Category Archives: Vol 3 | Issue 1 | Jan- Apr 2015

Effectiveness Of Incentive Spirometry In Improving Peak Expiratory Flow Rate In Post Abdominal Surgery : An Experimental Study.


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.

                                                        THESIS SUMMARY                                                             

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.


How to Cite this Article: Nandi B, Mishra S, Yeole U, Gawali P, Adkitte R. Effectiveness Of Incentive Spirometry In Improving Peak Expiratory Flow Rate In Post Abdominal Surgery : An Experimental Study. Journal Medical Thesis 2015 Jan-Apr ; 3(1):15-18.

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Estimation of Spirometric Reference Values, Prediction Equations & Correlations in Children Living in Maharashtra Aged 6-15 Years By Using Anthropometric Indices & Its Comparison With National & International Published Values & Equations : A Hypothesis.


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.

                                                        THESIS SUMMARY                                                             

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.


How to Cite this Article: Kale S, Deshpande M. Estimation of Spirometric Reference Values, Prediction Equations & Correlations in Children Living in Maharashtra Aged 6-15 Years By Using Anthropometric Indices & Its Comparison With National & International Published Values & Equations : A Hypothesis. Journal Medical Thesis 2015  Jan-April ; 3(1):8-10.

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Kale


 

Effect of additional use of shoe raise on unaffected side along with motor relearning programme (mrp) on ambulation in chronic hemiplegics: A Hypothesis.


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.

                                                        THESIS SUMMARY                                                             

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.
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6.Patricia M Dawies Right in the middle, Selective trunk activity in treatment of adult hemiplegia, 2003; Springer, 33, 34, 53, 54, 169-193.
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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.
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How to Cite this Article: Bhalerao G, Parab D. Effect Of Additional Use Of Shoe Raise On Unaffected Side Along With Motor Relearning Programme (Mrp) On Ambulation In Chronic Hemiplegics:A Hypothesis. Journal Medical Thesis 2015  Jan-Apr ; 3(1):11-14.

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Gajanan B


 

To Compare the Results of Operative and Non-operative Management of Rotator Cuff Injury.


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.

                                                        THESIS SUMMARY                                                             

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.

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How to Cite this Article: Shah Y, Saraf M . To Compare the Results of Operative and Non-operative Management of Rotator Cuff Injury. Journal Medical Thesis 2015 Jan-Apr ; 3(1):31-37.

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Triple Phase Computed Tomography In Hepatic Masses.


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.

                                                        THESIS SUMMARY                                                             

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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How to Cite this Article: Chauhan U, SolankiR, Udiya A, Shetty G, Narula M. Triple Phase Computed Tomography In Hepatic Masses. Journal Medical Thesis 2015  Jan-Apr ; 3(1):23-30.

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Effects Of Lumbar Core Stability Exercise Programme On Knee Pain, Range Of Motion And Function Post Anterior Cruciate Ligament Reconstruction.


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.

                                                        THESIS SUMMARY                                                             

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.

Bibliography

1. Norris CM. Cruciate Ligaments Structure and Function. Chap 10. The Knee. Sports injuries diagnosis and management. 3rd edition. Butterworth Heinemann Elsevier Ltd. 2004. Pg No. 225-226.
2. Khadilkar B, Bedekar N. The Effectiveness of Backward Walking Post Anterior Cruciate Ligament Reconstruction- Results of a Randomized Controlled Trial. Journal of Orthopedics and Rehabilitation 2011; Vol. 1, Issue 1. Pg no. 23-28.
3. Buckner P, Khan K. Functional Anatomy. Chap 27. Acute Knee Injuries. Clinical sports medicine. 3rd edition. Tata McGraw Hill Edition 2008. Pg. No. 461.
4. Kisner C, Colby L. Ligament Injuries: Non operative management; Chap 21. The Knee. Therapeutic exercise foundations and techniques. 6th edition. F.A. Davis Company. JP Brothers Medical Publishers. 2012. Pg no. 802.
5. Briggs C, Steven M, Zuluaga M. Chap 29. The Knee. Sports physiotherapy applied science and practice. Editor: Zuluaga M et al. Churchill Livingstone Pearson Professional (P) Ltd 1995; Pg. No. 545.
6. Kruse LM, Gray B, Wright RW. Rehabilitation after anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am 2012;94(19):1737-48.
7. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Recent advances in the rehabilitation of anterior cruciate ligament injuries. J Orthop Sports Phys Ther 2012;42(3):153-71.
8. Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. J Am Acad Orthop Surg 2005;13(5):316-25.
9. Shi DL, Li JL, Zhai H, Wang HF, Meng H, Wang YB. Specialized core stability exercise: a neglected component of anterior cruciate ligament rehabilitation programs. J Back Musculoskelet Rehabil 2012;25(4):291-7.
10. Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med 2006;36:189-98.
11. Akuthota V, A. Ferreiro, T. Moore, and M. Fredericson. Core stability exercise principles. Curr. Sports Med. Rep 2008; Vol. 7, No. 1, pp. 39- 44.
12. Anderson K, Behm DG. The impact of instability resistance training on balance and stability. Sports Med 2005;35:43-53.
13. Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med 2007;35:1123-30.
14. Boonstra AM Schiphorst Preuper HR, Reneman MF, Posthumus JB, Stewart RE. Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain. Int J Rehabil Res 2008;31(2):165-9.
15. Bedekar N, Suryawanshi M, Rairikar S, Sancheti P, Shyam A. Inter and intra-rater reliability of mobile device goniometer in measuring lumbar flexion range of motion. J Back Musculoskelet Rehabil 2013.
16. Sgaglione NA, Del Pizzo W, Fox JM, Friedman MJ. Critical analysis of knee ligament rating systems. Am J Sports Med 1995;23(6):660-7.
17. von Garnier K, Köveker K, Rackwitz B, Kober U, Wilke S, Ewert T, Stucki G. Reliability of a test measuring transversus abdominis muscle recruitment with a pressure biofeedback unit. Physiotherapy 2009;95(1):8-14.
18. Kisner C, Colby L. Stabilization exercises for the lumbar region. Chap 16. The Spine: Exercise Interventions. Therapeutic exercise foundations and techniques. 6th edition. F.A. Davis Company. JP Brothers Medical Publishers. 2012. Pg no. 460-461.
19. Bynum EB, Barrack RL, Alexander AH. Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study. Am J Sports Med 1995;23(4):401-6.
20. Hartigan EH, Axe MJ, Snyder-Mackler L. Time line for noncopers to pass return-to-sports criteria after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2010;40(3):141-54.
21. Morrissey MC, Drechsler WI, Morrissey D, Knight PR, Armstrong PW, McAuliffe TB. Effects of distally fixated versus nondistally fixated leg extensor resistance training on knee pain in the early period after anterior cruciate ligament reconstruction. Phys Ther 2002;82(1):35-43.


How to Cite this Article: Panchal P, Bedekar N. Effects Of Lumbar Core Stability Exercise Programme On Knee Pain, Range Of Motion And Function Post Anterior Cruciate Ligament Reconstruction. Journal Medical Thesis 2015  Jan-Apr ; 3(1):4-7.

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Nilima Bedkar


 

Guest Editorial for The Journal Of Medical Thesis

Vol 3 | Issue 1 | Jan - Apr 2015 | page:3 | Dr. K Mohan Iyer.


Author: Dr. K Mohan Iyer.

Retired,Formerly Locum Consultant Orthopaedic Surgeon,Royal Free Hospital,London,UK.
Email: kmiyer28@hotmail.com


It gives me tremendous pleasure writing an Editorial for the Journal of Medical Thesis,as I have written three Thesis in my orthopedic career.We all write many thesis on various topics,and I would like to concentrate on the Hip Joint only,as this happens to be my primary interest having worked with late Mr.Geoffrey V Osborne,Senior Consultant Orthopedic Surgeon,University of Liverpool,UK,who had described his Approach to the Hip Joint along with late Professor Brian McFarland,Professor of Orthopedic Surgery, University of Liverpool, UK.

Writing a thesis or a desertation should be analysed from all angles,particularly on the aspects that we learnt as subjects from the beginning,namely,Anatomy,Pathology,Surgery,Medicine,Surgical Anatomy,Surgical Pathology,etc.
The Thesis may be written in a stepwise fashion in the following way:Introduction,Review of literature,Material and Methods,Results,Discussion,Summary,References and Acknowledgments.
Normally a Thesis is compiled of about 30 cases in all.All the cases included in the thesis should have been treated in one particular way only,as it will be easier for the statistician to analyse the data obtained.All important points with respect to the thesis,such as Infection,Dislocation,resuts,etc are noted down in detail.I am at this point very happy to state that I had described an Approach to the Hip Joint way back in 1981.This Approach had appeared initially in the Yearbook of Orthopedics,Campbell's Operative Orthopedics,many others books written on the Hip Joint.I have been inspired and motivated by all these to write a final book entitled `THE HIP JOINT',dedicated to the memory of late Mr.Geoffrey V Osborne.There are more than 100 different approaches to the Hip Joint,but I had devised my Approach based on the increasing number of dislocations recorded in literature,which was reported as high as 8%. Dr.Robert H.Cofield of Mayo Clinic in Rochester,Minnesota,USA has been using this approach for the last 25 years with no regrets.He is extremely happy using this approach since I presented it during the Scientific Congress of the AseanOrthopaedic Association in Singapore in 1984.

My well wisher and friend Dr. Robert H Cofield of the Mayo Clinic, in Rochester, Minnesota, USA did assign a fellow (Dr.Jaoquin Sanchez Sotelo, MD, PhD)in his University while he was the Professor to study a series of cases done by my Approach and also write an Original Paper on it. He did publish a paper on it in the Belgian Journal of Orthopedic Surgery, wherein he has noted all the positive findings and advantages with respect to this approach.I was in regular touch with Emeritus Professor Robert H Cofield and Dr.Jaoquin Sanchez Sotelo,that they were all extremely happy with the results.This was reported by him and the others in the Department and was: Primary hip arthroplasty through a limited posterior trochnteric osteotomy-JaoquinSanchez-Sotelo,John Gipple,Daniel Berry,Charles Rowland,Robert Cofield(2005)Acta Orthop Belg.,71,548-554.Today,Dr.Joaquin Sanchez Sotelo is a well known Orthopedic Surgeon in the US,and has also written many books till today,with one of his books on the diseases of the Elbow in the 4th Edition.

I would certainly guide all interested students and young Postgraduate Orthopedic Surgeons in India and abroad to note all these aspects in writing an original paper or a Thesis.

References

1.Primary hip arthroplasty through a limited posterior trochnteric osteotomy-JaoquinSanchez-Sotelo,John Gipple,Daniel Berry,Charles Rowland,Robert Cofield(2005)Acta Orthop Belg.,71,548-554.


How to Cite this Article: Iyer K M. Guest Editorial for The Journal Of Medical Thesis. Journal Medical Thesis 2015 Jan-Apr ; 3(1):3

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Mohan Iyer


 

 

JMT Editorial :Statistics in Medical Thesis

Vol 3 | Issue 1 | Jan - Apr 2015 | page:1-2 | Dr. Ashok K Shyam.


Author: Dr. Ashok K Shyam

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


Statistics is an essential requirement for all medical thesis, the difference lies in the extent and complexity of the tests. I personally believe thesis should have the most basic statistics and a qualified statistician should be involved in every thesis. As per the scientific purview the hypothesis can only be tested by a proper study design and statistics for an essential aspect of hypothesis testing. Statistician should be involved in the thesis work from the beginning at the time of hypothesis generation. The study design in the hypothesis should contain details of statistics and assessment. Having said that I understand that thesis in medical curriculum [especially in India] is almost the first time that the student is exposed to research and research methodology. For the student to think about statistical part at this point in this thesis is very difficult. I believe the responsibility lies with the thesis guide and the institute to provide a good statistician who can help the students from the start of the thesis.
Also education about basic statistics is very essential for every student of medicine. Many a times it happens that the students simply give the data to the statistician [mostly at the time close to thesis submission date] and ask the statistician to analyse the data and give some 'significant' results. The statistician [who has minimal insight into the subject] simply puts the data in to a software and compares one column to another to generate tables and charts. These charts and tables are then simply inserted into the dissertation and comments are made of things where p value is significant. This leads to over simplification, over complexity or gross misinterpretation and mispresentation of the data. And since the review process of thesis in our country is quite poor, most of the thesis with complex statistical assessment get easily accepted. This can be changed very simply by involving a statistician in the study from the beginning, who can actually sit with the student and guide and understand the study design and hypothesis. Once he understands the subject and the research question it would be easy for him to suggest appropriate statistical test and get a more validate outcome. This small investment of time will make the thesis much stronger on statistical part.
Another advantage of involving a statistician early will be in education of the students. I would personally suggest a lecture series of minimum 4 lectures in study design and statistics to all medical students within 3 months of joining the post-graduation and before they are ready to submit their hypothesis or synopsis. This series should also be attended by the guides and every thesis should be discussed with the statisticians. This will not only help the students design the statistical framework for their study but will also help them understand the statistics used in literature and other journal articles. They will be able to understand the statistical part in the reference articles they read and will be able to point the strength and weakness of the studies in literature. In long run this will help them to make sense of literature throughout their lives and conduct a good appraisal of articles published.
Another advice will be to use only basic statistics and do not complicate the issues for the readers. Keep it Simple will hold the key especially when you intend to convert your thesis into a publication. Also even if you get no significant p value [negative results] do not get discouraged and go in for complex statistics [do not torture the data till it submits]. A study with no significant p value is as important and as valid as a study with significant p value. In fact at times the negative studies have much more clinical impact than the positive ones. To understand this write all results in simple English language. Have a session with your statistician where all numerical results are converted into simple English language sentences. This will help in writing the discussion and also help in understanding and interpreting the results.
So my advice will be to involve a statistician early in your study and keep the statistical methods simple and easy to understand. Get basic statistical knowledge so you can read and appraise literature correctly. We will include some reviews about statistical methods by statisticians in coming issues of Journal of Medical thesis and we hope this will help the students in planning their analysis.

Best Wishes
Dr Ashok Shyam
Editor- JMT.


How to Cite this Article:  Shyam AK. Editorial: Statistics in Medical Thesis. Journal Medical Thesis 2015 Jan - Apr; 3(1):1-2

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Editorial


 

 

Changes in the Postural Stability and Balance in Multitasking with Increasing Task Demands in Normal Healthy Individuals of Different Ages: A Hypothesis.


Vol 3 | Issue 1 | Jan - Apr 2015 | page:38-41 | Renuka A Hatekar,  Apurv P Shimpi.


Author: Renuka A Hatekar[1],  Apurv P Shimpi[1].

[1] Department of Community Physiotherapy, Sancheti Institute College of Physiotherapy, Sancheti Healthcare Academy, Thube Park, Shivaji Nagar, Pune, Maharashtra, India.

Institute at which research was conducted: Sancheti Institute College of Physiotherapy, Pune.
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.Apurv Shimpi
Sancheti Institute College of Physiotherapy, Sancheti Healthcare Academy, 12, Thube Park, Shivaji Nagar, Pune- 411005, Maharashtra.
Email: apurvshimpi@sha.edu.in


 Abstract

Background: Balance and postural instability disorders become more prevalent with age. The three sensory modalities responsible for normal balance and steadiness, viz. vision, vestibular system and proprioception, can become compromised as a result of normal aging process as well as age-related disease or pathology leading to increased risk of falls and related injury. The elderly fall more often and with greater consequence as a result of balance and postural instability issues, leading to huge personal costs as well as large health care costs. 1 in every 3 adults over the age of 65 will suffer from a fall,and these numbers are expected to rise making balance disorders a major healthcare crisis. But there is a dearth of literature in understanding the activities or specifictasks which may lead to falls, especially tasks having dual or multitasking components in our day to day activities which may be precursors of falls. Thus, there is a need to evaluate the changes occurring, if any, related to balance impairments with an increasing age or with relation to increasing in the difficulties in the levels of tasks performed and their relation with the falls.
Hypothesis: There will be a reduction in balance and stability parameters with an increase in the levels of difficulty of the task demands which will be enhanced with an advancing age.
Clinical Importance: The evaluation ofspecific tasks leading to impairments of balance with an advancing age can help us form optimum strategies for fall prevention and also may help us give functional balance trainingin accordance with the task demands in the varied ages.
Future Research: The effects of balance training on the variations of tasks can be evaluated to specify exercises which may help the higher age groups cope up in the dynamic challenges of the daily activities. Also environmental influences on these activities can be studied in order to improvise and enhance the quality of life in this population.
Key Words: Postural instability, Balance, Multitasking, Aging, Falls.

                                                        THESIS SUMMARY                                                             

Introduction

Aging is an extremely complex process which is characterized by the degeneration of organs and tissue[1].There are multiple theories of ageing. But broadly, ageing process is physiologically characterised into 3 groups. The first group comprises of the cellular homoeostatic mechanism such as blood pressure, body temperature.The second group characterises of the decreasing organ mass while the third and most important mechanism consists of the loss of functional body system which contributes in maintenance of the functional status of the body[2]. As aging occurs, there will be a concurrent deterioration in the other systems of the body as well[2]. The three sensory modalities responsible for normal balance and steadiness, viz.vision, vestibular system and proprioception, can become compromised as a result of normal aging process as well as age-related disease or pathology leading to increased risk of falls and related injury[2].
Balance is defined as a state in which weight is evenly distributed enabling a person or thing to remain steady and upright[3]. Balance is of two types: 1. Static balance/ static postural control,which is the ability to maintain a steady position in a weight bearing, anti-gravity postures. Impairments of static postural control are instability or increased postural sway in sitting/ standing, episodes of loss of balance and risk of falls. 2. Dynamic balance/ dynamic postural control,which is the ability to alter a position or change position while maintaining stability[3]. Impairments of dynamic postural control are difficulty in maintaining balance during weight shifting or rocking within a posture (e.g. sitting) and the inability to assume a posture independently. This activity requires movement against gravity through a large range of motion. Postural control depends on the integration and co-ordination of three body systems; Sensory, central nervous (CNS) and neuromuscular systems.The sensory system gathers essential information about the position and orientation of the body segments. CNS integrates, coordinates and interprets the sensory input and directs the movements while the neuromuscular system responds to the orders provided by the CNS[3]. The prime concern in geriatric rehabilitation is fall prevention. Studies have proved that falls are the leading cause of accidental death over 65 years of age[4]. Although there are intrinsic and extrinsic factors for the causes of fall but the authors believe that the prime reason of falls can be the challenges to the balance system, especially during the dual tasking and multitasking which are somehow not emphasized upon during the assessment and rehabilitation processes. Human Multi-tasking means dealing with more than one task by an individual at a time[5]. Multitasking trains the untrained part of the brain. Researchers have shown that adding cognitive demands to the performance will enhance the functional performance of the person, which is very necessary for maintaining a good functional status[6]. Multi-tasking is extremely essential component duringambulation and locomotor activities as this is the phase wherein there can be maximum falls due to impaired ability to maintain normal gait while simultaneously performing cognitive task or any other activity which leads to postural instability[6]. Also performance of daily activity requires a concurrent performance of multiple tasks as per the needs of the situation. Hence it is absolutely crucial to evaluate the balance specifically while doing multitasking activities; which can help the rehabilitation specialists tofocus on the training of the multitasking in functional activities.

Hypothesis

Humans are bipedal for their locomotive needs and need to maintain balance on single leg during stepping forward or while running[7]. Hence balance maintenance is crucial in our day to day activities. Falls have short term and long term consequences which can be difficult to manage further. It is commonly assumed that balance would be impaired only in elderly due to physiological status of the body and hence the young and middle age population is neglected for assessment of balance. Study done by Chony NL et al suggest that the balance can be impaired from any age, even from 40 yearsonwards, which is considered as the middle age[8]. Hence, variations in balance need not be only physiological, but even the environmental factors and task demands can contribute towards maintenance of balance and hence there is the need to understand the variations in balance, if any, in the various ages. Thus, there is a need to evaluate the changes occurring, if any, related to balance impairments with an increasing age or with relation to increasing in the difficulties in the levels of tasks performed and their relation with the falls.Thus, the study is based on the hypothesis that there will be a reduction in balance and stability parameters with an increase in the levels of difficulty of the task demands which will be enhanced with an advancing age with the objectives of measuring the static and dynamic balance in varied levels of task demands in normal healthy population from 10-80 years of age. To meet this purpose, an analytical cross sectional study will be conducted, the approval for which has been obtained from the institutional review board. The sampling will be done by the stratified sampling method wherein the sample will be collected from all the 7 legislative zones of Pune city, the single legislative zone being strata. This is to eliminate any potential confounders in the study based on demographic and geographic variations. The data collection, assessment and analysis shall be done as per STROBE statement guidelines.There will be 7 groups with the age group of from 10 to 80 years, having 100 subjects in each decade wise age group which has been calculated by the formula of the sample size (Z-VALUE)2 x p x (1-p)/c2, wherein, Z-value: 1.96 (for 95% confidence interval), p: 0.5 (% picking a choice, expressed as decimal (0.5is used for sample size needed)) c:confidence interval , expressed as decimal based on the 2011 census report for Pune city for the above mentioned age group.
The study shall include normal healthy individuals from 10 to 80 years of age who will be screened for physical fitness based on no history of any clinical complains and assessed by the PAR Q and YOU questionnaire. The individual with Visual problem (non – correctable), Vestibular disorder,Neurological disorder which leads to balance problem, Lower limb musculoskeletal problems (RA, recent fracture) etc., will be excluded from the study. The written informed consent form will be signed by the participants. Balance assessment shall be done by 5 outcome measures viz., 1.Bergs balance scale (BBS), 2.Dynamic gait index (DGI), 3.Time up and go test (TUG), 4.Star excursion balance test (SEBT) and 5.Single leg stance time (SLS). After this, the subjects will be asked to hold a glass of water filled with 80% of water and perform the above tests. Further, subjects will be asked hold a glass of water filled with 80% of water and to count numbers reverse from 100 to 1 (odd or even numbers) thus adding multitaskingincluding cognitive task. Balance of each subject will be measured by the varied outcome measures to understand the variations in these tests and to understand which clinical tool can be most appropriate to evaluate the minute variations in balance parameters. Statistical analysis for inter group variations, if any, shall be done with on way ANOVA Testfor TUG, SEBT and SLS and Kruskal Wallis Test for BBS and DGI measures with alpha set at p<0.05 at 95% confidence interval.

Discussion

The degeneration of the balance control system and many pathology in elderly has forced researchers and clinicians to understand more about how the System works and how to quantify its status at any point in time[7]. Due to sedentary and busy lifestyle now-a-days, few considerations are given to the physical fitness of the body. Postural stability (balance) is one of the very prime concerns for staying fit. Falls are one of the major problems in the elderly and are considered one of the “Geriatric Giants”[9]. Recurrent falls are an important cause of morbidity and mortality in the elderly and are a marker of poor physical and cognitive status[9]. Due to various changes that takes place in the body due to aging process, consideration for postural instability or balance while doing dual or multitasking is not given. The ability to control our body's balance may be impaired due to changes in the sensory, motor, and neurological system. Usually balance assessment gives us the purpose of scoring balance in the quantitative way such as scores for the scales. Many other technical aids such as balance platform which measures the balance in a very accurate form can be used[10]. But the functional component of the balance or the activities which is performed in day to day activities is neglected hence the functional component is missed which can be impaired in all the ages. It has been suggested that the balance impairment of the all the ages can be overcome by giving the balance training which include all the exercises of the body[10]. Task which challenges Balance while multitasking is observed in our day to day activities. Multitasking increases the work load on the mental system[11]. One form of multitasking, impaired ability to maintain normal gait while performing other cognitive tasks, may predispose individuals to postural instability while walking and to falls by reducing obstacle avoidance and ability to recover from a postural perturbation independent of neuromuscular function[12]. Hence it will be very important to assess and at the same time the treatment should be given in the functional way so that the post intervention the balance score is improved. There are many scales which asses the balance and give us the very accurate score in the functional form. The scales or the outcome measures which will be used in this research study are Bergs balance scale (BBS), Dynamic gait index (DGI), Single leg stance (SLS), Star excursion balance test (SEBT) and Time up and go test (TUG). These tests are used to assess the balance score in different ages. But there is no scale which can help us understand the complexities of dual-taskingto multi-tasking. According to literature, the rising awareness for maintenance of balance is taken into consideration and strategies to improve balance while doing multitasking specially for the elderly population should be developed. Damage to the prefrontal cortex (PFC) is associated with impaired Multitasking performance[13].Neuroscientific findings showed that, like other externally directed attention-demanding tasks such as working memory tasks, networks mainly consisting of the lateral frontal cortex and parts of the inferior and superior parietal lobes are activated during Multitasking[13]. Studies have investigated the effects of Multitasking training on cognitive functions and neural systems, and this training has been shown to lead to improvements in untrained Multitasking task[14]. Functional activity has been found to undergo changes during Multitasking in regions such as dorso lateral pre frontal cortex.  A study by Julia Karbach et al (2013),suggestthat the activity was decreased in most of the areas involved in task performance, buttraining given will increase changes in dorso Lateral Prefrontal cortex[15]. These changes suggest that adaptation to Multitasking leads to increased efficiency in task execution as well as learning to rely on cognitive processes involving dorsolateral prefrontal cortex[15-17]. Hence due to all this process which takes place in the gray matter in the brain, multitasking training can be started at any age so that we can avoid the risk of falls and create enhanced body balance. Thus, the study hypothesizes that there would be changes in balance in form of reduced balance scores as measured with the performance based balance tests in the higher age groups and in relation to the increase in the task demands.

Clinical Message

Reaching tasks are commonly performed during daily activities and require anticipatory postural adjustments (APAs) to ensure a stable posture during movement execution. Age-related changes may impact dynamic balance and cause postural instability during functional activities. Older adults are more likely to fall while performing concurrent tasks such as walking while performing other motor or cognitive tasks. Thus doing dual tasking while walking will add up to more risk of fall. This study may help the readers understand the exact functional components which need to be trained with an advancing age and with relation to the variations in task demands. This may help the rehabilitation specialists to focus on specific tasks and functional training demands in the rehabilitation process and may help in formation of task specific rehabilitation guidelines and protocols.

Future Direction

The effects of balance training on the variations of tasks can be evaluated to specify exercises which may help the higher age groups cope up in the dynamic challenges of the daily activities. Also environmental influences on these activities can be studied in order to improvise and enhance the quality of life in this population.

Bibliography

1.Nigam Y, Knight J, Bhattacharya S , Bayer A. Physiological Changes Associated with Aging and Immobility.J Aging ResVolume :2012.
2.LennoxS , Stewart U. Balance Disorders and Aging.Canadian Hearing Report | revue CanadienneD'audition. [cited 2015 April 27] Available from:http://www.hearingisbelieving.com/wp-content/uploads/balance-and-aging.pdf
3.Shumway-Cook A, Woollacott M et al. Motor Control translating research into clinical practice. 3rd edition. Lippincott Williams and Wilkins; 2007:218.
4.Silsupadol P, Ka-Chun S,Shumway-Cook A, WoollacottM et al Training of balance in single and dual task,Conditions in Older Adults With Balance ImpairmentJAPTA. 2006; 86:269-281.
5.Wikipedia[Internet]Multitasking [cited 2015 April 27]Available from: http//en.wikipedia.org/wiki/human-multitasking.
6.Buragadda S, Alyaemni A, Melam G.Effect of Dual-Task Training (Fixed Priority-Versus-Variable Priority)for Improving Balance in Older Adults.World ApplSci J2012. 20(6):884-888,
7.Winter D A. Human balance and posture control duringstanding and walking.Gait and Posture. December 1995. 3:193-214.
8.Chony NL, Brauer S, Nitz J. Changes in postural stability in women aged 20 to 80 years.J. Gerontol. A Biol. Sci. Med. Sci. 2003 Jun;58(6):525-30.
9.Krishnaswamy B, Gnanasambandam U. Falls In Older People National / Regional Review India. World health organization[cited 2015 April 27]Available from: http://www.who.int/ageing/projects/SEARO.pdf .
10. Sihvonen S Postural balance and aging- cross sectional comparative studies and a balance training Intervention. University of Jyvaskyla 2004[cited 2015 April 27] Available from:
https://jyx.jyu.fi/dspace/bitstream/handle/123456789/13495/951391920X.pdf?seq.
11. CullenR.Multimodal Multitasking: The Combined Effects of Postural and Cognitive Demands on Overall Workload: June 19th, 2014 [Dissertation] [cited 2015 April 27]Available from: https://vtechworks.lib.vt.edu/bitstream/handle/10919/49696/Cullen_RH_D_2014.pdf?sequence=1.
12. Faulkner KA, Redfern MS, Cauley JA, LandsittelDP, Studenski SA, RosanoC, et al. Multitasking: Association Between Poorer Performance and a History of Recurrent Falls; JAGS April 2007.55(4): 570-6.
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14. Voss M, Prakash R, Erickson K, Basak C, Chaddock L, Kim J,et al. Plasticity of brain networks in a randomized intervention trialof exercise training in older adults.Neurobiol. Aging;2010 August 26.2(32).
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How to Cite this Article: Hatekar R A, Shimpi A. Changes in the Postural Stability and Balance in Multitasking with Increasing Task Demands in Normal Healthy Individuals of Different Ages: A Hypothesis. Journal Medical Thesis 2015  Jan-Apr ; 3(1):38-41.

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Effectiveness of Core Muscle Strengthening on Prevention of Low Back Pain in 2nd Trimester Primigravid Females.


Vol 3 | Issue 1 | Jan - Apr 2015 | page:19-22 | Priyanka Mhalagi, Savita Rairikar, Apurv Shimpi.


Author: Priyanka Mhalagi[1], Savita Rairikar[1], Apurv Shimpi[1].

[1] Department of Community Physiotherapy, Sancheti Institute College of Physiotherapy, Sancheti Healthcare Academy, Thube Park, Shivaji Nagar, Pune, Maharashtra, India.

Institute at which research was conducted: Sancheti Institute College of Physiotherapy, Pune.
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.Apurv Shimpi
Sancheti Institute College of Physiotherapy, Sancheti Healthcare Academy, 12, Thube Park, Shivaji Nagar, Pune- 411005, Maharashtra.
Email: apurvshimpi@sha.edu.in


 Abstract

Background: Pregnancy comes with number of physiological changes. The effect of increasing size of uterus weakens core abdominal muscles. It is superimposed by the effect of hormone Relaxin which affects static stability of joints. On account of these musculoskeletal changes there is prevalence of low back pain during pregnancy. The aim of this study is to assess the effectiveness of core muscle strengthening exercises on prevention of low back pain in 2nd trimester primigravid females.
Hypothesis: In the present study it is assumed that specific core strengthening exercises will increase the core abdominal muscle strength which will, in turn, prevent the incidence of low back pain in the given population. The study is a randomized control trial with total sample size of 210 which will be recruited by computerized random table allocation technique. The study has three sub groups including primi gravid intervention (Group A), primi gravid control group (Group B), and a group of age matched nulli-gravid females (Group C) selected purposively for matching the exercise intensity effects. Exercises intervention for core strengthening will be given for 6 weeks/ 5 days per week to A and C. Abdominal core muscle strength will be assessed Pre and post intervention by using a pressure biofeedback device while presence and intensity of low back pain will be scored by the Rolland Morris disability index. Statistical analysis for intra group core strength will be done by paired 't' test and inter group by One way ANOVA while back pain by the test for intra group by Wilcoxon sign rank test and Kruskal Wallis test for inter group with alpha set at p<0.05.
Clinical Importance: This exercise protocol will prevent the incidence of low back pain in pregnancy period. As the use of NSAID is rigorously restricted in pregnancy, exercises will be definitely a better solution for this population.
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                                                        THESIS SUMMARY                                                             

Introduction

The female body undergoes many hormonal and anatomic changes which affect musculoskeletal system during pregnancy period. The abdominal muscles have to stretch in width and length to accommodate the growing uterus. The two sides of the rectus abdominis, obliques, and transversus abdominis (TA) expand and, in some cases, may separate by 3-6 inches. It creates lumbar lordosis which causes a shortening of the spinal extensors, lengthening of the abdominals and hip flexors. Studies have shown that during pregnancy the abdominal muscles become insufficient. Exercises during pregnancy have been shown to improve maternal fitness and well being. But very few studies have evaluated the efficiency of exercises during pregnancy on increasing the core abdominal muscle strength. Local core muscle consists of transverse abdominis, multifidii, pelvic floor muscles and diaphragm. It is observed that there is a correlation between core muscle strength and incidence of low back pain. Several studies have shown that at least 50% of women experience some kind of back pain during some period of pregnancy. The etiology and pathogenesis of back pain related to pregnancy is unclear. Most hypotheses have been focused on changed load resulting from increased weight and decreased stability of the pelvic girdle due to hormonal changes. Some studies have revealed a correlation between circulating levels of the hormone relaxin and pelvic pain in pregnancy; while others have found no such correlation. The three factors related to the development of back pain were abdominal sagittal diameter, transverse diameter and depth of the lumbar lordosis. Ostgaard et al. showed that rate of these complications in athletic women was less than nonathletic women. Meanwhile it is unclear in non-athletic pregnant women if exercise can reduce the intensity of low back pain. The study shows that no strong evidence exists concerning the effect of physical therapy interventions on the prevention and treatment of back and pelvic pain related to pregnancy. It is suggested in Cochrane review done on interventions for preventing and treating pelvic and back pain in pregnancy that more research in areas of education in early pregnancy on specially-adapted exercises, preventive studies beginning early in pregnancy will be helpful.
Thus the purpose of the current study is to find out whether core muscle strengthening helps in prevention of low back pain. If not there is a scope of further research in formulating better exercise programs for this population.

Need for study
As we all know in 2nd trimester the abdominal girth increases progressively contributing to weakness of core muscle which in return compromises posture trunk stability and motion, respiration etc. These biomechanical changes in musculoskeletal system are superimposed by effect of hormone relaxin thus the chances of developing low back pain during 2nd trimester increases. The effect of relaxin reduces static stability. And increasing size of uterus leading to elongation and weakness of abdominal muscles reduces dynamic stability. There are no strong measures to increase the static stability that is stability given by ligaments. Thus it is worthwhile to see the effect of improving the dynamic stability by strengthening exercises which is the essential step towards prevention of low back pain.

Hypothesis

It is observed that more than two thirds of pregnant women have back pain. And this pain increases as the pregnancy advances and interferes with activities of daily living. Exercises are given in antenatal period for low back pain but prevention of low back pain with exercises would be of great help for all pregnant mothers. There are many anatomical and physiological changes that take place in women's body during pregnancy. But it is said that pregnancy should not be considered as state of confinement. It is observed in that there is reduction in the core muscle strength in 2nd and 3rd trimester. But after 2nd trimester cardiovascular changes are seen in females after lying in supine position, thus in this study females in only 2nd trimester are included.Primigravid females without any complaints of low back pain will be the part of this study. According to guidelines of American college of obstetricians and gynecologists exercising during high-risk pregnancies may cause complications, such as increased fetal heart rate, intrauterine growth restriction, or fetal bradycardia, which can be caused by vagal reflex, cord compression, or fetal head malposition. Thus, females with pre-eclampsia, diabetes mellitus, placenta previa, incompetent cervix, multiple pregnancies will be excluded. To understand the efficacy of our strengthening program an additional group of nulligravid will be included. Same protocol will be given to them. Core abdominal strength will be checked pre and post intervention by using pressure biofeedback unit. Rolland Morris questionnaire will be used as an outcome measure for low back pain. Our main aim of the study is to understand if low back pain can be prevented by giving core strengthening program in 2nd trimester. Back pain in pregnancy has many contributing factors. The effect of pregnancy related hormone Relaxin and Estrogen affect the static stability of joints creating joint laxity. This is one of the important causes of low back pain and pelvic girdle pain during pregnancy. The ligament laxity is superimposed by progressive core abdominal muscle weakness from second trimester onwards. This is the time when the uterus starts growing in size, abdominal muscles get stretched and elongated which leads them to weakness. This is the main cause of low back pain during pregnancy. Along with this there is increase in the body weight which is one more contributing factor. Increase in the weight causes altered mechanics at lumbar level. There is forward shift of line of gravity which puts stress over intervertebral discs, ligaments, facetal joints etc. This pain is more likely to persist throughout the pregnancy and sometimes after the delivery. Out of all these contributing factors we cannot work on static stability but we can definitely improve the dynamic component of it that is muscle strength. It is obseved in various studies done on general population that core muscle weakness corelates with low back pain Core muscles strengthening have shown to reduce the incidence of low back pain in general population.  A study was carried out in pregnant population which concludes that there is corelation between low back pain and core muscle weakness. In present study the proven phenomenon of core strenthening to prevent low back pain is being tested in pregnant population. It was found out in one study that occurrence and size of diastasis recti abdominis is significantly more in females who didn't follow specific core strengthing program. In this study the incidence diastasis recti abdominis will be less as specific core strenthening exercises are given. In turn it will reduce the chances of pelvic pain in this population. The present study is a randomized control trial with total sample size of 210 which will be recruited by computerized random table allocation technique. The study has three sub groups including primi gravid intervention (Group A), primi gravid control group (Group B), and a group of age matched nulli-gravid females (Group C) selected purposively for matching the exercise intensity effects. Exercises intervention for core strengthening will be given for 6 weeks/ 5 days per week to A and C. Abdominal core muscle strength will be assessed pre and post intervention by using a pressure biofeedback device while presence and intensity of low back pain will be scored by the Rolland Morris disability index. Statistical analysis for intra group core strength will be done by paired 't' test and inter group by One way ANOVA while back pain by the test for intra group by Wilcoxon sign rank test and Kruskal Wallis test for inter group with alpha set at p<0.05
Non compliance shall be considered if the subjects perform less than 80% of the days of exercise training, i.e. less than 24 days out of the total 30 days of exercise training as logged in the exercise diary.
Exercise protocol will include simple core strengthening exercises which will be safe to practice during pregnancy and easy to understand. Subjects will be provided with exercise charts. Exercise prescription given by guidelines of American college of obstetrics and gynecology
Intensity; measured on RPE up to somewhat hard
Repetition; 10 repetition of each exercise 1 set each per day with an increment of 20% per week
Frequency: 20 to 30 min based on RPE, each day 5 times in a week.
Exercises to be given: 11-13
1) Core activation
2) Core with head lift
3) Core with straight leg raise
4) Core with bend leg fall out
5) Pelvic floor muscle strengthening
6) Core with hip abduction in side lying
7) Core with hip knee flexion without heel touch
8) Quadruped with pelvic tilts
9) Quadruped with arm lift
Here we assume that patients in control group will have reduction in core strength. Also they might develop low back pain. Whereas patients in intervention group will not have any complaint of low back pain. The core strength may increase or may remain the same. And we expect nulligravid group to have definite increase in core strength assuming the protocol to be efficient enough.
Data will be analyzed using paired and unpaired't' test.

Discussion

Low back pain during pregnancy and after delivery is one of the major issues. Patients usually get recurrent low back pain. Use of NSAID for pain management in pregnancy is should be rigouroustly restricted19.Thus the safer solution for this pain is physiotherapy. It is always better to give an intervention before the condition sets in rather than waiting for the condition and then treating the same.
Hence exercise intervention at this point of time can help the female to prevent low back pain during pregnancy6. Specific exercises targeting the core muscle group will be given for 6 weeks of duration17. In this duration subjects have been asked to follow the protocol as home exercise program. Here we should consider the fact that effect of relaxin and progressive weakness of abdominals on account of increase in the size of uterus are going to hamper the strengthening process. There could be increase in the strength of muscles or the strength might remain the same. Even if there is no detectable change in the strength it can be concluded that the core strenth has increased. Because reduction in core strength is expected due to numerous physiological changes. Thus even if the strenth is maintained there will be prevention of low back pain.

Clinical Message

Prevention is better than cure. These exercises given in antenatal period will prevent low back pain in pregnancy and after delivery. The exercises are safe and easy to understand. Exercises can be practices as group therapy or can be given as home exercise program.

Bibliography

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How to Cite this Article: Mhalagi P, Rairikar S, Shimpi A. Effectiveness Of Core Muscle Strengthening on Prevention of Low Back Pain in 2nd Trimester Primigravid Females. Journal Medical Thesis 2015  Jan-Apr ; 3(1):19-22.

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