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Scientific Research Journal of India (Multidisciplinary, Peer Reviewed, Open Access, Journal of science) ISSN: 2277-1700 Vol: 2, Issue: 2, Year: 2013

Editor in Chief Dr. Krishna N. Sharma (PT) Editors Dr. Popiha Bordoloi Dr. Kuki Bordoloi Dr. Sudeep Kale Dr. Waqar Naqvi Junior Editor Mrityunjay Sharma

Office Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403 Website http://www.srji.info.ms URL Forwarded to http://sites.google.com/site/scientificrji Email editor.srji@gmail.com Contact +91-9320699167, 9839973156


Copyright Š 2013 Scientific Research Journal of India All rights reserved.


CONTENTS

Title

Author/s

Editorial

Dr. Krishna N. Sharma

The Sustained Effect of Short Durations of Warm Up and Stretching Exercises on Shoulder Joint Proprioception

Department

Page i

Bala Jyoti, Pacheri Bari, Gupta Manish, Shaina

Physiotherapy

1

Physiotherapy

9

Physiotherapy

17

Physiotherapy

24

Physiotherapy

39

Computer Science

44

Industrial Management

54

-

63

Sandeep, Kumar Satish

Impact of Ageing on Depression and Activities of Daily Livings in

Vanshika Sethi,

Normal Elderly Subjects Living in

Vijeylaxmi Verma,

Old Age Homes and Communities

Udhbhav Singh

of Kanpur, U.P. To

Assess

between

the

Relationship

Temporomandibular

Joint Dysfunction and Cervical Spine Dysfunction

Khyati Harish Sanghvi, Amrit Kaur, Ganesh Subbiah

Effectiveness of Neuromotor Task Training

Combined

with

Kinaesthetic Training in Children with

Developmental

Ordination

Disorder

Co-

A

Sundaresan Chockalingam, Agnel Kevin Gomes

Randomised Trial Cognitive Rehabilitation in MS

Krishna N. Sharma

Network Border Patrol Eradicates the Over Loading of Data Packets and Prevents Congestion Collapse thereby Promoting Fairness Over

Lakshminarayanan T., Dr. Umarani R.

TCP Protocol in LAN /WAN

Use of Fuzzy TOPSIS Model for Evaluating Cooling Towers

Correction Notice

Dr. Ali Kheradmand, Mahdi Naqdi Bahar, Ali Ghani Abadi -


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iv


EDITORIAL

Dear Readers! I am very pleased to present this issue of the Scientific Research Journal of India (SRJI). With this issue. This issue of the multidisciplinary and open access Journal of science contains total 5 papers in Physiotherapy, 1 paper in Computer Science, and 1 paper in Industrial Management. Hopefully you’ll find these papers informative. Here I would like to bring one more thing to your notice that our URLs are hacked so from now our permanent URL will be http://sites.google.com/site/scientificrji . Do drop a mail to us (editor.srji@gmail.com) if you have any comment and suggestion.

Happy Reading.

Regards,

Dr. Krishna N. Sharma Editor in Chief

i


THE SUSTAINED EFFECT OF SHORT DURATIONS OF WARM UP AND STRETCHING EXERCISES ON SHOULDER JOINT PROPRIOCEPTION Bala Jyoti*, Pacheri Bari, Gupta Manish**, Shaina Sandeep, Kumar Satish

ABSTRACT

OBJECTIVE: To study the sustained effect of Short Durations of Warm up and Stretching Exercises on Shoulder joint Proprioception. DESIGN: Pre-test and Post test control group design. SETTING: Inpatient and rehabilitation hospital. PARTICIPANTS: A total number of 75 subjects free from pain and discomfort and any pathology in and around shoulder joint are allocated randomly into 1 of 5 groups.

INTERVENTION: Group A received 1 min. of warm up and stretching(n=15),Group B received 2 min. of warm up and stretching (n=15), Group C received 3 min. of warm up and stretching (n=15), Group D received 4 min. of warm up and stretching (n=15) and Group E control group received no warm and stretching (n=15)). All groups received intervention. MAIN OUTCOME MEASURES: A CPM Machine was used to move a desired joint continuously through controlled ROM without the subject’s active effort. To measure the JPS, passive CPM was used.

Outcomes were measured before and immediately after

intervention and 5 min. after 2nd data. All JPS scores were measured on same day. RESULTS: Outcome measures for all groups showed the effect of warm up and stretching still persisted after 5 min of 2nd data collection, except at 150 degrees of shoulder flexion in Group A. At 2 min, 3 min and 4 min of warm up and stretching, the improvement in joint position sense appreciation were significant at all ranges/target positions checked and this improvement sustained even after 5 min of 2nd data collection. Also group C i.e. 3 minutes warm up had the maximum gains, Group A had the minimum gains and Group D had the fewer gains due to the effects of muscular fatigue as reported by the subjects after performing this warm up.The control group

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showed the minimum non-significance across all the groups. CONCLUSION: This study concludes that warm up and stretching exercises improve shoulder joint position sense appreciation and this improvement sustained even after 5 min of 2nd data collection.

KEYWORDS: Contract-Relax Stretch, Performance, Proprioception, Sports, Injury Prevention

depending on the joint tested.

INTRODUCTION Proprioception is defined as the cumulative

The exact mechanism of proprioceptive

input to central nervous system from specialized

control remains unclear, particularly in the

nerve endings called mechanoreceptors. They are

shoulder.

located in the joint capsules, ligaments, muscles,

indispensable because the glenohumeral joint

1

Shoulder

proprioception

is

tendon and skin . It is currently acknowledged

relics primarily on dynamic restraint of rotator cuff

that

entity

to maintain stability. Proprioception may also

encompassing several different components such

affect injury predisposition and rehabilitation.

as sense of position, velocity, movement detection,

Several

and force and that the afferent signals that give rise

proprioception is impaired after fatigue, injury and

to them may well have origins in different types of

in overhand athletes.

proprioception

receptors2.

is

a

complex

Proprioception is the ability to

that

shoulder

exercise during rehabilitation of shoulder because

kinesthesia is the ability to detect movement. Joint

the rotator cuff is vital for glenohumeral joint

position sense is mediated by joint and muscle

stability4. In the present study our focus is on

receptors as well as visual, vestibular and

position sense here in defined as the awareness of

cutaneous input3.

actual position of the limb.

Early research suggested that the joint had

suggest

Clinicians commonly use proprioception

determine the location of a joint in space where as

receptor

studies

the

predominant

proprioception and kinesthesia.

role

Many researchers have used joint position

in

sense appreciation tests to evaluate knee joint

Joint receptors

performance after the administration of warm up

have been identified in joint capsules, ligaments,

exercises and stretching of different duration and

menisci, labrum and fat pads3. Recent research has

intensities.

identified ruffini−like ending in the glenohumeral

physical

joint capsules, found pacinian corpuscles in

fitness

.Stretching is used as a part of and

rehabilitation

programs

because it is thought to positively influence

glenohumeral ligaments, and free nerve endings in the glenoid labrum of human cadavers3.

5,6,7,8,9,10

performance and injury prevention 11.

Most Many

proprioception research has examined the elbow,

researchers

have

used

different

Some authors have

durations and intensities of stretching for different

attempted to generalize their findings to other

purposes viz. soft tissue extensibility modulation,

joints. However, proprioceptive control may differ

prevention of injury during sporting activity and

wrist, knee, and ankle.

2


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

also to increase proprioception in human joints.

interviewed

12,13,14,15,16

to

physiotherapist of Sir Ganga Ram Hospital who

investigate whether varying intensities of warm up

was unaware of their group. By using random

and stretching exercises helps in improving

sampling method, the subjects were assigned to 1

shoulder joint position sense appreciation

of 5 treatment groups. Group A received 1 min. of

.Therefore

this

study

is

aimed

and

examined

by

a

clinical

warm up and stretching(n=15),Group B received 2 min. of warm up and stretching (n=15), Group C

METHODOLOGY A total number of 75 subjects(N-15 X 5

received 3 min. of warm up and stretching (n=15),

groups) were included in the study, were recruited

Group D received 4 min. of warm up and

from the physiotherapy department of Sir Ganga

stretching (n=15) and Group E control group

Ram Hospital, NewDelhi, India.Subjects (N-15 X

received no warm and stretching (n=15)). The joint

5 groups) were included in the study.

position sense score was measured before warm up and stretching, after warm up and stretching and 5 min. after 2nd data with the help of CPM Machine.

Inclusion criteria were: 1. Mean Age of subject is 20-30 years,

CPM machine was considered most appropriate

2. Right Hand Dominant

and yield reliable and valid data. The subjects

3. Free from pain and discomfort in and

were instructed to remove their shirt and vest to allow for acclimatization to room temperature for

around shoulder joint 4. No

pathological

musculo-skeletal

conditions and

10 minutes.

affecting

The rig of CPM machine and chair was

neuromuscular

adjusted so that the rotation axis of the rig was

system. 5. Only Males are included.

congruent with centre of glenohumeral joint. The rotation axis of shoulder was adjusted by laser

Exclusion criteria were:

detection ray, which was present in machine.

1. Patients with previous shoulder surgery

Subjects were seated in chair and blind folded and

2. Patients who have signs and symptoms of

cotton gauge was put in the ear.

gross shoulder instability

All movements were performed on right shoulder

3. Patients who had red flags suggesting

joint.

serious shoulder pathology

Subjects were required to match a

4. Patients with cardio –pulmonary diseases

previously presented angle from starting position

5. Patients with tumor, infection and fracture

to target position by machine respectively i.e.

6. Patients with History of soft tissue injury

Flexion 30-90°, flexion 60-120° and flexion 90-

within one last year

150°.

7. Patients pathological conditions affecting musculo-skeletal

and

The shoulder joint (arm) was passively

moved at 2 degree/sec to predetermined target

neuromuscular

position. The arm remained at target position for 5

system

sec. (Same duration for all trials) and returned at a speed

Subjects who are willing to participate were

2°/sec

to

starting

position.

Three

familiarizing trails were given before data was 3


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collected.

Stop switch was given to subjects.

When the button was pressed by the subject, it indicated recognition of target position.

Each

movement

times

data

was

collected

two

measurements of JPS difference between the perceived angle and angle of flexion was recorded with the +ve sign of error. After recording data, warm-up and stretching were performed by the subjects for 1 min (Group A), 2 min (Group B), 3 min (Group C), 4 min (Group D) and no exercises for control group (Group E). Again data was collected immediately after warm up and also 5 min. after 2nd data . RESULTS

Similarly, at 2 min, 3 min and 4 min of warm

Since the data did not follow normal

up and stretching, the improvement in joint

distribution, therefore, repeated measure Anova

position sense appreciation were significant at all

was not used, instead Non-parametric tests were

ranges/target

used.

Wilcoxon-signed ranks test was used to

improvement sustained even after 5 min of 2nd

compare the pre-intervention, post-intervention

data collection.The control group result indicated

data collection errors among themselves (between

no improvements at all target positions checked.

group comparison) for all the 5 groups.

positions

checked

and

this

Examining the results (through master chart)

One way Anova was used to calculate the

from a clinical perspective, we observe that the

significance value of pre-intervention and post-

third group i.e. 3 minutes warm up had the

intervention data collection of all the 5 groups for

maximum gains, 1 minute warm up had the

both between-group comparison and within group

minimum gains and 4 minute warm up had the

comparison. Post-HOC and Mann-Whitney tests

fewer gains due to the effects of muscular fatigue

were used to compare significance values among

as reported by the subjects after performing this

all the groups (multiple comparisons).

warm up.

The gains in joint position sense appreciation

Examining Mann Whitney multiple group

were significant after 1 min of warm up at all the

comparison test results the 3 minute warm up

target positions checked. The effect of warm up

group showed maximum significance across all the

and stretching still persisted after 5 min of 2nd

groups.

data collection, except at 150 degrees of shoulder

minimum non-significance across all the groups.

flexion.

findings of this study indicate that warm up and stretching

Table 1: Wilcoxon Signed Ranks Test.

And the control group showed the

exercises

improve

shoulder

joint

position sense appreciation. This improvement in shoulder 4

joint

position

sense

appreciation


Scientific Research Journal of India â—? Volume: 2, Issue: 2, Year: 2013

enhances with increase in duration and intensity of warm up upto 4 minutes. At 4 minutes there are lesser gains in joint position sense because muscular fatigue starts setting in.

Table 2: Mann Whitney Tests (Multiple Group Comparison)

Graph 2: Mann Whitney Tests (Multiple Comparison 60-120)

Graph 1: Mann Whitney Tests (Multiple Comparison 30-90) Table 4: Mann Whitney Tests (Multiple Group Comparison)

Table 3: Mann Whitney Tests (Multiple Group Comparison)

Graph 3: Mann Whitney Tests (Multiple Comparison 60-120)

5


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warm up upto 4 minutes. At 4 minutes there are lesser gains in joint position sense because muscular fatigue starts setting in. In this study, the gains in joint position sense appreciation were significant after 1 min of warm up at all the target positions checked. The effect of warm up and stretching still persisted after 5 min of 2nd data collection, except at 150 degrees of shoulder flexion. that

Similarly, at 2 min, 3 min and 4 min of warm

Wilcoxon-signed ranks test was used to compare

up and stretching, the improvement in joint

the

position sense appreciation were significant at all

Interpretation:

The

pre-intervention

Table-1

and

showed

post-intervention

(between group comparison) for all the 5 groups.

ranges/target

positions

checked

and

this

the gains in joint position sense appreciation were

improvement sustained even after 5 min of 2nd

significant after 1 min, 2 min, 3 min and 4 min of

data collection. The control group result indicated no

warm up and stretching, The table-2,3,4 showed that three Examining

improvements at all target positions checked.

Mann Whitney multiple group comparison test

Examining the results (through master chart) from

results the 3 minute warm up group showed

a clinical perspective, we observe that the third

maximum significance across all the groups. And

group i.e. 3 minutes warm up had the maximum

the control group showed the minimum non-

gains, 1 minute warm up had the minimum gains

significance across all the groups.

and 4 minute warm up had the fewer gains due to the effects of muscular fatigue as reported by the

The improvement in joint position sense appreciation still persisted after 5 min of 2nd data

subjects after performing this warm up. Examining Mann Whitney multiple group

collection, except at 150 degrees of shoulder

comparison test results the 3 minute warm up

flexion in Group A.

group showed maximum significance across all the

At 2 min, 3 min and 4 min of warm up and stretching, the improvement in joint position sense

groups.

And the control group showed the

appreciation were significant at all ranges/target

minimum non-significance across all the groups. The results of this study match with the

positions checked and this improvement sustained even after 5 min of 2nd data collection.

results of previous studies done on same subject indicating that warming up exercises improve joint position sense appreciation5,20.

DISCUSSION The findings of this study indicate that warm up and stretching exercises improve shoulder joint

CONCLUSION

position sense appreciation. This improvement in shoulder

joint

position

sense

The findings of this study support that the

appreciation

larger amount or duration of warm up and

enhances with increase in duration and intensity of

stretching will give more accuracy of joint position

6


Scientific Research Journal of India â—? Volume: 2, Issue: 2, Year: 2013

sense before the occurrence of muscular fatigue.

position sense alter across the ROM with

Also the effect of warm up and stretching still

potentially greater position sense acuity in the

persisted after 5 min of 2nd data collection,

outer range of shoulder flexion where there is more tension upon the restraints of motion.

Clinicians should be aware of this information in making decisions during rehabilitation of

Muscular fatigue should not be allowed to set

shoulder injuries or proprioceptive training of

in during warm up period so as to prevent the loss

athletes. The results suggest that shoulder joint

of proprioceptive acuity.

REFERENCES

1.

Voight L.M., Allen J., Turner A,Tippett S. and Gary C., The effect of muscle fatigue and relationship of arm dominance to shoulder proprioception, J.O.S.P.T., 2(6), 348-352(1996)

2.

Lonn J., Albert M.S. and Pederson., Position sense testing: influence of starting position and type of displacement, APMR., 81, 592-593(2000)

3.

Marnic A., M Scott S.L., J.I.and F.H., Shoulder kinesthesia in healthy unilateral athletes participating in upper extremity sports, J.O.S.P.T., 21(4), 220-226( 1995)

4.

Drover G., M.S., C.A.T., A.T.C and Powers M.E.,Cryotherapy does not impair shoulder joint position sense, APMR., 85, 1241-1246(2004)

5.

Br. J. SP., Effect of warm up exercises on knee proprioception before sporting activity, Med.,36,132-134(2002)

6.

Effects of static stretch and warm up exercises on hamstring length over the course of 24 hours, J.O.S.P.T., 33(12), 727-33(2003)

7.

In sports & exercise:- A randomized trail of pre-exercise stretching for prevention of lower limb injury, Med. & Sc.

8.

After effects of resisted muscle contraction on accuracy of joint position sense in elite male athletes, A.P.M.R.,79,1250-1254(1998)

9.

Effects of age and activity on knee joint proprioception, Am.J.Phys.Med. Rehab., 9,235241(1997)

10.

Knee proprioception: A review of mechanism, measurements, and implications of muscular fatigue, Orthopedics., 21(4),463-471 (1998)

11.

Effect of superficial heat, deep heat, active exercises warm up on extensibility of plantar flexors, Phys. Ther., 81, 1206-1214(2001)

12.

The effect of time on static stretch on flexibility of hamstring muscles, PHY. THER.,74(9),845850(1994)

13.

The effect of duration of stretching of hamstrings for increasing ROM in people aged 65 years or older, PHY. THER., 81(5),1110-1117(2001)

14.

Duration of stretching effect on ROM in lower limb, A.P.M.R., 66,171-173(1985)

15.

Effects of static stretch versus static stretch and U.S. combined on triceps surae muscle extensibility in healthy women, PHY. THER.,67(5), 674-679 (1987) 7


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16.

SWD and prolonged stretching increase hamstring flexibility more than prolonged stretching alone, J.O.S.P.T.,34( 1), (2004)

CORRESPONDENCE

*Research Scholar, Singhania University. Rajasthan, India **Consultant Orthopaedics, Kapoor Medical Center

8


IMPACT OF AGEING ON DEPRESSION AND ACTIVITIES OF DAILY LIVINGS IN NORMAL ELDERLY SUBJECTS LIVING IN OLD AGE HOMES AND COMMUNITIES OF KANPUR, U.P. Vanshika Sethi*, Vijeylaxmi Verma**, Udhbhav Singh***

ABSTRACT INTRODUCTION: Ageing is a progressive generalized impairment of functions resulting in loss of adaptive response to stress and increasing the risk of age related disease. METHODOLOGY: A sample of 200 elderly subjects i.e. 100 from the community (group A) and 100 from Old age home (group B) of sixty & above years of age were taken by the convenience sampling method. The subjects were collected through various old age homes and community which includes Vaikunth Dham Old Age Home, Ishwar Prem Ashram, Swaraj Ashram, Ramkrishna Mission old age home and nearby community located in the Kanpur and Varanasi. The subjects were assigned a number to maintain the confidentiality of the subjects and then the scales were used to assess the scores i.e., Geriatric Depression Scale (GDS) and Barthel index of daily livings were used to check the level of depression & ADL’s and then the scores were compared. THE RESULTS: The mean GDS scores for group A were 11.32 and for group B were 16.42 with a value of -6.981 with a p value of 0.00* and mean ADL’s scores on the Barthel index for group A were16. 54 and 17.98 for group B within value of -2.898 with a p value of 0.004* which shows there is a significant difference. Conclusion: Elderly subjects living in Old age home are more affected in terms of depression and ADL’s as compared to community dwelling elder subjects as old people living in their own homes were most able to cope in their homes. They received more support from relatives and friends than from health and social services16

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KEY WORDS: Elderly, ADLs, Depression, Community, Old age home

INTRODUCTION

However elderly are not preparing themselves for long life, nor are we receiving any information

Age classification varied between countries

about the aging process at home, school,

and over time, reflecting in many instances the

community in general. Society tends to exclude the

social class differences or functional ability related

elderly. They are considered incompetent and are

to the workforce, but more often than not was a

denied any responsibilities. This is far removed

reflection of the current political and economic

from previous societies in which, given their

situation. Many times the definition is linked to the

experience, the eldest members enjoyed a much

retirement age, which in some instances, was

higher status. They considered wise, the teachers,

lower for women than men. This transition in

and traditions. A great number of people in this

livelihood became the basis for the definition of

sector are slightly depressed and tend to consider

old age which occurred between the ages of 45 and

themselves less productive than they really are5

55 years for women and between the ages of 55

Between the year 2000 to 2050, the

and 75 years for men1.

worldwide proportion of persons over 65 years of

Elderly people are classified into: - 1) 60 yrs

age is expected to more than double, from the

to 70yrs- Young old 2) 70 yrs to 80yrs- Middle old

current 6.9% to 16.4%. As healthcare facilities

3) 80yrs &above- Old old 2

improve in countries, the proportion of the elderly

The risk factors for reduced physical function

in the population & the life expectancy after birth

in elderly people, as identified in longitudinal

increase accordingly. This is the trend which has

studies, relate to comorbidities, physical and

been in both developed & developing countries. It

psychosocial health, environmental conditions,

is commonly believed that the majority of the

social circumstances, nutrition, and lifestyle3

elderly population resides in developed countries.

As the western population is increasingly

However, this is a myth, as about 60% of the 580

ageing, problems connected with old age will

million older people in the world live in

dominate healthcare. Depression, one of the most

developing countries, and by 2020, this value will

prevalent psychiatric disorders, is expected to take

increase to 70% of the total older population 6

an even more prominent position than presently, as

Depression is common in medically ill elderly

the risk for developing depression increases with

and

old age. Depressive symptoms are present in

associated

with

greater

morbidity

and

mortality, increased health service use and medical

almost one third of the elderly populations and

costs. Studies have shown that antidepressant and

major depression may be present up to 4%

structured psychotherapy, alone or combined, are

Furthermore, once present, the prognosis for

effective in reducing depressive symptoms among

elderly with depression is poor4

older adults7

There have always been elderly people, but

Depression and anxiety lead to a serious

what is new today that they now form the largest

impairment of daily functioning and quality of life.

sector of the population in industrialized societies. 10


Scientific Research Journal of India â—? Volume: 2, Issue: 2, Year: 2013

In frail elderly, the effects of depression and

The model of the International Classification

anxiety are especially deep encroaching .The

of Functioning, Disability and Health can describe

number of elderly is rapidly growing. Almost a

the consequences of dementia that eventually lead

third of elderly subjects in the community with sub

to deterioration in BADL and loss of autonomy. In

threshold depression or anxiety will develop a

the context of this review, dementia (health

major depressive or anxiety disorder in three years

condition) has a negative influence on mobility,

8

endurance, lower-extremity strength and balance The prevalence of major depressive disorder

(body functions and body structures). Those body

at any given time in community samples of adults

functions are important for BADL functioning

aged 65-67 older ranges from 1-5% in larger scale

(activity). Depending on the quality of the BADL

epidemiological investigations in the United States

performance, patients are less or more restricted in

and internationally, with the majority of studies

their participation (participation). By training

reporting prevalence at the lower end of the range.

physical components underlying ADL, or by a

Clinically significant depressive symptoms are

direct influence of exercise on ADL, healthy

present in approximately 15% of the community-

elderly subjects can stabilize or improve their

dwelling older adults 9

ADL score12

Major depressive disorder is one of the most

The mechanisms by which depression has an

common forms of psychopathology, one that will

effect on physical disability are not completely

affect approximately one in six men and one in

understood. Both behavioral (depressed patients

four women in their lifetimes. It is also usually

may have poor lifestyle, such as nonadherence to

highly recurrent, with at least 50% of those who

medication and self-care regiments) and biological

recover from a first episode of depression having

mechanisms (depression may worsen medical

one or more additional episodes in their lifetime,

diseases

and approximately 80% of those with a history of

pituitary-adrenal axis and the sympathetic nervous

two episodes having another recurrence. Once a

and immunological system) have been proposed.

first episode has occurred, recurrent episodes will

Each could lead to more disability13

through

changes

in

hypothalamic-

One might expect that elevated body mass

usually begin within five years of the initial episode, and, on average, individuals with a

index

history of depression will have five to nine

impairments in ADL through other mechanisms

10

that include associations with diabetes and

separate depressive episodes in their lifetime Disability in Activities of

(throughout life) could also promote

Daily Living

possibly knee joint injuries in

later life or

(ADL) , which are the essential activities that a

difficulties in walking around the house (more

person needs to perform to be able to live

common in Hawaii but unrelated to body mass

independently , is an adverse outcome of frailty

index in the current sample). It may be that

that places a high burden on frail individuals,

impairments in the ADL are more frequent in the

health care professionals and health care systems .

presence of subclinical frailty where weight loss is

Frail elderly people have a higher risk of ADL

a problem. Long-term follow-up of the effects of

11

body mass in middle adulthood on the risk of late-

disability compared to non-frail elderly people

11


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Ashram, Ramkrishna Mission old age home and

life ADL impairment might reveal a clearer 14

nearby

association

community

located

in

the

Kanpur

&Varanasi.

In a study of patients with and without depression during the immediate period after

All subjects signed consent forms & were

stroke but with similar impairments in ADL

ready to take part in the study .The subjects were

scores, we found, 2 years later, that the depressed

given the instructions regarding the procedure &

patients had significantly less recovery in their

the subjects who fulfilled the inclusion criteria &

ADL functions than the no depressed patients. The

were ready to actively participate, were selected.

recovery curves for ADL function were not

Inclusion criteria

significantly different between patients with major

1. Normal elderly male & female with age of ≥ 60 years.

depression versus those with minor depression, suggesting that both moderate and severe forms of

2. Able to understand verbal instructions &

depression lead to impaired recovery in ADL

completed 8-10 years of formal education.

functions. Morris et al who used an abbreviated

3. Subjects with stable medications Exclusion criteria

version of the Barthel index, also reported that at 15 months after stroke, patients with major

1. Any neurological problems such as

depression and those with minor depression had a

Parkinsonism, stroke, cerebellar disorders,

significantly greater physical disability than no

balance disorders, myopathy, myelopathy

depressed patients15

which can influence the psychological

As in elderly people living in community &

status of the subjects.

old age home depression and impairment in

2. Any cardiovascular or orthopedic problems

performing activities of daily livings are major

which affects their day to day routine

problem therefore assessing the prevalence of

activity & further may become the cause

depression and impairment in ADL’s forms the

of depression. 3. Significant hearing & vision impairment.

basis of the study.

4. Uncontrolled hypertension. 5. Any speech deficit interfering the survey.

MATERIALS & METHODS:

6. Unstable seizure / disorder affecting the

This study is a survey type of study which

psychological status of subjects.

intends to find changes in levels of depression and

7. Smoking or alcohol intake.

activities of daily livings scores in elderly subjects living in the community and in old age home. A sample of 200 elderly subjects i.e. 100 from

Procedure

the community and 100 from Old age home of sixty & above years of age were taken by the convenience sampling method. The subjects were collected through various

Group

Mean

Community

11.32

(gp A)

old age homes & which includes Vaikunth Dham

Home

Old Age Home, Ishwar Prem Ashram, Swaraj

(gp B) 12

Standard Deviation

T

0.000*

4.29 -6.981

16.42

5.90

P


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

Subjects were introduced to the study

The mean value of the Barthel index for the old

followed by the signing of consent forms ,general

age home was 16.54 with standard deviation

assessment regarding of socio-demographic data (

4.001and mean value for subjects living in the

name, gender, age), education level, past medical

community was 17.98 with SD 2.947 and p value

history, personal history, family history were

was 0.004 which shows there is a significant

gathered from the participants assessment forms.

difference in the scores hence Activities of daily

The subjects were collected from community &

livings are more affected in elderly people living

various old age homes & were divided into two

in an old age home town community.

groups a (community) and b (old age home) for comparison. Total 200 numbers of subject’s data

Table 2: Analysis of Activity Of Daily Living

was collected, 100 for Group A(community) and

by Barthel index between group ‘A’ & group

group B (old age home).The subjects were

‘B’

assigned a number to maintain the confidentiality of the subjects and then the scale was used to

Group

Mean

assess the scores i.e., Geriatric Depression Scale (GDS) and Barthel Index (BI) was used to check

Community

the level of depression and impairment in ADL’s

(gp A)

and then the scores were entered in the data

Home

collection form.

16.54

17.98

(gp B)

Standard Deviation

T

P

-2.898

0.004*

4.001

2.947

*Significant difference RESULTS Reading on GDS and BI were taken during

DISCUSSION

first interview contact with the subject and were

As results of the study shows that depression

tabulated as data.

level is more in elderly living in an old age home

The mean value of GDS for the old age

than in community. It is supported by a study

home (group B) was 16.42 with standard deviation

which

5.90 and mean value for subjects living in

suggests

that

urbanization

promotes

nucleation of the family system and a decrease in

community (group A) was 11.3 with SD 4.29 and

care and support for the elderly. Depression and

p value was 0.000 which shows there is a

physical illness often coexist in the elderly as they

significant difference in the score hence level of

both occur commonly in old age. There is a close

depression is more in elderly people living in an

relation between depression and physical illness.

old age home town community.

Depression may be caused by a specific physical disorder possibly as a direct consequence of the

Table 1: Analysis of GDS score in group A and

cerebral organic effect of these conditions.

group B

Therefore strategies to decrease depression should be utilized for persons living in an old age home.

*Significant difference

The

literature

shows

the

institutionalized

participants were more likely to report depressed 13


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mood, crime, wishing to be dead, future looking

4. Group involvement and interaction with

bleak and staying away from others. Therefore the

society may be suggested for subjects

persons living in an old age home should be

living in an old age home as loneliness

encouraged to intact with the society and family

may be the factor affecting ADLs and

members to cope up depression.

depression.

Literature shows that older people living in their own homes were most able to cope in their homes. They received more support from relatives and

friends

than

from

health

and

social

3

services .Result of the present study also shows that elderly people living in an Old age home were more affected in terms of ADLs than elderly people living in the community.

Relevance to clinical practice: This research study may serve as a basis for development and implementation of a new rehabilitation program to cope up depression and to improve daily living skills for subjects living in an old age home and in community by which further their level of dependency and depression can be reduced.

Future research: 1. This study is a survey type study in which no training was given to the improvement of ADLs and to decrease the depression hence in a future training program can be administered and its after effects may be noted down. 2. As sample size was small hence large sample size may be taken to generalize the results. 3. Task

oriented

goals/activities/training/may be used to improve the efficiency of subjects living in an old age home and community.

14


REFERENCES

1.

Definition

of

an

older

or

elderly

person

.

www.int/healthinfo/survey/agingdefinolder/en/index.html. 2.

Mascarenhas Steffi ,Yardi Sujata . Retrospective study on limitation of activity of daily living in geriartric women. Indian Journal Of Physiotherapy And Occupational Therapy .2012 ; 6(1)

3.

Beswick DA , Rees K , Dieppe P, Ayis Salma , Hill Gooberman R , Horwood J And Shah E. Complex study to improve physical function and maintain independent living in elderly people : a systemic review and meta analysis . Lancet.2008 ; 371(9614): 725-735

4.

Most IS Els, Scheltens Philip, Someren Van JW Eus. Prevention of depression and sleep disturbances in elderly with memory-problems by activation of the biological clock with light- a randomized clinical trial. Most et al. Trials. 2010:11-19

5.

Hernandezequena Carmen, Gonzalez Zubiaur Marta .Effects of Intergenerational Interaction on Aging. Educational Gerontology.2008;34:292-305

6.

Taqui Ather M, Itrat Ahmed, Qidwai Waris, Zeeshan Qadri. Depression in the elderly: Does family system play a role? A cross-sectional study.BMC Psychiatry.2007;7: 57

7.

Ell Kathleen , Unutzer jurgen, Aranda Maria, Gibbs E.Nancy, Lee Jiuan ,Xie Bin .Managing Depression in the Home Health Care: A Randomized Clinical Trial. Home Health Care servQ.2007;26(3):81-104

8.

Veer-Tazelaar, Marwick Harm van, Oppen Van Patricia, Ninpels Giel, Hout Van Hein, Cuijpers Pim, Stalman Wim, Beekma Aartjan. Prevention of anxiety and depression in the age group of 75 years and over: a randomized controlled trial testing the feasibility and effectiveness of a generic stepped care programme among elderly community residents at high risk of developing anxiety and depression versus usual care. BMC Public Health .2006; 6:186

9.

Fiske Amy, Wetherell Loebach Julie, Gatz Marget.Depression In Older Adults.Annu Rev Clin Psycho. 2009: 363-389

10.

Burcusa L. Stephanie, Locono G.William.Risk for Recurrence in Depression. Clin Psychol. 2007 ; 27(8):959-985

11.

Vermeulen Joan , Neyens Jacques Cl , Rossum Van Erik , Spreewenberg Marieke D and Witte De P Luc.Predicting Adl Disability In Community –Dwelling Elderly People Using Physical Frailty Indicators : Systemic Review . Bmc Geriatrics .2011;11:33

12.

Canhota Da Nogueira Manuel Carlos. Depressive disorders in elderly chienese patients in macau: a comparison of general practitioners consultations with a depression screening scale.Australian and New Zealand Journal of Psychiatry .2001;35:336-344

13.

Li W. Lydia, Conwell Yeates. Effects of changes in depressive symptoms and cognitive functioning on physical disability in home care elders. J Geronetol A Boil Sci Med Sci .2009; 64 (2):230-236 15


ISSN: 2277-1700 â—? Website: http://www.srji.info.ms â—? URL Forwarded to: http://sites.google.com/site/scientificrji

14.

Abbott Robert D. , Kadota Aya , Miura Katsuyuki , Hayakawa Takehito, Kadowaki Takashi , Okamura Tomonori , Okayama Akira , Masaki H. Kamal , Ueshima Hirotsugu . Impairment in activity of daily living in older japanese men in hawaii and japan .Journal Of Aging Research .2011 ;Article Id 324592

15.

Chemerinski Eran, Robinson G. Robert, Kosier T. James. Improved recovery in activity of daily living associated with remission of post stroke depression. Journal of the American heart Association Stroke. 2001; 32:113-117.

16.

Rogers C. Joan, Holm Margo B., Raina Ketki D., Dew Amanda Mary, Shih Min-Mei, Begley Amy, Houck R. Patricia , Majumdar Sati , Reynolds F. Charles.Disability in late life major depression : patterns of self-reported task ability, task habits and task performance . Psychiatry Res . 2010 ; 178(3): 475-479

CORRESPONDENCE

* Assistant Professor, Physiotherapy Dept., Saaii College of Medical Science and Technology, Kanpur, U.P. ** B.P.T. Student, Saaii College of Medical Science and Technology, Kanpur, U.P. *** B.P.T. Student, Saaii College of Medical Science and Technology, Kanpur, U.P.

16


TO ASSESS THE RELATIONSHIP BETWEEN TEMPOROMANDIBULAR JOINT DYSFUNCTION AND CERVICAL SPINE DYSFUNCTION Khyati Harish Sanghvi (BPT)*, Amrit Kaur (MPT)**, Ganesh Subbiah (MPT)***

ABSTRACT The temporomandibular joint is directly related to the cervical and scapular region. AIM- To assess any possible relationship between temporomandibular dysfunction (TMD) and cervical spine dysfunction (CSD) METHODS- Total 30 volunteers,15 volunteers that were presenting clinical signs and symptoms of TMD and 15 volunteers that were presenting CSD according to Temporomandibular Dysfunction Assessment Questionnaire and Neck disability Index respectively were selected for this study. Individuals having TMD were assessed for any signs and symptoms of CSD using Neck disability Index, Index of Cervical Mobility and VAS score. Individuals having CSD were assessed for TMD using Temporomandibular Dysfunction Assessment Questionnaire, Mandibular Mobility Index and VAS score RESULT-Correlation test (p ≤ 0.05) was performed to verify the relationship between CSD & TMD. The increase in TMD signs and symptoms was accompanied by increase in CSD severity. CONCLUSION- The result of this study concluded that TMD is accompanied with CSD and vice-a-versa.

KEYWORDS: Cervical pain, cervical spine dysfunction, Temporomandibular Joint; Temporomandibular joint dysfunction.

INTRODUCTION

conditions affecting the cervical region and related

Cervical spine dysfunctions are common

structures, with or without radiating pain towards 17


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the Shoulder, Arms, Inter scapular region and Head

considered a predisposing factor for cervical spine

1, 2, 3

. There are estimates that 67% of the

dysfunction, and supposing that the referred neck

population will suffer from neck pain at some

pain is of orofacial origin7, there should be direct

stage of life 3. Neck pain is often the major

relationship between the increase of cervical spine

symptom in cervical spine dysfunction related to

dysfunction

post-traumatic or to chronic micro-traumatic

previously

lesions of the joints and periarticular structures1.

dysfunction severity.

Temporomandibular dysfunctions are defined as

Mara

4

signs

and

symptoms

existing

Ines

the

temporomandibular

Baptistella

evaluated

Temporomandibular dysfunction is collective term

dysfunction in patients undergoing physiotherapy

applied

to

treatment for cervical pain. They concluded that

associated

90% of patients with cervical pain were found to

all

temporomandibular

problem joint

related

and

of

Ferao (2008)

common non-dental cause of orofacial pain .

to

prevalance

and

temporomandibular

have temporomandibular dysfunction16.

musculoskeletal structures. Temporomandibular dysfunction characterizes a cluster of disorders

However study done by BEVILAQUA-

marked by pain in the pre-auricular area,

GROSSI (2007) concluded that, cervical signs and

temporomandibular joint and masticatory muscles,

symptoms

as well as limitations or deviations during the

dysfunction but the inverse was not true, the

mandible range of motion, and temporomandibular

temporomandibular

joint sounds during function 5.

symptoms did not increase with cervical spine

accompanied

temporomandibular

dysfunction

sign

and

dysfunction severity in female community cases17.

Anatomically, the mandible and the base of skull presents the muscular and ligamentous

It is known that the balance of the body, as

connections with the cervical region, forming a

well as the movements of the head, originated

functional

from the positioning of the skull over the cervical

system

known

as

cranio-cervico-

mandibular system6.

and scapular region; determine the posture of the

If cervical spine dysfunction is considered

individual. Therefore, it is supposed that any

a predisposing factor for temporomandibular

alteration in these structures can bring about

dysfunction, and supposing that the related

postural imbalance, not only in these locations, but

Orofacial pain is of cervical origin 7, there should

also in other muscle groups of the body11. In this

be a direct relationship between the increase of

way,

temporomandibular

and

represent a constant concern for Medicine,

symptoms and the previously existing cervical

Dentistry, Physiotherapy and Public Health who

spine dysfunction severity. Thus, cervical spine

wish to understand the behavior of the joint in its

dysfunction

signs

8

Lesions caused by repetitive movements , head and cervical posture alterations

9, 10

temporomandibular

dysfunction

may

biomechanical activities.

likely lead to

The present study was done to determine

cervical spine dysfunctions and, subsequently, to

any possible relationship between cervical spine

the

dysfunction and temporomandibular dysfunction

manifestation

of

temporomandibular

dysfunction signs and symptoms. If

temporomandibular

in individuals aging from 18 to 40years. The dysfunction

is

findings of this study can be used to frame

18


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

assessment and management goals in patients with cervical

spine

dysfunction

Total between 70 and 100 points

and/or

Severe TMD

The mean of the patient’s age with

temporomandibular dysfunction.

primary temporomandibular dysfunction was 25 years (SD=7). Temporomandibular Joint ROM and

METHODS

VAS were recorded. Then they were assessed for

30 patients were selected to participate in the study

any signs and symptoms of cervical spine

on basis of inclusion criteria;

dysfunction using Neck disability Index13, index of cervical mobility (ICM)14 and VAS score.

Individuals aging from 18 to 40 years.

Other 15 volunteers that were primarily

15 Individuals having temporomandibular joint dysfunction (Group 1).

presenting cervical spine Dysfunction according to

15 Individuals having cervical spine dysfunction

Neck disability Index13 were selected as Group 2

(Group 2).

for this study. They were screened for any

Exclusion criteria was General Joint Disorder

exclusion criteria and then divided into severity

involving Head and Neck (e.g. Rheumatoid

i.e., mild, moderate or severe Cervical spine

Arthritis); History of Jaw Fracture; Individuals

dysfunction on basis of their scoring in Neck

suffering through Facial Palsy; History of Cervical

disability Index13. The Neck Disability Index is

vertebra fracture; Patients having Trigeminal

divided into 10 set of multiple choice questions

Neuralgia and Patients having braces applied for

which have 6 options for each and each 5 options

proper alignment of teeth.

are scored from 0 to 5 on basis of severity. Maximum score can be 50 and minimum 0.

15 volunteers that were primarily presenting clinical

signs

temporomandibular Temporomandibular 12

Questionnaire

and

symptoms

dysfunction Dysfunction

according

Table 2: NDI scoring Total between 0 and 4 Total between 5 and 14 Total between 25 and 34 Total between 35 and 50

of to

Assessment

No CSD Mild CSD Moderate CSD Severe CSD

were selected as Group 1 to

participate in the study. They were screened for

The mean of the patient’s age with

any exclusion criteria and then divided into

primary cervical spine dysfunction was 24.1 years

severity i.e., mild, moderate or severe of Temporo-

(SD=6.65). Cervical Spine ROM and VAS were

mandibular dysfunction on basis of their scoring in

recorded.

temporomandibular

temporomandibular

dysfunction

assessment

12

Then

they

were

assessed

dysfunction

for using

questionnaire . The questionnaire is set of 10

Temporomandibular

questions

Questionnaire, Index of Mandibular mobility

regarding

Temporo-mandibular

Dysfunction

Assessment

(IMM)15 and VAS score.

dysfunction and the symptoms. Answers were collected in terms of “YES”, “SOMETIMES” or

The

“NO” and were scored 10, 5 or 0 respectively.

movements

Maximum score can be 100 and minimum 0.

opening (MMO), maximal lateral deviation to

Table 1: TMDQ Scoring Total between 0 and 15 points Total between 20 and 40 points Total between 45 and 65 points

right and left (MLDR and MLDE) and maximal No TMD Mild TMD Moderate TMD

following were

Temporomandibular

recorded:

maximal

mouth

protrusion (MP). The cervical movements of flexion, extension, right and left rotations and right 19


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and left lateral flexions were recorded. To measure

correlation

Temporomandibular and Cervical range of motion,

p>0.05. As coefficient of correlation value is

a ruler (mm) and a universal Goniometer (°) were

between 0 and +1, we can say that the two sets of

used respectively.

data show weak, positive correlation. But as P

This

study

was

approved

by

coefficient

(SRCC) =

0.223214,

the

value is more than 0.05, the result is not

Committee for Ethics and Research of the

significant, i.e., there is no correlation between

NDMVP medical college and the patients signed a

scores of IMM and CMI scores.

term of free and informed consent confirming their

The correlation test was applied to check

agreement to participate in the study. Spearman’s

rank

correlation

prevalence of cervical spine dysfunction in test

was

patients with temporomandibular dysfunction. The

performed to verify the relationship between

result was, spearman’s rank correlation coefficient

cervical spine dysfunction & temporomandibular

(SRCC) = 0.62857, p<0.05. As coefficient of

dysfunction.

correlation value is between 0 and +1, we can say that

the

two

sets

of

data

show good,

RESULT

positive correlation. As P value is less than 0.05,

Descriptive data is given in table 3.

the result is significant, i.e., there is prevalence of cervical spine dysfunction in patients with temporomandibular dysfunction. Group 2 Total 15 individuals were selected under the category of cervical spine dysfunction after performing screening test (NDI). The mean of the

Table 3: Descriptive Data

patient’s age was 24.1 years (SD=6.65). On

Group 1

analysis it was found that, 40% had mild, 33% had

Total 15 individuals were selected under the

moderate

category of temporomandibular dysfunction after

and

26.67%

had

severe

temporomandibular dysfunction.

performing screening test (TMDQ). The mean of

The mean VAS of two groups was;

the patient’s age was 25 years (SD=7). On analysis

Cervical pain: 4.66

it was found that 26.67% patient had no cervical

Temporomandibular Joint pain: 1.6

spine dysfunction, 60% had mild, 6.67% had

The correlation test was applied to check

moderate and 6.67% had severe cervical spine

the association between the scores of index of

dysfunction.

mandibular mobility and index of cervical

The mean VAS of two groups was;

mobility. The Result was, spearman’s rank

Cervical pain: 2.64

correlation

Temporomandibular Joint pain: 4.25

coefficient

(SRCC) =

0.076786,

p>0.05. As coefficient of correlation value is

The correlation test was applied to check

between 0 and +1, we can say that the two sets of

the association between the scores of index of

data show very weak, positive correlation. But as P

mandibular mobility and index of cervical

value is more than 0.05, the result is not

mobility. The Result was, spearman’s rank 20


Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 2, Year: 2013

significant, i.e., there is no correlation between

neck

scores of IMM and CMI scores.

posteriorly the levator scapula. The mandible is

are

anteriorly

sternocleidomastoid

and

The correlation test was applied to check

controlled by the muscle of mastication and it is

prevalence of temporomandibular dysfunction in

connected to cranium through its articulation of

patients with cervical spine dysfunction. The result

the teeth and the temporomandibular joint. This

was, spearmanâ&#x20AC;&#x2122;s rank correlation coefficient

complex relationship is important since mandible

(SRCC) = 0.657143, p<0.05. As coefficient of

is attached to both cranium and cervical spine and

correlation value is between 0 and +1, we can say

any positional changes of either will produce

that

postural

the

two

sets

of

data

show good,

changes

of

mandible

and

hence

positive correlation. As P value is less than 0.05,

disturbances in its articulation. The inverce is also

the result is significant, i.e., there is a prevalence

true

of temporomandibular dysfunction in patients with

temporomandibular joint articulation, it can alter

cervical spine dysfunction.

the position of mandible and in turn cervical spine

that

if

there

is

disturbances

in

and shoulder girdle. DISCUSSION

Thus there is relationship between the

The result of this study demonstrated that

mandible,

is

temporomandibular

suprahyoid and infrahyoid structures, shoulder

dysfunction in patients with cervical spine

girdle, the thoracic spine and ultimately the

dysfunction or cervical spine dysfunction is one of

lumbosacral spine. These structures function as

the predisposing factors for temporomandibular

inter related biomechanical unit. Dysfunction in

dysfunction and vice-a-versa. However, significant

any one part of this unit may often lead to

differences in the values of Mandibular range of

dysfunction of unit as a whole. However in

motion among temporomandibular dysfunction

reviewed literature, there were no studies that

severity groups and in values of cervical range of

varified the time required for development of of

motion among cervical spine dysfunction severity

orofacial pain signs and symptoms caused by head

groups were not verified.

postuer alteration and vice-versa.

there

prevalence

of

the

cranium,

the

cervical

spine,

The ideal posture of head places the center

The result of this study suggest that almost

of gravity slightly anterior to the cervical spine.

all the individual with cervical spine dysfunction

For this reason, when sitting or standing the head

had temporomandibular dysfunction and about

falls anteriorly if the muscles of the head and neck

73% of individuals with temporomandibular

are totaly relaxed. To maintain this postural

dysfunction had cervical spine dysfunction.

position, strong posterior cervical muscles are needed. The anterior cervical muscles are small

CONCLUSION

and thin muscles which come from the clavicle, The

sternum and rib cage to the hyoid bone (infrahyoid

result

of

this

study

concluded

that

temporomandibular dysfunction is accompanied

muscles) and from the hyoid to the mandible

with cervical spine dysfunction and vice-a-versa.

(suprahyoid muscles). Two other important muscle

Almost all the individual with cervical spine

which controls position and stability of head and

dysfunction had temporomandibular dysfunction 21


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and

about

73%

of

individuals

with

dysfunction.

temporomandibular dysfunction had cervical spine

REFERENCES

1. Ciancaglini R, Testa M and Radaelli G (1999). Association of neck pain with symptoms of temporomandibular disorders in the general adult population. Scand J Rehabil Med.;31(1):17-22. 2. De Wijer A, Steenks MH, Bosman F, Helders PJ and Faber J (1996). Symptoms of the stomatognathic system in temporomandibular and cervical spine disorders. J Oral Rehabil; 23(11):733-741. 3. Visscher CM, Lobbezoo F, Boer W, van der Zaag J, Verheij JG and Naeije M (2000). Clinical tests in distinguishing between persons with or without craniomandibular or cervical spinal pain complaints. Eur J Oral Sci; 108(6):475-483. 4. Mcneill C (1997). Management of temporomandibular disorders: concepts and controversies. J Prosthet Dent; 77(5):510-522. 5. Dworkin SF, Huggins KH, Leresche L, Von Korff M, Howard J, Truelove E, et al (1990). Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in cases and controls. J Am Dent Assoc; 120:273-281. 6. Arrelano JCV (2002). Relações entre postura corporal e sistema estomatognático. JBA; 2: 155-164. 7. Browne PA, Clark GT, Kuboki T and Adachi NY (1998). Concurrent cervical and craniofacial pain: a review of empiric and basic science evidence. Oral Surg Oral Med Oral Pathol Oral Radiol Endod; 86(6):633-640. 8. Kirveskari P, Alanen P, Karskela V, Kaitaniemi P, Holtari M, Virtanen T, et al (1988). Association of functional state of stomatognathic system with mobility of cervical spine and neck muscle tenderness. Acta Odontol Scand; 46(5):281-286. 9. Gonzalez HE and Manns A (1996). Forward head posture: its structural and functional influence on the stomatognathic system, a conceptual study. Cranio; 14(1):71-80. 10. Mannheimer JS and Rosenthal R (1991). Acute and chronic postural abnormalities as related to craniofacial pain and temporomandibular disorders. Dent Clin North Am; 35:185-208. 11. Amantéa DV, Novaes AP, Campolongo GD and Barros TP(2004). A importância da avaliação postural no paciente com disfunção temporomandibular. Acta Ortop Brás; 12:1-8. 12. Kariny Nomura, Mathias Vitti, Anamaria Siriani de Oliveria, Thaís Cristina Chaves, Marisa Semprini, Selma Siessere, Jaime Eduardo Cecilio Hallak and Simone Cecilio Hallak Regalo (2007). Use of the Fonseca’s Questionnaire to assess the prevalence and Severity of Temporomandibular Disorders in Brazilian Dental Undergraduates. Braz Dent J; 18(2): 163-167. 13. Joy C. Macdermid, David M. Walton, Sarah Avery, Alanna Blanchard, Evelyn Etruw, Cheryl Mcalpine and Charlie H. Goldsmith (2009). Measurement Properties of the Neck Disability Index: A Systematic Review. Journal of orthopaedic & sports physical therapy; 39, 5:400-417.

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Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

14. Wallace C and Klineberg IJ (1993). Management of craniomandibular disorders. Part 1. A craniocervical dysfunction index. J Orofac Pain; 7(1):83-88. 15. Helkimo M (1974). Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state. Swed Dent J; 67(2):101-21. 16. Mara Ines Baptistella Ferao and Jefferson Traebert (2008). Prevalence of temporomandibular dysfunction in patients with cervical pain under physiotherapy treatment. Fisioter; 21(4):63-70. 17. Débora Bevilaqua-Grossi, Thaís Cristina Chaves and Anamaria Siriani de Oliveira (2007). Cervical spine signs and symptoms: perpetuating rather than predisposing factors for temporomandibular disorders in women. J Appl Oral Sci; 15(4):259-64.

CORRESPONDING AUTHOR: * N.D.M.V.P College of Physiotherapy, Email: drkhyati_26@yahoo.co.in ** Assistant Professor, Department Of Community Based Rehabilitation, N.D.M.V.P College of Physiotherapy, Email: dr_amritkaur@yahoo.co.in *** Associate Professor, Department of Musculoskeletal Sciences, N.D.M.V.P College of Physiotherapy, Email: ganeshmpt2006@yahoo.co.in

23


EFFECTIVENESS OF NEUROMOTOR TASK TRAINING COMBINED WITH KINAESTHETIC TRAINING IN CHILDREN WITH DEVELOPMENTAL CO-ORDINATION DISORDER - A RANDOMISED TRIAL Sundaresan Chockalingam* Agnel Kevin Gomes**

ABSTRACT The aim and objectives of this study was to find out the prevalence of Developmental coordination disorder (DCD, a chronic motor impairment affecting child’s ADL) in school children from 5 to 10 years of age and to analyse the effectiveness of Neuromotor Task Training when combined with Kinaesthetic training in managing them. Using Pretest-Posttest Quasi Experimental study design, 56 samples of children with indication or suspect for DCD in DCDQ’07 who also obtained total scores below the 15th percentile on the TGMD-2 were randomly assigned for two interventions, Neuromotor Task Training (NTT) combined with Kinaesthetic training (Intervention Group 1) and NTT alone (Intervention Group 2) for a period of 7 weeks in small groups. The outcome was assessed with Gross Motor Quotient of TGMD-2. The data were analysed with Student’t’ tests comparing values within the groups and between the groups. Results showed that the prevalence of DCD in the local population is 6.82% and there is no significance difference between the improvements made in the two intervention groups but the differences in the mean value support the combined therapy group to have some better effects.

KEYWORDS: Developmental Coordination Disorder (DCD), Developmental Coordination Disorder Questionaire’07(DCDQ’07), Test of Gross Motor Development-2 (TGMD-2), Neuromotor Task Training, Kinaesthetic Training. 24


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

there is extensive evidence that motor difficulties

INTRODUCTION disorder

have a pervasive effect on children’s lives. The

of children between 5 and 11

difficulties affect the child both in school and at

. Prevalence of movement

home, and in contrast with similar aged children

difficulties in children has been reported as high

who acquire skills with little effort such as

as 19%. However, two studies undertaken in the

dressing, playing ball games and handwriting,

UK reported a prevalence of 5% and 8.5%

these children take longer to learn and automate

Developmental affects about 6% years of age

respectively

1

coordination

2

motor skills. Increasing interest in these children,

. DCD is defined, using the

Diagnostic and Statistical Manual of Mental

in

academic

research

and

in

clinical

and

Disorders, Fourth Edition (DSM-IV), as a

educational practice, has focused on the need not

condition marked by a significant impairment in

only for early identification but also to consider

the development of motor coordination, which

the presentation in adolescence and adulthood, as

interferes with academic achievement and/or

around 70% of children continue to have

activities of daily living (ADL). These difficulties

difficulties when grown up5.

are not due to a general medical condition (e.g.,

Over the past forty years, various

cerebral palsy) and are in excess of any learning

treatment programs have been developed for

difficulties if present

1

children

. The symptoms of

with

Developmental

Coordination

developmental coordination disorder may include

Disorder (DCD). These treatment programs can

marked delays in achieving milestones of motor

roughly be divided into two categories: the

development, dropping things, clumsiness, and

process-oriented approaches and the task-oriented

poor performance in sports or poor handwriting. If

approaches 6. The process-oriented approaches

any of these symptoms interferes with a child’s

concentrate on the treatment of deficits in

performance of daily activities, a diagnosis is

processes assumed to underlie poor motor

warranted 1. Observations of school-age children

coordination. Task-oriented approaches, on the

with Developmental coordination disorder during

other hand, focus directly at the functional skills

organized and free play show that these children

with

spend less time in formal and informal team play

Examples of process-oriented approaches are

than children without the disorder3.

kinesthetic training developed by Laszlo et al.

which

a

child

experiences

problems.

DCD is defined on the basis of a failure

(1988) and Sensory Integration Therapy developed

of the acquisition of both fine and gross motor

by Ayres (1972). Neuromotor Task Training

skills, which is not explicable on the basis of

(NTT) was recently developed for treating children

impaired general learning and similar exposure to

with DCD by pediatric physical therapists 7. The

opportunity to gain motor skills as their peers.

training concerns a task-oriented program based

DCD is often seen as the ‘Cinderella’ of

upon recent insights about motor control and

developmental

always

motor learning. The developmental coordination

considered routinely by clinicians 4. However,

disorder questionnaire 2007 (DCDQ’07) was

disorders

and

not

25


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motor difficulties, while others have difficulties

developed to screen for the presence of motor 8

with both fine and gross motor tasks 18.

problems and as an adjunct to standardized tests . Over the past 10 years, it has also proven to be a valid measure of everyday

Use of the DCDQ’07 by occupational

functioning, as

and physical therapists, as well as researchers, to

academic achievements or activities of daily

both screen for DCD and to confirm the functional

living. It is recommended that The Movement

consequences of a motor deficit, will support the

Assessment Battery for Children (M-ABC) and

identification of children in need of services. The

The Test of Gross Motor Development (TGMD-2)

DCDQ’07

should be considered for assessing the gross motor

collaboration and application of research results

performance of children with DCD in the first

across cultures 15.

will

also

allow

international

instance. Both these tests give standardized scores

Neuromotor Task Training (NTT) was

that are easily explained to the patient/parent, and

developed for treating children with DCD by

both have items that children would find

pediatric physical therapists. Within this approach,

9

acceptable and relevant .

physical therapists start with the assessment of the strengths and weaknesses of a child’s functional

BACKGROUND

performance. Next, therapists will analyze which

Developmental coordination disorders

cognitive or motor control processes might be

may first become apparent in early childhood, but

involved in deficient motor skill performance. A

they are difficult to assess reliably before the age

child can fail to learn a specific motor skill

of 5 years. Children with DCD are usually first

because of attention problems, fear of failure, lack

noted in primary school when the condition clearly

of motivation, or lack of understanding how to

interferes with school performance or activities of

execute a particular skill. In addition, motor-

daily living. Most of these children are therefore

control

diagnosed between 6 and 12 years of age. Some

performance, such as timing of the components of

may even go unnoticed

17

processes

might

hamper

successful

. The teachers may

a motor skill pattern, motor planning, or parameter

initially notice children on the basis of difficulties

setting (the execution of a motor act with the

and poor handwriting is now one of the major

required speed and force).

reasons for the clinical referral of children with

In NTT, the functional exercises are

18

DCD . The DCD population is considered to be

designed in such a way that the therapist can

at risk for a range of associated psychosocial

analyze which motor control processes are

difficulties,

expected

deficient. Another important characteristic of NTT

educational achievement and low self-esteem.

is that teaching principles derived from motor

Children with DCD may show functional deficits

learning research are applied. The ultimate goal of

over a range of motor tasks. Some are impaired in

treatment is not only to improve functional task

whole body tasks such as running and jumping,

performance during treatment but also to transfer

ball skills, and tasks involving balance, such as

learned skills to daily life performance.

such

as

poorer

than

riding a bicycle. Some children may have fine

Kinesthesia is integral to the acquisition of motor skills in process-oriented treatment

26


Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 2, Year: 2013

approaches. Therapeutic intervention with process-

manner to which children respond to intervention.

oriented treatment is based on specifically

They also have stated that some children may

designed

As

require varying amounts of exposure to activities

described by Laszlo and Bairstow, this approach

with the amount being the influential factor,

has an inherent reward system built into it through

whereas with others, most notably the ones who

its use of positive reinforcement, presentation of

did not improve following intervention and

desirable activities within the capabilities of the

concluded that a qualitatively different type of

child, and judicious progression of the level of

approach may be required in dealing with children

difficulty. The usefulness of the process-oriented

with DCD 10.

kinesthetic

training

activities.

treatment approach has been the subject of

To date, combined approaches are

considerable study. Sims and colleagues suggested

largely untested, research has provided limited

that much of the success of this approach can be

evidence to support combined approaches as they

attributed to a strong motivation effect, fostered by

made smaller effects than pure approaches. It will

positive feedback and a sense of self-competence

be important for us to develop a systematic,

19

. Children with DCD benefit from using vision in

evidence-based approach to the treatment of these

combination with touch information for standing

children 13. To date there is no studies that have

control possibly due to their less well developed

clearly focused on finding out the incidence of

internal models of body orientation and self-

DCD in South Indian population. Considering

motion. Internal model deficits, combined with

these statement, it is very clear that there is a need

other known deficits such as postural muscles

for a good experimental trail on finding the

activation timing deficits, may exacerbate the

effectiveness of combined approaches (top down

12

balance impairment in children with DCD .

and bottom up approaches) in children with DCD.

Group-based motor skill training may have its own advantages. First, the group setting

METHODOLOGY

provides opportunities for social interaction.

Participants for this study included

Secondly, children are competitive, and this

children, both boys and girls, aged 5 to10 years

motivates them to perform better. Furthermore, a

from Bharathidasan Matric Higher Secondary

stronger sense of competence may be developed if

School, Kanchipuram, Tamil Nadu, India. In two

a child can successfully demonstrate the acquired

stage selection process, sequential sampling was

motor skills in front of his or her peers in the

used to screen 1407 students (boys and girls).

group. This perceived competence may further

Among the subjects screened by staged procedure,

encourage the childrenâ&#x20AC;&#x2122;s participation in the

54 were selected and assigned randomly into two

training and in other physical activities affecting

groups and considered for intervention. All

14

their motor competence .

children with indication or suspect for DCD aged

Children with DCD do not form a

from 5 to 10 years in DCDQâ&#x20AC;&#x2122;07, Obtained total

homogeneous group. It is possible that, just as

scores on the TGMD-2 below the 15th percentile

characteristics are showing differences across

and their motor problems could not be attributed to

clusters of children, differences are evident in the

evident pathological neurological signs were

27


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are under indication, or suspect for DCD.

included. Only children attending schools for

In the second stage of selection process,

general education were considered which implies

the children under indication or suspect for DCD

an IQ-score in the normal range. The children those who had received or

underwent TGMD-2. The TGMD-2 was conducted

were undergoing physical therapy or occupational

in the outdoor play area. 2 Physical Education

therapy and those who have any profound visual or

Teachers and 1 special skill training staff were

hearing deficiencies that could not be corrected by

involved in this selection process, assisting the

external devices were excluded.

procedure. On the first testing day, the procedure

In the first stage selection process, 2

was explained to the participants in details. Then,

Physical Education Teachers 1 special skill

their names were asked and a name tag was

training staff and 63 Class Teachers from the

provided for each of them for identification. The

School, handling children from 5 to 10 years of

TGMD-2 was operated with the following

age forming standard I to standard V in State

sequences: run, gallop, hop, leap, horizontal jump,

Board of Education were called for a meeting for

slide, striking a stationary ball, stationary dribble,

about 2 hrs in school conference hall for two

catch, kick, overhand throw and underhand roll.

consecutive days. On the first day of meeting, A

The participants were queued behind the first line

talk

coordination

and performed the skill within 50 feet of clear

disorder, including the prevalence, nature of the

space, which was marked with tape and cones

disorder, diagnostic criteria, complications, role of

were placed.

about

the

Developmental

health care professional, teachers and parents in

The assessment was preceded with an

dealing with these children, and management of

accurate demonstration and verbal description of

the condition were given. On the second day, the

the skill, i.e., run. Then, a practice trial was

selection of children based on the DCDQ’07 was

provided for the child who queued at the front, to

demonstrated and the teachers were trained

assure the child understands what to do. After that,

individually to fill the questionnaire. The teachers

two test trials were given to the subjects and the

were instructed to observe their class students for 3

raw skill score was given for each item ranged

days on play ground activities like ball handling,

from 0-2. When the first subject was done, the

running, jumping and on class room activities like

second one at the queue was instructed to start the

writing and learning. With the knowledge and

test

practice obtained from the meeting, observation on

demonstration was also been when he or she did

child’s activities, teachers were asked to fill

not appear to understand the two test trials. The

questionnaire for the average of 30 students they

procedures were repeated until the last participant

handle in the class room. Under supervision the

was completed. The test was then followed by

process of filling up the questionnaire was made

second skill task, i.e., gallop and the process was

and doubts in marking the questionnaire were

as same as before. However, the sequence of the

clarified then and there during the process. With

queue was alternate so that one child did not

the total scores obtained from the questionnaire,

always go first or last. Scoring was made with

screening was done to find out the children who

observation of all participants’ performance. The

28

with

the

practice

trial;

an

additional


Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 2, Year: 2013

assessment protocols were also standardized for all

performance criteria for hop were as follows:

participants according to the test manual of

nonsupport leg swings forward in pendular fashion

TGMD-2 (Ulrich, 2000) (38).

to produce force; foot of nonsupport leg remains

Locomotor Subtest-Run

behind body; arms flexed and swing forward to

50 feet of running space and 8 feet of

produce

force;

takes

off

and

lands

three

safe stopping distance were made for this test

consecutive times on preferred foot; takes off and

(Ulrich, 2000). The child ran as fast as he or she

lands three consecutive times on non-preferred

can from the green cone to the red cone when the

foot.

examiner said â&#x20AC;&#x153;Goâ&#x20AC;?. For the second trial, the child

Locomotor Subtest-Leap

ran from the red cone back to the green cone and

A minimum of 20 feet of clear space was

then waited at the end of the queue. According to

made and a 10 inch plastic ball was used (Ulrich,

Ulrich (2000), the performance criteria for run

2000). First, the ball was placed 10 feet away from

were as follows: arms move in opposition to legs,

the green cone. The child stood behind the line of

elbows bent; brief period where both feet are off

the green cone and ran and leaped over the ball. A

the ground; narrow foot placement landing on heel

second trial was made by leaping back to the line

or toe (i.e., not flat footed); and nonsupport leg

of green cone. According to Ulrich (2000), the

bent approximately 90 degrees (i.e., close to

performance criteria for leap were as follows: take

buttocks).

off on one foot and land on the opposite foot; a

Locomotor Subtest-Gallop

period where both feet are off the ground longer

25 feet distance was made for this test

than running; forward reach with the arm opposite

(Ulrich, 2000). From the green cone, the child

the lead foot.

galloped to the line in middle between the green

Locomotor Subtest-Horizontal Jump

and red cones and repeated a second trial by

10 feet of clear space was made (Ulrich,

galloping back to the green cone. According to

2000). The child started behind the starting line of

Ulrich (2000), the performance criteria for gallop

green cone and jumped as far as he or she can. A

were as follows: arms bent and lifted to waist level

second trial was from the starting line again.

at takeoff; a step forward with the lead foot

According to Ulrich (2000), the performance

followed by a step with the trailing foot to a

criteria for horizontal jump were as follows:

position adjacent to or behind the lead foot; brief

preparatory movement includes flexion of both

period when both feet are off the floor; maintains a

knees with arms extended behind body; arms

rhythmic pattern for four consecutive gallops.

extend forcefully forward and upward reaching

Locomotor Subtest-Hop

full extension above the head; take off and land on

15 feet of clear space was made (Ulrich,

both

feet

simultaneously;

2000). The child was told to hop three times on his

downward during landing.

or her preferred foot and then three times on the

Locomotor Subtest-Slide

arms

are

thrust

other foot towards the line next to the green cone.

25 feet of clear space was made during

The trial was repeated by hopping back to the

the test (Ulrich, 2000). The child was told to stand

green cone. According to Ulrich (2000), the

sideway to the performing space, i.e., left foot

29


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parallel to the starting (green cone) line. The first

with one hand at about belt level; pushes ball with

trial began by sliding from the starting line to the

fingertips (not a slap); ball contacts surface in front

middle line between the green and red cone, i.e.,

of or to the outside of foot on the preferred side;

slide to the left. Then, repeated a second trial by

maintains control of ball for four consecutive

sliding back to the starting (green cone) line, i.e.,

bounces without having to move the feet to

slide to the right. According to Ulrich (2000), the

retrieve it.

performance criteria for slide were as follows:

Object Control Subtest-Catch

body turned sideways so shoulders are aligned

The 8- to 10-inch playground ball was

with the line on the floor; a step sideways with

used as mentioned by Ulrich (2000) in the manual.

lead foot followed by a slide of the trailing foot to

15 feet of clear space was also made (Ulrich,

a point next to the lead foot; a minimum of four

2000). The child and the tosser stood 15 feet away

continuous step-slide cycles to the right; a

of each other and the latter tossed the ball

minimum of four continuous step-slide cycles to

underhand directly to the child with a slight arc

the left.

aiming for his or her chest. The child was told to

Object Control Subtest-Striking a Stationary Ball

catch the ball with both hands for two times.

A plastic bat, a batting tee and two 4-

According to Ulrich (2000), the performance

inch lightweight balls were used in this test

criteria for catch were as follows: preparation

(Ulrich, 2000). The batting tee was adjusted to the

phase where hands are in front of the body and

child’s waist level. In the performing area, the

elbows are flexed; arms extend while reaching for

child was told to hold the bat with both hand and

the ball as it arrives; ball is caught by hands only.

hit the ball hard. For time saving, a second trial

Object Control Subtest-Kick

was done by using another ball. According to

Two 8- to 10-inch playground balls, a

Ulrich (2000), the performance criteria for striking

plastic ring instead of a bean bag to place the ball

a stationary ball were as follows: dominant hand

were used and 30 feet of clear space was made for

grips bat above non-dominant hand; non-preferred

this test (Ulrich, 2000). The ball was placed on the

side of body faces the imaginary tosser with feet

top of the ring between the green and red cones,

parallel; hip and shoulder rotation during swing;

i.e., 10 feet away from the starting line. The child

transfers body weight to front foot; bat contacts

waited behind the starting line and then ran up and

ball.

kicked the ball hard. A second trial was repeated

Object Control Subtest-Stationary Dribble

by using another ball. According to Ulrich (2000),

An 8- to 10-inch playground ball was

the performance criteria for kick were as follows:

used in this test (Ulrich, 2000). The test was held

rapid continuous approach to the ball; an elongated

in the performing area. The child was told to

stride or leap immediately prior to ball contact;

dribble the ball four times without moving his or

non-kicking foot placed even with or slightly in

her feet, using one hand, and then stop by catching

back of the ball; kicks ball with instep of preferred

the ball. A second trial was done. According to

foot (shoelaces) or toe.

Ulrich (2000), the performance criteria for

Object Control Subtest-Overhand Throw Two tennis balls were used and 20 feet

stationary dribble were as follows: contacts ball

30


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

of clear space was made this test (Ulrich, 2000).

descriptive rating of below average, poor and very

The child was told to stand behind the starting line

poor were considered for intervention.

and threw the ball hard. A second trial was done

Parental consent forms were sent out to

by using another ball. According to Ulrich (2000),

parents of those ninety-six children, and a total of

the performance criteria for overhand throw were

fifty-four signed forms were returned on time.

as follows: windup is initiated with downward

After obtaining informed consent from parents,

movement of hand/arm; rotates hip and shoulders

clinical observations were made to assess the

to a point where the non-throwing side faces the

child’s musculoskeletal flexibility and movement

wall; weight is transferred by stepping with the

patterns. This ensured that the child met DSM IV

foot opposite the throwing hand; follow-through

criteria. TGMD-2 scores of the selected subjects

beyond ball release diagonally across the body

were recorded as Pre test values. These children

toward the non-preferred side.

were randomly assigned to one of the two

Object Control Subtest-Underhand Roll

intervention groups. All underwent 20 minutes of

Two tennis balls, a cone were used and

intervention for 5 days a week for 7 consecutive

25 feet of clear space was made for this test

weeks. The intervention includes NTT, based on

(Ulrich, 2000). The cone was placed between the

the assessment of child’s motor performance on

starting and ending line, i.e., 20 feet away from the

the range of tasks then the kinaesthetic training

starting line. The child was told to stand behind the

based on Laszlo’s kinaesthetic approach. At the

starting line and rolled the ball hard towards the

end of 7 weeks of intervention TGMD-2 post test

bean bag. A second trial was repeated by using

values were taken for statistical analysis.

another tennis ball. According to Ulrich (2000), the performance criteria for underhand roll were as

INTERVENTION

follows: preferred hand swings down and back,

There were two intervention groups,

reaching behind the trunk while chest faces cones;

NTT

strides forward with foot opposite the preferred

(intervention

hand toward the cones; bends knees to lower body;

(intervention group 2). Fifty- four children from

releases ball close to the floor so ball does not

different class sections of standard I to standard V,

bounce more than 4 inches high.

by

combined

simple

with

group

kinaesthetic 1)

randomization

and

training

NTT

using

alone

computer

In the TGMD-2, individual performance

generated random numbers from statistical website

was scored with 1 or 0 to show the presence or

were assigned to either intervention group 1 or

absence of that particular skill while each skill

intervention group 2. Intervention groups had 27

ranged from 6 to 10 points. Raw scores were

participants each and both the groups were

added up across skills to form a sub-set of

subdivided into 5 instructional subgroups for the

locomotor or object control, with ranged from 0 to

purposes of instruction.

48 points. The two sub-set total raw score were

Intervention group 1

converted into standard scores so to achieve a

The group was the NTT combined with

Gross Motor Development Quotient (GMDQ) by

KT group consisted of 27 children including 7

summing them. Ninety-six children showing

females and 20 males. NTT was given in group

31


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intervention, in the school play ground, for 20 minutes of 3 sessions per week for 7 weeks

(11)

successful

performance

such

as

timing

of

. KT

components of a motor skill pattern, motor

was also given as group training for 20 minutes

planning, or parameter setting (the execution of a

sessions 2 times per week for 5 weeks (39). These

motor act with the required speed and force) were

two interventions were administered on basis of

also taken consideration (40).

one intervention a day in alternate days.

Each session started with general warm up program for 10 minutes which was followed by intervention of task training (considering all the principles of ntt) over the range of tasks which the child failed to perform in tgmd2 (locomotor and object control subsets) during the pre test. The progression was made by combining two or more tasks into a game in groups (e.g., tasks like hitting, over head throw, under arm roll and catch combined into a game activity of cricket). Each children were given time to comment on their as well as others performance. As the children were trained in group of five, everyone was made to perform their role as a leader once during the week. Kinaesthetic Training Developed by Laszlo (1985). Training

Intervention group 2 This was the NTT only group. It consisted of

was based on kinesthetic awareness â&#x20AC;&#x201C; class room

27 participants with 9 females and 18 males. NTT

and individual practice Performa from Therapy

was given as group intervention, in school, for 20

skill builders

minutes of 5 sessions per week for 7 weeks.

training were, 1. Recognizing and Reproducing

Neuromotor task training.

line direction and length. 2. Awareness activities

(41)

. The activities included in the

During the training, the therapist noted

for fingers and hands. 3. Controlling direction of

the extent to which motor tasks are performed

movements- Dot to dot designs. 4. Recognizing

below the expected level, such as handwriting or

and controlling grip position 5.Recognizing and

ball skill tasks. Second, they were analyzed for the

reproducing Size, Shapes- Glue drawing, Template

cognitive or motor control processes that were

activities.

involved in the deficient motor performance. The RESULTS

reason for the failure to learn a specific motor skill were found out , for e.g., attention problems, fear

The results of prevalence of DCD in

of failure, lack of motivation, or lack of

children in age group between 5 and 10 years in

understanding of how to execute a skill. In

the school population considered shows that the

addition, motor control processes might hamper

rate of prevalence is 6.82. The pre test and post

32


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

test values of Group 1 (Neuromotor Task Training

Kinaesthetic training against Neuromotor task

Combined

was

training alone in children with DCD. The results of

analysed using paired‘t’ test. For 24 degrees of

the post test values comparing two groups shows

freedom and at 5% level of significance, the

COHEN’S d = 0.362229. The results suggest that

table‘t’ value is 2.064 and the calculated ‘t’ value

there was a Medium Effect size.

with

Kinaesthetic

Training)

was 11.586 . As the calculated‘t’ value was greater than the table ‘t’ value and P value < 0.05, there was a significant effectiveness of Neuromotor Task

Training

Training

in

combined children

with

with

Kinaesthetic

Developmental

Coordination Disorder. The pre test and post test values of Group 2 (Neuromotor Task Training Only) was analysed using paired‘t’ test. For 25 degrees

of

freedom

and

at

5%

level

of

significance, the table‘t’ value is 2.060 and the calculated

‘t’

value

was

11.588.

As

the

calculated‘t’ value was greater than the table ‘t’ value and P value < 0.05, there was a significant effectiveness of Neuromotor Task Training alone in children with Developmental Coordination Disorder. The pre test values of both the groups were analysed using independent‘t’ test. For 49 degrees of freedom and 5% level of significance, the

DISCUSSION

table‘t’ value 1.960 and the calculated ‘t’ value is

Out of 121 children suspected for DCD

0.207. As the calculated‘t’ value was lesser than

with initial screening by DCDQ’07, One child was

the table‘t’ value and P value > 0.05, there was no

diagnosed of having congenital hemiplegia, One

significant difference between the pre test values

with ADHD and 5 dropped out as they were absent

of both groups. Hence there was homogenicity

during the sessions of screening. Thus 114

between both the groups before the experiment.

children underwent secondary screening with

The post test values of both the groups were

TGMD-2. Out of 96 children identified with DCD,

analysed using independent‘t’ test. For 49 degrees

only 54 who consented on time (before the start of

of freedom and 5% level of significance, the

intervention) were included, as the study duration

table‘t’ value 1.960 and the calculated ‘t’ value is

is

1.292. As the calculated‘t’ value was lesser than

training

combined

randomized

groups

for

of the study, 2 subjects from the intervention

significant difference between the effectiveness of task

Two

intervention had 27 subjects each on the initiation

the table‘t’ value and P value > 0.05, there was no

Neuromotor

limited.

group 1 and 1 subject from the intervention group

with

2 were excluded from the results reported as they 33


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missed out many of the sessions during the

et al., (2009), found that 18 of 1000 7-year-olds

intervention period due to illness.

have DCD according to strict DSM-IV criteria and that 49 of 1000 7-yearolds have DCD or probable

The result from our study on local school

(16)

population of Kanchipuram, South India on age

DCD

group between 5 and 10 years shows that DCD is

1000 (5 to 10 years old children) have DCD and

prevailing in 6.82 % of children. The result is

approximately 86 of 1000 have probable or

correlating

suspect for DCD. The problem predominantly

with

the

previous

statement

of

. In our study the approximate of 68 of

(24)

‘Approximately 6% of children in mainstream

affects boys in a ratio of 3–4: 1

primary schools demonstrate motor competence

McKinley, 1980). In our study the boys to girls’

below normal range, although they appear both

ratio is 3.36: 1. Thus our results add support to the

physically and intellectually normal’

1

(Gordon &

previous studies.

(American

Psychiatric Association, 1994). But in contrast to

Angela D. Mandich et al., (2001), have

the study done on the local population group in

stated that, 1. To date, combined approaches are

kattankulathur of South India

by Ganapathy

largely untested and research has provided limited

Sankar U and Saritha S (2011) have shown that

evidence to support combined approaches. 2.

there is prevailing (Prevalence rate=1.37%) of

Combined approaches have demonstrated smaller

Developmental Coordination Disorder among the

effects than pure approaches. 3. The evidence for

(13)

. As this study was done

bottom up approaches would suggest that no one

only with DCDQ’07 screening, the prevalence rate

approach, or combination of approaches, is

is only the suspect and the methodology of survey

superior to another in improving motor skill. 4. No

was also not clearly explained, so this is

bottom up approach has been shown to be reliably

incomparable with our results.

better than no treatment at all

age group of 5–10 years

these

statements,

Top

(11)

. Considering

down

approach

of

Neuromotor Task Training was combined with Bottom up approach of Kinaesthetic Training. With the hypothesis to prove the effectiveness of Neuromotor

Task

Training

combined

with

Kinaesthetic Training in children with DCD, our study compared the groups with interventions combined (NTT with KT) on one group and NTT alone on another group. The results are statistically insignificant

to

prove

the

effectiveness

of

combined group over group with NTT alone, but there is a considerable difference in the mean values and the medium effect size shown by Cohen’s d effect size measure shows its beneficial effect. The effectiveness of Neuromotor Task Training in DCD is promising in this study, The UK population based study by Raghu Lingam 34


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

because there is a significant improvement seen in

secondary screening with TGMD-2 administered

both the subsets of TGMD-2 in the two

by the principle investigator. The diagnosis was

intervention groups. Kinaesthetic training in

made with the children falling below 15th

combined therapy group has added some benefits

percentile in the test. The intervention were given

by producing difference in mean value between

in two groups , one with combined therapy and the

the groups.

other with Neuromotor Task Training alone for a

The reason for the effectiveness of

period of 7 weeks in small groups. The outcome

intervention may be due to the physical activity as

was assessed with Gross Motor Quotient of

running, jumping and aerobic game playing which

TGMD-2. The data were analysed with Student’t’

has a definite impact on children’s frontal lobe, the

tests comparing values within the groups and

primary brain area for mental concentration,

between the groups. Results showed that the

planning and decision making(25). It is also

prevalence of DCD in the local population is

commonly believed that children automatically

6.82% and there is no significance difference

acquire motor skills as their bodies develop but

between the improvements made in the two

scientists now believe that the opportunities for

intervention groups.

practice, encouragement and instruction are crucial

Thus

to the development of mature patterns of fundamental motor skills

(26)

it

is

concluded

that

the

prevalence of DCD in the locality, Kanchipuram

. The benefits made

of South India is 6.82%. The conclusions drawn

would have been due to the group training in both

from our results are, 1. There is a significant

the groups as this has provided opportunity for

effectiveness of Combined therapy of Neuromotor

social

Task Training with Kinaesthetic Training in

interaction

competence

(14)

and

stronger

sense

of

.

children with DCD. 2. There is a significant

The added benefits of Kinaesthetic training

effectiveness of Neuromotor Task Training in

may be due to the processing of visual information

children with DCD. 3. There are no statistical

about

environment,

significant differences between the effectiveness of

proprioceptive information about limb and body

combined therapy Group against Neuromotor Task

position, and then the initiation of an appropriate

Training alone in children with DCD. The

corrective response. The integration or mapping of

differences in the mean value support the

these two sources of sensory information is also a

combined therapy group to have some better

the

body

and

external

critical ingredient in balance control

(27)

.

effects.

CONCLUSION The effectiveness

LIMITATIONS AND SUGGESTIONS

study of

was

to

find

out

the

This study was done with limited number of

Neuromotor

Task

Training

samples from a single school of a locality in South

combined with kinaesthetic training in children

India.

with Developmental coordination disorder. With

produce long term effects and the stability of the

the DCDQ’07 questionnaire filled by the school

effects produced cannot be determined. This

teachers the initial screening was done followed by

simple measure of gross motor development alone

35

Intervention duration is not enough to


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is not enough to measure all the characteristics of

participation in assessing and managing these

children

Assessment

children to be considered. Stability of the effects

Battery for Children 2 (MABC-2) which was

produced with the intervention to be studied. Other

proven to be a valid measurement tool for children

combinations of approaches can be tried.

with

with

DCD

DCD.

should

Movement

be

considered.

Parental

REFERENCES: 1. Disorders Usually First Diagnosed In Infancy, Childhood Or Adolescence. Diagnostical and Statistical Manual Of Mental Disorders: DSM-IV-TR: 4th Edition Text Revision. American Psychiatry Association. Pg. No. 56-58. 2. Developmental Co-Ordination Disorder: A Review Of Evidence And Models Of Practice Employed By Allied Health Professionals In Scotland. Specification/PDU/AHP/2006/001. 3. Smyth, M. M., & Anderson, H. I. Coping with Clumsiness In The School Playground: Social And Physical Play In Children With Coordination Impairments. British Journal of Developmental Psychology, 2000, 18, 389-413. 4. Kirby, A. & Davies, R. Developmental Coordination Disorder and Joint Hypermobility Syndrome - Overlapping Disorders? Implications for Research and Clinical Practice. Child Care Health and Development, 2007, 33(5), 513-9. 5. Kirby, A., Sugden, D., Beveridge, S. & Edwards, L. Developmental Co-Ordination Disorder (DCD) In Adults and Adolescents. Journal of Research In Special Education Needs, 2008, 8,12031. 6. Sugden, D. A., &Wright, H. C. Motor Coordination Disorders In Children. Thousand Oaks, CA: Sage. 1998. 7. M.M. Schoemaker, A.S. Niemeijer, K. Reynders, B.C.M. Smits-Engelsman Effectiveness Of Neuromotor Task Training For Children With Developmental Coordination Disorder: A Pilot Study. Neural Plasticity Volume 10, No. 1-2, 2003 8. Wilson, BN, Kaplan, BJ, Crawford, SG, And Roberts, G., The Developmental Coordination Disorder Questionnaire 2007 (DCDQ’07) October 2007 ©B.N. Wilson 2007 9. Leanne M. Slater, Susan L. Hillier, Lauren R. Civetta. The Clinimetric Properties Of Performance-Based Gross Motor Tests Used For Children With Developmental Coordination Disorder: A Systematic Review Pediatric Physical Therapy: Summer 2010 - Volume 22 - Issue 2 - Pp 170-179 10. David A. Sugden and Mary E. Chambers., Intervention In Children With Developmental Coordination Disorder: The Role Of Parents And Teachers. British Journal Of Educational Psychology (2003), 73, 545–561.

36


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

11. Angela D. Mandich, Helene J. Polatajko, Jennifer J. Macnab, Linda T. Miller. Treatment Of Children With Developmental Coordination Disorder: What Is The Evidence? Physical & Occupational Therapy In Pediatrics, Vol. 20, No. 2/3, 2001 51-68. 12. Woei-Nan Bair. Children With Developmental Coordination Disorder Benefit From Using Vision In Combination With Touch Information For Quiet Standing. Gait & Posture. June 2011. Volume 34, Issue 2 , Pages 183-190. 13. Sankar U and Saritha S. A Study Of Prevalence Of Developmental Coordination Disorder (DCD) At Kattankulathur, Chennai. Indian Journal Of Physiotherapy And Occupational Therapy. Year: 2011, Volume: 5, Issue: 1 :( 63-65) 14. Winnie W. Y. Hung And Marco Y. C. Pang.Effects Of Group-Based Versus Individual-Based Exercise Training On Motor Performance In Children With Developmental Coordination Disorder: A Randomized Controlled Pilot Study. J Rehabil Med 2010; 42: 122–128 15. Brenda N. Wilson, Susan G. Crawford, Dido Green, Gwen Roberts, Alice Aylott, Bonnie J. Kaplan. Psychometric Properties of The Revised Developmental Coordination Disorder Questionnaire. Journal Of Physical And Occupational Therapy In Pediatrics.2009. 29(2): 182202. 16. Raghu Lingam, Linda Hunt, Jean Golding, Marian Jongmans And Alan Emond., Prevalence Of Developmental Coordination Disorder Using The DSM-IV At 7 Years Of Age: A UK Population_Based Study. Pediatrics 2009; 123; E693-E700. 17. Reint H. Geuze., Static Balance and Developmental Coordination Disorder. Human Movement Science. 22 (2003)527–548. 18. Margaret Cousins, Mary M. Smyth., Developmental Coordination Impairments in Adulthood. Human Movement Science 22 (2003) 433–459. 19. Barnhart RC, Davenport MJ, Epps SB, Nordquist VM. Developmental Coordination Disorder. Phys Ther. 2003; 83: 722–731. 20. Dale A Ulrich. Test Of Gross Motor Development. Examiner’s Manual - Second Edition. Pro-Ed, 2000. 21. Polatajko H, McNab J, Anstett B, Malloy-Miller T, Murphy K, Noh S. A Clinical Trial Of The Process Oriented Treatment approach For Children With Developmental Coordination Disorder. Developmental Medicine And Child Neurology. 1995. 37. 310-319. 22. Anuschka S. Niemeijer et al., Developmental Medicine & Child Neurology. 2007; 49: 406-411. 23. Kinesthetic Awareness – Class Room And Individual Practice Performa From Therapy Skill Builders. A Division of Communication Skill Builders/ 602-323-7500 (1991). 24. Gordon N, McKinley I Helping clumsy children. Churchill Livingstone, Edinburgh.1980 25. http://www.ivyacademy.cn/MI/BodilyKinesthetic%20Intelligence.pdf. The Multiple Intelligences Preschool - IVY Academy.

37


ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji

26. Wafaa Abd Elzafez Abd Elmaksoud Ghaly. The Effect of Movement Education Program by Using Movement Pattern to Develop Fundamental Motor Skills For Children Pre School. World Journal of Sport Sciences. 2010; 3 (S); 461-491. 27. Sharon A. et al. Developmental coordination disorder. Cengage learning.2001.

CORRESPONDING AUTHOR: *M.P.T. (Neurology)., F.N.R., P.G.C.D.E. Health Care Consultant, Bharathidasan Matric Hr Sec School, Kanchipuram, Tamilnadu, India. & Consultant Physical Therapist, Star Health Care Center, Kanchipuram, Tamilnadu, India. **Bachelors in Physiotherapy (India), PG Dip Sci - Exercise Rehabilitation (Clinical Exercise Physiology), University of Auckland, New Zealand.

38


COGNITIVE REHABILITATION IN MS Krishna N. Sharma. MPT (Neuro)*

INTRODUCTION

that connect with primary sensory, motor, speech, and integration areas of the cerebrum. It may result

Cognition

refers

to

the ‘higher’

brain

in poor recognition of deficits as well as an

functions e.g. memory and reasoning. Sometimes the

MS

patients

associate

the

inability to store and retrieve new information. The

cognitive

combination of these two issues becomes a major

dysfunction to severity of physical symptoms or to

obstacle in the way to rehabilitation.10

duration of the disease which is actually a misbelief.1,2 Cognitive problems are one of the

Testing Cognitive Dysfunctions:

most frequent symptoms of MS, which is evident

Neuropsychological testing can assist in

in about 50% of the patients.3,4 Approximately

determining the degree of cognitive impairment in

10% to 20% patients show significant cognitive

patients with MS. Wallin et al (2006) et al.

dysfunction. Symptoms may be exaggerated by

categorized the tests for cognitive dysfunctions

underlying depression.5 The most often affected

associated with MS in three main schools of

cognitive functions are - memory, attention, speed

thought:11

of processing, abstract reasoning, verbal fluency, and

executive

functions.6,7,8

Widespread

1. Short screening with traditional measures

deterioration of intellectual function in MS is rare.9

in a neurologist’s office i.e. BRB-N (Brief Repeatable Battery of Neuropsychological

Why do they occur?

Tests). It is composed of the Buschke

The Cognitive problems in MS are actually

Selective Reminding Test, the 7/24 Spatial

the result of demyelination in the cerebral tracts

Recall Test, the Paced Auditory Serial 39


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Addition

Test

(PASAT),

and

Designing Interventions:

the

Designing intervention is the second step of

Controlled Oral Word Association Test (COWAT).12

the cognitive rehabilitation. It is intended to improve the patient's ability to function in all

2. Testing by a neuropsychologist with a minimal

(but

aspects - personal, family, social, and vocation

comprehensive)

neurocognitive battery i.e. MACFIMS

life.

(Minimal

Cognitive

progressive, and fluctuating in nature and there is a

Function in Multiple Sclerosis). It is

complex interaction of motor, sensory, cognitive,

composed of PASAT, COWAT, SDMT

functional, and affective impairments, it requires

etc.

Assessment

of

13

Since

periodic

3. Testing with automated, computerized

the

disease

reassessment,

rehabilitative

is

unpredictable,

monitoring,

interventions.

The

and

therapist

measures in a neurologist’s office or as

recognizes the deficit and includes the functionally

part of a clinical trial i.e. ANAM

oriented therapeutic tasks accordingly.

(Automated

Neuropsychological

There are two approaches - Restorative

Assessment Metrics). It is composed of

Strategies and Compensatory Strategies, which are

Procedural

believed

Reaction

Time,

Code

Substitution, Sternberg Memory Search etc.

to

be

dysfunctions.

14

helpful

Since

the

in

the

cognitive

effectiveness

of

Restorative Strategies to cognitive rehabilitation is largely inconclusive15, Compensatory strategies

Such an evaluation could be helpful in the

(i.e. teaching to use intact skills with/without

following ways:

external aids) are widely used and are suggested

by most authors.

It can identify impaired and intact functions.

The MS patient as well as the family

Compensatory Strategies-

members may have a better understanding •

of the nature and extent of the illness. •

Cognitive

Structuring-

The

therapist

The evaluation may help the person

applies suitable learning theory and make

develop realistic vocational and other life

the patient practice the cognitive task to

goals.

turn it in a routine behaviors. •

The results can suggest compensatory techniques.

Substitution

Strategies-

The

therapist

teaches to use the intact cognitive abilities to circumvent the impaired abilities. For example- Using intact visual memory in place of impaired verbal memory function. •

Scheduling and Timelines- The patients are encouraged to use schedulers and alarms.

40


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

Using the recording devices- It helps the patients remember and store the important details.

Memory strategies- The patients are taught and encouraged to use mnemonics, lists, clustering, and visualization techniques etc. to remember things.

Assistive Technology- The patients are advised to use handheld computers,

electronic calendars, and memory logs etc.

An MS Patient using COGNIsoft-I for Cognitive

Creating structured environment- It helps

Rehabilitation

the patients find their things on certain

Tips:

fixed places to avoid the hassle in

forgetting and searching things.

places to avoid distractions. •

Restorative Strategies-

games/ activities are available for restoring or improving cognition, there is lack of evidence-

The activity should be demonstrated first.

The instructions should be simple and short.

based-practice of the restorative strategies for the

cognitive deficits associated with MS. There are

mind. Application of the principles of

improvement by the cognitive games.16,17 many

toy

games

for

Spaced

cognitive

of computer and technology few application

etc. would enhance

Instructions may be given in the forms of

would

Games etc; and online cognitive rehabilitation

help

them

remembering

the

activities even when they are at home.

multiplesclerosis.com18,

BICBrainInjuryCentre.co.uk19,

Story

Audio/ video tape, printed material also. It

softwares e.g.- COGNIsoft-I, BrainTrain, MSTY

on

24

the outcome.

Quoridor, Tenzi, Fiddlesticks etc. But in this age

available

Learning,23

Retrieval

Memory Technique,

rehabilitation e.g.- Peg Board, Puzzle-cubes,

games

The activities should be carried out with the concept of Errorless Learning22 in

very less researches which confirm significant

are

The sessions should be well-designed and engaging.

Though so many verities of therapeutic tasks/

There

The activities should be conducted in quiet

Peartrees.com20,

The exercises should be done for the

Mind360.com21 etc. are proving to be effective and

shorter periods of time to avoid cognitive

easily administrable.

fatigue. New skills should not be taught before the previous skill has been strongly established.

41


REFRENCES 1. Peyser JM. Edwanb KR, Poser CM, et al: Cognitive function in patients with multiple sclerosis. Arch Neurol 37:577-579, 1980 2. Beatty WW, Goodkin DE. (1990) Screening for cognitive impairment in multiple sclerosis: An evaluation of the Mini Mental State Examination. Arch Neurol, 47, 297–301. 3. Aronson K, G. E.; Socio-demographic characteristics and health status of persons with multiple sclerosis and their care givers. MS Management 3(1), 5-15. 1996. 4. Lublin F, Reingold S; Defining the course of multiple sclerosis. Neurology 46(4):907-911, 1996. 5. Debra I. Frankel; Multiple Sclerosis. DA Umphred (Ed.), Neurological Rehabilitation, The CV Mosby Company, St. Louis, pp. 714. 1995 6. Debra I. Frankel; Multiple Sclerosis. DA Umphred (Ed.), Neurological Rehabilitation, The CV Mosby Company, St. Louis, pp. 714. 1995 7. Rao SM, Leo GL, Bernardin L, et al: Congnitive dysfunction in multiple sclerosis. I. Grequency, patterns, and prediction, Neurology 41(5):685-691, 1991 8. Peyser JM. Edwanb KR, Poser CM, et al: Cognitive function in patients with multiple sclerosis. Arch Neurol 37:577-579, 1980 9. Lublin F, Reingold S: Defining the course of multiple sclerosis. Neurology 46(4) :907-911, 1996. 10. Debra I. Frankel; Multiple Sclerosis. DA Umphred (Ed.), Neurological Rehabilitation, The CV Mosby Company, St. Louis, pp. 728. 1995 11. Wallin et al. Cognitive dysfunction in multiple sclerosis. JRRD, Volume 43, Number 1, 63-71. 2006 12. Rao SM, Leo GJ, Bernardin L, Unverzagt F. Cognitive dysfunction in multiple sclerosis. I. Frequency, patterns, and prediction. Neurology. 1991;41(5):685–91. 13. Benedict RH, Fischer JS, Archibald CJ, Arnett PA, Beatty WW, Bobholz J, Chelune GJ, Fisk JD, Langdon DW, Caruso L, Foley F, LaRocca NG, Vowels L, Weinstein A, DeLuca J, Rao SM, Munschauer F. Minimal neuropsychological assessment of MS patients: a consensus approach. Clin Neuropsychol. 2002;16(3):381–97. 14. Wilken JA, Kane R, Sullivan CL, Wallin M, Usiskin JB, Quig ME, Simsarian J, Saunders C, Crayton H, Mandler R, Kerr D, Reeves D, Fuchs K, Manning C, Keller M. The utility of computerized neuropsychological assessment of cognitive dysfunction in patients with relapsing-remitting multiple sclerosis. Mult Scler. 2003;9(2):119–27. 15. O’Brien AR, Chiaravalloti N, Goverover Y, Deluca J. Evidenced-based cognitive rehabilitation for persons with multiple sclerosis: a review of the literature. Arch Phys Med Rehabil 2008;89(4):761–9. 16. Chooi, Weng-Tink; Thompson, Lee A. (2012). "Working memory training does not improve intelligence in healthy young adults". Intelligence 40 (6): 531–42.

42


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

17. Redick, T. S.; Shipstead, Z.; Harrison, T. L.; Hicks, K. L.; Fried, D. E.; Hambrick, D. Z.; Kane, M. J.; Engle, R. W. (2012). "No Evidence of Intelligence Improvement After Working Memory Training: A Randomized, Placebo-Controlled Study". General J Exp Psychol Gen. 2012 Jun 18. 18. http://www.multiplesclerosis.com/us/index.php 19. http://www.bicbraininjurycentre.co.uk 20. http://www.pearltrees.com/#/N-play=0&N-s=1_4127047&N-u=1_487865&N-p=44503368&Nf=1_4127047&N-fa=4055621 21. http://www.mind360.com/games 22. Wilson BA, Baddeley A, Evans J, et al. Errorless learning in the rehabilitation of memory impaired people. Neurospsychol Rehabil 1994; 4(3): 307–26. 23. Heesen C, Kasper J, Segal J, et al. Decisional role preferences, risk knowledge and information

interests in patients with multiple sclerosis. Mult Scler 2004; 10: 1–8. 24. Camp CJ, Foss JW, O’Hanlon AM, et al. Memory interventions for persons with dementia. Appl Cog

Psychol 1996; 10: 193–210.

CORRESPONDING AUTHOR: * Senior Physiotherapist. Multiple Sclerosis Society of India (Mumbai Chapter), Mumbai, India. Cont: +91-9320699167. Email: dr.krisharma@gmail.com

43


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NETWORK BORDER PATROL ERADICATES THE OVER LOADING OF DATA PACKETS AND PREVENTS CONGESTION COLLAPSE THEREBY PROMOTING FAIRNESS OVER TCP PROTOCOL IN LAN /WAN Lakshminarayanan T.*, Dr. Umarani R.**

ABSTRACT The Project flow chart algorithm is multicast service. It is very simple being LAN/WAN broadcasting tool. The LAN/WAN links are often private Lines, unlike submarine and over network. A private network has the advantage of being managed and by few people so to avoid many problems about the property and origin of LAN/ WAN has been investigated in the literature for some use. The fundamental philosophy behind the internet is expressed by scalability argument No protocol, mechanism or service should be introduced in to the internet if it does not scale well. A key corollary to the scalability argument is the end to end argument to maintain scalability algorithmic complexity should be pushed to the edges of the network to whenever possible Perhaps the best example of the internet philosophy the TCP congestion control which is implemented primarily to algorithms operating at end systems unfortunately TCP congestion control also illustrates some of the shortcomings the end to end argument As a result of its strict adherence to end and congestion control. KEYWORDS: LAN/WAN, TCP Congestion Control

RELATED WORKS

undelivered packets and of unfair bandwidth allocations have not gone unrecognized. Some

The maladies of congestion collapse from 44


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

have argued that there are social incentives for

On the second bottleneck link (R2-S4),

multimedia applications to be friendly to the

much of the traffic from flow B is discarded. Due

network, since an application would not want to be

to the link’s limited capacity (128 kbps). Hence,

held responsible for throughput degradation in the

flow A achieves a throughput of 750 kbps and

Internet. However, malicious denial-of-service

flow B achieves a throughput of 128 kbps. Clearly,

attacks using unresponsive UDP flows are

congestion collapse has occurred, because flow B

becoming disturbingly frequent in the Internet and

packets, which are ultimately discarded on the

they are an example that the Internet cannot rely

second bottleneck link, unnecessarily limit the

solely on social incentives to control congestion or

throughput of flow A across the first bottleneck

to operate fairly. Some have argued that these

link. Furthermore, while both flows receive equal

maladies may be mitigated through the use of

bandwidth allocations on the first bottleneck link,

improved

packet

scheduling1

or

queue

their allocations are not globally max-min fair. An

2

management mechanisms in network routers.

allocation of bandwidth is said to be globally max-

For instance, per-flow packet scheduling

min fair if, at every link, all active flows not

mechanisms like Weighted Fair Queuing (WFQ)3,4

bottlenecked at another link are allocated a

attempt to offer fair allocations of bandwidth to

maximum, equal share of the link’s remaining

flows Contending for the same link. So do Core-

bandwidth9.

Stateless Fair Queueing (CSFQ)5, Rainbow Fair Queueing6 and Choke7, which are approximations of WFQ that do not require, core routers to maintain per-flow state. Active queue management mechanisms like Fair Random Early Detection (FRED)8 also attempt to limit malicious or unresponsive flows by preferentially discarding packets from flows that are using more than their

Fig: 1, Example of a Network Which Experiences

fair share of a link’s bandwidth.

Congestion Collapse

All of these mechanisms are more

A globally max-min fair allocation of

complex and expensive to implement than simple

bandwidth would have been 1.372 Mbps for flow

FIFO queuing, but they reduce the causes of

A and 128 kbps for flow B. This example, which is

unfairness and congestion collapse in the Internet.

a variant of an example presented by Floyd and

Nevertheless, they do not eradicate them. For

fall10, illustrates the inability of local scheduling

illustration of this fact, consider the example

mechanisms,

shown in Figure 1. Two unresponsive flows

congestion collapse and achieve global max-min

compete for bandwidth in a network containing

fairness without the assistance of additional

two bottleneck links arbitrated by a fair queuing

network mechanisms. Jain et al. have proposed

mechanism. At the first bottleneck link (R1-R2),

several rate control algorithms that are able to

fair queuing ensures that each flow receives half of

prevent congestion collapse and provide global

the link’s available bandwidth (750 kbps).

max-min fairness to competing flows11.

45

such

as

WFQ,

to

eliminate


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These algorithms (e.g., ERICA, ERICA+) are designed for the ATM Available Bit Rate (ABR) service and require all network switches to compute fair allocations of bandwidth among competing connections. However, these algorithms are not easily tailor able to the current Internet, because they violate the Internet design philosophy of keeping router implementations simple and pushing complexity to the edges of the network. Fig: 2, The Core-Stateless Internet Architecture

Rangarajan and Acharya proposed a network

Assumed By NBP

border-based approach, which aims to prevent

1.1 TCP congestion control has mainly two

congestion collapse through early regulation of

phases:

unresponsive flows (ERUF)12. ERUF border

Slow Start and Congestion avoidance. A

routers rate control the input traffic, while core

new connection begins in Slow-start, setting its

routers generate source quenches on packet drops

initial cwnd to 1 packet, and increasing it by 1 for

to advise sources and border routers to reduce their

every received Acknowledgement (ACK). After

sending rates. While

this

approach

may

cwnd reaches ssthresh, the connection switches to

prevent

congestion-avoidance where cwnd grows linearly.

congestion collapse, it does so after packets have

A variety of methods have been suggested in the

been dropped and the network is congested. It also

literature recently aiming to avoid multiple losses

lacks mechanisms to provide fair bandwidth

and achieve higher utilization during the startup

allocations to flows. That is responsive and

phase. A larger initial cwnd, roughly 4K bytes, is

unresponsive to congestion. Floyd and fall have

proposed in.

approached the problem of congestion collapse by

This could greatly speed up transfers with

proposing low-complexity router mechanisms that

only a few packets. However, the improvement is

promote the use of adaptive or “TCP-friendly”

still inadequate when BDP is very large and the

end-to-end congestion control10. Their suggested

file to transfer is bigger than just a few packets.

approach requires selected gateway routers to monitor determine

high-bandwidth whether

they

flows are

in

order

to

responsive

to

Fast start uses cached cwnd and ssthresh in recent connections to reduce the transfer latency. The cached parameters may be too aggressive or too

congestion. Flows determined to be unresponsive

conservative when network conditions change

to congestion are penalized by a higher packet

Smooth start has been proposed to slow down

discarding rate at the gateway router. A limitation

cwnd increase when it is close to ssthresh. The

of this approach is that the procedures currently

assumption here is that default value of ssthresh is

available to identify unresponsive flows are not

often larger than the BDP, which is no longer true

always successful5.

in large bandwidth delay networks. Proposes to set the initial ssthresh to the BDP estimated (Packet Network Discovery) has been proposed to derive 46


Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 2, Year: 2013

optimal TCP initial parameters. SPAND needs

System Flow diagram are directed graphs

leaky bucket pacing for outgoing packets, which

in which nodes specify processing activities and

can be costly and Problematic in practice.

arc

TCP

Vegas

detects

congestion

specify

data

item

transmitted

between

processing nodes .Data Flow diagrams represent

by

the system between individual items in fig: 5.a,

comparing the achieved throughput over a cycle of length equal to RTT, to the expected throughput implied by cwnd and base RTT (minimum RTT) at the beginning of a cycle. This method is applied in both Slow-start and Congestion-avoidance phases. During Slow-start phase, a Vegas sender doubles

Fig: 5.A, Backward Feed Back

its cwnd only every other RTT, in contrast with

2.1 System implementation

Renoâ&#x20AC;&#x2122;s doubling every RTT. A Vegas connection

Egress module- Input parameters: (I) Data packets

exits slow-start when the difference between

from router. (II)Forward feedback from the router.

achieved and expected throughput exceeds a

Egress module- Output parameters: (I) Data

certain threshold. However, Vegas are not able to

packets. (II)Backward feedback.

achieve high utilization in large Band width delay networks as we will, due to its over-estimation of

Destination module: (I) Message received from the

RTT.

egress router will be stored in the corresponding We believe that estimating the eligible

folder as a text file depends upon the source

sending rate and properly using such estimate are

machine name.

critical to improving bandwidth utilization during Slow-start.TCP Westwood and Eligible Rate

2. Network border patrol

Estimation Overview in TCP Westwood (TCPW),

Network Border Patrol is a network layer

the sender continuously monitors ACKs from the

congestion avoidance protocol that is aligned with

receiver and computes its current Eligible Rate

the core-stateless approach. The core-stateless

Estimate (ERE). ERE relies on an adaptive

approach, which has recently received a great deal

estimation technique applied to ACK stream. The

of research attention [13], [5], allows routers on

goal of ERE is to estimate the connection eligible

the borders (or edges) of a network to perform

sending rate with the goal of achieving high

flow classification and maintain per-flow state but

utilization, without starving other connections. We

does not allow routers at the core of the network to

emphasize that what a connection is eligible for is

do so. Figure 2 illustrates this architecture. As in

not the residual bandwidth on the path. The

other work on core-stateless approaches, we draw

connection is often eligible more than that. For

a further distinction between two types of edge

example, if a connection joins two similar

routers. Depending on which flow it is operating

connections, already in progress and fully utilizing

on, an edge router may be viewed as ingress or an

the path capacity, then the new connection is

egress router. An edge router operating on a flow

eligible for a third of the capacity.

passing into a network is called an ingress router, whereas an edge router operating on a flow

1. Problem Methodology 47


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passing out of a network is called an egress router.

Fig: 3- An Input Port of an NBP Egress Router.

Note that a flow may pass through more than one egress (or ingress) router if the end-to-end path crosses

prevents

The only components of the network that

congestion collapse through a combination of per-

require modification by NBP are edge routers; the

flow rate monitoring at egress routers and Per-flow

input ports of egress routers must be modified to

rate control at ingress routers. Rate monitoring

perform per-flow monitoring of bit rates, and the

allows an egress router to determine how rapidly

output ports of ingress routers must be modified to

each flow’s packets are leaving the network,

perform per-flow rate control. In addition, both the

whereas rate control allows an ingress router to

ingress and the egress routers must be modified to

police the rate at which each flow’s packets enter

exchange

the network. Linking these two functions together

illustrates the architecture of an egress router’s

are the feedback packets exchanged between

input port. Data packets sent by ingress routers

ingress and egress routers; ingress routers send

arrive at the input port of the egress router and are

egress routers forward feedback packets to inform

first classified by flow. In the case of IPv6, this is

them about the flows that are being rate controlled,

done by examining the packet header’s flow label,

and egress routers send ingress routers backward

whereas in the case of IPv4, it is done by

feedback packets to inform them about the rates at

examining the packets Source and destination

which each flow’s packets are leaving the network.

addresses and port numbers. Each flow’s bit rate is

This section describes three important

then rate monitored using a rate estimation

aspects

multiple

of

the

networks.

NBP

NBP

3.1 Architectural Components

mechanism:

(a)

the

and

handle

feedback.

Figure:

3,

algorithm such as the Time Sliding Window

architectural components, namely the modified

(TSW) [14].

edge routers, which must be present in the

These rates are collected by a feedback

network, (b) the feedback control algorithm, which

controller, which returns them in backward

determines

is

feedback packets to an ingress router whenever a

exchanged between edge routers, and (c) the rate

forward feedback packet arrives from that ingress

control algorithm, which uses the information

router. The output ports of ingress routers are also

carried in feedback packets to regulate flow

enhanced. Each contains a flow classifier, per-flow

transmission rates and thereby prevent congestion

traffic shapers (e.g., leaky buckets), a feedback

collapse in the network.

controller, and a rate controller. See Figure 4. The

how

and

when

information

flow classifier classifies packets into flows, and the traffic shapers limit the rates at which packets from individual flows enter the network. The feedback controller receives backward feedback packets returning from egress routers and passes their contents to the rate controller. It also generates forward feedback packets, which it occasionally transmits to the network’s egress

48


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

routers. The rate controller adjusts traffic shaper

is the combination of source address, destination

parameters according to a TCP-like rate control

address, source port number, and destination port

algorithm, which is described later in this section.

number. An edge router adds a flow to its list of active flows

Fig: 4, an Output Port of an NBP Ingress

Fig: 5, Forward and Backward Feedback Packets

Router.

Exchanged By Edge Routers.

3.2 The Feedback Control Algorithm

Whenever a packet from a new flow arrives; it removes a flow when the flow becomes

The

feedback

control

algorithm

inactive. In the event that the network’s maximum

determines how and when feedback packets are exchanged

between

edge

routers.

transmission unit size is not sufficient to hold an

Feedback

entire list of flow specifications, multiple forward

packets take the form of ICMP packets and are

feedback packets are used. When an egress router

necessary in NBP for three reasons. First, they

receives a forward feedback packet, it immediately

allow egress routers to discover which ingress

generates a backward feedback packet and returns

routers are acting as sources for each of the flows

it to the ingress router. Contained within the

they are monitoring. Second, they allow egress

backward feedback packet are the forward

routers to communicate per-flow bit rates to

feedback packet’s original time stamp, a router

ingress routers. Third, they allow ingress routers to

hop count, and a list of observed bit rates, called

detect incipient network congestion by monitoring

egress rates, collected by the egress router for each

edge-to-edge round trip times. The contents of

flow listed in the forward feedback packet.

feedback packets are shown in Figure 5. Contained

The router hop count, which is used by the

within the forward feedback packet are a Time

ingress router’s rate control algorithm, indicates

stamp and a list of flow specifications for flows

how many routers are in the path between the

originating at the ingress router. The time stamp is

ingress and the egress router. The egress router

used to calculate the round trip time between two

determines the hop count by examining the time to

edge routers, and the list of flow specifications

live (TTL) field of arriving forward feedback

indicates to an egress router the identities of active

packets. When the backward feedback packet

flows originating at the ingress router. A flow

arrives at the ingress router, its contents are passed

specification is a value uniquely identifying a

to the ingress router’s rate controller, which uses

flow. In IPv6 it is the flow’s flow label; in IPv4, it

them to adjust the parameters of each flow’s traffic 49


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else

shaper. In order to determine how often to generate forward feedback packets, an ingress

f.phase = CONGESTION_AVOIDANCE;

router keeps a byte transmission counter for each

if (f.phase == CONGESTION_AVOIDANCE)

flow it processes. Whenever a flow’s byte counter

if (deltaRTT × f.ingressRate < MSS × e.hopcount)

exceeds a threshold, denoted TX, the ingress

f.ingressRate = f.ingressRate + rateQuantum ×

router generates and transmits a forward feedback

RTTsElapsed;

packet to the flow’s egress router. The forward feedback

packet

includes

a

list

of

else

flow

f.ingressRate = f.egressRate - rateQuantum;

specifications for all flows going to the same egress router, and the counters for all flows

Fig: 6, Pseudo Code for Ingress Router Rate

described in the feedback packet are reset.

Control Algorithm.

Using a byte counter for each flow ensures that

feedback

packets

are

generated

more

3. The Rate Control Algorithm

frequently when flows transmit at high rates,

The NBP rate control algorithm regulates

thereby allowing ingress routers to respond more

the rate at which each flow enters the network. Its

quickly to impending congestion collapse. To

primary goal is to converge on a set of per-flow

maintain a frequent flow of feedback between edge

transmission rates (hereinafter called ingress rates)

routers even when data transmission rates are low,

that prevents congestion collapse from undelivered

ingress routers also generate forward feedback

packets. It also attempts to lead the network to a

packets whenever a time-out interval, denoted tf, is

state of maximum link utilization and low router

exceeded.

buffer occupancies, and it does this in a manner that is similar to TCP. In the NBP rate control algorithm, shown in Figure 6, a flow may be in

On arrival of Backward Feedback packet p from

one of two phases, slow start or congestion

egress router e

avoidance, which is similar to the phases of TCP

Current RTT = current Time - p.time stamp;

congestion control. New flows enter the network

if (currentRTT < e.base RTT)

in the slow start phase and proceed to the

e.base RTT = currentRTT;

congestion avoidance phase only after the flow has

delta RTT = currentRTT - e.base RTT;

experienced congestion.

RTTsElapsed = (current Time -

The rate control algorithm is invoked

e.lastFeedbackTime) / currentRTT;

whenever a backward feedback packet arrives at

e.lastFeedbackTime = current Time;

an ingress router. Recall that BF packets contain a

for each flow f listed in p

list of flows arriving at the egress router from the

rateQuantum = min (MSS / currentRTT,

ingress router as well as the monitored egress rates

f.egressRate / QF);

for each flow. Upon the arrival of a backward

if (f.phase == SLOW_START)

feedback packet, the algorithm calculates the

if (deltaRTT × f.ingressRate < MSS × e.hopcount)

current round trip time between the edge routers

f.ingressRate = f.ingressRate × 2 ^ RTTsElapsed;

and updates the base round trip time, if necessary.

50


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

The base round trip time reflects the best observed

since the last backward feedback packet arrived.

round trip time between the two edge routers. The

The estimated number of round trip times since the

algorithm then calculates delta RTT, which is the

last feedback packet arrived is denoted as

difference between the current round trip time

RTTsElapsed.

(currentRTT) and the base round trip time (e.base

Doubling the ingress rate during slow start

RTT). A delta RTT value greater than zero

allows a new flow to rapidly capture available

indicates that packets are requiring a longer time to

bandwidth when the network is underutilized. If,

traverse the network than they once did, and this

on the other hand, the flow is in the congestion

can only be due to the buffering of packets within

avoidance

the network. NBP’s rate control algorithm decides

conservatively incremented by one rateQuantum

that a flow is experiencing congestion whenever it

value for each round trip that has elapsed since the

estimates that the network has buffered the

last backward feedback packet arrived. This is

equivalent of more than one of the flow’s packets

done to avoid the creation of congestion. The rate

at each router hop. To do this, the algorithm first

quantum is computed as the maximum segment

computes the product of the flow’s ingress rate and

size divided by the current round trip time between

deltaRTT.

the edges routers. This results in rate growth

phase,

then

its

ingress

rate

is

This value provides an estimate of the

behavior that is similar to TCP in its congestion

amount of the flow’s data that is buffered

avoidance phase. Furthermore, the rate quantum is

somewhere in the network. If the amount is greater

not allowed to exceed the flow’s current egress

than the number of router hops between the ingress

rate divided by a constant quantum factor (QF).

and the egress router multiplied by the size of the

This guarantees that rate increments are

largest possible packet, then the flow is considered

not excessively large when the round trip time is

to be experiencing congestion. The rationale for

small. When the rate control algorithm determines

determining congestion in this manner is to

that a flow is experiencing congestion, it reduces

maintain both high link utilization and low

the flow’s ingress rate. If a flow is in the slow start

queuing delay. Ensuring there is always at least

phase, it enters the congestion avoidance phase. If

one packet buffered for transmission on a network

a flow is already in the congestion avoidance

link is the simplest way to achieve full utilization

phase, its ingress rate is reduced to the flow’s

of the link, and deciding that congestion exists

egress rate decremented by MRC. In other words,

when more than one packet is buffered at the link

an observation of congestion forces the ingress

keeps queuing delays low. A similar approach is

router to send the flow’s packets into the network

used in the DEC bit congestion avoidance

at a rate slightly lower than the rate at which they

mechanism [15].

are leaving the network.

When

the

rate

control

algorithm

determines that a flow is not experiencing

RESULT

congestion, it increases the flow’s ingress rate. If

In this paper, we have presented a novel

the flow is in the slow start phase, its ingress rate

congestion avoidance mechanism for the Internet

is doubled for each round trip time that has elapsed

called network border patrol. Unlike existing

51


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internet congestion control approaches, which rely

that they can perform the requisite per-flow

solely on end-to-end control, NBP is able to

monitoring, per-flow rate control and feedback

prevent congestion collapse from undelivered

exchange operations.

packets. It does this by ensuring at the border of

Extensive simulation results provided in

the network that each flows packets do not enter

this paper show that NBP successfully prevents

the network faster than they are to leave it NBP

congestion collapse from undelivered packets.

requires no modification to core routers or to end

They also show that, while NBP is unable to

systems. Only edge routers are enhanced so that

eliminate unfairness on its own, it is able to

they can perform the requisite per – flow

achieve approximate global max-min fairness for

monitoring, per-flow rate control and feedback

competing network flows when combined with

exchange operations.

WFQ, Furthermore, NBP, when combined with CSFQ, approximate global max-min fairness in a

CONCLUSION

completely core-stateless fashion.

In this paper, we have presented a novel

As

in

any

feedback-

based

traffic

congestion avoidance mechanism for the Internet

mechanism, stability is an important performance

called Network Border Patrol.

Unlike existing

concern in NBP. Using techniques described in

Internet congestion control approaches, which rely

(16), a plan as part of my future works to perform

solely on end-to-end control, NBP is able to

an analytical study of NBP’s stability and

prevent congestion collapse from undelivered

convergence

packets. It does this by ensuring at the border of

Preliminary results already suggest that NBP

the network that each flow’s packets do not enter

Benefits greatly from its use of explicit rate

the network faster than they are able to leave it.

feedback, which prevents rate over-corrections in

NBP requires no modifications to core routers or

response to indications to indications of network

to end systems. Only edge routers are enhanced so

congestion.

toward

max

min

fairness.

REFERENCES 1. B. Suter, T.V. Lakshman, D. Stiliadis, and A. Choudhury, “Design Considerations for Supporting TCP with Per-Flow Queueing,” in Proc. Of IEEE Infocom ’98, March 1998, pp. 299–305. 2. B. Braden et al., “Recommendations on Queue Management and Congestion Avoidance in the Internet,” RFC 2309, IETF, April 1998. 3. A. Demers, S. Keshav, and S. Shenker, “Analysis and Simulation of a Fair Queueing Algorithm,” in Proc. of ACM SIGCOMM, September 1989,pp. 1–12. 4. A. Parekh and R. Gallager, “A Generalized Processor Sharing Approach to Flow Control – the Single Node Case,” IEEE/ACM Transactions on Networking, vol. 1, no. 3, pp. 344–357, June 1993. 5. I. Stoica, S. Shenker, and H. Zhang, “Core-Stateless Fair Queueing: Achieving Approximately Fair Bandwidth Allocations in High Speed Networks,” in Proc. of ACM SIGCOMM, September 1998, pp. 118–130.28

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Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

6. Z. Cao, Z. Wang, and E. Zegura, “Rainbow Fair Queuing: Fair Bandwidth Sharing Without Per-Flow State,” in Proc. of IEEE Infocom ’2000, March 2000. 7. R. Pan, B. Prabhakar, and K. Psounis, “CHOKe - A stateless active queue management scheme for approximating fair bandwidth allocation,” in Proc. of IEEE Infocom ’2000, March 2000. 8. D. Lin and R. Morris, “Dynamics of Random Early Detection,” in Proc. of ACM SIGCOMM, September 1997, pp. 127–137. 9. D. Bertsekas and R. Gallager, Data Networks,

second edition, Prentice Hall, 1987.

10. S. Floyd and K. Fall, “Promoting the Use of End-to-End Congestion Control in the Internet,” IEEE/ACM Transactions on Networking, August 1999, to appear. 11. R. Jain, S. Kalyanaraman, R. Goyal, S. Fahmy, and R. Viswanathan, “ERICA Switch Algorithm: A Complete Description,” ATM Forum Document 96-1172, Traffic Management WG, August 1996. 12. A. Rangarajan and A. Acharya, “ERUF: Early Regulation of Unresponsive Best-Effort Traffic,” International Conference on Networks and Protocols, October 1999. 13. S. Blake, D. Black, M. Carlson, E. Davies, Z. Wang, and W. Weiss, “An Architecture for Differentiated Services,” Request for Comments 2475, Internet Engineering Task Force, December 1998. 14. D. Clark and W. Fang, “Explicit Allocation of Best-Effort Packet Delivery Service,” IEEE/ACM Transactions on Networking, vol. 6, no. 4, pp. 362–373, August 1998. 15. K.K. Ramakrishna and R. Jain, “A Binary Feedback Scheme for Congestion Avoidance in Computer Networks with a Connectionless Network Layer,” ACM Transactions on Computing Systems, vol. 8, no. 2, pp. 158–181, May 1990.

CORRESPONDING AUTHOR: * Research Scholar , Department of Computer Science , Periyar University College of Arts and Science, Mettur Dam-636401. Email- lakshmitvr@rediffmail.com ** Associate Professor, Department of Computer Science, Sri Sarada College for Women, Salem -07

53


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USE OF FUZZY TOPSIS MODEL FOR EVALUATING COOLING TOWERS Dr. Ali Kheradmand*, Mahdi Naqdi Bahar**, Ali Ghani Abadi***

ABSTRACT Present paper applies Fuzzy TOPSIS Model for identification of indicators regarding to cooling towers and assigning weight to indicators and prioritizing Cooling Towers distributed questionnaires among 37 expert and specialist in Besat Electricity Production Company in Tehran – Iran. The current research concluded to this result that in most of the existing studies on decision making issue , the issue is supposed in an environment of definitive data but in some cases it seen that determination of exact values for the criteria is difficult and the value should be considered as Fuzzy Values. KEY WORDS: Fuzzy TOPSIS (Technique for Order Preference by Similarity to Ideal Situation) Model, Cooling Tower, Technology Selection, Decision Making

INTRODUCTION

involves ‘gathering information from various sources about the alternatives, and the evaluation

Technology selection is concerned with

of alternatives against each other or some set of

choosing the best technology from a number of

criteria’.(Lamb and Gregory,1997) Technology

available options. The criteria for a ‘best’

selection

technology may differ depending on the specific

technology

selection

process

which

master’.(Garegory,1995)

the

firm

technology

seeks

involve

decision

growth of a company in the increasing competitive

as

global scenario.(Chan et al, 2000) One of the

‘identification and selection of new or additional technologies

justification

makings that are critical to the profitability and

requirements of a company. (Shehabuddeen et al, 2006)

and

technologies regarding the industry is cooling

to

tower which has many applications in industries.

selection

Role of cooling towers for chemicals producing 54


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

units is like role of radiator in an automobile. As

assessing

cutting off flow of cooling water in automobile

technologies. To select the best technologies in the

and radiator break down causes irreparable

existence of both cardinal and ordinal data

damages to engine and other parts of automobile,

Faerzipoor Saen(2006) proposed an innovative

in industry too, cutting off cooling water even for a

approach, which is based on Imprecise date

short time involves huge damages as consequence

envelopment analysis (IDEA). Lee and Hwang

so that operators in case of cooling water cut-off

(2010) proposed to use AHP as a tool for

for any reason often consider it a saving action to

prioritizing the strategically promising nuclear

put the system out of service in spite heavy costs

technologies for commercial export from Korea.

of production halt. This strong dependence of

Jaganathan et al (2007) proposed an integrated

production on cooling towers function indicates

Fuzzy AHP based approach to facilitate the

their special economic importance. On the other

selection and evaluation of new manufacturing

side, limitation of water sources and necessity of

technologies

their use make the towers’ economic role more

attributes and uncertainty. However, AHP as two

obvious and on the other side, incorrect selection

main weaknesses First subjectivity of AHP is a

of this technology may in addition to loss of water

weakness.

sources, bring irremediable damages to the

interrelationship within the criteria in the model

country’s industry. Hence, selection of this

this paper, using Fuzzy TOPSIS Model tries to

technology is of very high importance. This paper,

evaluate and prioritize cooling towers.

the

in

prior

the

Second

order

of

presence

AHP

could

regenerative

of

intangible

not

include

using Fuzzy TOPSIS Model tries to evaluate and prioritize cooling towers.

FUZZY TOPSIS METHOD The TOPSIS is widely used for tackling

LITERATURE REVIEW Some

mathematical

ranking problems in real situations. This method is programming

often criticized for its inability to adequately

approaches have been used for technology

handle the inherent uncertainty and imprecision

selection in the past. Hsu et al. (2010) provided a

associated with the mapping of the decision-

systematic approach towards the technology

makers perception to crisp values. In the

selection in which two phase procedures were

traditional formulation of the TOPSIS, personal

proposed. The first stage utilized fuzzy Delphi

judgments are represented with crisp values.

method to obtain two the critical factors of the

However, in many practical cases the human

regenerative technologies by interviewing the

preference model is uncertain and decision makers

experts. In the second stage, fuzzy AHP was

might be reluctant or unable to assign crisp values

applied to find the importance degree of each

to the comparison judgments (Chan & Kumar,

criterion as the measurable indices of the

2007; Shyur & Shih, 2006). Having to use crisp

regenerative technologies. They considered eight

values is one of the problematic points in the crisp

kinds of regenerative technologies which have

evaluation process. One reason is that decision-

already been widely used, and established a

makers usually feel more confident to give interval

ranking model that provides decision markers to

judgments rather than expressing their judgments

55


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in the form of single numeric values. As some

competitive and to sustain growth (McNamara and

criteria are difficult to measure by crisp values,

Baden-Fuller, 1999). These firms engage in

they are usually neglected during the evaluation.

various technology management practices, and

Another reason is mathematical models that are

deploy technology strategies and planning in order

based on crisp value. These methods cannot deal

to meet these needs. This is becoming more

with decision-makers’ ambiguities, uncertainties

difficult

and vagueness which cannot be handled by crisp

technologies,

values. The use of Fuzzy set theory (Zadeh, 1965)

abundance of technological options, higher cost of

allows

incorporate

technological development, and rapid diffusion of

incomplete

technologies (see Lei, 2000; Steensma and

the

decision-makers

unquantifiable information;

to

information, non-obtainable

information

and

due

to

increasing

convergence

complexity of

of

technologies,

Fairbank, 1999; Berry and Taggart, 1994). The

partially ignorant facts into decision model (Kulak,

dispersion

Durmusoglu, & Kahraman, 2005). As a result,

organizations,

Fuzzy TOPSIS and its extensions are developed to

countries, and the resulting obscurity, makes the

solve

problems

task of accessing suitable technologies and

(Büyükzkan, Feyzioglu, & Nebol, 2008; Chen &

selection of the most suitable option more difficult

Tsao, 2007; Kahraman, Büyükzkan, & Ates, 2007;

(Cantwell, 1992). Greenberg and Cazoneri (1995)

Onüt & Soner, 2007; Wang & Elhag, 2006; Yong,

and Hackett and Gregory (1990), report that

2006). This study uses triangular Fuzzy number

projects to incorporate new technology, in a

for Fuzzy TOPSIS. The reason for using a

majority of companies, are failing or are not

triangular Fuzzy number is that it is intuitively

fulfilling expectations. Nabseth and Ray (1974) in

easy for the decision-makers to use and calculate.

their study of the European and USA machine tool

In addition, modeling using triangular Fuzzy

companies found that similar problems still remain

numbers has proven to be an effective way for

although

formulating

the

undertaken to study these issues. As Huang and

information available is subjective and imprecise

Mak (1999) explain in their study of 100 British

(Chang, Chung, & Wang, 2007; Chang & Yeh,

manufacturing companies, the failure of a chosen

2002; Kahraman, Beskese, & Ruan, 2004;

technology often results from poor management

Zimmerman, 1996). In practical applications, the

and preparation of the change process. Some of the

triangular form of the membership function is used

causes have been attributed to the inability to

most often for representing Fuzzy numbers (Xu &

consider the wider relationship of technology to

Chen, 2007).

the business and organizational context and

ranking

and

decision

justification

problems

where

of

technology geographical

several

sources locations

investigations

have

across and

been

include these issues in the technology investment NEED FOR A TECHNOLOGY SELECTION

considerations (Schroder and Sohal, 1999). This

METHOD

finding is echoed by Efstathiades et al. (2000) who

Technology based businesses rely on

assert the need for careful assessment of potential

renewal of existing technological resources and

problems before introducing a technology into an

exploitation of new technologies to remain

organization.

56


Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

RESEARCH PURPOSES

various models existing in the area of decision

I.

making with multi-indices, TOPSIS method due to

Identification of indicators regarding cooling

its advantages relative to other method has been

towers II.

Assigning

weight

to

indicators

selected for weight assignment and prioritization.

and

Step 1: formation of Fuzzy Decision Making

prioritizing cooling towers

Matrix in which m alternatives by n indices are assessed. A Fuzzy multi-indicator decision making

RESEARCH METHODOLOGY

matrix is defined as follows.

This research in terms of purpose is of applied type and the research execution method is of descriptive and survey type. The research’s

C1

statistical society includes two parts: the first part

1)

is for identification of cooling towers’ indicators including experts and specialists of cooling towers of Besat Electricity Production Company. Given

~ A1  X11 ~ ~ A X D = 2  21 M  M ~ Am Xm1

C2

L Cn

~ ~ X12 L X1n  ~ ~  X22 L X2n  , i =1,2,...,m, j =1,2,...,n M M M  ~ ~  Xm2 L Xmn

In which, A , A ,..., A represent alternatives, 1 2 m

that the statistical society was a limited society, 32 specialists were selected and the questionnaire was

C , C ,..., C represent 1 2 n

distributed among them. The second part regards weight assignment and prioritization of cooling

indices,

denotes Fuzzy value of the option

towers’ various options in which 5 connoisseurs

and

~ x ij

i in terms

of the index j . Verbal variables and Fuzzy

were questioned.

numbers equivalent to each verbal variable used in this study are presented in table (1).

DATA COLLECTING TOOL In this paper, to collect information with

Table(1)

regard to the research’s theoretical bases and literature, index cards and tables have been used. To gather the data from the 3 used questionnaires (first questionnaire for identification of indices, the two other questionnaires for weight assignment to the indices and prioritization of cooling towers) the validity of which has been confirmed by professors and its stability using Cronbach Alpha was found to be 75% and hence confirmed.

Step 2: Make normalize matrix decision making

DATA ANALYSIS METHOD the

matrix as relation (2) which takes place by means

alternatives, given the determined indicators, it

of relations (3) and (4). Relation (3) is used for

was found that this issue in the field of decision

scale less making of indices with positive aspect

making with multi indices and from among

and relation (4) for scale less making indices with

After

data

collection

for

all

negative aspect. 57


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[ ]

~ (2) R = ~ rij

m× n

v~ ~ (8) v

, i = 1,2,..., m, j = 1,2,..., n

(7)

 aij bij cij  (3) ~ rij =  + , + , + , c +j = max cij c c c   j j j 

v~

 a _j a _j a _j  (4) ~ rij =  , , , a _j = min aij  cij bij aij   

m× n

− j

{( v~ ~ = {(min v

= max

And

ij

ij

v~

) } j ∈ J )i = 1,...., m } j ∈ J i = 1,...., m

ij

takes place in three stages and

using the following relations. Obviously, if at both stages the greatest and smallest Fuzzy numbers are found, there will be no need for other stages.

matrix as relation (5) using relation (6).

[ ]

j

+

ij

Step 3: calculation and make harmonic normalize

~ (5) V = v~ij

+

, i = 1,2,..., m, j = 1,2,...n

Stage 4.1: at this stage, using relation (9) we rank Fuzzy numbers in order to find its greatest and

~ (6) v~ij = ~ rij ⊗ w j

smallest quantity. At this stage, we need to evaluate indices’ weights.

(~ )

(9) S A,0 =

To calculate indices’ weight in this research the suggested method by Wang and Chang (1995) has

a + 2b + c 4

Stage 4.2: if at stage one there are numbers which

been used. For this purpose, five connoisseurs

are placed in one group, or in other words, using

have been asked to determine indices’ importance

relation (9) we cannot determine their smallness or

with verbal variables. To determine importance of

greatness relative to each other, we take their tide

the constituents and the respective weights, the

into consideration and using Fuzzy numbers’ tide

respective verbal variables and Fuzzy numbers

we rank them.

(~ )

suggested by Wang and Chang (1995) have been

(10) mod e A

used. Table 2 shows verbal variables and Fuzzy

Stage 4.3: at third stage, if there are still numbers

numbers. This method has been used by Wang and

which are placed in one group, for their ranking

Chang (1995) and Chen (2000), Wang and Elhag

we consider Fuzzy numbers’ Domain.

(2007) to determine the indices’ weights.

(~ )

(11) A

Table(2)

Stage 5: distance of each alternative is found through positive and negative ideal solution. This is done using relations (12) and (13). (12)

(~

~

)

(13) In which

by taking

and into account as two

triangular Fuzzy numbers it calculated as relation (14). Source: (Wang & Chang, 1995; 2007)

(14)

Step 4: determining positive and negative ideal for

Step 6: calculation of relative closeness of each

each index using relations (7) and (8).

alternative to ideal solution which is done using 58


Scientific Research Journal of India â&#x2014;? Volume: 2, Issue: 2, Year: 2013

Table 2: Closeness of Alternative to the Ideal

relation (15).

Solution

_

(15) cci =

di , i = 1,2,..., m + d i + d i_

Step 7: alternatives ranking; at which the existing alternatives from the hypothetic problem are ranked in ascending order starting from the most important.

RESULT: The questionnaire which had been provided to the statistical society (32 persons) was analyzed

RANKING OF ALTERNATIVES:

and 8 indicators were selected for cooling towers evaluation. Next, 5 connoisseurs were asked to

Table 3: Ranking Based on the Preferred

assign weight to the indices the results of which

Alternatives

are presented in the table below:

Table 1: Weights Indices

Check rank the cooling tower can be seen Tower with a suction fan(A4) rated first and Tower with a blower fan(A3), Tower with normal tension(A5), Tower with a Traction stokehole(A6), Tower with normal tension(A2), Tower with mechanical tension(A1) were next to the stars.

CONCLUSION: Given identification of the identified indices

In this paper, evaluation of level and prioritization

and weigh of each index, now using Fuzzy

of cooling towers technology based on the

TOPSIS method which has been explained in data

specified indices by experts using ranking method

analysis method we prioritize the options. The

based on similarity with ideal answer Fuzzy

following results indicate relative closeness of

TOPSIS was investigated. In most of the existing

each option to the ideal solution.

studies on decision making issue, the issue is supposed in an environment of definitive data but in some cases, it is seen that determination of exact 59


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values for the criteria is difficult and the values

Fuzzy Sets and then based on TOPSIS method

should be considered as Fuzzy values. In this

approach which is a simple method and quickly

paper, we have investigated the existing options in

specifies the required answer, we calculated the

Fuzzy environment and based on the Theory of

closest option to the ideal solution.

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CORRESPONDING AUTHOR: * Department of Accounting, Zahedshahr Branch, Islamic Azad University (IAU), Zahedshar , Iran. ** Corresponding Author: Research Scholar, Thiruvananthapuram, Kerala, India, E mail: mahdinaqdibahar@yahoo.com, Mobile phone: +919623566206 *** Ali Ghani Abadi, Master of Industrial Management

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Scientific Research Journal of India ● Volume: 2, Issue: 2, Year: 2013

CORRECTION NOTICE It is hereby informed to all the readers of Scientific Research Journal of India that the main author of the article entitled “Effect of McConnell Taping on Pain, ROM & Grip Strength in Patients with Triangular Fibrocartilage Complex Injury” published in the Year: 2013, Vol:2, Issue:1 was Babloo Sharma. So kindly read the authors as- Babloo Sharma, Dr. Shahid Mohd. Dar and Dr. R Arunmozhi instead of Dr. Shahid Mohd. Dar, Dr. R Arunmozhi, Babloo Sharma. Thanks for your kind cooperation.

Editor-in-Chief

63


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Scientific research journal of india (SRJI Vol-2 Issue-2 Year-2013)  

SRJI Vol-2 Issue-2 Year-2013

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