Vol 3 | Issue 2 | May - Aug 2015 | page:3-7 | Archana Bodhale, Nilima Bedekar.

Author: Archana Bodhale[1], Nilima Bedekar[1].

[1] Department of Musculoskeletal Physiotherapy, Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, Thube Park, ShivajiNagar, 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 Bedekar
Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, 12, Thube Park, Shivaji Nagar, Pune - 411005, Maharashtra.
Email: nilimabedekar@yahoo.com

 Abstract

Background: Osteoarthritis (OA) is the most common type of arthritis and knee OA, being highly prevalent, accounts for as much or more lower extremity disability. Limited disease-modifying treatment exists and still under investigations, and knee OA may progress from a dynamic process of injury and repair to irreversible joint damage requiring joint replacement to treat the unrelenting pain and/or significant disability. Nonsurgical management is an important first step to prevent disability and maintain quality of life in the growing number of people with knee OA[1]. In clinical practice, physiotherapists tailor multicomponent interventions to the needs of the individual with knee OA in order to attain the goals of treatment. For example, physical agents may be administered as adjunctive to exercise interventions. Efficacy of therapeutic ultrasound (US) and interferential therapy (IFT) is of particular interest as this is the physical agent most commonly used by physiotherapists for treatment of painful musculoskeletal conditions and, therefore, widely available[1]. Electrotherapeutical modalities of rehabilitation are important resources in the treatment of musculoskeletal pain[2]. Theoretical, biological, and clinical rationales for the use of US and IFT in the management of nonsurgical knee OA have been reported. Besides different sites of action, the combination of interferential therapy and ultrasound is more effective than each of them separately because it provides localized analgesia on previous detected painful areas. Despite the fact that US and IFT are an adjunctive therapy, the effectiveness of specific combinations of interventions for knee OA has yet to be established[1]. The benefits of both modalities may be achieved at the same time, making the therapy time efficient for the therapist and patient[3].
Hypothesis: There will be improvement with combination therapy on pain, range of motion and function in osteoarthritis of knee.
Clinical Importance: Help us formulate a better training approach osteoarthritis of knee management. By combining the two treatment modalities, none of the individual effects of the treatments are lost, but the benefit is that lower treatment intensities can be used to achieve the same results, & there are additional potential benefits in terms of outcome measure[4].
Future Research: Further study with the long term follow up could be done to see the effect of combination therapy.
Keywords: Combination Therapy, Osteoarthritis, Knee, Pain.

Introduction

Osteoarthritis (OA) is the most common type of arthritis and knee OA, being highly prevalent, accounts for as much or more lower extremity disability. Limited disease-modifying treatment exists and still under investigations, and knee OA may progress from a dynamic process of injury and repair to irreversible joint damage requiring joint replacement to treat the unrelenting pain and/or significant disability. As the population ages and at the same time is becoming increasingly heavier, the prevalence of knee OA and the associated economic and personal burden are expected to rise. Nonsurgical management is an important first step to prevent disability and maintain quality of life in the growing number of people with knee OA[1]. In clinical practice, physiotherapists tailor multicomponent interventions to the needs of the individual with knee OA in order to attain the goals of treatment. For example, physical agents may be administered as adjunctive to exercise interventions. Efficacy of therapeutic ultrasound (US) and interferential therapy (IFT) is of particular interest as this is the physical agent most commonly used by physiotherapists for treatment of painful musculoskeletal conditions and, therefore, widely available[1]. Electrotherapeutical modalities of rehabilitation are important resources in the treatment of musculoskeletal pain[2]. Theoretical, biological, and clinical rationales for the use of US and IFT in the management of nonsurgical knee OA have been reported. In pulsed ultrasound therapy, therapeutic acoustic radiation is transmitted into the target tissue via US as high-frequency pressure waves generated by a piezoelectric crystal in the sound head of the US device. These pressure waves produce mechanical effects and/or thermal effects aiming to promote tissue healing, favour microcirculation and vascular permeability, promote muscle relaxation stimulate angiogenesis, and increase the metabolism and permeability of the cell membrane, thereby justifying its analgesic effects[1,2].  IFT is a popular treatment for pain and dysfunction associated with musculoskeletal conditions. Interferential electrotherapy with amplitude modulated at low frequencies reaches deep muscles and nerves, stimulates voluntary muscles, promotes an increase in peripheral blood flow, accelerates bone healing, and reduces pain. There is evidence that Interferential Therapy (IFT) may inhibit the nociceptive stimulus, possibly due to the stimulation of large diameter afferent fibres that inhibit the entrance of algid stimuli into the posterior horn of the medulla through small diameter afferent fibres [3]. Besides different sites of action, the combination of interferential therapy and ultrasound is more effective than each of them separately because it provides localized analgesia on previous detected painful areas. Ultrasound may reduce muscle tension and increases microcirculatory flow at tender points and that interferential current may increase pain threshold, we hypothesize that the Combined Therapy with Ultrasound and Interferential Current might be of greater clinical benefit than individual therapies in OA[3]. Despite the fact that US and IFT are an adjunctive therapy, the effectiveness of specific combinations of interventions for knee OA has yet to be established[1]. The benefits of both modalities may be achieved at the same time, making the therapy time efficient for the therapist and patient[4].

Hypothesis

A lot studies have been done on osteoarthritis with use of different modalities but unfortunately combination therapy is often missed which in turn is a new modality in rehabilitation and there are a few studies done only for combination therapy[2, 3]. At the present time and in the absence of any specific evidence of additional effect when used in combination, this would seem to be the sole justification for the modality[5]. Evidence to support the use of combination therapy in patients with fibromyalgia has been reported[2, 3], yet, because the treatment pattern of each modality varies, It would be useful to determine if combination therapy offered similar benefits in patients with osteoarthritis of knee.  By combining the two treatment modalities, none of the individual effects of the treatments are lost, but the benefit is that lower treatment intensities can be used to achieve the same results, & there are additional potential benefits in terms of outcome measure[5]. Many unanswered questions still exist regarding the optimal treatment modality in treating osteoarthritis of knee. Hence it is important to know whether combination therapy or interferential therapy which is more effective when compared to each other in the patients with osteoarthritis of knee. Thus, it is hypothesized that combination therapy is more effective as compared to IFT in pain, knee ROM and functional status of OA knee patients. 60 subjects will be participating in this study. Subjects who fulfil the inclusion criteria will be included in the study and a written consent will be taken from them.
Before conducting the actual treatment, the patients of osteoarthritis of knee will be evaluated by using an evaluation format. Patients will be assessed on the first day before treatment and at end of 6th day for following:
a) Pain evaluation by numerical rating scale
b) Knee range of motion
c) Knee pain scale

Patients will be randomly assigned into 2 groups (group A and group B of 30 each) Each group will receive conventional therapy.
Apart from the common conventional therapy of these groups will receive additional therapy:

GROUP A: Combination therapy (IFT+US)

GROUP B: Interferential therapy

Demographic data will be collected for each patient including age, sex, occupation, height, weight, duration of symptoms, presence of symptoms, medications and present activity level. For pain evaluation Numerical rating scale will be used. Knee pain scale will be used to assess functional ability of patient.
Both the groups will receive treatment for 6 sessions for 6 days
GROUP A: COMBINATION THERAPY (IFT+US)
Patient Position: Supine Lying
Technique:
Three Interferential pad electrodes will be placed around the affected knee joint.
US treatment head to be applied over the site of maximum pain of the affected knee joint.
The patient will be explained that he will feel a tingling sensation which should not be unpleasant
US dose:
Frequency = 1 MHz
Intensity = 0.8 W/cm2,
Mode = Pulse (1:1)
Duration = 10 minutes
Interferential dose:
Frequency = 4000 Hz
Base = 90Hz
Sweep = 40Hz
AMF / Beat Frequency = 90-130 Hz
Quadripolar / Two channel
Duration = 10 minutes
First US will be turned on , followed by the IFT (parameters as above)
Starting with the US head over the maximum painful area of the joint, gradually the IFT output intensity will be increased until the `normal' tingling is encountered by the patient[5].

GROUP B: INTERFERENTIAL THERAPY
Patient Position: Supine Lying
Technique:
Four interferential pad electrodes will be placed around the affected knee joint.
The patient will be explained that he will feel a tingling sensation which should not be unpleasant.
Interferential dose:
Frequency = 4000 Hz
Base = 90Hz
Sweep = 40Hz
AMF / Beat Frequency = 90-130 Hz
Quadripolar / Two channel
Duration = 10 minutes
IFT will be turned on (parameters as above)
Gradually the IFT output intensity will be increased until the `normal' tingling is encountered by the patient[5].

Conventional Therapy
Knee Exercises:
1. Isometric quadriceps contraction
Position and technique, sitting with straight out toes pointed up to the ceiling. Tighten the quadriceps muscles on top of the thigh. Patient should see knee cap move up toward the hip. Patient's knee may push down toward the floor and foot may come on the floor.
2. Terminal knee extension with lower limb in lateral rotation.
Patient position and procedure: Supine. A towel or bolster will be placed under the knee to support it in flexion. Patient will be asked to extend the knee in the terminal 30 degrees only.
3. Dynamic exercises for knee joint
Dynamic quadriceps
Position and technique in sitting patient extends the knee from 90 degrees to full extension
Hamstring curls-
Prone: Place a small towel roll under femur just proximal to the patella to avoid compression of the patella between the treatment table and femur. Have the patient to flex the knee to only 90 degrees
4. Mini squats
Patient will stand with feet 15cms apart (roughly shoulder width) and squat till 15 degrees initially and gradually progress to 45 degree.
Maintain for 5 seconds.
Frequency: 5 reps in sets of three with adequate rest pause.
5. Partial lunges
The patient has to assume a step forward stance position and rock his body weight forward, allowing the knee to flex slightly (approximately 30 degrees) and then rock backwards and control knee extension.
6. One leg balance
The patient will stand on his left foot with relaxed, upright posture and with his right leg flexed at the knee so that the right foot is off the floor or ground. His left, weight-bearing leg will be lightly flexed at the knee, hip and ankle. The patient will hold this position for 10 to 20 seconds and then will rest for 10 to 20 seconds, and this will be repeated twice more. After a brief rest, complete three similar repetitions will perform with his right leg as the weight-bearing limb.

Self stretching will be taught for the tight muscles on evaluation and given as home program.
1. To stretch the hip flexors:
Patient position: Prone lying with the knee flexed on the side to be stretched.
Procedure:
Have the patient grasp the ankle on that side (or place a towel or strap around the ankle to pull on) and flex the knee.
2. To stretch the hip extensors:
Patient position: Supine with a towel under the thigh.
Procedure:
Have the patient perform straight leg raising with one extremity and apply the stretch force by pulling on the towel to move the hip into more flexion.
3. To stretch the hip abductors:
Patient position: Side-lying, with the leg to be stretched uppermost.
Procedure:
The bottom extremity is flexed for support and the pelvis tilted laterally so the waist is against the mat or floor.
Abduct the top leg and align it in the plane of the body.
While maintaining this position, have the patient externally rotate the hip and then gradually lower the thigh to the point of stretch.
4. To stretch the hip adductors:
Patient position: Standing in a fencer's position but with the hind leg externally rotated.
Procedure:
Have the patient shift the weight onto the front leg until a stretch sensation is felt along the medial thigh in the hind leg.
5. To stretch the knee flexors:
Patient position: Place the patient in prone with a belt or sheet strapped around the ankle and the other end placed over the shoulder and held in the hand.
Procedure:
Have the patient perform knee flexion with one extremity and apply the stretch force by pulling on the belt or sheet to move the knee into more flexion.

6. To stretch the knee extensors:
Patient position: Standing with the foot of the involved knee on a step.
Procedure:
Have the patient rock forward over the stabilized foot, flexing the knee to the limit of its range, then rock back and forth in a slow, rhythmic manner or hold the stretched position[6].

CORE STABILITY EXERCISE:
The patient is in supine lying with hip and knees flexed. Tactile cue will be given medially and inferiorly to anterosuperior iliac spine and lateral to rectus abdominis muscle.
Patient is then asked to pull in the lower abdomen.
Patient will be instructed prior to this to relax completely and that he has to draw the abdomen in without breathing in.
If the patient will be unable to do this, the procedure will be altered by allowing patient to draw the abdomen in without altering breathing pattern.
With the correct pattern of activation, narrowing of the waistline will be noted, with the smooth, slow and controlled contraction.

STATISTICAL ANALYSIS TESTS:
Intra group analysis will be by the paired t-test for assessment of range of motion while pain and function shall be assessed by Wilcoxon test. Inter group shall be by unpaired t-test for range of motion and Man-Whitney U-test for pain and function.

Discussion

There is a significant lack of research in this area. It is suggested that by combining US with IFT, the effects of each treatment modality can be achieved but lower intensities are used to gain the effect. The main advantage of such type of combination is said to be in localized, deeper lesions and trigger points to give better effect. The combination of US with IFT appears to give rise to less adverse treatment effects than are associated with the combination of US with Diadynamic Currents or other electrical stimulations[5].  The interferential electric current is characterized by a medium frequency wave with low frequency modulated amplitude[3]. IFT is widely used for pain control. The rationale for this was provided by the gate control therapy of pain proposed by Melzack and Wall. The input of the mechanoreceptors reduces the excitability of the nociceptor responsive cells to pain generated stimuli; thus producing a presynaptic or segmental inhibition.  Therapeutic US is frequently used in physiotherapy clinics to treat various musculoskeletal disorders. Non thermal effects include molecular vibration, which increases cell membrane permeability and thereby enhances metabolic product transport[7]. Tim Watson the great pioneer, electrotherapy specialist suggests that a more effective treatment depth can be gained with the US ‑ IFT combination though there is no direct evidence for this. Exposure of a peripheral nerve to US reduces the membrane resting potential by increasing its permeability to various ions specially Sodium and Calcium. Because of this adjusted permeability, the nerve membrane is taken closer to the point where it depolarizes, though doesn't usually make the nerve fire. The simultaneous application of the Interferential current through the nerve induces the depolarisation potential, though it will take a smaller current than usual to achieve this due to the potential effect of the US. As a treatment, it is appropriate when the therapeutic effects of US and IFT are both justified. Currently and in the absence of any specific evidence of additional effect when used in combination, this would seem to be the sole justification for the modality. The individual doses for the US and IFT should be those which are appropriate for the condition and the required effects. There is no research that 'special' treatment doses are required. It should be noted that the intensity of the IFT required to gain the usual effect is likely to be lesser than normal[5]. Specifically in osteoarthritis, Erkan Kozanoglu et al. demonstrated that phonophoresis and ultrasound both therapeutic modalities were found to be effective. Ibuprofen PH was not superior to conventional ultrasound[7]. Boyaci A et al. showed that in comparison of ketoprofen phonophoresis, ultrasound, and short-wave diathermy in patients with OA knee there was no significant difference between the three modalities in terms of efficacy. There was also no significant difference between the three groups in terms of post-treatment general evaluation of the physician and the patient.8 Atamaz FC et al. studied that use of physical therapy agents like transcutaneous electrical nerve stimulation (TENS), interferential currents (IFCs), and shortwave diathermy (SWD) with exercise training and education provided additional benefits in improving pain as compared to sham intervention with exercise training and education in knee OA[9]. Pelin Oktayoğlu et al found that phonophoresis (PH) and conventional US both therapeutic modalities were effective. They suggest neither therapy is superior to the other but PH can improve painless walking duration more successfully than US[10]. Gundog M et al demonstrated the superiority of the IFC with some advantages on pain and disability outcomes when compared with sham IFC for the management of knee osteoarthritis. However, the effectiveness of different amplitude-modulated frequencies of IFC was not superior when compared with each other[11]. Adalberto Loyola Sánchez et al. showed that low intensity pulse ultrasound (LIPUS) has a benefic effect over pain and functionality/severity in patients with Kellgren and Lawrence grade 2 and 3 osteoarthritis of the knee[12] Dr John Z Srbely demonstrated that US demonstrates the ability to evoke a broad range of therapeutically beneficial effects which may provide safe and effective applications in the management of osteoarthritis[13]. Cakir S et al. study demonstrated that all assessment parameters in patients with OA knee significantly improved in all groups i.e. continuous US, pulsed US and sham US without a significant difference. This result suggested that therapeutic US [14]. Yang PF et al showed that Ultrasound treatment significantly alleviates joint symptoms, relieving joint swelling, increasing joint mobility and reducing inflammation, in osteoarthritis patients[15]. Tascioglu F et al, suggested that pulsed ultrasound therapy is a safe and effective treatment modality in patients with knee OA[16] Ozgönenel L et al study suggested that therapeutic US is safe and effective treatment modality in pain relief and improvement of functions in patients with knee OA[17]. C. Zeng et al showed that pulse ultrasound (PUS), with a greater probability of being the preferred mode, is more effective in both pain relief and function improvement when compared with the continuous US[18]. Tatiana F. Almeida et al showed that combination therapy with pulse US and IFT can be an effective therapeutic approach for pain and sleep manifestations in FM[3]. Thus, the study hypothesis states that a combination therapy is more effective as compared to IFT in pain, knee ROM and functional status in patients with OA knee.

Clinical Importance

Help us formulate a better treatment option for management of osteoarthritis of knees. By combining the two treatment modalities, none of the individual effects of the treatments are lost, but the benefit is that lower treatment intensities can be used to achieve the same results, & there are additional potential benefits in terms of outcome measure[5].

Future Direction

Further study with the long term follow up could be done to see the effect of combination therapy.

Bibliography

1. MacIntyre NJ, Busse JW, Bhandari M. Physical Therapists in Primary Care Are Interested in High Quality Evidence Regarding Efficacy of Therapeutic Ultrasound for Knee Osteoarthritis: A Provincial Survey. The Scientific World Journal. 2013
2. Moretti FA, Marcondes FB, Provenza JR, Fukuda TY, de Vasconcelos RA,
Roizenblatt S. Combined therapy (ultrasound and interferential current) in patients with fibromyalgia: once or twice in a week? Physiother Res Int. 2012 Sep; 17(3):142-9.
3. Almeida TF, Roizenblatt S, Benedito-Silva AA, Tufik S. The effect of combined therapy (ultrasound and interferential current) on pain and sleep in fibromyalgia. Pain. 2003 Aug; 104 (3):665-72
4. Robertson V, Ward A, Low J and Reed A. Electrotherapy Explained Principles and Practice. 4th Edition. Heidi Harrison Publishers, 2010. Pg. No. 167-208, 251-305 http://www.electrotherapy.org/modality/combination-therapy 5
6. Kisner C., Colby L. Stretching for impaired mobility. Therapeutic Exercise. Philadelphia: F.A.Davis Company; 2012. p. 108-112.
7. Kozanoglu, Erkan, et al. "Short term efficacy of ibuprofen phonophoresis versus continuous ultrasound therapy in knee osteoarthritis." Swiss medical weekly133.23-24 (2003): 333-338.
8. Boyaci A, Tutoglu A, Boyaci N, Aridici R, Koca I. Comparison of the efficacy of ketoprofen phonophoresis, ultrasound, and short-wave diathermy in knee osteoarthritis. Rheumatol Int. 2013 Nov; 33(11):2811-8.
9. Atamaz FC, Durmaz B, Baydar M, Demircioglu OY, Iyiyapici A, Kuran B, Oncel S, Sendur OF. Comparison of the efficacy of transcutaneous electrical nerve stimulation, interferential currents, and shortwave diathermy in knee osteoarthritis: a double-blind, randomized, controlled multicenter study. Arch Phys Med Rehabil. 2012 May; 93(5):748-56.
10. Oktayoglu P.; Gür A.; Yardımeden I. Calayan M.; Cevik F.; Bozkurt M. et. al. Comparison of the efficacy of phonophoresis and conventional ultrasound therapy in patients with primary knee osteoarthritis. Erciyes Medical Journal 2014; 36 (1) : 11-18.
11. Gundog M, Atamaz F, Kanyilmaz S, Kirazli Y, Celepoglu G. Interferential current therapy in patients with knee osteoarthritis: comparison of the effectiveness of different amplitude-modulated frequencies. Am J Phys Med Rehabil (2012) Feb; 91(2):107-13.
12. Sánchez A, Wakamatzu M, Zamudio J, Casasola J, Cuevas C, González A et al. Effect of low-intensity pulsed ultrasound on regeneration of joint cartilage in patients with second and third degree osteoarthritis of the knee. Reumatol Clin (2009); 5 (4):163-167.
13. Ultrasound in the management of osteoarthritis: part I: a review of the current literature Dr John Z Srbely, DC, DAc, PhD (candidate)* 0008-3194/2008/30–37/$2.00/©JCCA 2008
14. Cakir S, Hepguler S, Ozturk C, Korkmaz M, Isleten B, Atamaz FC. Efficacy of therapeutic ultrasound for the management of knee osteoarthritis: a randomized,controlled, and double-blind study. Am J Phys Med Rehabil. 2014 May; 93(5):405-12.
15. Yang PF, Li D, Zhang SM, Wu Q, Tang J, Huang LK, Liu W, Xu XD, Chen SR.Efficacy of ultrasound in the treatment of osteoarthritis of the knee. Orthop Surg. 2011 Aug; 3(3):181-7.
16. Tascioglu F, Kuzgun S, Armagan O, Ogutler G. Short-term effectiveness of ultrasound therapy in knee osteoarthritis. J Int Med Res. 2010 Jul-Aug; 38(4):1233-42.
17. Ozgönenel L, Aytekin E, Durmuşoglu G. A double-blind trial of clinical effects of therapeutic ultrasound in knee osteoarthritis. Ultrasound Med Biol. 2009 Jan; 35 (1):44-9.
18. Zeng C, Li H, Yang T, Deng ZH, Yang Y, Zhang Y, Ding X, Lei GH. Effectiveness of continuous and pulsed ultrasound for the management of knee osteoarthritis: a systematic review and network meta-analysis. Osteoarthritis Cartilage. 2014 Aug; 22 (8):1090-9.

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Vol 3 | Issue 2 | May - Aug 2015 | page:16-18 | Shamika Bhatwadekar,  Apurv P Shimpi, Savita Rairikar.

Author: Shamika Bhatwadekar[1],  Apurv P Shimpi[1], Savita Rairikar[1].

[1] Department of Community 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: 2015.

Address of Correspondence
Dr. Savita Rairikar
Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, 12, Thube Park, Shivaji Nagar, Pune - 411005, Maharashtra.
Email: savitarairikar@sha.edu.in

 Abstract

Background: Women's health issues have gained lot of importance in recent years. Lack of education, high illiteracy rate and increasing level of poverty are making health improvements for women in India extremely difficult. There are still certain gynaecological issues which are not addressed in India. In Maharashtra it has been shown that many women are not involved in their personal health care decisions. Urban women with higher educational status have been shown to involve in their health care decision. Addressing gynaecological health of women is a necessity in forthcoming century. On this background this study aims to know the extent of knowledge regarding gynaecological health issues among females in studied city. It also evaluates their attitude towards these problems and their help seeking behaviour towards it. It is hypothesized that level of education has highest impact on attitude and behaviour towards gynaecological problems amongst females. Also socio economic status have impact on the same whereas geographical and age wise variation may or may not have impact on attitude and behaviours amongst females. A cross-sectional questionnaire based study will be performed on 3500 females in age group of 18 to 80 years in Pune district in state of Maharashtra. All females with medical and paramedical background will be excluded from the study. Questionnaire with LIKERTS scale would be pre-validated by the experts in the field for its content validity. After establishing it's inter and intra rated reliability an interview would be performed. Descriptive analysis shall be done for the entire data with Chi squared test for significance. Comparison of the knowledge, attitude and practices between the groups based on geographical, educational, socio economical and age wise variations would be done by the Mann-Whitney U test.
Clinical importance: Knowing about the extent of knowledge, their attitude and their help seeking behaviours towards gynaecological issues would help to determine the target population group for health promotion and improve quality of life among Indian female population.
Keywords: Women's health, gynaecological issues, Pune, Maharastra.

Introduction

This project comes exclusively under Women's health in Community Physiotherapy. It has been undertaken as a part of health promotion of women's health in the community. As for the health promotion, it is a part of broader of public health in community [1]. WHO defines health promotion as 'all organised measures (whether public or private) to prevent disease, promote health and prolong life among the population as a whole' [2]. In this study all the gynaecological issues faced by women are highlighted so that they can be prevented with proper knowledge at a very early stage thus promoting healthy lifestyle in women of our society. A woman plays a multifaceted role contributing to the progress of society balancing her personal as well as professional life. Women have responsibilities to effectively manage their domestic as well as professional life. In order to deal with these stresses of family as well as professional life, a Woman should have a healthy lifestyle. In all this, gynaecological health of a woman plays a very important role. Gynaecological disorders can have a considerable impact on women's reproductive status, mental and emotional status and quality of life [3]. Gynaecological disorders which are taken into account are pelvic floor dysfunction, menstrual issues and menopause. Thus this study aims to know the extent of knowledge regarding gynaecological health issues among females in this city. It also evaluates their attitude towards these problems and their help seeking behaviour towards it. This project is undertaken in a city which represents a blend of both traditional and modern Indian culture. It is well known for private sector institute of information technology that attracts many students and professional from all over the India representing highest educational status.

Hypothesis

It is hypothesized that level of education has highest impact on attitude and behaviour towards gynaecological problems amongst females. Also socio economic status have impact on the same whereas geographical and age wise variation may or may not have impact on attitude and behaviours amongst females. After obtaining approval from ethical committee of institution a cross sectional questionnaire based study will be performed on 3500 females in age group of 18 to 80 years in Pune district in state of Maharashtra. All females with medical and paramedical background will be excluded from the study. Pune city is divided into 7 sections based on the electoral constituencies. The target population of 500 females per constituency would be selected by stratified random sampling wherein each constituency zone shall be considered as 1 stratum. The females shall be selected from those included in the voters list based on the population number of respective constituency wherein the population number (n) shall be divided by 500 and every kth female from the n population shall be included. E.g., if the population of zone A is 43,256, every 87th female shall be included. If not consented, the inclusion shall be of the 174th, 261st, 384th and so on. Only the females of the selected number shall be included per stratum. Questionnaire with LIKERTS scale would be pre-validated by the experts in the field by face validity. After establishing it's inter and intra rated reliability an interview would be performed. Descriptive analysis shall be done for the entire data with Chi squared test for significance. Comparison of the knowledge, attitude and practices between the groups based on geographical, educational, socio economical and age wise variations would be done by the Mann-Whitney U test.

Discussion

Many studies have been done evaluating knowledge, attitude and perception regarding gynaecological issues amongst women globally. Pelvic floor dysfunction is common and undermines the quality of life in at least one third of adult female population and is a growing component of health care needs. Davis K et al (2003)[3] concluded that Functional pelvic floor problems are perceived to have low priority compared with other health disorders, and treatment remains sub-optimal. Inaccurate knowledge, myths and misconceptions of the incidence, cause and treatment of pelvic floor dysfunction abound. Education needs to be given greater priority. Buumman MB et al (2013) [4] studied women perception of pelvic floor dysfunction and their help seeking behaviours towards it. They found that all women suffered from pelvic floor dysfunction such as urinary incontinence, pelvic floor pain, prolapse, haemorrhoids, anal fissure, constipation and dyspareunia. They hoped their problems would improve by themselves. The women, in their study, talked to close initiates (female relatives and friends who had had deliveries themselves), who confirmed that the problems were an inevitable consequence of vaginal delivery and that there were no real treatment options. The women indicated they needed professional information about their pelvic floor problems but were ashamed to talk about them outside their inner circle. Most common pelvic floor dysfunctions reported by the authors were urinary incontinence, faecal incontinence and pelvic organ prolapse. Physiotherapists have become involved in clinical management of urinary incontinence as the presumptive underlying impairments (i.e., decreased pelvic floor muscle strength and/or endurance, decreased awareness of bladder irritants) fall within the scope of physiotherapy practice according to the Guide to Physical Therapist Practice[5]. A systematic review performed by Havey M (2003)[6] concluded that Postpartum Pelvic floor exercises appear to be effective in decreasing postpartum urinary incontinence. Dumoulin et al (2010)[7] reviewed that widespread recommendation that Pelvic floor muscle training be included in first-line conservative management programmes for women with stress, urge, or mixed, urinary incontinence. Other gynaecological problems taken into consideration in this study are menopause and menstrual issues. Hamid S et al (2014)[8] studied women's knowledge, attitude and perception towards menopause and hormone replacement therapy. They concluded that there is poor knowledge about menopause and HRT among the participants. Level of knowledge was associated with the level of education. There was a positive attitude towards menopause, with women suffering the most from menopausal symptoms showing positive attitude towards HRT. Also Memon FR et al (2014)[9] studied knowledge, attitude and practices regarding menopause among highly educated Asian women in their midlife. They found that despite the fact that the majority of women felt well informed and exhibited a positive attitude towards menopause, a strong urge for more knowledge was expressed for which Health professionals are an important information resource. Of 60% of cases, only 5% of participants knew about hormone replacement therapy and none knew about available alternative therapies. A study performed by Kemmler W et al (2015)[10] concluded high anti-fracture efficiency of multipurpose exercise programs in post menopausal women. Another study by Basat H (2014)[11]concluded that mixed loading exercise programmes combining jogging with other low-impact loading activity and programmes mixing impact activity with high-magnitude exercise as resistance training appear effective in reducing postmenopausal bone loss at the hip and spine. It highlights the role of physiotherapy in improving quality of life in post menopausal women. Also physical therapy plays an important role in menstrual issues faced by young women. Polycystic ovarian syndrome (PCOS) is common disorder with prevalence ranging from 2.2 percent to 26 percent. Most reports have shown adult women in age group of 18 to 45 years[12]. Obesity increases some features of PCOS[13]. In a study performed by Li Y et al (2011)[14], PCOS has been shown to decrease quality of life among young females. A study performed by Steiner Victorin E et al (2013)[15] has shown that there is improvement in symptoms of PCOS and quality of life in young women with physical exercise. Thus a physical therapist plays a prime role in women's health problems in terms of their prevention and health promotion. Not only exercises play a major role but exercises along with various other physical therapy modalities can also help in overcoming women's problems[15]. This study typically falls under the domain of Community Physiotherapy. On the basis of the results obtained from this study target population can be identified to carry out various prevention and health promotion programmes. It could act as an important factor in public health care system and improve quality of life in female population by screening and identifying the problem at its initial stage and avoiding its further progression.
Bibliography

1. Perreault K. Linking health promotion with physiotherapy for low back pain: a review. J Rehabil Med. 2008 Jun;40(6):401-9.
2.Glossary of gobalisation trade and health terms [Internet]: World health organization:2006: [cited on 23 April 2015].Available from
http://www.who.int/trade/glossary/story076/en/print.html
3. Davis K, Kumar D. Pelvic floor dysfunction: a conceptual framework for collaborative patient-centred care. J Adv Nurs. 2003 Sep;43(6):555-68.
4.Buurman MB, Lagro-Janssen AL. Women's perception of postpartum pelvic floor dysfunction and their help-seeking behaviour: a qualitative interview study. Scand J Caring Sci. 2013 Jun;27(2):406-13.
5. "Women in History". National Resource Center for Women. Archived from the original on 2009-06-19. Retrieved on 22nd June 2015 2006.
6. Harvey MA. Pelvic floor exercises during and after pregnancy: a systematic review of their role in preventing pelvic floor dysfunction. J Obstet Gynaecol Can. 2003 Jun;25(6):487-98. Review.
7. Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2010 Jan 2O.
8. Hamid S, Al-Ghufli FR, Raeesi HA, Al-Dliufairi KM, Al-Dhaheri NS, Al-Maskari F, Blair I, Shah SM. Women's knowledge, attitude and practice towards menopause and hormone replacement therapy: a facility based study in Al-Ain, United Arab Emirates.J Ayub Med Coll Abbottabad. 2014 Oct-Dec;26(4):448-54.
9. Memon FR, Jonker L, Qazi RA. Knowledge, attitudes and perceptions towards menopause among highly educated Asian women in their midlife. Post Reprod Health. 2014 Dec;20(4):138-42.
10.Kemmler W, Bebenek M, Kohl M, von Stengel S. Exercise and fractures in postmenopausal women. Final results of the controlled Erlangen Fitness and Osteoporosis Prevention Study (EFOPS). Osteoporos Int. 2015 May 12.
11. Basat H, Esmaeilzadeh S, Eskiyurt N. The effects of strengthening and high-impact exercises on bone metabolism and quality of life in postmenopausal women: a randomized controlled trial. J Back Musculoskelet Rehabil. 2013;26(4):427-35. doi: 10.3233/BMR-130402. PubMed PMID: 23948830.
12. Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Prevalence of polycystic ovarian syndrome in Indian adolescents. J Pediatr Adolesc Gynecol. 2011 Aug;24(4):223-7.
13. Motta AB. The role of obesity in the development of polycystic ovary syndrome. Curr Pharm Des. 2012;18(17):2482-91. Review. PubMed PMID: 22376149.
14. Li Y, Li Y, Yu Ng EH, Stener-Victorin E, Hou L, Wu T, Han F, Wu X. Polycystic ovary syndrome is associated with negatively variable impacts on domains of health-related quality of life: evidence from a meta-analysis. Fertil Steril.2011 Aug;96(2):452-8. doi: 10.1016/j.fertnstert.2011.05.072. Epub 2011 Jun 24 Review.
15.Stener-Victorin E, Holm G, Janson PO, Gustafson D, Waern M. Acupuncture and physical exercise for affective symptoms and health-related quality of life in polycystic ovary syndrome: secondary analysis from a randomized controlled trial. BMC Complement Altern Med. 2013 Jun 13;13:131. doi: 10.1186/1472-6882-13-131.
16. R Baranitharan. Physiotherapy care for women's health. Jaypee Brothers Medical Publishers(P)Ltd.2010.Pg 1.

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Vol 3 | Issue 2 | May - Aug 2015 | page:12-15 | Sayli Kawatkar, Savita Rairikar, Apurv Shimpi.

Author: Sayli Kawatkar[1], Savita Rairikar[1], Apurv Shimpi[1].

[1] Department of Community Based Rehabilitation, Sancheti Institute College of Physiotherapy, Thube Park, Shivajinagar Pune, Maharashtra, India.
Institute at which research was conducted: Sancheti institute College of Physiotherapy, Thube park, Shivajinagar Pune 411005, Maharashtra.
University Affiliation of Thesis: Research hypothesis (synopsis) submitted for mpth registration to maharashtra university of health siences (MUHS), Nashik.
Year of Acceptance: 2014.

Address of Correspondence
Dr. Savita Rairikar,
Department of Community Based Rehabilitation, Sancheti Institute College of Physiotherapy, Thube park, Shivajinagar, Pune - 411005, Maharashtra
Email: savita_rairikar@hotmail.com

 Abstract

Background: Menopause is a condition caused by the depletion of ovarian function followed by cessation of menstruation in women. Due to the regional, cultural and level of activity variations, symptoms vary in rural and urban post menopausal women.
Objective: To find mobility with timed up and go test, body mass index with the formula weight in kilogram divided by height in meter square and quality of life with WHOQOL-BREF questionnaire in urban and rural post menopausal women. To compare the three parameters in rural and urban postmenopausal women and find out what parameters are affected in both the populations.
Methodology: 700 postmenopausal women below 60 years of age will be included in the study out of which 350 were from rural population and 350 were from urban population.After considering inclusion criteria written informed consent form will be taken. All participants will be assessed using the outcome measures. Comparison will be done of individual parameters in both the group of population. Also comparison will be done between the individual parameters in one group of population.
Result: Within the same group the comparison of parameters will be tested with the paired t test and Wilcoxon signed ranks test. The comparison between both the groups will be statistically significant with the unpaired t test and Mann-Whitney test.
Conclusion: Within the same group of population it would seen that women with higher body mass index will have reduced mobility and lower quality of life. In urban population the mobility was reduced but the quality of life was better compared to rural population. Whereas the body mass index will be lower in rural women than in urban women.
Key words: Body mass index, quality of life, mobility, postmenopausal women.

Introduction

Menopause is a condition caused by the depletion of ovarian function followed by cessation of menstruation in women. Modern medicine has significantly prolonged the life span of humans and most women spend one-third to half of their lifetime in post- menopause[1]. Information regarding experiences in menopause among different racial and ethnic groups should be given importance by healthcare personnel to provide appropriate and specific interventions[2,3].  Menopause is a degenerative transition associated with aging and loss of fertility. Women during menopause experience not only biological changes but also social and cultural changes. These changes make them more vulnerable to physical health problems and mental health disorders. Several studies in western countries have demonstrated that menopause related symptoms may impact health[4].Menopausal symptoms vary according to racial groups and areas of living. Vasomotor, sexual and psychological symptoms are more frequent among peri-menopausal and postmenopausal women[5-8]. During menopause, women often experience some symptoms which may affect their daily activities. Recent years, studies have shown that menopausal symptoms may affect health-related quality of life[8]. It is observed that there are dietary and nutritional variation seen in rural and urban postmenopausal women. This affects the height weight and thus the body mass index in them. Studies have shown that the body mass index is more in the urban women than the rural postmenopausal women[9]. Osteoporosis is a systemic disease in which bone density is reduced, leading to the weakening of the skeleton and increased vulnerability to fractures. It is a widespread disease in which about 75 million people are affected, mostly postmenopausal women. It is called “the silent disease” since there are very few associated symptoms; osteoporotic fractures are the chief clinical feature with an enormous burden on health-related quality of life and mortality[10]. Osteoporosis that is low bone mineral density can be caused due to the increased body mass index and low level of activities[10]. Osteoporosis can reduce mobility and might be painful, which may limit everyday activities, can lead to increasing isolation, which has a negative impact upon self-esteem, causes depression, and affects emotional state and quality of life[11-13]. The quality of life and body mass index along with the systemic illnesses affect the mobility of the individual. The level of activity differs in rural and urban population. The rural postmenopausal women were seen to be more active than the urban postmenopausal women. This was one of the reason the body mass index was more in urban women due to their sedentary lifestyle and the nutritional habits[14]. The educational level was also one of the factors contributing to the affection of the quality of life in the rural postmenopausal women than the urban women[12]. There are more facilities and better infrastructures available for the urban population and the literacy level is also higher in urban population than rural population. Thus the quality of life is better in urban than in rural postmenopausal women[13]. Need for the study was to find out what extent the menopause affects the quality of life rural and urban population. The difference in the body mass index and thus the mobility in the rural and urban post menopausal women are necessary to be considered. These three factors and their differences will help in further designing a wholistic programme specifically for the postmenopausal group of population and thus improve their physical fitness level and their quality of life.

Hypothesis

Within the same group of population the women who will be having higher body mass index will have reduced mobility. The quality of life will be better in urban than the rural post menopausal women. The body mass index will be lower in rural than in urban postmenopausal women due to level of activities and nutritional habits[15]. As body mass index is directly associated with the mobility, the later will be better in rural postmenopausal women.Women between the age group of 40 to 60 years who had attained natural menopause without hysterectomy and who were not on any hormonal replacement therapy and also without any recent traumatic, musculoskeletal or neurological injury were included in the study. Individual woman will be evaluated for the mobility and body mass index and a questionnaire will be given to them for the quality of life assessment.  For measuring mobility the timed up and go test the patient will be performed with the following instructions. The person may wear their usual footwear and can use any assistive device they normally use. Have the person sit in the chair with their back to the chair and their arms resting on the arm rests. Ask the person to stand up from a standard chair and walk a distance of 10 ft. (3m). Have the person turn around, walk back to the chair and sit down again. Timing begins when the person starts to rise from the chair and ends when he or she returns to the chair and sits down.The person should be given 1 practice trial and then 3 actual trial. The times from the three actual trials are averaged[16]. This test is used for elderly population but has also been used for normal adults[17-18]. Height and weight of the women will be measured. The body mass index will be calculated by the formula weight in kilogram divided by height in meter square. This formula has its validity and reliability already tested. The values of individual women were graded according to the standard ranges[19,20].
Underweight: BMI is less than 18.5[21].
Healthy: BMI is between 18.5 to 24.9[21].
Overweight: BMI between 25 to 29.9[21].
Obese: BMI is 30 or higher[21].

WHOQOL is a questionnaire used for checking the quality of life which will be given to the women individually and the questions in it were explained. The questionnaire will be given according to the individual language preference[22].

Statistical Analysis
Test of significance will be set at 0.05. The data analysis within the same group for timed up and go test and body mass index will be done by paired t test. WHOQOL-BREF questionnaire within the same group will be analysed by Wilcoxon signed rank test. For comparison in between two groups data analysis of timed up and go test and body mass index will be done by unpaired t test and for the WHOQOL BREF questionnaire will be done using Mann-Whitney test.

Result

Within the same group the comparison of body mass index mobility and quality of life will be statistically significant with the paired t test also the comparison between both the groups will be statistically significant with the Mann-Whitney test and Wilcoxon signed ranks test.

Discussion

Menopause is a condition there is depletion of ovarian function followed by cessation of menstruation in women. Post menopause is the phase after menopause[1].
In the same group of population the women who had normal or slightly more than normal body mass index that is from 25 to 28 had a better mobility[15]. The higher body mass index was due to the sedentary lifestyle and the dietary and nutritional habits. The low level of physical activities have a direct impact on the body mass index and thus the mobility[9]. The educational status and the facilities available in the area of living plays an important role in the quality of life of an individual[12]. The educational status is lower in the rural as compared to the urban postmenopausal women[12]. This could be due to the cultural variation, taboos, facilities available and the infrastructural development[12]. There were better facilities available in the urban area as compared to rural areas. Because of this the quality of life rated on the WHOQOL-BREF questionnaire was observed to be better in the urban than in rural postmenopausal women. The post menopausal women in the rural area have higher level of physical activity compared to the urban women. Along with the sedentary life style the nutritional and dietary habits were a contributing factor to the more than normal body mass index. Thus the body mass index was moreover in the normal range in the rural. Whereas the urban post menopausal women had low level of activity as compared to their dietary intake and thus the height weight and body mass index was in the higher range. The body mass index was measured with the standard formula weight in kilogram divided by height in meters square[9]. Due to the higher requirements of physical activities and the moreover normal body mass index the mobility which will be measured with the timed up and go test will be better in the rural post menopausal women[10]. Higher body mass index is also associated with lower bone mass density causing osteoporosis. Low bone mass density thus results in reduced mobility. As the body mass index will be higher than the normal range in urban post menopausal women the mobility will be seen to be lesser in them according to the timed up and go test[10].

Acknowledgement

I take immense pleasure to express my sincere and deep sense of gratitude to Dr. Mrs.Savita Rairikar (Director, Sancheti College of Physiotherapy) the guide of my project for guiding and correcting various documents of mine with attention and care. Also, special thanks to Dr. Apurv Shimpi (HOD of community based rehabilitation and associate professor) for helping me to write the manuscript & Rummy Dasgupta (Statistician) for helping me statistical analysis of my study..

Bibliography

1. World Health Organisation (WHO): Scientific Group on Research on the Menopause in the 1990s. Research on the menopause: Report of a WHO scientific group. WHO technical report series Geneva: WHO866; 1990.
2. Rotem M, Kushnir T, Levine R, Ehrenfeld M: A psycho-educational program for improving women's attitudes and coping with menopause symptoms. J Obstet Gynecol Neonatal Nurs. 2005 Mar-Apr;34(2):233-40.
3. Nusrat N1, Nishat Z, Gulfareen H, Aftab M, Asia N. Knowledge, attitude and experience of menopause. J Ayub Med Coll Abbottabad.2008 Jan-Mar;20(1):56-9.
4. Kuo Liu1, Liu He, Xun Tang, Jinwei Wang, Na Li, Yiqun Wu, Roger Marshall, Jingrong Li, Zongxin Zhang, Jianjiang Liu, Haitao Xu, Liping Yu and Yonghua Hu. Relationship between menopause and health-related quality of life in middle-aged Chinese women: a cross-sectional study. BMC Women's Health 2014, 14:7.
5. Boulet MJ, Oddens BJ, Lehert P, Vemer HM, Visser A : Climacteric and menopause in seven South-east Asian countries. Maturitas 2002, 41:269-274.
6. Fuh JL, Wang SJ, Lu SR, Juang KD, Chiu LM :The Kinmen women-health investigation (KIWI): a menopausal study of a population aged 40-54 .Maturitas 1994, 19:157-176.
7. Waidyasekera H, Wijewardena K, Lindmark G, Naessen T: Menopausal symptoms and quality of life during the menopausal transition in Sri Lankan women. Maturitas 2001, 39:117-124.
8. Chim H, Tan BH, Ang CC, Chew EM, Chong YS, Saw SM,: The prevalence of menopausal symptoms in a community in Singapore. Menopause 2009, 16:164-170.
9. Rahman SA, Zainudin SR, Mun VL. : Assessment of menopausal symptoms using modified Menopause Rating Scale (MRS) among middle age women in Kuching, Sarawak, Malaysia. Maturitas 2002, 41:275-282
10. Budakoglu II, Ozcan C, Eroglu D, Yanik F Asia : Quality of life and postmenopausal symptoms among women in a rural district of the capital city of Turkey.Pac Fam Med 2010, 9:5.
11. M.S. Mendes Mental Health, Instituto Superior de Educação e Ciências - Depression And Women´s Life Cycle:Comparative Prevalence Of Depressive symptoms In Women Along The Life Cycle In A Portugese Community Sample. European Psychiatry Volume 28, Supplement 1, 2013, Pages 1.
12. A. Nemati and A. Naghizadeh Baghi. Assessment of nutritional status in postmenopausal women of Ardebil, Iran. Journal of biological sciences 8(1)2008:196-200.
13. Kuo Liu, Liu He, Xun Tang, Jinwei Wang, Na Li, Yiqun Wu, Roger Marshall, Jingrong Li, Zongxin Zhang, Jianjiang Liu, Haitao Xu, Liping Yu and Yonghua Hu*: 10 January 2014Relationship between menopause and health-related quality of life in middle-aged Chinese women: a cross-sectional study.BMC Women's Health 2014, 14:7 doi:10.1186/1472-6874-14-7.
14. Dr. Dinesh Das & Minakshee Pathak. The Growing Rural-Urban Disparity in India: Some Issues. International Journal of Advancements in Research & Technology, Volume 1, Issue 5, October-2012 .
15. Kaur R, Sharma VL, Singh A. Prevalence of knee osteoarthritis and its correlation in women of rural and urban parts of Hoshiarpur (Punjab) J Postgrad Med Edu Research 2015;49(1):32-36.
16.Mpalaris V, Anagnostis P, Goulis DG, Iakovou I.Complex association between body weight and fracture risk in postmenopausal women. Epub 2015 Jan 13.2015 Mar;16(3):225-33.
17. Bohannon RW. Reference values for the Timed Up and Go Test: A Descriptive Meta-Analysis. Journal of Geriatric Physical Therapy, 2006;29(2):64-8.
18. Veronica Southard, Arti Dave, Peter Douris :Exploring the Role of Body Mass Index on Balance Reactions and Gait in Overweight Sedentary Middle-aged Adults A Pilot Study Journal of Primary Care & Community Health October 2010 1: 178-183.
19. Monique M. samson Ingrid B. A. E. Meeusen, Alan Crowe Jos A. G. Desen, Sijmen A Duursma, Harald J. J Verhaar. Relationship between physical performance, measures, age, height, and body weight in healthy adults. Age and aging 2000; 29 235-242..
20. Deurenberg P, Andreoli A, Borg P, Kukkonen-Harjula K. The validity of predicted body fat percentage from body mass index and from impedance in samples of five European populations. European J Clin Nutr.2001 Nov:55(11):973-9.
21. Liette B. Ocker, Don R. Melrose. Examining the validity of the body mass index cut off score for obesity of different ethnicities.journal of multicultural, gender and minority studies.Volume 2, issue 1,2008.
22. WHOQOL-BREF June 1997U.S. Version University of Washington Seattle, Washington United States of America Emblem..Soul Catcher: a Northwest Coast Indian symbol of physical and mental well-being. Artist: Marvin Oliver WHOQOL-BREF, Questionnaire, June 1997, Updated 1/10/2014.

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Vol 3 | Issue 2 | May - Aug 2015 | page:39-43 | Satish R Gawali,  Mahesh N Gude, Pramod V Niravane, Raman O Toshniwal.

Author: Satish R Gawali[1],  Mahesh N Gude[1], Pramod V Niravane[1], Raman O Toshniwal[1].

[1] Government Medical College & Hospital, Latur.
Institute Where Research Was Conducted: Government Medical College & Hospital, Latur.
University Affiliation: Maharashtra University of Health Sciences, Nashik.
Year Of Acceptance Of Thesis: 2014.

Address of Correspondence
Dr. Satish R Gawali
Associate Professor, Dept. of Orthopaedics, Government Medical College & Hospital, Latur.
Email:satishgawali61@gmail.com

 Abstract

Background: Supracondylar fracture of humerus is the commonest injury around elbow which requires hospital admission in children. The supracondylar fracture of humerus demand great respect in treatment because its association with different types of complications We intend to study and evaluate methods of treatment and clinical outcome of fracture supracondylar humerus and evaluation of any shortcomings which causes secondary loss of reduction.
Method : In this study, 45 cases of supra condylar fracture were treated either with closed or open reduction and K-wire pinning. The purpose of this study was to evaluate the result of the surgery with reference to restoration of function and prevention of complications of the fracture.
Results : In our study,43(95.55%) patients had satisfactory results. Of these Patients , 29(64.44%) patients were rated as excellent, 13(28.89%) patients were rated as good & 01(2.22%)patient as fair and 02 (4.44%)patient was rated as poor. 01 patient had developed FFD as he had undergone open reduction and not done good physiotherapy after slab removal, and second patient had myositis ossificans.
Conclusion : Anatomical reduction is the key to obtaining good results, which is possible both through open or closed reduction. The results obtained in this study shows that anatomical reduction (closed/open) with slab/ K-wire fixation is the treatment of choice for supracondylar fractures in children
Keywords : Supracondylar humerus, Carrying angle, Boumann's angle, K-wire, above elbow slab.

Thesis Question: What is incidence of early and late complications & what is the best modality of treating supracondylar humerus fracture in children?
Thesis Answer: Depends upon age, type of fracture, associated neurovascular status of the limb, stability of reduction, and anatomical reduction (closed/ open), immobilised with slab/K-wires and early ROM (range of movement) of elbow to give effective treatment for supracondylar fracture.

Introduction

Supracondylar fracture of humerus is the commonest injury around elbow which requires hospital admission in children. It constitutes 3% of all fractures and about 65.4% of all the fractures around the elbow in children. This is the most common fracture requiring re- reduction as it is commonly associated with secondary loss of reduction if no internal fixation is done. So check x-ray after 10 days and immediate re-reduction is mandatory. The occurrence rate increases progressively in the first five years of life to peak between 5 - 7 years of age*. The supracondylar fracture of humerus demand great respect in treatment because supracondylar fractures are more commonly associated with different types of complications as compared to any other fractures in the body such as, compartment syndrome(1%), brachial artery injury(0.5-1%), Volkmann’s ischemic contracture(0.5%), elbow stiffness(5-7%),nerve injury(3- 22%), Ipsilateral fracture of extremity(5%), cubitus varus(14% in CR, 3% in percutaneous pinning),myositis ossificans(0.5-1%). The management of displaced supracondylar fracture of the humerus is one of the most challenging one to prevent complications. It needs accurate anatomical reduction and internal fixation. So no longer is it acceptable to near “not bad for a supracondylar fracture”[3]. There is no controversy in the management of the un-displaced fractures. But various modalities of treatment have been proposed for the treatment of displaced supracondylar fractures of the humerus in children, such as closed reduction and plaster of paris slab application, skin traction, overhead skeletal traction, closed reduction and percutaneous pin fixation and open reduction with internal fixation4,closed reduction and Posterior intrafocal pinning5,closed reduction and Lateral External Fixation [6]. Closed reduction with splint or cast immobilization and treatment with traction has traditionally been recommended for displaced supracondylar fractures, but difficulty in reduction, necessity of repeated manipulations, loss of reduction postoperatively or during follow up leads to malunion and elbow stiffness [7]. Supracondylar fracture of humerus often installs ‘sense of apprehension’ even in the mind of most experienced surgeon. Even various studies have shown that for displaced supracondylar fractures of humerus, open reduction and internal fixation with K-wires gives more stable fixation, better anatomical reduction with minimal complications. So still close reduction or open reduction and internal fixation with K-wires is the most commonly accepted treatment of displaced (Gartland Type3) supracondylar fractures of the humerus in children.

Aims and Objective

1. To study the etiopathogenesis of fracture patterns of supracondylar fractures in children.
2. To know etiopathogenesis of Early, Immediate and late complications and study its management.
3. To study the importance of secondary loss of reduction in case when no Internal fixation was done, by check x rays after 10 days and at 3 weeks.
4. To study and evaluate methods of treatment and clinical outcome of fracture supracondylar humerus and evaluation of any shortcomings which causes secondary loss of reduction.

Material And Methods

The clinical material for the study, consists of 45 cases of fresh supracondylar fractures of humerus in children of traumatic etiology, meeting inclusion and exclusion criteria, admitted to Government Institute, between year 2012 to 2014
Inclusion Criteria:
1. Age group; 0 to 16 years of both sexes
2. Compound fractures
3. Poly-trauma patients

Exclusion Criteria:
1. Intra articular fractures of lower end humerus.
2. Fracture in children more than 16 years of age.
3. Any pathological fracture.
4. Any pre-existing motor and sensory weakness, such as Cerebral palsy, PPRP.

Method of study:-
As soon as the patient was admitted, a detailed history was taken and a Meticulous examination of the patient was done. Specific attention was given to Neurovascular status of limb distal to fracture site that is w/f any radial, ulnar, Median nerve injury, w/f signs of compartment syndrome, w/f radial pulse, nail bed circulation return. In case of suspected median nerve injury, special attention was given for notifying early compartment syndrome as there is no pain when patient has median nerve injury and has compartment syndrome. The required
information was recorded in the proforma prepared. The patients radiograph was taken in antero-posterior and lateral views. The diagnosis was established by clinical and radiological examination. In this study, supracondylar fracture of humerus was classified according to modified Gartland's classification.
Type I : Undisplaced Supracondylar fracture of humerus.
Type II : Displaced Supracondylar fracture with intact posterior cortex.
Type III : Displaced Supracondylar fracture with no cortical contact.
a) Postero-medial
b) Postero-lateral.
Type IV : Fractures with considerable displacement without contact fragments, which displaces in to flexion and extension during manipulation under IITV control.
Temporary closed reduction was done on admission and above elbow Posterior pop slab was applied in 90° of flexion at elbow. The limb was elevated to reduce swelling of the elbow. All patients were taken for elective surgery as soon as possible after necessary blood, urine and radiographic pre-operative work-up.
Patients' attendants were explained about the nature of injury and its possible complications. Patient's attendant were also explained about the need for the surgery and complications of surgery.
Written and informed consent was obtained from the parents of children before surgery.
All patients with grade III fractures were started on prophylactic antibiotic therapy. Intravenous Cephalosporin was used. It was administered according to body weight of the children, prior to induction of anaesthesia and continued at 12 hourly intervals post-operatively for 3 days in closed reduction and k-wire casesand for 5 days in open reduction cases. In closed reduction and k-wire casesantibiotics were withdrawn after 3 days while in open reduction cases after I.V.
antibiotic for 5 days, oral antibiotics were given till suture removal.

Operative Technique
Anaesthesia: All patients were taken up for surgery under general anaesthesia.
Patient Positioning: Patient was positioned supine with ipsi-lateral shoulder at the edge of the
table.
Painting and Draping: Affected elbow, arm a forearm was scrubbed, painted and draped leaving
the elbow, lower third of arm and upper third of forearm exposed.

Technique of closed reduction:
1. Longitudinal traction with elbow in extension and supination was given. At
the same time counter traction was given by an assistant by holding
proximal portion of arm.
2. Continuing traction and counter traction, medial or lateral displacement
were corrected by valgus or varus force respectively at fracture site.
3. After that, posterior displacement and angulation was corrected by flexing
the elbow and simultaneously applying posteriorly directed force from
anterior aspect of proximal fragment and anteriorly directed force from
posterior aspect of distal fragment over olecranon while maintaining
traction.
4. If an adequate reduction is obtained the elbow should be capable of
smooth and almost full flexion. Radial artery pulsation checked, if
pulsations disappear, degree of flexion is reduced by progressive10-
20degrees till pulsation returns.
5. Confirm the adequacy of reduction under image intensifier in two views.
A) Antero-posterior view or Jone's view.
B) Lateral view by externally rotating the arm.
6. After getting satisfactory alignment reduction, and if reduction is stable
then POP slab with elbow flexion more than 90 Degrees was given .If reduction is unstable then reduction was maintained by percutaneous K-wire
fixation.
After experiencing failure to obtain a satisfactory reduction after two or
three manipulations we considered open reduction.

Technique of open reduction:
Triceps Splitting Approach:
Under GA, in lateral position, in IITV control.
Standard posterior approach
1. Midline central incision taken over posterior aspect of lower third arm and elbow.
2. Incision deepened in layers and triceps splitted in centre with sharp dissection.
3. Reduction is done- by removing any buttonholing of distal spike of proximal fragment or any periosteum getting entrapped at fracture site, after holding the proximal fragment with bone holding forceps.
4. Following reduction, two crossed K-wires were put percutaneously as in Closed reduction technique. Cut pins were bent and kept outside the skin
for removal later.
5. Wound was washed and closed in layers.
6. Sterile dressing was put and above elbow posterior POP splint was applied in 90°of elbow flexion and midprone position.

Introduction of K-wires:
Stainless steel Kirschner's wires of about 1.2mm to 2.0mm were used. We used two crises-cross pins, one from medial epicondyle and one from lateral condyle. After achieving satisfactory reduction either closer or by open technique, K-wires were introduced with the help of a power drill under image intensifier control.
Selection of first pin placement was done according to initial fracture displacement. In cases of postero medial displacement we preferred to put medial pin first while in cases of postero lateral displacement lateral pin was put first. Medial pin entry was from tip of the medial epicondyle and lateral pin was entered at the centre of the lateral condyle. Both pins were directed 40° to the humeral shaft in sagittal plane and 10° posteriorly. K-wire placement was checked in image intensifier in antero-posterior and lateral views. If reduction was unstable after 2 cross k wires, then additional k wire passed either medially or laterally. K-wires were bent and kept at least 1 cm outside the skin. Sterile dressing was applied. Above elbow posterior pop splint in 90° elbow flexion and midprone position of forearm applied.
Treatment for flexion type of injury:
1. Reduction is done by longitudinal traction to the forearm with supination and elbow in extension and counter traction is given to arm by assistant.
2. After correcting the overriding, the distal fragment is pushed posteriorly by direct pressure, and simultaneously the proximal fragment i.e. shaft is pushed anteriorly.
3. Reduction is achieved and checked under C-arm control in AP and Lateral views.
4. The extremity is mobilised with POP AE slab with elbow in extension, as
flexion of the elbow is again causing redisplacement of distal fragment anteriorly.
5. The POP slab is continued for 3 weeks and the routine physiotherapy
advised.

NOTE:
We Did Not Require Skin Traction (Dunlop Traction) Or Overhead Skeletal Traction Or Posterior Intrafocal Pinning Or Lateral External Fixator Modality For Any Of The Fracture Treatment In Our Series.

Post – Operative management:-
Post-operatively, operated limb was elevated on a drip-stand and patient was encouraged to move fingers. First 24 hours, patient was closely monitored for signs and symptoms of early compartment syndrome i.e. w/f stretch pain, nail bed return, pulse ox meter oxygen (O2) saturation. At 3rd post-operative day, check dressing was done and condition of the operative wound or pin site were noted. Following dressing, check x-ray in AP &
lateral views were done. Patients in whom closed reduction was done were discharged on 3rd Or 4th post-operative day. Patients in who open reduction was done, were discharged after 5 days
with oral antibiotics. These patients were reviewed on 12th postoperative day on O.P.D. basis for suture removal.
K-wires were removed at 3 weeks post-operatively after X – Ray confirmation of satisfactory callus formation. Pop splint was discarded at the same time and patient was encouraged to do active elbow flexion extension and supination – pronation exercises. Patients were advised not to lift heavy weight till 12 weeks postoperatively.
Follow up was done on O.P.D. basis at 3rd 6th & 12th week postoperatively.
The follow up was done by clinical and radiological evaluation, and results were assessed based on:
1. Pain.
2. Swelling.
3. Tenderness at fracture site.
4. Movements of the elbow.
5. Carrying angle of the elbow compared with normal elbow.
6. Union of the fracture.
7. Baumann's angle.

Post-OP Complications
Immediate And Delayed Post Op. Complications.
Immediate Complications
1 Nerve injury-median/radial/ulnar.
2 Vascular injuries (brachial artery).
3 Compartment syndrome.
4 Secondary loss of reduction.
Delayed:
1 Iatrogenic nerve palsy
2 Superficial pin tract infection
3 Migration of k -wires
4 Restriction of movements
5 Operative wound infection
6 Volkmann's ischemic contracture
7 Cubitus varus / valgus
Follow – Up:
All the cases were followed-up at 3rd week, 6th week and 12th week. During the follow-up the patients were assessed with respect to the following parameters and the findings were recorded in the proforma:
1. Pain – Presence of pain around the elbow is noted and severity of pain is mentioned as severe (+++), moderate (++), mild (+) or nil (O).
2. Tenderness – Presence of tenderness at fracture site is noted as Present (P) or not presents (NP).
3. Swelling – Presence of swelling around the elbow joint is noted as present (P) or not present (NP).
4. Movements – Movements of the elbow joint are recorded and noted as the range of motion present in degrees.

Post – Operative management:-
Post-operatively, operated limb was elevated on a drip-stand and Patient was encouraged to move fingers. First 24 hours, patient was closely monitored for signs and symptoms of early compartment syndrome i.e. w/f stretch pain, nail bed return, pulse ox meter oxygen O2 saturation. At 3rd post-operative day, check dressing was done and condition of the operative wound or pin site were noted. Following dressing, check x-ray in AP & lateral views were done. Patients in whom closed reduction was done were discharged on 3rd or 4th post-operative day, with oral antibiotics. Patients in who open reduction was done, were discharged after 5 days with oral antibiotics. These patients were reviewed on 12th postoperative day on O.P.D. basis for suture removal. K-wires were removed at 3 weeks post-operatively after X - Ray confirmation of satisfactory callus formation. Pop splint was discarded at the same time and patient was encouraged to do active elbow flexion extension and supination – pronation exercises. Patients were advised not to lift heavy weight till 12 weeks post-operatively.

Results

The final results were evaluated by Flynn’s criteria. The results were graded as excellent, good, fair and poor according to loss of range of motion and loss of carrying angle. In our study, 43(95.55%) patients had satisfactory results. Of these Patients , 29(64.44%) patients were rated as excellent, 13(28.89%) patients were rated as good & 01(2.22%)patient as fair and 02 (4.44%)patient was rated as poor. 01 patient had developed FFD as he had undergone open reduction and not done good physiotherapy after slab removal, and second patient had myositis ossificans.

Conclusion

• Supracondylar fracture of humerus is one of the commonest fractures seen in children.
• Incidence is higher in boys.
• Left sided injury is more common than right side.
• Due to the frequent occurrence of complications, a detailed neurovascular examination is a must in all cases.
• Anatomical reduction is the key to obtaining good results, which is possible both through open or closed reduction.
• Rigid fixation can be achieved either closed reduction and slab /through criss-cross K wire or 2 lateral pins.
• By the aforementioned surgical methods, early mobilization of the elbow with good range of movement and fewer complications were achieved.
• The results obtained in this study shows that anatomical reduction (closed/open) with slab/ K-wire fixation is the treatment of choice for supracondylar fractures in children.

Clinical Message
Anatomical reduction (closed/open) with slab/ K-wire fixation is the treatment of choice for supracondylar fractures.

Bibliography

1. David DA, Bruce IP. Supracondylar fractures of humerus – a modified Technique of closed pinning. CORR 1987;219:174-178.
2. Pirone AM, Graham HR, Krajbich JI. Management of displaced extensiontype Supracondylar fractures of the humerus in children. JBJS 1988;70- A(5):641-650.
3. Hamid RM, Charles S. Crossed pin fixation of displaced Supracondylar fractures in children. CORR 2000;376:56-61.
4. James RK, James HB. Rockwood Wilkin's fractures in children. 7th ed. Philadelphia. Lippincot, William &Wilkins:2010.
5. John AH, Tachdjian's pediatric orthopaedics.4th ed. Philadelphia.
Saunders:2008.
6. Jeffrey LN, Malcolm LE, Stanley MK, Paul AL, Marianne D.
Supracondylar fractures of humerus in children treated by closed
reduction and percutaneous pinning. CORR 1983;177:203-209.
7. Canale TS. Campbell's Operative orthopaedics.12th ed. Philadelphia. Mosby;2013.
8. Robert EL, Ryan WS, Peter MW. Supracondylar fractures of humerus. OCNA 1999;30: 120-124.
9. Attenborough CG. Remodelling of humerus after Supracondylar fractures in childhood. JBJS 1953;35-B:386-395.
10. Madsen E. Supracondylar fractures of the humerus in children. JBJS 1955;38-B:241.

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Vol 3 | Issue 2 | May - Aug 2015 | page:31-35 | Satish R Gawali, Kathar M Gajanan, Mansoor Bhosage, Pramod V Niravane.

Author: Satish R Gawali[1], Kathar M Gajanan[1], Mansoor Bhosage[1], Pramod V Niravane[1].

[1] Government Medical College & Hospital, Latur.
Institute Where Research Was Conducted: Government Medical College & Hospital, Latur.
University Affiliation: Maharashtra University of Health Sciences ,Nashik.
Year Of Acceptance Of Thesis: 2013.

Address of Correspondence
Dr. Satish R Gawali
Associate Professor, Dept. of Orthopaedics, Government Medical College & Hospital, Latur.
Email: satishgawali61@gmail.com

 Abstract

Background: Distal femur fractures remain difficult fractures to treat successfully as they are often communitted, unstable, with intra-articular extension and associated with severe soft tissue injury to the quadriceps mechanism and ligament disruption of knee joint. We intended to study the outcome and results of operative modalities of treatment for Distal femur fracture with Locking compression plates, Condylar buttress plate, Dynamic condylar screw with side plate and Retrograde intramedullary supracondylar nail.
Method: Different treatment modalities used for 50 patients with distal femur fractures are LOCKING COMPRESSION PLATE, CONDYLAR BUTTRESS PLATE, and DYNAMIC CONDYLAR SCREW WITH SIDE PLATE AND RETROGRADE INTRAMEDULLARY SUPRACONDYLAR NAIL.
Results: Extraarticular fractures (Type-A) had 90.90% excellent to good results and 9.09% fair to poor results whereas, Intraarticular fracture (type-C) had 60.72% excellent to good results and 39.28% fair to poor results. Average period of radiological union in this study was 14.16 weeks. Average knee flexion in our study was 109.5 degrees.5.55% of cases had superficial to deep infection in plating group which recovered with necessary treatment. Significant extension lag of 15 degree developed in 8% patients. Knee stiffness developed in 8% patients. 6% patients (3 out of 50) of our study had limb shortening > 1.5cm.
Conclusion: In AO type A fracture pattern, all treatment modalities yields excellent to good results. In AO Type C1 and C2 fractures, locking compression plate, Condylar buttress plate and Dynamic condylar screw with side plate (DCS) had favourable outcome. Type C3 fractures with severe intraarticular communition had less favourable outcome when fixed with any implant.
Keywords: Distal femur fracture, Condylar buttress plate, Locking compression plate, Dynamic condylar screw, Supracondylar nail.

Thesis Question: What is the best modality of treatment of Fractures of distal femur in adults?
Thesis Answer: It depends upon Patients age, configuration of fracture, with intra-articular extension and communition, associated soft tissue injury and ligament injury of knee joint & Modality of fixation, Type C3 fractures with severe intraarticular communition had less favourable outcome when fixed with any implant.

Introduction

As Stewart et al. (1966) claimed that "fractures in the distal third of the femur continue to perplex the surgeon. Whether they are transverse, oblique, or comminuted, supracondylar or intercondylar in a T, Y or V fashion their management still evokes much controversy because of the consistently poor results obtained." Distal femoral fractures are much less common than hip fractures and account for about 4-7% of all femoral fractures. If fractures of the hip are excluded, 31% of femoral fractures involve the distal portion[1].  There is bimodal distribution of fractures. Most high energy distal femur fracture caused by motor vehicle accidents, sports and pedestrian accidents occurs in male between 15 & 50 years; while in women above 50 years, with osteoporosis, fractures occurs due to low velocity trauma such as fall from standing height at home[2]. Distal femur fractures remain difficult fractures to treat successfully as they are often communitted, unstable, with intra-articular extension and associated with severe soft tissue injury to the quadriceps mechanism and ligament disruption of knee joint. Both articular and extraarticular distal femur fractures require anatomical reduction in order to restore the functional and mechanical axis of the extremity. Also a stable internal fixation is required in order to start early range of movements to avoid stiffness of knee joint. Various modes of treatment have been advocated by number of authors. They vary from closed treatment with traction, application of cast brace following preliminary traction, to open reduction and internal fixation with a variety of devices. But no single method of management overcomes all the problems associated with distal femur fractures. Before 1970, the majority of distal femur fractures were treated conservatively where traction achieved acceptable results but exposed patient to the risk of prolonged bed rest, in addition to persistent angulatory deformity, knee joint incongruity and loss of knee motion[3]. With the development of improved internal fixation devices by the AO group, treatment recommendations have changed. Operative treatment is recommended for most fractures of the distal femur. The goal of operative treatment are anatomical reduction, stable internal fixation, early rapid mobilization of adjacent joints, preservation of blood supply and early functional rehabilitation of the knee.3 Early surgical stabilization can facilitate care of the soft tissue, permit early mobility and reduces the complexity of nursing care[4].  Several treatment options are available for fractures of the distal femur which require internal fixation using various plates such as 95 degree angled blade plate, condylar buttress plate, dynamic condylar screw with 95 degree side plate, locking compression plate, LISS (less invasive stabilization system) and intramedullary nails (ante grade/retrograde)[5]. It is not clear whether one implant is more reliable than another in achieving consistently good results. And there is no consensus on the ideal implant as such due to variable fracture patterns, comminution, and intra-articular extension in distal femoral fractures. 95⁰angled blade plate was one of the first plates; but due to problems like inadequate fixation in osteoporotic bone & difficulty in accurate insertion in three planes; it is not commonly used. Dynamic condylar screw is the implant of choice when distal bone block of 4 cm was available for supracondylar fixation. Its advantages includes its ability to apply the inter-fragmentary compression across the femoral condyles for intercondylar fractures, better purchase in osteoporotic bones and the need for only two plane alignment..Main disadvantage is DCS fixation requires removal of large amount of bone from femoral condyles which makes revision surgery difficulty (if necessary). Condylar buttress plate should be restricted to cases in which the femoral condyles are comminuted or there are multiple intra-articular fractures in the coronal & saggital plane. Most recently condylar locked plating systems has been developed. Locking condylar plates with minimum invasive technique yields higher union rates & have better fixation in osteoporotic bones & have better knee range of motion. Locking plates are relatively costlier than other devices. Locking plates are very useful in osteoporotic bones and in communitted fractures. In today's orthopedics, Locking plate is one of the main treatment modality in fractures of distal femur. Intramedullary supracondylar nail are load sharing rather than load bearing implant. Intra- medullary supracondylar nailing can be used for most AO type A fractures & may be used for intercondylar type C-1 & type C-2 fractures. Advantage with nailing is less tissue trauma & high union rates. Limitation for its use is that it cannot be used in intraarticular comminuted fracture.

Aims & Objectives

This study was conducted in the Department of Orthopaedics of Government medical college, Latur to study and compare the results of:
1. LOCKING COMPRESSION PLATE.
2. CONDYLAR BUTTRESS PLATE.
3. DYNAMIC CONDYLAR SCREW WITH 950 SIDE PLATE.
4RETROGRADE INTRAMEDULLARY SUPRACONDYLAR NAIL.
In various types of fractures of distal femur.

Materials and Method

Study Design
The present clinical study was carried out in our tertiary Institute over a period of December 2011 to November 2013. Patients with fracture of distal femur admitted to the hospital were selected as cases & all the necessary clinical details were recorded in proforma prepared for this study. Different treatment modalities used for 50 patients with distal femur fractures are LOCKING COMPRESSION PLATE, CONDYLAR BUTTRESS PLATE, and DYNAMIC CONDYLAR SCREW WITH SIDE PLATE AND RETROGRADE INTRAMEDULLARY SUPRACONDYLAR NAIL.
Inclusion criteria
1. The fractures of the distal femoral metaphyseal, metaphysiodiaphysial with or without intraarticular extension.
2. Closed fractures.
3. All compound fractures
Exclusion criteria
1. Fracture in patients of age <18 years.
2. Any pathological fracture (except due to osteoporosis)
Method of study
Every patient was evaluated after history, clinical examination and radiological investigation and fracture pattern was classified according to AO classification. The best suitable FDA approved implant for a particular fracture pattern of distal femur was used.  All patients were followed up at 1.5, 3, 5 & 7th post operative months for assessment of fracture union, range of knee motion, knee pain, and to note any complications. At time of follow up a thorough clinical evaluation was done for any complaints, severity of knee pain, healing of wound, and knee range of motion, weight bearing, limb length discrepancy and deformity. Implant status and signs of union were also assessed on X-rays. Accordingly weight bearing was allowed. At final follow up all the cases were evaluated clinically and radio graphically as per the under mentioned proforma and the results were rated on the basis of 'Schatzker and Lambert criteria' as – excellent, good, fair and poor results.

Results

In this study, patients were of age group between 20-70 years. Average age was 46.12 years. The ratio between male to female was 2.84:1. In our study, 66% of the fractures were because of Road traffic accident, 32% of fractures were because of fall, and only 2 % were due to other causes such as assault. In this series, Road traffic accident constitutes the major cause of morbidity (81.81%) in < 50 years of age whereas self fall mainly results in morbidity (64.71%)) in > 50 years of age.  In this study, 66% of fractures were closed and 34% of fractures were compound. In this series, majority of the fractures were Intra-articular (56%) out of which AO type C1, C2 & C3 were 16%, 20% and 20% respectively. Remaining were Extra- articular (44%) out of which AO type A1, A2 & A3 were 16%, 20% and 8% respectively. In this study, 62.5% of the patients operated with Locking compression plate had blood loss >300ml whereas 37.5% had blood loss <300ml. Average blood loss was 284.38 ml. 57.2% of the patients operated with Condylar buttress plate had blood loss >300ml whereas 42.8% had blood loss <300ml.Average Blood loss was 282.14ml. 33.4% of the patients operated with Dynamic compression screw with plate had blood loss <300ml whereas 66.6% of the patients had blood loss >300ml. Average blood loss was 291.66 ml. All the patients (100%) fixed with Supracondylar nail had blood loss <300ml as compared to 37.5% of those operated with Locking compression plate,42.8% those operated with Buttress plate and 33.4% of those operated with Dynamic compression screw with plate. The average blood loss was least (142.85 ml) with Supracondylar nail and when compared with Locking compression plate, Condylar Buttress plate and Dynamic compression screw with plate, it was found to be statistically significant. (t=8.505, df=28, p<0.0001 highly significant for Locking plate and Nail, t=7.848 df=26 p<0.0001 highly significant for Buttress plate and Nail, t=8.851 df=18 p<0.0001 Highly significant for Dynamic condylar screw with plate and Nail)
· Average period of union in our study was 14.16 weeks.
· The average weight bearing in our study was at 15 wks
· In this study, 75% patients fixed with Locking plate had no shortening, 18.75% had <1.5 cm shortening, while 6.25% had 1.5-2.5 cm of shortening. All patients fixed with Dynamic compression screw with plate had no shortening, 85.72% patients fixed with Buttress plate had no shortening, 7.14% had <1.5 cm and 7.14% had 1.5-2.5 cm shortening. 85.72% patients fixed with Supracondylar nail had no shortening, 7.14% had <1.5 cm shortening, while 7.14% had shortening between 1.5-2.5cm. No patient had shortening >2.5 cm. In this study, 43.75% patients fixed with Locking compression plate had knee flexion >110 degrees, 43.75% patients had knee flexion between 110-90 degrees, while only 12.5% had knee flexion < 90 degrees. Average knee flexion for locking plate was 109.370 28.57% patients fixed with condylar buttress plate had knee flexion >110 degrees, 50% had knee flexion between 110-90 degrees and 21.42% had flexion <90 degrees .Average knee flexion for condylar buttress plate was 105 degree. 83.33% patients fixed with Dynamic compression screw with plate had knee flexion >110 degrees, 16.67% patients had knee flexion between 110-90 degrees, while no patients had knee flexion < 90 degrees. Average knee flexion for Dynamic compression screw was 118.350.50% patients fixed with Supracondylar nail had knee flexion >110 degrees, 35.71% had knee flexion between 110-90 degrees and 14.28% of patients had flexion <90 degrees. Average knee flexion for Supracondylar nail was 110.350. In this study, 31.25% of the fractures fixed with locking plate had excellent results, 43.75% had good results, and 12.5% had fair results, whereas only 12.5% had poor results.21.45% of fractures fixed with buttress plate had excellent, 42.85% had good results, 14.28% had fair and 21.42% had poor results. 66.66% of the fractures fixed with Dynamic compression screw with plate had excellent results, 33.33% had good results. 42.85% of the fractures fixed with Supracondylar nail had excellent results, 28.57% had good results and 14.28% had fair results, whereas 14.28%) had poor results. In this study, 90.90% patients with extra-articular fractures had excellent to good results. Whereas only 60.17% patients with intra-articular fractures had excellent to good results indicating that the extra-articular fracture patterns are associated with favourable outcome as compared to intra-articular fracture pattern.
Type A fracture pattern In this study, all 4(100%) patients having AO type A fracture pattern operated with locking plates had excellent to good results. Whereas, 2 (66.66%) out of 3 patients operated with condylar buttress plate had excellent to good results. On the other hand, all 4(100%) patients operated with DCS with plate had excellent to good results & 10(99.99%) out of 11 operated with supracondylar nail had excellent to good result.
Type C1 fracture pattern In this study, 3(100%) patients operated with locking plate for above fracture pattern had excellent to good results. Whereas out of 2 patients operated with DCS with plate 1(50%) had Excellent and 1(50%) had good result. On the other hand, 2 patients operated with condylar buttress plate, 1(50%) has excellent & 1(50%) has good result. 1 patient operated with Supracondylar nail, had fair result.
Type C2 fracture pattern In this fracture pattern, out of 5 patients operated with locking plates, 1(20%) had excellent results, 2(40%) had good results, 1 had fair & 1 poor result. Out of 3 operated with condylar buttress plate 1(33.33%) has excellent and 2(66.67%) had good result. 2 (100%) patients operated with supracondylar nail has poor results.
Type C3 fracture pattern In this fracture pattern, out of 4 patients operated with locking plates, 2(50%) had good results, 1(25%) had fair results and 1(25%) had poor results. Out of 6 patients operated with condylar buttress plate 2(33.33%) had good, 1(16.7%) has fair and 3 (50%) had poor results. This fracture pattern is unsuitable for DCS and Supracondylar nail. So, DCS and Supracondylar nail are not included in AO type C3.
In this study, 81.81% patients having closed fractures were having excellent to good results as compared to 57.13% of Gr-I compound and 66.37% of Gr-II Compound fractures with excellent to good results .Closed fractures had 18.18% of fair to poor results whereas Gr-I compound had 42.85% and Gr-II Compound had 33.33% fair to poor results.
In this study, superficial infection in the form local stitch abscess developed in 1 patient operated with Locking plate which subsided after local drainage and i.v. antibiotics. Deep infection in the form of frank pus from the operated site developed in 1 patient operated with condylar buttress plate which has associated ipsilateral Grade III compound fracture calcaneus and same case has gone into delayed union which eventually united on 24th week postoperatively. One case fixed with Supracondylar nail had knee impingement and continuous knee pain while weight bearing which relieved after nail removal. Significant Shortening (>1.5cm) developed in 3 patients out of which 1 patient was fixed with Locking plate (2cm shortening), 1 fixed with Buttress plate (2cm shortening) 1 patient was fixed with Supracondylar nail (2.5 cm shortening). Significant extension lag of 15 degree developed in 4 patients (1 with Locking plate, 2 with condylar buttress plate and 1 with supracondylar nail). Knee stiffness developed in 4 patients (1 patient fixed with locking plate, 2 with condylar buttress plate and1 with Supracondylar nail) . One patient fixed with buttress plate had Loosening of screws and another has preoperative foot drop.

Discussion

Fractures of the distal part of femur are difficult to treat, whether surgical or non-surgical methods are selected. Conservative treatment often leads to knee stiffness, quadriceps wasting, fracture angulation, knee joint incongruity and displacement within the cast. The surgical principles outlined and popularized by AO/ASIF group have improved the operative results in these fractures significantly. As with any other Fracture treatment the goal of treatment is restoration of limb function .These can be achieved with anatomic reduction of the distal femoral articular surface, stable internal fixation with restoration of axial alignment, minimal soft tissue stripping and early active mobilisation[51]. Although surgical treatment is recommended for most of the distal femoral fractures, controversy remains selecting the optimum fixation device[52]. Available implants for fixation of these fractures are- Fixed angle blade plate, Condylar buttress plate, DCS with side plate, cancellous screws, Locking plate and Supracondylar nail. The standard treatment for distal femoral fracture, with or without intra-articular involvement is open reduction and stable internal fixation with plates and screws. With the use of aseptic precautions, the incidences of infection and non-union have been lessened, but still are frequent. The use of plates and screws in the fixation of fractures has the inherent drawback of producing load-shielding effect. This is especially important in elderly patients who have osteoporotic bones[36]. On the contrary, locking plates are considered as the treatment of choice in elderly patients due to multiplanar cancellous screw fixation with locking heads in the condylar region which provide better fixation of osteoporotic femur. Despite a proven higher stiffness of plate systems compared with intramedullary nails, the latter devices provide the advantage of an indirect fracture reposition away from the almost always comminuted metaphyseal region. The use of bone grafts may be reduced. In addition, nail acts as a load sharing implant. Thus avoiding the drawback of load-shielding effect of plates[46] .Retrograde nail also does not provide stable and rigid fixation due to wide medullary cavity in the distal femur and relatively small size of the nail.  A prospective study was conducted in 50 patients who presented with closed and compound supracondylar fracture femur and fitting in the determined inclusion and exclusion criteria. Informed and written consent taken of each patient. The patients were thoroughly assessed with regards to complete history, clinical examination, and routine haematological and radiological investigation. The patients were classified according to AO/OTA classification. The best operative modality of treatment (FDA approved implant) for a particular fracture pattern was chosen. After getting anaesthesia fitness, patients were operated. Routine post operative care was given and patients were called for follow-up visits after discharge. Thus the study was conducted with the aim to evaluate the clinical profile of distal femoral fractures, to compare the results and complications of operative modalities by following implants namely- Locking plate, Condylar buttress plate, Dynamic condylar screw with side plate and Retrograde Supracondylar nail for Distal femoral fractures.

Conclusion

In AO type A fracture pattern, all treatment modalities yields excellent to good results. In AO Type C1 and C2 fractures, Locking compression plate, Condylar buttress plate and Dynamic condylar screw with side plate (DCS) had favourable outcome. Type C3 fractures with severe intraarticular communition had less favourable outcome when fixed with any implant.

Clinical Message

How results of your thesis might affect clinical practice.

Bibliography

1. Areneson TJ, Melton LJ, Lewallen DG, et al .Epidemiology of diaphyseal and distal femoral fractures in Rochester , Minnesota,1965-1984.Clin Orthop Relat Res
1988;234:188-194.
2. Martinet O, Cordey J, Harder Y, et al (2000). The epidemiology of fractures of the
distal femur. Injury; 31 Suppl 3:C62-3.
3. M-Hosam Nagy, M.D., Emad EI-Mehy,M.D. & Khaled Issa,M.D.Buttress Condylar
Plating in Treatment of Intercondylar Supracondylar Fractures of Distal Femur, Pan
Arab J.Orth.Trauma,January 2007,Vol.(11)No.(1):26-34.
4. Muhammad Ayaz Khan, Muhammad Shafique, Ahmed Sohail Sahibzada, Shahid
Sultan. Management of type – A supracondylar fractures of femur with dynamic
condylar screw (DCS). Journal of Medical Sciences January 2006; Vol. 14, No. 1:44-
47.
5. EJ Yeap, AS Deepak. Distal Femoral Locking Compression Plate Fixation in Distal
Femoral Fractures: Early Results. Malaysian Orthopaedic Journal 2007; Vol 1. No.1.
6. Hugh Owen Thomas. Quoted by Rockwood CA, Green DP. Fractures in adult,
4th ed, Vol. II, pg. 1972-1993, 1996.
7. J.N. Wilson (ed.), Watson-Jones Fractures and Joint Injuries. Seventh Edition,
Elsevier, 2009.p:888-889.

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Vol 3 | Issue 2 | May - Aug 2015 | page:27-30 | Anupama Thakur, Ravinder Kaur Mahapatra.

Author: Anupama Thakur[1], Ravinder Kaur Mahapatra[1].

[1] Department of Musculoskeletal Physiotherapy, Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, 12, Thube Park, ShivajiNagar, Pune - 411005, Maharashtra.
Institute at which research was conducted: Sancheti Institute of Orthopaedics and Rehabilitation, Kamla Nehru Hospital.
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. Ravinder Mahapatra
Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, 12, Thube Park, ShivajiNagar, Pune - 411005, Maharashtra.
Email: drravinder82@gmail.com

 Abstract

Background: Lumbar radiculopathy is a benign, often self-limiting condition, commonly managed by rest, pharmacotherapy, physical therapy or alternate medicine options. It is characterised by low back pain radiating into one or both lower limbs. Conventional physical therapy comprises electrotherapeutic devices, hot water fomentation and standard spinal exercises. Studies carried out in patients diagnosed with chronic low back pain reveal inhibition of the multifidii and transversus abdominis muscles. Some studies direct the probable causes of radicular symptoms towards adhesions along the mechanical interface of neural tissue, or presence of a positional fault at the corresponding vertebral level. In conjunction to electrotherapy, various methods of manual therapy are known to help alleviate pain, ie, mobilising the vertebra involved, or correcting pathomechanics of the neural tissue. However, studies establishing their effectiveness are scarce.
Purpose of the study: To assess which of the two methods of manual therapy- Mulligan's Spinal Mobilization With Leg Movements (SMWLMs) and Shacklock Neural Tissue Mobilization (NTM) is more effective in improving low back pain (VAS), radiating limb pain (SLR), lumbar spine stiffness (lumbar range of motion assessment with a dual inclinometer) and disability (ODI) in patients with Lumbar Radiculopathy.
Method: A Randomised Controlled Trial will be performed on 102 patients with lumbar radiculopathy. Both groups will receive conventional treatment in the form of hot packs, Lumbar core activation exercises and ergonomic advice. In addition, Group A will receive Mulligan's SMWLMs and group B will receive Shacklock NTMs, through randomised sampling by chit method. 3 sessions will be carried out in the first week on alternate days followed by two days in the next week, on alternate basis. At the end of 2 weeks, the follow-up assessment will be documented. A home-based exercise program will be given for further strengthening of the lumbar core stabilizers for the next two weeks and the patients must be assessed again at the end of 4 weeks. Outcome measures included Visual Analog Scale scores, Lumbar range of motion (ROM) assessment using dual inclinometer, Goniometric measurement of angle of the Straight Leg Raise and Oswestry Disability Index.
Results: Both groups show a significant improvement in VAS, spinal ROM, SLR range and ODI scores. However, SLR improves to a greater degree in the SMWLM group. Inter-group comparison of ODI scores will not show significant difference. Group A shows consistent pain relief on follow up at the end of 4 weeks.
Conclusion: Patients treated with Spinal Mobilization with Leg Movement technique produce more significant improvement than those treated with Shacklock Neural Tissue Mobilization in leg pain intensity, lumbar range of motion and back specific disability.
Keywords: Shacklock Neural Tissue Mobilization, Mulligan Spinal Mobilization with Leg Movement, Lumbar Radiculopathy, low back pain.

Introduction

Low back pain is neither a disease nor a diagnostic entity of any sort. In India, the incidence of low back pain has been reported to be 23.09% and has a lifetime prevalence of 60-85%.[4],[5] Causes of lower back pain are numerous, with or without accompanying radicular symptoms, constituting idiopathic, degenerative, traumatic, inflammatory, congenital, neoplastic, metabolic, postural and gynaecological, rectal or rectal systemic pathologies.[6] Lumbar radiculopathy may be described as pain originating in the lower back region, and radiating into one or both lower limbs. It usually follows a specific dermatomal distribution, indicating the level of spinal nerve root involvement. Sensory symptoms are pain, typically accompanied with paraesthesias, numbness; motor symptoms include muscle weakness, reduced deep tendon jerks. The pain may demonstrate multiple pathogenesis. Degenerative spondyloarthropathies form the principal underlying cause of radicular symptoms [1], [2] due to disc herniations, and facetal hypertrophy that may compress the nerve root at the lateral foraminal exit[3]. Other causes constitute idiopathic, traumatic, inflammatory, congenital, neoplastic, metabolic, postural and gynaecological, rectal or rectal systemic pathology[6]. Lumbosacral radiculopathy secondary to disc herniation forms one of the most common health related complaints[7]. Lumbar disc herniation with radiculopathy may be defined as localized displacement of disc material beyond the normal margins of the intervertebral disc space resulting in low back pain, and/or weakness, paraesthesiae or numbness in a myotomal or dermatomal distribution[5] . Sciatica refers to radiculitis or radiculopathy of the lumbosacral spine. The Mulligan concept has its foundation built on Kaltenborn's principles of restoring the accessory component of physiological joint movement. Mulligan proposed that injuries or sprains might result in a minor positional fault to a joint, thus altering the biomechanics at the joint, causing restrictions in physiological movement. Mobilization of the spine maybe done in the functional, weight bearing position by applying the force parallel to the spinal facet planes. It maybe oscillatory (Natural Apophyseal Glides- NAGs) or a sustained glide maintained coupled with the patient performing the offending spinal movement (Sustained NAGs- SNAGs). In 1990, Brian Mulligan introduced a technique known as: spinal mobilisations with limb movements (SMWLMs). Here, a sustained transverse glide is applied to the spinous process of a vertebra while the restricted peripheral upper or lower limb movement is performed, actively or passively. The foremost emphasis remains that the mobilization must result in symptom-free movement. Mulligan proposed that utilization of these mobilization techniques was indicated when peripheral joint limitation of movement is spinal in origin[8]. Neuromobilization is a set of techniques designed to restore plasticity of the nervous system, it may be defined as the ability of the nerve, its sheath and structures surrounding it to shift in relation to other such structures[7]. The goal of mobilization is to increase the flexibility of collagen that maintains the integrity of the nerve, thereby improving movement of the nerve in relation to its interface. Shacklock's method of Neurodynamics is based on The Sliding Principle, which consists of an alternation of combined movements of at least two joints, wherein one movement lengthens the nerve bed thus increasing tension in the nerve, while the other movement decreases the length of the nerve bed which unloads the nerve, keeping it in its slack position thereby reducing intraneural pressure. These techniques aim to mobilise a nerve with a minimal increase in tension and are thought to result in a larger longitudinal excursion than techniques which simply elongate the nerve bed, such as tensioning techniques[8]. Conventional method of treatment of low back pain with lumbar radiculopathy involves rest, pharmacotherapy in the form of NSAIDs, and physical therapy using a combination of intermittent lumbar traction, core stability exercises, TENS, superficial and deep heating modalities, manual therapy, neural mobilization principles, orthotics, ergonomics etc.[9] However, not always are these methods directed towards treating the primary cause of sciatica and the patient usually returns with residual symptoms.
Neural tissue mobilization targets breaking adhesions in the structures present along the course of the nerve, at the mechanical interface, thereby improving the gliding of the nerve by eliminating the cause of symptom-causing obstruction; while the Mulligan concept involves correcting the positional fault at the spinal level along with performing the offending physiological movement (here, the Straight Leg Raise). The clinical appropriateness and effectiveness of this technique is based on the immediate reduction in pain and increase in mobility[10]. Studies have been conducted to prove the significance of neural mobilization in treating patients with radiating neural symptoms. The Straight Leg Raise (SLR) test is a useful tool in assessing severity of symptoms. Improving the range of SLR has a beneficial effect in alleviating sensory symptoms, thereby restoring normal physiological spinal movements and reducing the degree of impairment due to low back dysfunction.

Need For Study
Studies have been conducted measuring the efficacy of Shacklock NTMs, showing the beneficial effects. However, data regarding the effects of SMWLM is scarce. This study aims to gain data regarding the effectiveness of Mulligan SMWLM and to obtain a comparison between the effects of the both techniques, thereby providing clinical therapists an evidence-based better choice of treatment.

Hypothesis

The study aims to assess and compare the effects of neurodynamics, and spinal mobilization with limb movement on the pain, lumbar spine range of motion, and level of disability of a patient diagnosed with lumbar radiculopathy, so as to draw a conclusion, regarding which technique yields better alleviation of symptoms and improves function It is hypothesized that there will be a difference in results of both treatment techniques, one yielding better outcomes than the other.  In this study, subjects will be screened as per the inclusion and exclusion criteria and allocated in either Group A or B using chit method of randomisation.
Group A: Spinal Mobilization With Leg Movement (SMWLM) & conventional therapy.
Group B: Shacklock neural tissue mobilization (NTM) & conventional therapy.
Pre-treatment evaluation will be carried out on the first day. A follow up evaluation will be done at the end of one week, two weeks and four weeks.
The data obtained will be recorded and statistically analysed with the Repeated Measures ANOVA test for SLR and spinal mobility readings; and Friedman's ANOVA test for VAS and ODI scales within each group. The Unpaired 'T' test will be used to analyse SLR and spinal mobility readings; Mann Whitney U test for VAS and ODI readings, for inter-group comparison.

Technique for Mulligan SMWLMs: 2 therapist method.
Let us assume, on evaluation, there is an L4-5 lesion with symptoms in the right leg.
The patient is taken in left side lying position.
The affected leg is abducted to approximately 10 degree and supported by the second therapist or an assistant.
The therapist places the thumb on the right side of the L4 spinous process and applies a downward glide, causing side flexion at that level, and rotation on the vertebra below.
The patient performs an active leg raise simultaneously. The motion must be pain free. As progress occurs, overpressure maybe applied. [11]
DOSAGE: Rule of 3, 3 days a week, for 2 weeks. (Rule of 3, i.e., 3 sets of 7-10 repetitions.)

Technique for Shacklock neural tissue mobilization.
The straight leg raise (SLR) will be done for inducing longitudinal tension as the sciatic nerve.
The leg is lifted upward passively beyond 350, as a solid lever, while maintaining extension at the knee.
To introduce additional traction (i.e., sensitization) into the proximal aspect of the sciatic nerve, hip adduction, medial rotation or ankle dorsiflexion is added to the SLR.
Step 1: Sliders- using unaffected joints (remote sequence, remote sliders); affected area is places in the neutral or symptom free position.
Step 2: Sliders- using unaffected joints (remote sequence, remote sliders); affected area is placed in some range of motion, but without or with minimal symptoms.
Step 3: sliders- move affected area and any other area, but with or without minimal symptoms (remote sequence, local sliders).
DOSAGE: 30seconds-2minutes, 5 sets for 3 days a week, for two weeks.

Conventional therapy.
Hot packs for 10 minutes.
Exercises:
Phase 1
Local Segmental Control. In patients with lower back pain, local core muscles undergo inhibition and are substituted by globalmuscle contraction. The aim of this phase is to reestablish local segmental control of multifidus and transverses abdominis. The therapist will palpate the local muscles to confirm their recruitment.
It includes
Transversus Abdominis contraction with pelvic floor muscle activation with lateral costal diaphragm breathing pattern in supine. Bilateral activation of multifidus with transverses abdominis activation, with controlled breathing.
Phase 2
Closed chain exercises with local segmental control with the patient in crook lying position.
Single leg slide with contra lateral limb supported:
Initially, ask the patient to perform the single leg slide with heel support, progress to single leg slide with the heel 5cms above the plinth.
Single leg slide with contra lateral leg unsupported:
Initially, ask the patient to perform the single leg slide with heel support, progress to single leg slide with the heel 5cms above the plinth.

The patient will be treated in the Out Patient Department for the first two weeks of intervention by superficial moist heat therapy and exercises for 5 sessions, along with SMWLM for group A and NTMs for group B, following the afore mentioned dosage.
Home exercise program for the next 2 weeks will be given to both groups, consisting of core strengthening exercises as per phase 2.

The outcome measures are as follows:
Pain rating using Visual Analogue Scale [VAS].
Hip range of movement (ROM) during SLR using goniometer.
Lumbar spine mobility using inclinometer.
Functional disability scores (Oswestry Disability Index).

Discussion

In SMWLMs group (A), the patients will report reduced pain, on Visual Analog Scale; and improved Lumbar range of motion (ROM), measured by dual inclinometer. In Shacklock Group B, patients will report reduced pain and improved Lumbar ROM. However, in group A, pain relief and improved mobility will be observed in the first follow up (at the end of one week), whereas Group B will obtain pain relief and improved Lumbar mobility by the second follow up (at the end of the second week). Both the findings will remain constant till the end of 4th week, at the third follow up. The pain relief and improved Lumbar mobility obtained in group A can be explained by the following mechanism. Mulligan's technique corrects the positional fault[12] at the spinal level and relieves pain by the neurophysiologic mechanism. A minor positional fault may cause pressure on pain-sensitive structures and the nerve root traversing closely. Mobilization at the spinal level itself corrects this fault and relieves the impingement occurring thereby reducing pain in the low back as well as freeing the nerve so as to relieve the radiating symptoms in the lower limbs. Hence improved VAS may be attributed to this effect. Absence of pain will then lead to improved range of motion in the hypo-mobile segments. Complete evaluation will reveal the following positive results: negative SLR at the end of first, second and third follow up in Group A; as compared to group B wherein SLR will be negative at second follow up (2 weeks). At the end of 4 weeks, SLR remains negative and ODI scores improve to the same extent in both groups. In Group A, where Mulligan mobilization was done, negative SLR may be attributed to the effect of a rotational glide being applied to the spinous process of the affected vertebral segment, that increases the diameter of the canal at that level on the opposite side[13], thereby allowing the nerve to glide freely; due to absence of the mechanical compression that had caused paraesthesia. Shacklock neural mobilization is thought to be effective due to its positive impact on restoring restricted mobility of the nerve, thereby improving neural tissue glide with respect to its interface[14]. Compression, that may cause altered blood flow and axonal transport dynamics within the neural tissue, is relieved due to breaking of adhesions[14], thereby correcting the pathophysiology, hence relieving pain, radiating symptoms and Lumbar ROM in patients of group B.

Conclusion

In conclusion, SMWLM in conjunction with conventional therapy produces significant improvement in the low back pain radiating to the limb, range of motion and function of the patients. A four week follow up will reveal maintenance of the beneficial effects achieved during therapy.
Shacklock neural tissue mobilization in conjunction with conventional therapy also shows improvement in pain in the low back region and in the lower limb, Range of motion and ODI scores. However Group A will show consistently quicker positive results in pain relief and lumbar mobility as compared to Group B.

Limitations
1. Unadvisable activities (gym, lifting heavy objects) carried out at home in spite of ergonomic advice will not be monitored.

Clinical Implications

The study will provide evidence for the beneficial effects of both Mulligan SMWLMs and Shacklock NTMs as an adjunct to Lumbar core strengthening and afore mentioned conventional therapy. Furthermore, it suggests that Mulligan spinal mobilization produces quicker relief of patient reported symptoms, as compared to neural mobilization. This may assist clinical physical therapists with a clearer approach while handling patients suffering from lumbar radiculopathy.

References

1. Andrew W. Tarulli MD, Elizabeth M. Raynor MD. Lumbar Radiculopathy. Neurologic clinics May 2007 Vol 25 (2):387-405 Neck and back pain.
2. Priya Igatpurikar, Dr. Sona Kolke. Efficacy of maitland's spinal mobilization in lumbar spondylosis with radiculopathy. Indian Journal of Physiotherapy and Occupational Therapy - An International Journal Year : 2013, Volume : 7, Issue : 3
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4. Sharma SC, Singh R, Sharma AK, Mittal R: Incidence of low back pain in workage adults in rural North India, Medical Journal of India 2003; 57(4):145-147.
5. M. Krismer M. Van Tulder: Low back pain (nonspecific), Best practice and research clinical rheumatology 2007; 21(1):77-91.
6. Patricia A Downie (FCSP): Cash's textbook of orthopaedics and rheumatology for physiotherapists, 1st Indian edition 1993.
7. Ibrahim M Moustafa PT, PhD and Aliaa A. Diab, PT, PhD. The effect of adding forward head posture corrective exercises in the management of lumbosacral radiculopathy: A randomized controlled study. Journal of Manipulative and Physiological Therapeutics.
8. Linda Exelby. The Mulligan Concept: Its application in Management in Spinal Conditions. Manual Therapy (2002) 7(2), 64–70
9. F Ellis and Wayne A Hing. Neural mobilization, The Journal of Manual and Manipulative Therapy. Volume-16, no-1(2008), 8-22.
10. Mulligan BR. Manual Therapy. “nags”, “Snags”, “MWMs”, etc 4th edition. Pgs 44-45.'
11. Mulligan Brian R., Spinal Mobilisations with Leg Movement, The Journal of Manual & Manipulative Therapy, Vol. 3 No.1 (1995), 25-27
12. Vincenzino et al. Mulligan's mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature, Manual Therapy 12 (2007) 98–108
13. Maitland GD. Vertebral manipulation. Butterworths- Heinemann. 1986.
14. Sarkari, E. and Multani, N.K. Efficacy of Neural Mobilisation in Sciatica. Journal of Exercise Science and Physiotherapy, 3(2): 136-141.

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Vol 3 | Issue 2 | May - Aug 2015 | page:23-26 | Bhakti Jamdade V, Apurv Shimpi, Savita Rairikar.

Author: Bhakti Jamdade V[1], Apurv Shimpi[1], Savita Rairikar[1].

[1] Department of Community Physiotherapy, Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, Thube Park, Shivaji Nagar, Pune, Maharashtra,India.
Institute at which research was conducted: Sancheti institute College of Physiotherapy, Thube park, Shivajinagar Pune 411005, Maharashtra.
University Affiliation of Thesis: Research hypothesis (synopsis) submitted for mpth registration to maharashtra university of health siences (MUHS), Nashik.
Year of Acceptance: 2015.

Address of Correspondence
Dr. Apurv Shimpi
Sancheti Healthcare Academy, Sancheti Institute College of Physiotherapy, 12, Thube Park, Shivaji Nagar, Pune - 411005, Maharashtra.
Email: apurvshimpi@sha.edu.in

 Abstract

Background: Low back pain is a leading cause of disability and it occurs in similar proportions in all the sectors of working as well as non-working population. It also interferes with quality of life and work performance, and is the most common reason for medical consultations. Work related musculoskeletal disorders especially low back pain leads to substantial economic losses to individuals as well as community. In industrial population various factors like postural deviations, core strength, flexibility and psychosocial aspects are responsible for low back pain. There has also been a high prevalence of low back pain reported in the automobile industry. Although studies have been done to find the etiological factors for low back pain in industrial workers, but there is a dearth of literature in understanding the factors which have a high impact in development of low back pain and the relationship of these factors to the severity of the dysfunction present in this population. Thus, it becomes important to know which are the major factors leading to low back pain and other causative factors for postural deviations which in turn are leading to low back pain in automobile industrial sector. Present study hypothesized that various factors like work postures, core muscles strength, and flexibility of the workers have a major influence on the presence of low back pain in automobile industry workers in a varied proportion. 300 workers from automobile industry will be assessed using the outcome measures like core strength, flexibility, Rapid entire body assessment for high risk postures at work and Nordic musculoskeletal questionnaire for pain analysis. Statistical analysis will be done by Spearman's Correlation coefficient with alpha set at p<0.05.
Clinical importance: The assessment of the factors which contributes maximally to work related low back pain can help target the specific line of management while treating this patients and also prevention of those factors which are leading to low back pain in industrial workers.
Future research: On the basis of this factors contributing to work related low back pain in industrial workers a specific exercise protocol can be designed to minimize the disability and help them to cope up with increasing work demands. Also various environmental factors and psychological factors can be considered.
Keywords: Low back pain, musculoskeletal disorders, automobile workers.

Introduction

Low back pain is neither a disease nor a diagnostic entity of any sort. The term refers to pain of variable duration in an area of the anatomy afflicted so often that it is has become a paradigm of responses to external and internal stimuli [1]. Low back pain is an important public health, economic and social problem. It is a disorder with many aetiologies occurring in different age groups and it is also a common health condition in working population as well as non working population [2]. International surveys of low back pain report a point prevalence of 15–30%, and a 1-month prevalence of between 19 and 43% [3]. Worldwide estimates of lifetime prevalence of low back pain vary from 50 to 84% [2-6]. Back pain leads to high cost for individual, the workplace and society. The prevalence of low back pain is high among industrial workers [7,8]. The working environment may be hazardous and stressful [9,10]. Work schedule and the design of the working environment can lead to errors and accidents [11,12]. Several occupational injuries exist such as musculoskeletal injuries (MSIS), spinal disorders, gas burns, scalds, and respiratory complications [12]. MSIS are among the major occupational hazards facing the working population today, especially among the working class. Burdorf, Rossignol, Fathallah, et al reported that 80% of the adult working population, would experience back pain sometime during their active life because of their nature of work, which requires heavy physical work, awkward posture, or prolong periods in one posture [13]. In occupational health, the type and severity of spinal complaints have high relationship with workload [14,15]. In automobile industries, certain activities like manual handling of weights, lifting, pushing or pulling weights or heavy objects are co related with low back pain [16].There have been several studies done which confirm that manual handling of heavy objects in industries lead to spinal complaints [17-21]. In most of the automobile industries manual handling of weights, lifting, pushing or pulling of heavy object are constant part of work among workers in production part especially [22]. Several studies have reported incidence and prevalence of musculoskeletal disorders in industrial workers of which low back pain is reported much higher [17-21]. Many studies include various etiological factors for this low back pain like constant physical activity, reduced flexibility and core strength and also psychosocial factors [23]. Additional data on various factors predisposing to work related low back pain is very important for health promotion programmes. The main focus is to identify the work related factors for low back pain among industrial workers. This kind of knowledge is important for different levels from patients to employees, health professionals and clinical settings and finally for public health policy workers.

Hypothesis

Low back pain (LBP) is one of the most significant medical and socioeconomic problems in modern society [24]. The main predictors of back pain include physical stress (e.g., prolonged lifting, driving, forceful or repetitive movements involving the back). Low back pain prevalence is related to the type of occupations such as driving, manual handling and occupations that involve a lot of improper body movements [25]. Work-related physical exposures, especially heavy lifting and manual materials handling, working in awkward postures, and whole-body vibration, are well established risk factors for LBP [25-26]. Low back syndrome, although self-limiting in most cases, leads in a small percentage of patients to chronic problems that can be very costly to manage, and those cases that resolve are prone to recurrence at a rate of up to 90% [27]. The main risk factors for low back pain among production workers were extreme trunk flexion, as well as lifting of loads, pushing or pulling heavy loads and exposure to whole body vibration. Thus it becomes important to assess the various factors like work posture, core muscle strength and flexibility which influence the presence of low back pain in automobile industry workers and also to find the maximum extent to which this various factors influence the low back pain among industrial workers. This study is based on the hypothesis that some of the factors like core strength, high risk work postures and flexibility; causing work related low back pain industrial workers contribute more than the other factors to cause symptoms and disorders in automobile industry workers. 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 sample will be collected from an automobile industry that has an incidence report of low back pain as per the records available in the occupational health centre of the concerned industry by convenient sampling method. On the basis of incidence report of low back pain in past 1 year sample will be recruited. Workers working for more than 6 months in industry and having low back pain since 1 month within the age group of 20 – 50 years will be recruited in the study; this is done to eliminate the potential confounders in the study. Workers with any surgical intervention, diagnosed as prolapsed intervertebral disc or pain due to any metastatic or infective origin will be excluded from the study. The data collection, assessment and analysis shall be done as per STROBE statement guidelines. Study will include all the population of the workers having low back pain in the past 1 year. Factors like core strength, flexibility, postural analysis at work place and pain intensity will be assessed. Core strength will be assessed using pressure biofeedback device, flexibility will be assessed using sit and reach test, and postural analysis will be using rapid entire body assessment (REBA) with a photographic method. Pain intensity, severity and location will be assessed using Nordic musculoskeletal questionnaire (NMQ). Statistical analysis will be done by Spearman's Correlation coefficient with alpha set at p<0.05.

Discussion

Work related musculoskeletal disorders (WMSDS) continue to be a major source of disability and lost work time. Low back pain is not a disease but a constellation of symptoms that usually is acute or self limiting. A combination of physical, psychological and psychosocial workplace risk factors have been documented to be responsible for low back pain. Physical risk factors such as high forces, high repetition, and working with arms overhead, long-term static postures, local contact forces and vibration have been commonly identified [28]. Various intrinsic and extrinsic factors are responsible for the low back pain in industrial sector. Noor Sazarina Mad Isa et al (2014) conducted a study in automotive industry workers in Selangor to evaluate the prevalence and the risk factors of low back pain which included work postures and physical activity [29]. The study concluded that occupational risk factors mainly physical demands were significant risk for low back pain among manual material handling workers. This study included only the sustained work posture and physical demands of the manual material handling workers. Jonathan L Vandergrift et al (2011) conducted a study to examine the association between occupational physical and psychosocial ergonomic risk factors and low back pain. The study concluded that exposure to awkward back postures and hand force exertion in automotive industry increased the risk of low back pain also observed the impact of psychosocial work environment on risk of low back pain [30]. Murtezani A et al (2011) conducted the study to determine the prevalence of low back pain (LBP) in industrial workers, to check for possible low back pain related risk factors and investigate the associations between physical activity and severity of low back pain and concluded that work-related physical factors showed strong associations with low back pain. Above mentioned studies considered the extrinsic factors like physical activity demands of the workers working in automotive industry and its association with low back pain but none of them concentrates on the assessment of the intrinsic factors of the workers which includes core muscles strength, flexibility of the workers and also if the working posture of the worker is at risks, which are also the risk factors for low back pain. So this study concentrates on various intrinsic factors such core muscles strength, flexibility, work postures and pain intensity in the automobile industry population. Industrial workers have to adjust their postures according to the work assembly which includes manufacturing the parts, fixation of various parts, assemble the body, paint shop, quality assurance department. All this assemblies includes bending, twisting the trunk, overhead activities, forward leaning postures, slump sitting, stooping, kneeling, manual handling of weights in awkward positions, pushing or pulling of weights and transfer of which predispose them to be at high risk postures and all this postural deviations equally contribute to low back pain [29]. The core muscle strength is one of the contributing factors for low back pain. The core consists of the abdominal muscles groups (transverse abdomens, internal oblique, external oblique and rectus abdomens), hip abductors/ adductors, hip flexors, the pelvic floor, and lumbar spine. Core stability is important for the maintaining an upright posture and especially for movements and lifts that require extra effort such as lifting a heavy weight from the ground. Without core stability the lower back is not supported and can result in low back pain, poor posture. Workers in automobile industrial have to work in various awkward positions and static postures for long duration with repetition of activities [31]. Mehdi Ghasemkhani et al (2008) discussed that repetitive movements with awkward postures are hazardous when they involved the same joints and muscle groups and when workers do the same motion too often, too quickly and for too long. Manual workers have a static posture of the neck and back. A static posture can produce fatigue because constantly tensed muscles never have an opportunity to recover; thus the potential for discomfort increases [32]. Flexibility is another component that can lead to low back pain. Lack of flexibility in the lower body, particularly in the hamstrings and hip flexors, can cause low back pain [33]. Individuals with LBP commonly present decreased flexibility in the lumbar region, and lower limb muscles which in turn can cause low back pain. Reduced flexibility in low limbs especially in hamstrings and hip flexors due to prolonged sustained positions and lack of stretching leads to low back pain. The hamstrings, when tight, can pull on the pelvis and cause tightness and discomfort in the lower back. Also when hip flexor muscles such as iliopsoas are tight, they tilt your pelvis forward and compress your lower back and cause symptoms of low back pain. Piriformis tightness can also lead to back and leg pain [33].Thus flexibility can be one of the important factors leading to low back pain in industrial population. Thus this study will be concentrating on this various factors leading to low back pain in automobile industrial population and also find the impact of these factors in producing the symptoms and disorders.

Clinical Implication

Systematic study of all the causative factors of low back pain in automobile industry workers will help us to know the impact of core muscle strength, flexibility, and work posture in producing the symptoms of low back pain and also which of these factors contribute maximum in producing the symptoms. This in turn can help us to formulate a structured protocol for the treatment of such complaints which will target the specific factor leading to low back pain. Also various preventive measures can be taken to reduce the prevalence of low back pain in this population by taking extrinsic and intrinsic factors into consideration. Various motivational and informative lectures, group activities to maintain the flexibility, strength and endurance of muscles and training of manual material handling can be undertaken.

Future Direction

Specific exercise protocol can be designed for this population considering the factors that is maximally responsible for producing the symptoms. Various other factors like psychosocial and environmental factors can also be taken into consideration.

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