areli Cunha Pinhiero, Michheli Christina Magalhaes Novais, Mansueto Gomes Neto; Estimation of Lung Vital Capacity Before & After CABG Surgery: A Comparison Of Incentive Spirometry and Ventilometry; Journal of Cardiao-Thoracic Surgery; 2011.
13.Celso R.F Carvalho, Denise M Paisani, Adriana C Lunard; Incentive Spirometry In Major Surgeries: A Systemic Review; Brazilian Journal Of Physiotherapy;2011; Vol-15 No-5.
14.Gerald W Smetana; Postoperative Pulmonary Complication-An Update on Risk Assessment and Reduction; Cleveland Clinical Journal Of Medicine; 2009; Vol-76.
15.Paula Agostini, Rachel Calvert, Hariharan Subramanium, Babu Naidu; Is Incentive Spirometry Effective Following Thoracic Surgery; Interactive Cardiovascular And Thorcic Surgery; 2008; Vol-7.
16.Josef Windler, Ralph Thomas Kiefer; The Efficacy of Postoperative Incentive Spirometry Is Influenced By Device Imposed Work Of Breathing; American College of Chest Physicians; 2001; Vol-119, No-6.
17. Tom J Overend, Catherine M Anderson, Deborah Lucy, Christina Bhatia; The Effect Of Incentive Spirometry on Postoperative Pulmonary Complications; American College Of Chest Physicians; 2001; Vol-120.
18. Gosselink R, Schrever K; Incentive Spirometry Does not Enhance Recovery After Thoracic Surgery; US National Library Of Medicine; 2000; Vol-28, Issue 3.
19. Jean M Crowe, Christine A Bradley; The Effectiveness Of Incentive Spirometry With Physical Therapy For High Risks Patients After CABG; Physical Therapy Journal Of American Physical Therapy Association; 1997; Vol-77.
20. John C Hall, Richard Tarala, Julien Harris, Jeff Tapper; Incentive Spirometry Versus Routine Chest Physiotherapy For Prevention Of Pulmonary Complications After Abdominal Surgery; 1991; Vol-337.
21. N M Saifakass, I Mitrouska, D Bouros, D Georgopoulos; Surgery And The Respiratory Muscles; Thorax.bmj.com; 1999; Vol-54.

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PHOTO

Vol 3 | Issue 1 | Jan - Apr 2015 | page:8-10 | Sudeep Kale, Mangla Deshpande.

Author: Sudeep Kale[1], Mangla Deshpande[2].

[1] M.P.Th(Cardio-respiratory Physiotherapy) Terna Physiotherapy College, Sector 12, Nerul (W) Navi Mumbai .
[2] M.P.Th,V.S.P.M. Physiotherapy College, Lata Mangeshkar Hospital, Digdoh hills, Nagpur.
Institute at which research was conducted: Primary & secondary urban & rural schools of Maharashtra.
University Affiliation of Thesis: Maharashtra University of Health Sciences (MUHS), Nashik for Ph.D registration.
Year of Acceptance: 2011.

Address of Correspondence
Dr. Sudeep Kale
M.P.Th(Cardio-respiratory Physiotherapy) Terna Physiotherapy College, Sector 12, Nerul (W) Navi Mumbai.
Email: sudeepkale@gmail.com

 Abstract

Background: PFT is commonly used investigation in order to diagnose respiratory diseases. Computerized PFT machines use   software which consists of prediction equation developed from normal population data. The American Thoracic Society (ATS) has recommended that PFT laboratories should have their own set of prediction equation[12]. In India, prediction equations derived from Caucasian population is commonly used.  Those equations are markedly heterogeneous in terms of ethnic composition & not suitable for Indian population [1, 12]. However, due to unavailability of such prediction equation in Indian children, the western equations are used in software of PFT machine. This study is designed to understand relation of anthropometric parameters & lung function, to establish standard reference data & design best statistical prediction model for 6 -15 years aged 2000 primary & secondary school going children of rural & urban Maharashtra.
Clinical Importance: Normative data for pulmonary function parameters in pediatric population is needed in Indian population. Such data & prediction equations will help to understand a relationship between anthropometric measures like height, weight, BMI & age with 19 PFT parameters. Appropriate prediction equation has to be selected before its use in any population to be tested with PFT for accurate diagnosis & treatment. Already available Caucasian equations have to be validated with advanced statistical tests before using in Indian context. It will help in prevention of misdiagnosis of respiratory conditions in pediatric population.
Future direction: Multicentre studies can be carried out in adults, elderly to derive best prediction equation for lung function for all ages.
Keywords: Lung function, Indian children, prediction equation, reference data.

Introduction

PFT is commonly used investigation in respiratory diseases as it gives reliable information about status of respiratory system.The most important step in diagnosing abnormality of lung function in individuals is to define whether they are within or outside the healthy subjects range. Computerized PFT machines use software which consists of prediction equation developed from normal population. The American Thoracic Society (ATS) has recommended that laboratories should use the published reference equations that most closely describe the populations with a similar ethnic background tested in their labs[12]. Difficulties arise when either the patient population being investigated at a particular centre is markedly heterogeneous in terms of ethnic composition, or when no prediction equations are available for use in the patient population predominantly investigated at a centre [1, 12].
ATS – ERS Task Force appealed worldwide researchers to develop reference values & equation for different population, ethnic groups, and regions [12]. They have recommended equations given by few authors for use in western countries (e.g.: Knudson, Crapo, ECCS, NHANES III etc) [12]. Theses equations are derived from the Caucasian & white population. In India most of the PFT machine manufacturers use these equations in their software. This is purely because of lack of such equations in Indian population[1]. The research to establish reference values & equations for different population is going on in different countries. But on contrary, it remained quite neglected area of research in Indian context.
Physiotherapists are involved in conducting PFTs in most of the hospitals & physiotherapy management completely depends up on diagnosis of patient. In Indian context Physiotherapists, Physicians and even researchers, rely on the results obtained from Caucasian prediction equations incorporated into the software of spirometers. But these Caucasian prediction equations & predicted values results in misinterpretation in significant proportion of patients in India[1]. Hence, these equations are not applicable for Spirometric interpretation in India.[1]
Nomograms predicting the FEV1, FVC, PEFR, and MVV from height, weight are available for western adult & paediatric population. In India, such data is available for North and South Indian adults but not for paediatric population. It is often essential and important to have regional values for predictions in a diverse country like India where diversity exist in culture, ethnicity, socioeconomic status, eating habits [1,8,10,11]. In our country, large number of sources for reference data of PEFR in children exists in the form of prediction regression equations. Most of these studies are from south India i.e. Andhra Pradesh, Tamil Nadu, Karnataka and few studies are from North & East India i.e West Bengal, Delhi, Rajasthan, Punjab, Hariyana, Himachal Pradesh & Kashmir. Most of these studies have included PEFR & not other parameters of PFT. Surprisingly such data is not available in children leaving in Maharashtra.Therefore, it is necessary to have normal pulmonary function data in terms of prediction equations & values for children leaving in Maharashtra so that it will be easy to interpret accurately the pulmonary function changes in Childhood pulmonary diseases. Hence, to prevent misinterpretation, misdiagnosis & wrong categorization of childhood pulmonary disease in clinical practice, we designed this study to throw light on such neglected aspects of pediatric pulmonology research and practice. This study will be first of its kind to investigate 19 parameters of lung function in Indian context in a mixed population of both urban & rural children.

Hypothesis

The lung function is quite well studied in Indian adult population & various researchers designed prediction equation for estimation of the lung function values. However it's not similar situation of Indian children. Most of the times the adult data is extrapolated & used in children. Larger studies, while providing useful preliminary data on the subject, have been pointed out to be biased because of unsubstantiated extrapolation of adult data to children in other diverse geographic regions where differences in nutritional status and racial anthropometric indices could affect the findings Agarwal A.N, Gupta D. et al [1] studied applicability of commonly used Caucasian equation in interpreting spirometry data in India & found that these equations resulted in poor agreement, misinterpretation & bias in Indian population. Charles Rossiter , Hans Weil [2] studied lung function in black African & white European & found that white European have 13.2 % higher lung volumes. They concluded that ethnicity has great impact on pulmonary function. Chatterjee Satipati, Mandal Andita [3] studied pulmonary function in healthy school boys of West Bengal & developed prediction equations. They compaired these values & equation with boys of Delhi, South India & America. They found that west Bengal boys have lower values than Delhi & American boys but more than South Indian boys Dugdale A.E, Moeri Margaret [5] studied FEV1, FVC, and PEFR in Australian children & found that there is strong correlation between anthropometric parameters & pulmonary function. Multiple regression equations are more accurate in predicting lung function than single regression equation. Kashyap S, Puri D.S et.al [8], studied & developed equations for PEFR of healthy tribal children living at high altitudes in Himalaya, Himachal Pradesh & found that these values are greater than values from Western countries Swaminathan S et.al [10] studied PEFR in South Indian children of Dravidian in origin & found that PEFR values correlates strongly with height & also found that South Indian children has lower values than Caucasian but equal to North Indian children Swaminathan Sumati, Diffey Bronwyn et.al [11] evaluated suitability of 18 linear predicted equations for lung function in Indian children & found that equation has to be validated & self tested before using for patient population in India.
The current research aims to derive reference values of lung function, establish a prediction model for lung function, understand relationship between age, height, weight, body surface area, BMI & lung function in children living in Maharashtra. A prospective, observational study with multistage cluster randomized sampling method will be carried out. Clusters will be formed at district, Tehsil, town or village level. Normal healthy children living in Maharashtra aged 6-15 years after their written consents will be recruited in study whereas children with pulmonary, cardiac endocrine disorders, malnourishment will be excluded. Standing Height, weight, age, BMI & body surface area will be documented. After proper demonstration, practice & trials PFT will be performed as per ATS guidelines at BTPS. Best values out of three will be documented for statistical analysis. 19 PFT parameters will be documented for analysis. The data collected will be analyzed using inferential statistics. Range of PFT parameters among studied population will be derived from simple statistics. Mean values of these parameters will be compared with national & international published values. Correlation coefficients will be derived to determine relation between anthropometric measures & PFT parameters. Data will be analyzed by using Pearson product moment correlation tests. Multiple regression analysis will be done by using R statistical software & the best fitted model will be selected as prediction equation.

Discussion

Use of inappropriate references for lung function may lead to erroneous clinical categorization, inaccurate interpretation, which may have consequences for an individual & is certainly important for research. The success of physiotherapy intervention highly depends on precise diagnosis of respiratory patient. When used in Indian patients, Caucasian prediction equation diagnosed Obstructive patients as restrictive & vice versa [1]. In such cases the obstructive patients will be treated on the lines of restrictive condition & will be loaded with inspiratory & lung expansion exercises. This wrong protocol due to wrong diagnosis will aggravate hyperinflation & will impact negatively on patient's health status. So each ethnic group should ideally have its own reference values for better evaluation & comparison. Therefore, it is imperative that ethnic differences in lung function are acknowledged by development and use of appropriate reference values [3-6] [9] [11].

Clinical Importance

Normative data for pulmonary function parameters in pediatric population is needed in Indian population. Such data & prediction equations will help to understand a relationship between anthropometric measures like height, weight, BMI & age with 19 PFT parameters. Appropriate prediction equation has to be selected before its use in any population to be tested with PFT. Already available Caucasian equations have to be validated before using in Indian context. It will help in prevention of misdiagnosis of respiratory conditions in pediatric population.

Future Direction

Multicentre studies can be carried out in adults, elderly to derive best prediction equation for lung function for all ages.

Bibliography

1. Aggarwal A.N,Gupta D. et.al. Applicability of commonly used Caucasian equations for spirometry interpretation in India, Indian Journal of Medical Research, Vol. 122 (2005-153-164).
2. Charles R, Weill Hans et. al., Ethnic differences in lung function: Evidence for proportional differences, Inter.Jurn.of Epidemiology 1974, 3: 55-61.
3. Chatterjee Satpati, Mandal Andita, Pulmonary function studies in healthy school boys of West Bengal, Japanes Journal of Physiology 41:797-808, 1991.
4. Conneett G.J, Quak S.H et.al Lung function reference values in Singaporean children aged 6-18 years, Thorax 1994; 49:901-905.
5. Dugdale A.E, Moeri Margaret Normal Values of Forced Vital Capacity, Forced Expiratory Volume and Peak Flow Rate in Children Arch. Dis. Childh., 1968, 43, 229.
6. Faridi MMA, Gupta Pratibha Lung Functions In Malnourished Children aged Five To Eleven Years, Indian Paediatrics Vol 32, Jan 1995, 35-42
7. Joshi Anuradha , Singh Ratan, Correlation Of Pulmonary Function Tests With Body fat Percentage In Young Individuals Indian J Physiol Pharmacol 2008; 52 (4) : 383–388.
8. Kashyap S, Puri D.S et.al, Peak Expiratory flow rates of healthy tribal children living at high altitudes in the Himalayas, Indian Pediatrics, Vol 29, 283-286
9. Prasad Rajendra ,Verma, S.K. Prediction Model for Peak Expiratory Flow in North Indian Population The Indian Journal of Chest Diseases & Allied Sciences 2006; Vol. 48, 103-106.
10. Swaminathan S, Venkatesan P et.al Peak expiratory flow rate in South Indian children. Indian Pediatrics Vol 30, Feb 1993,207-211
11. Swaminathan Sumati, Diffey Bronwyn et.al, Evaluating the Suitability of Prediction Equations for Lung Function in Indian Children: A Practical Approach Indian Pediatrics Volume 43,Aug 2006, 680-69.
12. Stocks J, Quanjer P, ATS Workshop Report Statement : Reference values for Residual volume, Functional Residual capacity & Total lung capacity, Eur.Resp.Jour.1995,8 492-506.
13. Yarnell JWG, Leger AS et.al Respiratory morbidity and lung function in schoolchildren aged 7 to 11 years in South Wales and the West of England. Thorax 1981;36;842-84.

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Vol 3 | Issue 1 | Jan - Apr 2015 | page:11-14 | Gajanan Bhalerao, Dhanashre Parab.

Author: Gajanan Bhalerao[1], Dhanashre Parab[1].

[1] Department of Neuro-Physiotherapy, Sancheti Healthcare Academy, Pune Maharashtra.
Institute at which research was conducted: Sancheti Institute of Orthopaedics and Rehabilitation.
University Affiliation of Thesis: Research Hypothesis (Synopsis) submitted for MPTh Registration, Dr Dhanashree Parab to Maharashtra University of Health Sciences (MUHS), Nashik.
Year of Acceptance: 2014.

Address of Correspondence
Dr. Gajanan Bhalerao
Department of Neuro-Physiotherapy, Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, 12, Thube Park, Shivaji Nagar, Pune - 411005, Maharashtra.
Email: gajanan_bhalerao@yahoo.com

 Abstract

Background: Ambulation is a complex movement pattern which relates to one's ability to transport oneself in the environment, both on a small (i.e., household) and large (i.e., community) scale. Patients who have had a cerebrovascular accident (CVA) present with disruptions to many physiologic systems, leading to multiple disabilities out of which walking is most commonly affected. About 52% to 85% of hemiplegics regain the capacity to walk, but their gait differs from that of the healthy subjects. Hemiplegic gait is characterised by gait deviations and alterations in gait parameters. Motor Relearning Programme (MRP) is a safe and evidence based treatment technique which can be used to improve hemiplegic gait cycle. Increasing the length of unaffected leg by shoe-raise of 1 cm will help in foot clearance of affected leg .In -turn reducing the effort of walking and the circumduction pattern of gait Hence, to find out the use of shoe raise on uninvolved leg along with motor relearning program to improve gait parameters and gait deviations of the affected gait cycle, is a need of time in neuro rehabilitation.Present study is a Randomised Single Blinded Control Trial enrolling 30 (15 per group) chronic stroke patients subjected to Motor Relearning Programme (MRP) (Group A) and combination of MRP and shoe raise on uninvolved leg (Group B) for 1 hr/day for 6 days/wk for a period of four weeks.
Hypothesis: It is hypothesised that combined use of shoe raise on uninvolved leg with MRP is more effective in improving the gait parameters and reducing gait deviations compared to MRP alone.
Clinical Importance: Use of shoe raise in gait training will be helpful in reducing the difficulty of foot clearance, more energy expenditure and assist in symmetrical weight bearing. So use of shoes raise can be a good adjunct in initial period of gait training.
Future direction: Along with the gait parameters there is a need for studying the effects of combination of shoe raise of 1 cm on uninvolved leg with MRP on kinematic parameters post-stroke.
Keywords: Shoe-raise, motor relearning programme, hemiplegia, ambulation.

Introduction

Ambulation is a complex movement pattern which relates to one's ability to transport oneself in the environment, both on a small (i.e., household) and large (i.e., community) scale.[ 1,2] Patients who have had a cerebrovascular accident (CVA) present with disruptions to many physiologic systems, leading to multiple disabilities out of which walking is most commonly affected.About 52% to 85% of hemiplegics regain the capacity to walk, but their gait differs from that of the healthy subjects[3]. Hemiplegic gait is characterised by gait deviations and alterations in gait parameters. The parameters which are affected are reduced gait velocity, step length, stride length and cadence[4]. The stroke patients present with lower extremity extensor synergy with equinovarus positioning of foot and ankle complex, sustained knee and hip extension, pelvic retraction and reduced weight bearing symmetry on involved side. Owing to the above mentioned factors the patient is not able to do the required hip-knee-ankle flexion while walking; this leads to the lengthening of affected lower extremity. Thus giving rise to a circumduction gait[5,.6]. Based on Dynamic System's theory of Motor Control concepts, different task specific training approaches for Stroke have evolved such as Motor Relearning Program (MRP), Sensory Integration, Robotic Therapy, Mental Imagery, Virtual Reality, and Body Weight Supported Treadmill Training and Neuro-developmental Treatment. Despite the evolution of these task specific approaches, in India many physical therapists tend tocommonly practice and teach the traditional approaches likeRoods Approach; Brunnstrom Approach, Proprioceptive Neuromuscular Facilitatory Techniques(PNF) ,Bobath Approach and strength training[7]. Current rehabilitation approaches in stroke rehabilitation are shifting trends and task specific training is gaining importance amongst the neuro-physical therapists. Studies have been conducted to show that MRP shows significant improvement in functional recovery, ambulation and motor function, balance and quality of life usually in acute and sub-acute stroke patients[8,9,10]. Aruin et al studied the immediate effect of shoe lifts on static balance and weight bearing symmetry, ranging from 0.6 to1.2 cm with more symmetrical weight distribution with increase in the size of lifts[11]. Compelled Body Weight Shift Therapy (CBWST) is defined asprolonged lift of the unaffected lower extremity through the use of shoe insert which forces loading of bodyweight towards the affected lower extremity during treatment and daily activities, thus helping in overcoming learned disuse of affected lower limb. Jeba Chitra et al evaluated the effect of CBWST along with conventional physiotherapy for 2 weeks on weight bearing symmetry and on the Berg Balance Scale components in post stroke patients[15]. There is a dearth of literature about the long term effects of using shoe raise on uninvolved leg on gait parameters and gait deviations in stroke subjects.Hence, to find out the use of shoe raise on uninvolved leg along with motor relearning program to improve gait parameters and gait deviations of the affected gait cycle, is a need of time in neuro rehabilitation.

Hypothesis

MRP is a therapeutic approach which was developed based on Motor learning theory by Card and Shepherd. To enhance the relearning post-stroke, the motor task involved is practiced within a context that can be a task or environment specific with active participation of subjects[16]. Additionally by increasing the length of uninvolved lower extremity with shoe raise of 1 cm will help to reduce the effort of walking by mechanically correcting joint position and limb length discrepancy, thus promoting foot clearance of affected lower extremity[15]. Thus, it becomes necessary to introduce and evaluate the combined effect of MRP and shoe raise on uninvolved leg on Hemiplegic gait. Hence, it is hypothesised that effect of use of shoe raise on uninvolved leg along with MRP is more effective in improving the gait parameters and gait deviations compared to MRP alone. The present study is a Randomised Control Trial. Thirty stroke patients will be recruited from Tertiary Health Care Centre located in Pune, India. The participants will be screened using the following inclusion criteria: chronic patients with first time stroke, both male and female, FAC score more than 2, ambulatory with or without device for at least 10 meters, with or without AFO or cane or any such orthosis. Patients with unstable medical conditions, history of other neurological diseases and fixed contracture or deformities will be excluded from the study. Patients will be randomly allocated in two group using block randomization. Group A, 15 subjects will receive Motor Relearning Programme (MRP) (Carr and Shepherd, 1987) and Group B, 15 subjects will receive MRP along shoe raise of 1 cm on uninvolved leg. Both the groups will receive treatment for 1 hr/day for 6 days/wk for a period of four weeks. All the procedure was approved by the Institutional Ethics Committee on Human Research and conducted in conformity with ethical and principles of research. Pre and post the treatment protocol the subjects will be assessed for gait parameters such as step length, stride length, speed, cadence, angle of toe-out using foot-print method , additionally gait deviations will also be assessed using Rivermaid Visual Gait Analysis (RVGA) Scale[17,18].
Group A:
The patients in this group will receive MRP.
There are 4 steps in MRP.
1. Identification of missing performance components
2. Training of missing components
3. Practice of walking
4. Transfer of skills to functional task performance
Group B:
Shoe raise of 1cm on uninvolved leg while ambulating with or without assistive device along with MRP will be given to all subjects in this group. The patients will also wear the shoe raise daily during all the activities of daily living. Shoe to be used in the experiment will be a pair of floaters. A raise with height of 1 cm will be prepared according to the shoe base shape. All the cutting, pasting work will be done at workshop for prosthesis an orthotics at Sancheti hospital.
Paired t- test shall be used for intra-group assessment of gait parameters. Unpaired t- test shall be used for inter-group assessment of gait parameters .Mann Whitney U Test shall be used for intra-group assessment of the gait deviations using the RVGA scale .Wilcoxon matched pair shall be used for intra-group assessment of the gait deviations using the RVGA scale.

Discussion

Gait problem is evident in most of stroke patients, often making them dependent in their day to day activities[1,2,3]. Previous studies concluded that MRP shows significant improvement in functional recovery, ambulation and motor function, balance and quality of life usually in acute and sub-acute stroke patients. Thus MRP is a safe and evidence based treatment technique which can be used to improve hemiplegic gait cycle[16]. Aruin et al studied the immediate effect of shoe lifts on static balance and weight bearing symmetry, ranging from 0.6 to1.2 cm with more symmetrical weight distribution with increase in the size of lifts[11]. Compelled Body Weight Shift Therapy (CBWST) is defined as prolonged lift of the unaffected lower extremity through the use of shoe insert which forces loading of bodyweight towards the affected lower extremity during treatment and daily activities, thus helping in overcoming learned disuse of affected lower limb. Jeba Chitra et al evaluated the effect of CBWST along with conventional physiotherapy for 2 weeks on weight bearing symmetry and on the Berg Balance Scale components in post stroke patients[15]. This weight shift on affected side during walking will improve the motor control in stance phase. The subjects with hemiplegia will bear equal weight on bilateral lower extremities which will correct the asymmetry and improve balance. Due to extensor synergy seen in affected leg the stroke participants are not able to perform desired hip-knee-ankle flexion while walking, leading to lengthening of affected leg during swing phase. Thus while walking the subjects perform various gait deviations inorder to achieve foot clearance of affected leg, i.e. circumduction. Treatment of this can be, improving the hip and knee control in swing phase or increasing the length of unaffected leg by shoe-raise of 1 cm helping in foot clearance of affected leg .In -turn reducing the effort of walking and circumduction pattern of gait[5]. Hence, the study hypothesis states that the combination of shoe raise on uninvolved leg along with motor relearning programme will improve the gait parameters and reduce the gait deviations of the affected gait cycle.

Clinical Importance

Use of shoe raise in gait training will be helpful in reducing the difficulty of foot clearance, more energy expenditure and assist in symmetrical weight bearing. So use of shoes raise can be good adjunct in initial period of gait training.

Future Direction

Along with the gait parameters there is a need for studying the effects of combination of shoe raise of 1 cm on uninvolved leg with MRP on kinematic parameters post-stroke.

Bibliography

1.Duck-Woh Oh, Int J Phys Med Rehabil Community
Ambulation: Clinical Criteria for Therapists' Reasoning and Decision-making in Stroke Rehabilitation2013, 1:4.
2.Perry J, GarretM, GronleyJK, Mulroy ST Classification of walking handicap in stroke population Stoke, 1995, June; 26(6): 982-989.
3.Burdett RG,Borello France D, BlatchyC,PoptterC. Gait comparison off subjects with hemiplegia walking unbracedwith ankle foot orthosis and air–stirupbrace, PhysTher 1988; 68.
4.Hendriks HT, Vav Limber J, GeursAC, Zwarts MJ Motor recovery after stroke, Archives Physical Medicine and Rehabilitation;83:1629-37.
5.Susan Ryeuron Functional Movement and re-education, second edition;441-442.
6.Patricia M Dawies Right in the middle, Selective trunk activity in treatment of adult hemiplegia, 2003; Springer, 33, 34, 53, 54, 169-193.
7.Davidson I,Waters K Physiotherapists working with stroke patients : A national survey Physiotherapy 86 269-8.
8.Langhammer B, Stanghella JK Bobath or Motor Relearning Programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: a randomized controlled study, Clinical Rehabilitaion 2000;14:361-369.
9.Langhammer B, Stanghella JK. Bobath or Motor Relearning Programme? A follow-up one and four years post stroke Clinical Rehabilitation,2003;17.
10.Bhalerao G,Kulkarni V, Doshi C, Rairikar S, Shyam A, Sancheti P. Comparison of MRP vs Bobath Approach at every 2 weeks interval for improving Activities of daily living and Ambulation in Stroke Rehabilitation, Int J of Basic and Applied Medical Sciences 2013;3:3.
11.Aruin AS, Hanke T, Chaudhari G, Harvey R, Rao N Compelled weight bearing in persons with hemiparesis following stroke :The effect of a lift insert and goal directed balance exercises,J of Rehabilitation Research and Development;37:1.
12.Rodriguer GM, Aruin AS. The effect of shoe wedges and lifts on symmetry of stance and weight bearing in hemiparetic individuals, Arch Phys Med Rehabil 2002;83.
13.Mohapatra S, Evioto AC, Ringquist KL, Muthukrishnan SR, Aruin A. Compelled Body Weight Shift Technique to facilitate rehabilitation of individuals with acute stroke,Int Scholarly Research Network Rehabil 2012;10.
14.Chaudhari S, Aruin SA. The effect of shoe lifts on static and dynamic postural control in individuals with hemiparesis, Arch Phys Med Rehabil 2000;81.
15.Jeba C, Mishra S. Effect of Compelled Body Weight Shift Technique on weight bearingsymmetry and balance in post stroke patients: An experimental Pre-Post study, Int J Physiother 2014;2:6.
16.Carr JH, Shepherd RB. A Motor Relearning Programme for stroke ,Aspen Publishers,2nd edition 1987.
17.Zverev Y, Adeloye A, Chisi J. Quantitative analysis of gait pattern in hemiplegic patients ,East African Medical Journal 2002;79:8
18.Lord SE, Halligan PW, Wade DT.Visual gait analysis: the development of a clinical assessment and scale,Clinical Rehabilitation 1998;12.

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Vol 3 | Issue 1 | Jan - Apr 2015 | page:31-37 | Yash Kishore Shah, M L  Saraf.

Author: Yash Kishore Shah[1], M.L. Saraf [1].

[1] Bombay Hospital Institute of Medical Sciences, Mumbai.
Institute at which research was conducted: Bombay Hospital Institute of Medical Sciences, Mumbai.
University Affiliation of Thesis: Maharashtra University of Health Sciences, Nashik, Maharashtra.
Year of Acceptance: 2012.

Address of Correspondence
Dr. Yash Kishore Shah,
Orthopaedic Consultant, Matruseva Hospital, 407/5(OLD) 665(NEW) Nana Peth, Quarter Gate, Pune 411002.
Email: dr.yashshah@gmail.com

 Abstract

Background: Rotator cuff tears are a common source of shoulder pain. The incidence of rotator cuff damage increases with age and is most frequently d/t degeneration of the tendon, rather than injury.
Methodology: 15 patients chosen having rotator cuff injuries and undergone conservative therapies and 15 patients chosen undergone operative management for the rotator cuff tear after failed conservative management.
Patients were assessed w.r.t
i.Range of Motion
ii.ADL (Activities of Daily Life) Affection
iii.Night pains
iv.Constant score
v.Tear size
Result and Conclusions: The incidence of rotator cuff damage increases with age and is most frequently due to degeneration of the tendon, rather than injury . Supraspinatus is one of the most consistently involved. Some tears are asymptomatic. Higher incidence of tears were seen in females than in males. Tear size has no relation in the final outcome of range of motion and pain scores. The indications for operative treatment are presence of bursitis, young age, large tear size. And for non operative treatment are presence of fatty degeneration and/ or muscle atrophy.
Keywords: Rotator cuff, supraspinatus tear.
Thesis Question: Is non –operative treatment just as good as operative treatment for rotator cuff injuries and whether all people need operative treatment?
Thesis Answer: Thus the mandatory indications for operative treatment are presence of bursitis, young age, large tear size. The mandatory indications of non operative treatment are presence of fatty degeneration and/ or muscle atrophy. Otherwise all cases must be tackled initially non operatively.

Introduction

Rotator cuff tears are a common source of shoulder pain. The incidence of rotator cuff damage increases with age and is most frequently due to degeneration of the tendon, rather than injury from sports or trauma. Treatment recommendations vary from rehabilitation to surgical repair of the torn tendon(s). The best method of treatment is different for every patient. The decision on how to treat rotator cuff tears is based on the patient's severity of symptoms and functional requirements, and presence of other illnesses that may complicate treatment.

Aims and Objectives

Rotator cuff tears are a common problem of the aged and often neglected in the earlier phases, but with better imaging and health care more and more cases are being seen.
1. To study the natural history and prognosticate the end result of disease with or without operative treatment
2. Further to see whether the natural history can be altered for the better using non operative or operative treatment.
3. To compare the results of operative vs non operative treatment
4. For the future to establish guidelines for treatment purposes, to discuss absolute and relative indications of treatment and to streamline the need for operative treatment and earmark the point of time when such treatment should be instituted.

Material and Method

Design: An observational study; prospective study; retrospective study
Sample size: - 15/15
In this study 15 patients were selected having rotator cuff injuries and undergone conservative therapies and 15 patients were selected having undergone operative management for the rotator cuff tear after having failed the conservative management.
All patients were assessed with respect to
I. Range of Motion
ii. ADL (Activities of Daily Life) Affection
iii. Night pains
iv. Constant score (which includes pain, activities of daily living, range of motion and power.)
v. Tears whether small/medium/large and whether full thickness/partial thickness
The patients had a pre-op USG and/or MRI done.
Definition of the subject to be studied
Inclusion criteria
a) Rotator cuff tears proven on imaging
b) Symptomatic patients who have failed conservative management will be included in the second group i.e. for operative treatment.
c) High Constant scores
Exclusion criteria
a) Concomitant plexus injuries along with cuff tears
b) Previous steroid injection with sepsis
Parameters studied
a) Range of movement
b) ADL (Activities of Daily Life) affection.
c) Night pains
d) Constant score
Duration of follow up
1-3 years
DATA AND RESULTS
Constant score of Group 1. (Operative treatment)
Mean constant score improvement in Operative group = 26.66
Constant score of Group 2. (Conservative treatment)
Mean constant score improvement in Conservative group=28.13
Night pains and A.D.L. (Activities of Daily living) in operative group
Mean improvement in night pain in conservative group is 33.33%
Night pains and A.D.L. (Activities of Daily living) in operative group
Mean improvement in night pain in operative group is 31.7%
Mean minimum time taken for complete pain relief for operative group is 97.46 days
Mean minimum time taken for complete pain relief for conservative group is 95.00 days
The TEAR SIZE has NO RELATION to outcome whatsoever.

Summary and Conclusions

1. Rotator cuff tears are a common source of shoulder pain. . The incidence increases with age and is more due to degeneration than injury.
2. Supraspinatus is one of the most consistently involved in the tears.
3. Higher incidence of tears were seen in females.
4. Tear size = no relation in outcome
5. It is essential to identify whether the patients will do better by surgery or not.
6. The time to complete recovery will be also be prolonged depending upon the pathology involved.
7. Bursitis or Bicipital tendinitis when present are bad prognostic factors.
8. Thus the factors affecting outcome are Bursitis, Fatty degeneration, Muscle atrophy, Original tear and age.
9. An average re- tear rate post surgery is 13% & is related to initial tear size.
10. Conservatively managed cases generally tend to become symptomatic in 5 years
11. In late cases surgery does more relief by decompression buy it may increase the chances of a re-rupture.

Bibliography

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Vol 3 | Issue 1 | Jan - Apr 2015 | page:23-30 | Udit Chauhan, Ravi Shanker Solanki, Alok Kumar Udiya, Gurucharan S Shetty, M K Narula.

Author: Udit Chauhan[1], Ravi Shanker Solanki[1], Alok Kumar Udiya[1], Gurucharan S Shetty[1], M K Narula[1].

[1] Lady Hardinge Medical College, University of Delhi.
Institute at which research was conducted: Lady Hardinge Medical College,New Delhi.
University Affiliation of Thesis: University of Delhi.
Year of Acceptance: 2013.

Address of Correspondence
Dr. Udit Chauhan
31 B, Pusa Road ,Opposite Metro Pillar 121,
110005, Delhi.
Email: dr.udit.chauhan@gmail.com

 Abstract

The study was aimed to evaluate the features of various hepatic masses using triple phase multidetector computed tomography and to correlate features of triple phase multidetector computed tomography with clinical and cytohistopathology/operative findings. Technique of the triple phase was individualised as per the case with the application of empirical delay technique for timing the scan delay. Authors found the modality to be highly accurate for detection and characterisation of hepatic masses in addition to be able to provide significant information for the planning and management of the disease.

Introduction

Liver is a important constituent of the digestive tract and is involved in maintenance of the body's metabolic homeostasis. Because of its major function of detoxification of body and its rich blood supply by hepatic artery and portal vein, it becomes prone to various diseases including benign, malignant and metastases.

Material and Method

PLACE OF STUDY
The study is proposed to be conducted in the department of radiodiagnosis,Lady Hardinge Medical College and Associated Smt Sucheta Kriplani and Kalawati Saran Children Hospital ,New Delhi in close association with Department of Surgery .
STUDY PERIOD
The study period will be from November 2010 to March 2012.
STUDY POPULATION
The study will comprise of patients with hepatic masses on basis of cilinical findings or on ultrasonography.A minimum of 30 patients will be included in the study.

STUDY METHOD
Each patient included in the study after obtaining an informed consent ,will be subjected to a detailed history ,clinical examination and diagnostic work up plan. Plain X-ray abdomen ,routine Hb%,TLC DLC,ESR and liver function tests,renal function tests would be done in all patients.
PlainCT will be followed by triple phase contrast ct using iodinated water soluble contrast media. Technique of triple phase will be individualized as per the case.

Result and Discussion

Out of 60 patients referred from various clinical departments a total of 15 patients were excluded.8 patients were excluded as USG features suggested abscess, 4 patients had USG features suggestive of hydatid cyst, 2 patients had USG features suggestive of simple cyst of liver and 1 patient suspected of HCC was lost to follow up and FNAC could not be performed. Therefore a total of 45 cases were included in the study. Out of 45 cases there were a total of 4 benign and 41 malignant masses. Of the 4 benign cases there were 3 hemangioma and 1 infantile hemangioendothelioma. Of the malignant masses, 16 cases were of metastases, 14 cases were CA GB with hepatic infiltration, 5 cases were of HCC and 3 each were hepatoblastoma and cholangiocarcinoma.
Maximum number of cases were in the age group of 41-50yrs (24.44%) and 55.56% were females.
Metastases were seen in 16 of the total of 45 cases (35.56%) and was single largest group.Ca GB with hepatic infiltration was the second largest group (14 cases) comprising 31.11%. Most common symptom in the cases presenting with hepatic masses was pain abdomen (71.11%) with weight loss being the second most common symptom (68.88%). Most common sign was lump RHC /hepatomegaly (62.22%). Most common abnormality in LFT was elevated alkaline phosphatase (46.67%).
Out of the total of 4 benign lesions, 3(75%) were correctly diagnosed on US. All the lesions were correctly diagnosed on CT. Out of 41 malignant lesions, 39 (95.12%) were correctly diagnosed on USG and 2 cases (4.88%) were misdiagnosed. Triple phase CT was able to correctly diagnose 40 malignant lesions (97.56%) and misdiagnosed 1 lesion (2.44%).
HEMANGIOMA (n=3): All the 3 cases of haemangioma in our study were females. Two of the cases were in the age group of 51-60yr and one was 33yrs old. All the lesions were hyperechoic in echogenecity and were single in number (100%). 2 lesions (66.67%) had well defined margins and one had ill defined margins (33.34%). All the lesions (100%) were hypo dense on plain scan and showed early discontinuous peripheral enhancement in arterial phase with progressive centripetal filling in the delayed phase.
INFANTILE HEMANGIOENDOTHELIOMA (n=1): This was a case of 10mth old male child who was referred with clinical suspicion of hepatoblastoma. Case had pallor, lump and tenderness right hypochondrium, laboratory investigations were normal except for anaemia. On USG multiple well defined lesions were seen in both lobes and were heterogeneous with predominantly hyperechoic character. The lesions showed arterial flow pattern on Doppler examination.On triple phase CT the lesions were multiple, seen in both the lobes with largest lesion of app. 5cmx4.5cm size. The lesions were hyper dense on plain scan with early and discontinuous peripheral enhancement on arterial phase and progressive centripetal fill in on delayed phase. Additionally there was narrowing in calibre of infra celiac aorta.
HEPATOCELLULAR CARCINOMA (n=5): There were 5 cases of HCC in the study and all of them were correctly clinically suspected based on the clinical features and elevated levels of AFP in all the cases. 4 cases were in the age group of 40-70yrs and 1 case was 29yr old. All the cases were males. In our study all the cases had pain abdomen (100%) as the presenting feature, 4 cases had abdominal distension (80%). Lesions were multiple in all the cases (100%). There was bilateral lobe predominance (80%) with well defined margins of the lesions in 80% of cases. 60% cases had heterogeneous predominantly hyperechoic lesions, 20% of the cases had heterogeneous predominantly hypoechoic lesions and 20%had hyperechoic lesion with hypoechoic capsule. All the cases had cirrhosis and ascites (100%). All the lesions (100%) were hypodense on NCCT and showed early enhancement in arterial phase with persistent enhancement in portovenous inflow phase and washout in portovenous phase. Tumoral vessels were seen in 4 cases (80%) and 2 cases (20%) showed presence of arterioportal shunts. All the cases had portal vein thrombosis (100%). IVC thrombus and hepatic vein thrombus was seen in 2 (40%) cases each. 4 cases were in stage IIIa (80%), and one (20%) case was in stage IIIc.
HEPATOBLASTOMA (n=3): Of the 3 cases in the study 2 were males and one was female. One patient was 7yr old and the other two were 2yrs old each. AFP was elevated in all the cases (100%). Abdominal X-ray was done all the cases which revealed hepatomegaly. Lesions were seen in right lobe and were single in all the cases (100%). Lesions were well defined in two cases (66%) and ill defined in one case. In 2 cases the lesions were heteroechoic and hypoechoic in one of the cases. Calcification was seen in one case. One case had ascites (33%). Two lesions were hypodense on NCCT (33%) while one was heterogeneous. Only one of the lesions showed calcification. One of the lesions showed enhancement in arterial phase with evidence of washout in portovenous phase (early washout). The other two cases enhanced in portovenous inflow and portovenous phase with no evidence of early washout rather they showed persistent enhancement.
CHOLANGIOCARCINOMA (n=3): Of all the cases with cholangiocarcinoma 2 were females (66.67%) and were in the age group of 40-50yrs. One of the case was male (33.34%) of 71yr age. All the cases had jaundice and hyperbilirubinemia at presentation (100%). All the cases had single lesion (100%) in right lobe (100%), with well defined margins (100%). All the lesions were hypoechoic and were associated with IHBRD (100%). Gall bladder was distended in 2 cases (66.67%) and these 2 cases had calculus also (66.67%). In none of the cases primary confluence was patent. One (33.34%) case had lymph node enlargement and 2 cases (66.67%) had ascites. All the lesions were isodense on NCCT and showed no enhancement in arterial and porto venous inflow/late arterial phase but were enhanced in delayed phase (100%).
METASTASES (n=16): Metastases were seen in 16 of the total of 45 cases (35.56%) and was the largest number among the group, majority of these cases were in the age group of 61-70y (25%). Weight loss was most common symptom (87.5%). The lesions were multiple (87.5%), distributed in both the lobes (81.25%) and had well defined margins (93.75%) in most of the cases. Most common character was hyperechoic (37.5%) followed by target appearing (31.25%). 1 case had anechoic cystic character. Lymphnodes were enlarged in 7 cases (43.75%). In 87.5% of the cases lesions were multiple and were well defined in 100% of the cases. 93.75% of the cases showed hypodense lesions on NCCT. 7 cases (43.75%) showed enhancement in the arterial phase while 3 cases each (18.75%) showed enhancement in portovenous inflow and portovenous phase.3 cases did not enhance in any of the phases(18.75%). 2 cases showed washout (12.5%) while 7 cases (43.75%) showed persistent enhancement. There were 2 cases of Ca larynx in the age group of 50-60yrs .Both were males. One case had single lesion in right lobe with ill-defined margins and hyperechoic character. This lesion was hyperdense on NCCT and showed early enhancement in arterial phase with persistent enhancement in portovenous phase and did not show early washout. Second case had multiple lesions in both the lobes target type in character. The lesions in this case were hypodense on NCCT and showed early enhancement in arterial phase with no evidence of early washout. One case had CA rectum (35Y/F) with bilateral ovarian metastases, ascites and rectovaginal fistula. The lesions were multiple in both the lobes with target appearance on USG and hypodense on NCCT. The lesions showed no enhancement throughout the arterial and portovenous inflow/ late arterial phase with only peripheral enhancement in portovenous phase. There were two cases of adenocarcinoma lung and both had multiple well defined target like lesions in both the lobes on USG. Neither of the case showed enhancement in arterial phase but showed enhancement in portovenous inflow/late arterial and portovenous phase. There were two cases of RCC with metastases to liver. Lesions were single in one case and multiple in another with hyperechoic character. Both the cases had hypodense lesions on NCCT with one case showing early arterial enhancement and early washout while other showed enhancement in portovenous inflow phase. There was a case of 59Y/M that had Ca oesophagus. Lesions were multiple, bilateral and well defined with hyperechoic character on USG. The lesions were hypodense on NCCT with early arterial enhancement and no early washout. There were 2 cases of malignancy of anal canal. One was 65Y/F who had multiple hyperechoic lesions on USG. The lesions were hypodense on NCCT with early peripheral enhancement on arterial phase and persistent enhancement through the portovenous inflow and portovenous phase. Other was a 30Y/M diagnosed with malignant melanoma of anal canal. This patient had multiple anechoic lesions which were hypodense on NCCT showing no enhancement on any phase. A case of 65Y/F that had CA breast with multiple hypoechoic lesions on USG. The lesions were hypodense on NCCT with no enhancement on any of the phases. A case of 35Y/F with bulky ovaries and elevated CA-125 levels was diagnosed CA ovary. There were multiple metastases to spleen, liver and omentum. There were multiple well defined hypoechoic lesions on USG. The lesions were hypodense on NCCT and did not show enhancement on any of the phases. A case of 42Y/M who had illeal thickening and multiple target like lesions on USG was diagnosed as small bowel malignancy on USG. On NCCT the lesions were hypodense and enhanced only on portovenous phase. A 25Y/F with periampullary carcinoma had multiple hypoechoic lesions in both the lobes of liver which were hypodense on NCCT and showed early peripheral enhancement on arterial phase with persistent enhancement on portovenous inflow and portovenous phase with no early washout
CARCINOMA GALL BLADDER WITH HEPATIC INFILTRATION (n=14): There were total 14 cases of Ca gall bladder with hepatic infiltration. Majority of the cases (57.14%) were in the age group of 41-50yrs. All the cases were females except for 3 males (21.42%). Most common abnormality in the gall bladder was irregular asymmetric thickening of the wall predominantly in the region of neck and body (35.71%). Mass replacing the GB fossa was seen in 4 cases out of 14(28.57%). Lesions in liver were single and in right lobe in 13 cases (92.85%). These lesions were predominantly hyperechoic (78.57%). 5 cases had involvement of porta hepatis(35.71%). Non contiguous involvement of liver was seen in 1 case (7.14%). On triple phase CT most of the lesions show early enhancement in arterial phase (57.14%). 1 case did not show any enhancement in any of the phases. Only one case showed early washout while 12 cases showed persistent enhancement (87.71%). 11 cases showed lymphnode enlargement in the peripancreatic and periportal region on CT and 4 had pyloroduodenal involvement (28.57%).
Overall the diagnostic accuracy of USG was 93.33% and that of triple phase CT was 97.78%.

Conclusion and Recommendation

Ultrasonography is a useful screening modality for hepatic masses with a diagnostic accuracy of 93.33%. So all the patients with the clinical suspicion of hepatic masses should be subjected to ultrasonography for initial detection and localisation of lesion.
·Triple phase MDCT is excellent for the characterisation of hepatic masses with a diagnostic accuracy of 97.78%.
·Metastases are the most common hepatic malignancy (35.56%) and are far more common than primary causes like HCC (11.11%).
·Amongst the benign lesions the most common is hemangioma (6.67%).
·MDCT with its short scanning times (single breath hold) is ideal for imaging in sick patients and pediatric age group.
·Triple phase MDCT is ideal for diagnosis of benign conditions like hemangioma and infantile hemangioendothelioma.
·Triple phase MDCT with its arterial, portovenous inflow (late arterial) and portovenous phases is an ideal modality for diagnosis and characterisation of HCC. It is helpful to provide additional information like vascular invasion, capsular delineation, arterioportal shunts and also provide a vascular road map for surgery and image guided interventions. Thereby having a promising role in management also.
·Pediatric malignant tumors like hepatoblastoma are diagnosed and managed with help of important information provided by triple phase MDCT. Vascular and tumor anatomical details are helpful to plan for neoadjuvant chemotherapy and surgical or image guided interventions.
·Cholangiocarcinoma is diagnosed in delayed phase images acquired during triple phase MDCT protocol. Vascular and biliary tract anatomical details provided by MIP and MinIP images are helpful in planning management.
·Metastases could be differentiated as hyper or hypovascular type based on triple phase CT characteristics. This further helps to define primary lesion. Information derived by various phases can help in planning image guided interventions.
Carcinoma gall bladder is usually detected at advanced stage. In these cases vascular and biliary anatomy and involvement of adjacent structure help in planning the management. These details are enhanced by the use of MPR, MIP and MinIP images..

Future Direction

To find out the beneficial effects on sports persons performance, lumbar core stability exercises could be given for a longer duration.

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Vol 3 | Issue 1 | Jan - Apr 2015 | page:4-7 | Priyanka Panchal, Nilima S Bedekar.

Author: Priyanka Panchal[1], Nilima S Bedekar[1].

 Priyanka Panchal[1], Nilima S Bedekar[1].

[1] Department of Musculoskeletal Physiotherapy, Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, Thube Park, Shivaji Nagar, Pune, Maharashtra, India.
Institute at which research was conducted: Sancheti Institute of Orthopaedics and Rehabilitation.
University Affiliation of Thesis: Research Hypothesis (Synopsis) submitted for MPTh Registration to Maharashtra University of Health Sciences (MUHS), Nashik.
Year of Acceptance: 2014.

Address of Correspondence
Dr. Nilima S Bedekar
Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, 12, Thube Park, Shivaji Nagar, Pune - 411005, Maharashtra.
Email: nilimabedekar@yahoo.com

 Abstract

Background: Anterior Cruciate Ligament (ACL) is the most commonly injured ligament of the knee joint. Injuries to the ACL are common in sports activities like football, basketball etc. which involves twisting or pivoting movements of the knee as well as in road traffic accidents and falls. The ACL injuries can be managed conservatively or operatively. The surgical management can be open or arthroscopic reconstruction. Core stability or strengthening is now an integral part of fitness and rehabilitation. A clear relationship exists between the trunk muscle activity and lower extremity movement. The trunk muscle activity maintains the integrity of the spinal column and forms a stable base for movement of the extremities resulting in proper force distribution and maximum force generation with minimal compressive, translational, or shearing forces at the joints of the kinetic chain. To accelerate recovery, core exercises should be made an integral part of ACL rehabilitation. Thus the study objective is to study the effectiveness of lumbar core stability exercises on knee pain, range of motion and function in ACL reconstruction (ACLR) population aged between 20-40 years by a prospective randomized control trial on 60 participants (30 per group) subjected to a control group (Group A) and an experimental group (Group B) for four weeks.
Hypothesis: ACL-R rehabilitation programme if clubbed with lumbar core stability exercises would give a better functional outcome as compared to the rehabilitation programme alone.
Clinical Importance: Adding lumbar core stability exercises to the ACLR rehabilitation programme would result in early recovery of this population in terms of returning back to routine or sports activities.
Future direction: To find out the beneficial effects on sports persons performance, lumbar core stability exercises could be given for a longer duration.
Keywords: Core stability, ACL Reconstruction, Function.

Introduction

ACL is the most commonly injured ligament of the knee joint [1]. Injuries to the ACL are not uncommon in sports activities like football, basketball etc. which involves twisting or pivoting movements of the knee [1-3]. Athletic population in the age group of 20-40 years is prone to such injuries [4]. Damage to ACL and related structures would lead to pain, instability, swelling, difficulty in climbing stairs, squatting, walking etc [1, 3, 4]. The ACL injuries can be managed conservatively or operatively. The surgical management can be open or arthroscopic reconstruction [3-5]. Rehabilitation post surgical intervention helps in reducing the pain, swelling, stiffness, instability and also to regain the strength and normal functional activities [4]. Many studies on use of post operative bracing, accelerated strengthening of the muscles, home based rehabilitation program and neuromuscular training have been conducted [6]. According to Wilk K. et al rehabilitation process should be­gin immediately following ACL injury, with emphasis on reducing swelling and inflammation, regaining quadriceps control, allowing immediate weight bearing, restoring full passive knee extension, and gradually restoring flexion focusing on prevention of several postoperative com­plications, such as loss of motion, patello-­femoral pain, graft failure, and muscular weakness [7]. Rehabilitation pro­grams aimed to restore full, unre­stricted function and to assist the patient to return to 100% of the pre-injury level while achieving excellent long-term out­comes [7].
Core stability or strengthening is now an integral part of almost all fitness and rehabilitation programmes, but literature lacks on its use in early post-operative rehabilitation plan. A clear relationship exists between the trunk muscle activity and lower extremity movement [8]. Core stability is defined as the ability to control the position and motion of the trunk over the pelvis to allow optimal production of force and motion, and their transfer to the terminal segment [9, 10]. It is necessary to maintain the integrity of the spinal column and forms a stable base for movement of the extremities [8]. As a result, there is proper force distribution and maximum force generation with minimal compressive, translational, or shearing forces at the joints of the kinetic chain. It provides proximal stability for distal mobility [11]. Core muscle strength provides the foundation for motor skills and activities of daily living allowing an individual to exert external force whilst maintaining dynamic balance [9, 12]. Therefore, core stability is related to the ability to control the trunk's responses to internal and external interference, including power generated by the distal body segments [9, 13]. There are however lack of studies stating effect of core stability on various functional impairments such as range of motion, pain etc, and activity limitation following ACLR. A lot of studies have been done on formulating rehabilitation protocol post ACLR with use of different interventions which does not include lumbar core stability and strengthening. To accelerate recovery, core exercises should be made an integral part of ACLR rehabilitation [9]. Hence, there is a need for incorporation of lumbar core stability exercise program to the ACLR rehabilitation protocol to know the additional effects it has in the rehabilitation process.  Many unanswered questions still exist regarding the optimal physiotherapy treatment for ACLR. Hence it is important to understand whether including lumbar core stability exercise programme will benefit existing ACLR rehabilitation protocol.

Hypothesis

Core stability exercises are used in almost all the rehabilitation programmes. As a well-known fitness trend, it is being used extensively in the sports medicine world. [14] Proximal stability leads to distal mobility. It becomes necessary to introduce and study the effects of the lumbar core stability exercises to the ACLR rehabilitation programme to observe early functional improvement in the activities of daily living. Hence, it is hypothesized that lumbar core stability exercises combined with ACLR rehabilitation programme offers improvement in knee joint function as well as reducing the pain and range of motion of the knee joint as compared to only ACLR rehabilitation programme. The current research aims at studying the effects of lumbar core stability exercises along with ACLR rehabilitation programme on knee joint pain, range of motion and function post ACLR in participants aged between 20-40 years. A Prospective Randomized Control Trial will be performed after ethical approval from the Institutes ethical committee. The sampling will be done by chit method after obtaining consent from the participants. Participants who would undergo isolated ACLR, or with associated meniscal tear excision or trephination would be included in the study. Participants who would undergo ACLR with meniscal repair shall not be included as the rehabilitation protocol differs with that of the one followed for ACLR with or without meniscal excision or trephination. Those having associated fracture and/or avulsion, history of previous knee surgery, fracture, dislocation, acute infection, neuropathic conditions, malignancy, and any other condition that might hamper the rehabilitation process at the time of data collection will be excluded from the study. Before commencing the physiotherapy rehabilitation, the participants shall be evaluated and demographic data will be collected from each patient that includes age, sex, and occupation, time of injury, and mechanism of injury, pre-surgery rehabilitation status, and medications. For pain evaluation, Visual Analogue Scale will be used [14]. For range of motion evaluation, Goniometer Records application on android mobile device shall be used [15]; and Modified Lysholm Scoring Scale (MLSS) shall be used to assess functional ability and Tegner Activity Level (TAL) for the activity level [16].
Participants shall be assessed for knee pain, before treatment and at the time of discharge, at the end of second and fourth week. On the day of discharge, at the end of second week and fourth week range of motion shall be assessed. And at the end of fourth week of treatment, assessment of functional ability and activity level shall be done by using MLSS and TAL. Participants shall be assigned into Group A (control group) and Group B (experimental group). Females will be equally allotted to each group and equality shall be maintained in terms of the associated meniscal surgeries. Each group shall undergo ACLR rehabilitation. Additionally, Group B shall undergo lumbar core stability exercise programme. Before commencing the treatment, the participants will be assessed for lumbo-pelvic stability using Stabilizer Pressure Biofeedback Unit [17] by using the progressive leg loading test emphasizing on abdominals as a measure of control and hold time as a measure of endurance of the lumbo-pelvic complex [18]. Prior to testing for lumbo-pelvic stability all patients would receive training in the drawing-in manoeuvre to activate the abdominal core muscles in a supine modified crook lying position (operated leg straight and non-operated leg bent at 90° of knee flexion) with neutral pelvis. Participants in both the groups shall be tested for core stability and endurance pre-treatment. And, participants in the experimental group shall be given progressive leg loading exercises emphasizing on the abdominals, starting at the level at which they will be for a week and progressing it level wise every week, for four weeks as part of their home exercise regime. Both the groups will receive treatment until discharge (within first week) after which patients will continue with home exercise programme consisting of rehabilitation exercises with (for experimental group) or without (for control group) lumbar core stability exercises for the next four weeks which will be taught and explained thoroughly. To keep a record of the home exercise programme, patients will be given an exercise sheet for ease of following the exercises.
Thus, all the participants shall undergo a home exercise programme for four weeks. Paired t-test shall be used for analysing intra-group assessment of range of motion. Un-paired t- test shall be used for inter-group assessment of range of motion. Wilcoxon test shall be used intra-group assessment of pain. Mann Whitney U Test shall be used for inter-group assessment of pain, function and activity level using the Lysholm Knee score and Tegner activity level.

Discussion

Many ACLR rehabilitation programmes talk of early weight bearing, prevention of re-injuries, open versus closed kinetic chain exercises, return to play, balance and proprioceptive training and also neuromuscular facilitation [6, 19-21]. But none has focused on incorporating core stability exercises as a part of rehabilitation training from the very beginning of the rehabilitation process post ACLR. Stability means any foundation or base which is firm and allows no change. In context of the human body, the spinal column which consists of the vertebrae and the various joints and ligaments aligning the adjacent vertebras, provides stability to the bony skeleton along with the various musculature surrounding the spinal column which consists of the deep and superficial core muscles. The stability of any system depends on its ability to limit displacement along with maintenance of integrity [8]. Stronger core muscles would provide a strong and stable proximal component which would result in efficient distal component mobility. Relationship of core stability exercises in preventing lower extremity injuries has been proved. There is a negative correlation that exists between core stability and ACL injuries [9]. Several studies have evaluated various treatment techniques to reduce the risk of knee injuries, specifically the ACL injuries in males as well as females. The basic component of any rehabilitation programme involves training for task specific activities; for example, a sports person would be trained for cutting, pivoting, jumping etc which focuses on the rotational control of the extremity underneath the pelvis. As a clear relationship exists between core stability and lower extremity movement, one can be clear that decreased core stability predisposes a person to lower extremity injuries and that improved core stability reduces the chances of injuries [8]. It is observed that the deep abdominal muscles, i.e. the transverses abdominis get activated in anticipation to limb movement. Strength training of these trunk muscles would provide a better rotational control of the limb. This interrelationship between the lower extremity function and core stability should be used to an advantage while treating the patients who have undergone ACLR. Thus, lumbar core stability exercises should be combined with the current ACLR rehabilitation programme in order to achieve its benefits in terms of achieving functional independence at the earliest. Functional independence could be achieved not only by the ability to perform tasks but by the availability of the range of motion required to accomplish the same along with low levels of pain.
Thus, this hypothesis states that a combination of lumbar core stability exercises with an emphasis on the abdominal limb loading exercises with ACLR rehabilitation programme, if progressively given to the subjects would help benefit them with achieving functional tasks earlier in the rehabilitation process along with an increased improvement in the range of motion and reduced pain levels as compared to the ACLR rehabilitation programme alone.

Clinical Message

Adding lumbar core stability exercises to the ACLR rehabilitation programme would result in early recovery of this population in terms of returning back to routine or sports activities.

Future Direction

To find out the beneficial effects on sports persons performance, lumbar core stability exercises could be given for a longer duration.

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