Scientific Research Journal of India SRJI Vol-1 No-4 October-December 2012

Volume: 1 » No: 4 » Year: 2012 ISSN » 2277-1700

Scientific Research Journal of India

SRJI an open access journal

Scientific Research Journal of India (SRJI) Dr. L. Sharma Campus, Muhammadabad Gohana Mau, U.P., India. Pin- 276403 | Cont: +91-9320699167, 8822485959, 9305835734 Email: editor.srji@gmail.com | Web: http//www.srji.co.cc

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

1

About Us: Scientific Research Journal of India (SRJI) is the official organ of Dr. L. Sharma Medical Care and Educational Development Society. It was founded by Dr. Krishna N. Sharma. It is funded by the Dr. L. Sharma Medical Care and Educational Development Society. It is a Multidisciplinary, Peer Reviewed, Open Access Journal of science. The intended audiences of this journal are the professionals and students. The scope of journal is broad to cover the recent inventions/discoveries in structural and functional principles of scientific research.

The Journal publishes selected sele original research articles, reviews, short communication and book reviews in the fields of Botany, Zoology, Medical Sciences, Agricultural Sciences, Environmental Sciences, Natural Sciences, Anthropology and any other branch of related sciences.

Frequency: The issues will be regularly published quarterly.

Special Issue: Special issue based on specific themes may be published at the suggestion of the executive committee of Dr. L. Sharma Medical Care and Educational Development Society and the members of editorial of SRJI. Disclaimer: • • •

Information provided on the site is meant to complement and not replace any advice or information from a health professional.

We do not make claims relating to the benefit or performance of a specific medical treatment, commercial product or service.

All the papers published are claimed to be original by the authors. The editors, publisher, and reviewers will not be responsible for plagiarism.

Contact Us: Scientific Research Journal of India, Dr.L.Sharma Campus, Muhammadabad Gohana, Mau, U.P., India. PinPin 276403 Website: http://www.srji.co.cc Email: editor.srji@gmail.com Cont: +91-9320699167, 9320699167, 8822485959, 9305835734

http://www.srji.co.cc

This page is intentionally left blank

Vol.1 â—? No.4 â—? 2012

Scientific Research Journal of India

3

Index

Editorial

Dr. Krishna N. Sharma

5

Comparison of Clinic and Home Based Exercise Programs after Total Knee Arthroplasty: A Pilot Study

Bijender Sindhu, Dr.Manoj Sharma, Dr.Raj K Biraynia

7

Electrical Muscle Stimulation (EMS) Improve Functional Independence in Critically Ill Patients

Dharam Pani Pandey, Dr. Uday Shankar Sharma, Dr. Ram Babu

19

A Comparative Study on Supervised Clinical Exercise versus Home Based Exercise in Primary Unilateral Total Knee Arthroplasty

Bijender Sindhu, Dr.Manoj Sharma, Dr.Raj K Biraynia

Comparison of the Effect of Isometric Exercise of Upper Limb on Vitals between Young Males and Females

Pranjal Parmar

37

Paraplegia with Sacral Pressure ulcer treated by Ultrasound therapy- A Single Case Report

Shanmuga Raju P., Ramalingam P.

50

Arterio-Enteric Fistula: A Case Report

Anil Degaonkar, Nikhil Bhamare, Mandar Tilak

Surgery

57

All-Oxide Solar Cells: The Way of the Future

Akshay Vijay Dongarwar

Chemical Engineering

63

Physiotherapy

27

http://www.srji.co.cc

This page is intentionally left blank

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

5

Editorial Dear Readers, I am very pleased to present the fourth issue of the Scientific Research Journal of India (SRJI) as the next Editor in Chief. This multidisciplinary and open access Journal of science is the official organ of Dr. L. Sharma Medical Care and Educational Development Society. The previous issues had covered three disciplines of science Physiotherapy, Agriculture, Anthropology and Computer science. In this current issue we are covering two new branches of science- Surgery, and Chemical Engineering. I would like to mention that this journal is intended to publish selected original research articles, reviews, short communications and book reviews etc. in the various fields of science like Botany, Zoology, Medical Sciences, Agricultural Sciences, Environmental Sciences, Natural Sciences, Anthropology and any other branch of related sciences and we’ll be more than happy to recognize any of your works in these field too.

Your comments and suggestions are very valuable for us.

Happy Reading.

Regards,

Dr. Krishna N. Sharma Editor in Chief

http://www.srji.co.cc

This page is intentionally left blank

Vol.1 â—? No.4 â—? 2012

Scientific Research Journal of India

7

Comparison of Clinic and Home Based Exercise Programs after Total Knee Arthroplasty: A Pilot Study Bijender Sindhu PhD, PT*, Dr.Manoj Sharma, MBBS, MS(Ortho)**, Dr.Raj K Biraynia, MBBS, D.Ortho***

Abstract: Sixteen patients (mean age, 68+-8 years) having primary total knee arthroplasty were assigned randomly to two rehabilitation programs: (1) clinicbased rehabilitation provided by outpatient physical therapists; or (2) homebased rehabilitation monitored by periodic telephone calls from a physical therapist. Both rehabilitation programs emphasized a common home exercise program. Before surgery, and at discharge and follow up after surgery, no statistically significant differences were observed between the clinic and the home-based groups on any of the following measures: (1) total score on the Knee Society clinical rating scale; (2) total score on the ILOA level of assistance (3) total score on the Goniometry; (4) total score of VAScale. After primary total knee arthroplasty, patients who completed a home exercise program (home-based rehabilitation) performed similarly to patients who completed regular outpatient clinic sessions in addition to the home exercises (clinic-based rehabilitation).

Additional studies need to determine which patients are likely to benefit most from clinic-based rehabilitation programs.

Key Words: Total Knee Arthroplasty, Home Based Exercise Program, Clinic Based Exercise Program

http://www.srji.co.cc

INTRODUCTION The aim of the arthroplasty is to resurface

support

the tibiofemoral joint to allow better

programs, however, typically do not

articulation and to reciprocate normal

require the patient to attend outpatient

kinematics of the knee (Palmer &

clinic sessions or require attendance at a

Cross,2004) Another aim of surgeons is to

minimum number of outpatient sessions,

correct valgus deformity through the

and provide fewer opportunities for

release of lateral structures (Elson &

monitoring

Brenkel,

2006).

common

Although usually developed by and taught

approach

is

parapatellar

to patients by physical therapists, home-

approach. This has been shown to give

based exercises typically are completed

better radiological results, but more pain

independently by the patient at home.

in the short term than the minimally

The populations examined in those studies

invasive

(Chen,

have tended to be younger individuals

2006). Soft tissue and bony alignment can

who otherwise were healthy, and with an

be ensured using the Tensor/ Balancer

interest in returning to work or sporting

system (Winemaker, 2002). The Tensor/

activities or both. The efficacy of clinic-

Balancer

as

and home-based rehabilitation programs is

malalignment can lead to failure of the

particularly important with respect to

operation (Winemaker,2002) Prostheses

elderly patients. Owing to the older age of

consist of a femoral and tibial component.

patients who have total knee arthroplasty,

The femoral or tibial component can be

the likelihood of complicating medical

cemented,

conditions, the serious implications of

The

the

most

medial

mid-vastus

system

approach

is

hybrid

important

(one

component

and

motivation.

or

program

Home-based

modification.

cemented and the other uncemented) or

postoperative

uncemented (Zavadak et al., 1995). The

population,and the medicolegal climate,

type of prosthesis used depends on the

surgeons may be hesitant to prescribe non

surgeons’

is

clinically based rehabilitation programs

important because of time and cost

after hospital discharge. An often used

differences between these service delivery

alternative

settings. Clinic-based programs typically

physical therapy has been having all

are

physical

patients complete a limited number of

therapy clinics, and facilitate monitoring

clinic visits. Another alternative may be a

the

home-based

protocol.This

provided

patient’s

question

by outpatient

progress,

modifying

individual programs, and providing patient

complications

to

mandatory

program,

in

this

outpatient

monitored

via

periodic telephone calls. Monthly phone

Vol.1 ● No.4 ● 2012 calls

by

therapist

Scientific Research Journal of India individuals

were

9

or major neurologic conditions were

associated with increased function in

excluded.

patients

Randomization to Groups

with

osteoarthritis.

Although

caution must be exercised in generalizing

At the time of primary total knee

the findings of their study, home exercise

arthroplasty, 32 patients were assigned

programs developed and monitored by

randomly to two rehabilitation programs

physical therapists via periodic phone

(1) clinic-based rehabilitation provided by

calls may provide an alternative to

outpatient physical therapy clinics; or (2)

mandatory clinic-based programs and to

home-based rehabilitation, monitored by a

requiring a defined number of clinic visits,

physical therapist via periodic telephone

and a means to provide some monitoring

calls.

of patients during the early rehabilitation phase.

Inpatient and Home Exercise.

Familiarization Period

Objective of the Study:

All Objective patients received standard inpatient of the Study:

The purpose of the current study was to

physical therapy twice daily, for 20

compare two rehabilitation programs after

minutes on each occasion. Inpatient

total knee arthroplasty: (1) clinic-based

physical therapy also included instruction

rehabilitation

outpatient

in a series of home exercises to be

physical therapy clinics; and (2) home-

completed daily after discharge, regardless

based

of

delivered

in

rehabilitation monitored

by a

the

patient’s

group

assignment.

physical therapist via periodic telephone

Ambulatory status on the surgical side

calls, on disease-specific, joint-specific,

was weight bearing as tolerated on

and functional outcome measures.

discharge after surgery, at which time the patient progressed to walking with walker.

MATERIAL AND METHODS

Discharge criteria included the ability to

Inclusion and Exclusion Criteria

transfer independently, ambulate more

Patients were selected using the following

than 30 m using walker/crutches, and

criteria: patients having primary unilateral

ascend and descend at least five steps.

total knee arthroplasty as a result of

Medication given at discharge was pain

osteoarthritis, both male and female who

killer, nutrition’s and antibiotics.

had a primary unilateral TKA, age 50-85.

Common Home Exercises (for both

Able

groups)

to

give

independent

informed

consent. Patients with rheumatoid arthritis http://www.srji.co.cc

The common home exercise program was

Group A physical therapist familiar with

that developed for routine total knee

the common home exercises telephoned

arthroplasty rehabilitation at the authors’

each patient in the home-based group at

institution, and consisted of basic (Stage 1)

least two times ask whether the patient

and more advanced (Stage 2) ROM and

was having any problems with the

strengthening

exercises,

exercises.

Each

patient

to

remind

them

of

the

received Stages 1 and 2 booklets, which

importance of completing the exercises,

included written and pictorial descriptions

and to provide advice on wound care, scar

of

educational

treatment, and pain control. During each

information on using ice, controlling

telephone call, which lasted approximately

swelling, walking, and ROM. They were

10 minutes, the patient was asked when

instructed to complete the common home

and how often he or she wished to be

exercises three times daily until their 8-

telephoned in the future. Patients also

week follow up, at which time they were

were provided with a contact telephone

advised to continue the home exercises at

number to call if additional questions

least once daily, indefinitely. Home-Based

arose.

each

exercise

and

Variable Continuous variables: mean (standard deviation) Age (years) Height (cm) Mass (kg) Disease duration (years) Discrete variables: frequency and percent of group (percent) Gender—female Left replacement Contralateral knee involvement Contralateral hip involvement Ipsilateral hip involvement

Clinic-Based (n=16)

HomeBased(n=16)

65.2 (6.9)* 160.2 (9.6) 86.4 (15.6) 9.8 (6.4)

64.6 (7.8) 162.3 (11.1) 85.5 (15.9) 9.2 (7.3)

9 (56.25%) 6 (37.5%) 8 (50%) 3 (18.75%) 1 (6.25%)

5 (31.25%) 3 (18.75%) 6 (37.50%) 1 (6.25%) 0 (0%)

Table 1. Patient Baseline Characteristics for the Clinic- and Home-Based Groups

Clinic-Based Group

In addition to the common home exercises, patients in the clinic-based group were

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

required to attend outpatient physical therapy after discharge to 8 weeks after surgery, for as many as three sessions per

11

Fig 1. The study time-sequence flow chart is shown. Patients in both rehabilitation groups completed the common home exercises daily between Weeks 2 to 8.

week, for approximately 1 hour per session. Outpatient physical therapists were provided with copies of the Stages 1 and 2 exercise booklets, and were asked to use these exercises as the basic component of their rehabilitation program. However, they were not advised that the patient was participating in a study comparing two rehabilitation programs. Therapists were permitted to modify or add exercises, use therapeutic modalities (such as ice, heat, and ultrasound), joint mobilizations, or other

measures

as

they

deemed

appropriate. Patients in the clinic-based group were requested to complete the common home exercises at home only twice on days that they attended clinic

Assessments and Measurements In conjunction with routine orthopaedic clinic evaluations pre surgically, and at discharge, 8 weeks after surgery, patients completed a series of questionnaires and functional

tests

that

required

approximately 1 hour. Throughout the study, these tests were conducted by two experienced testers who were blinded as to the patient’s group assignment, and gave the test results directly to the study coordinator. The following tests were completed: (1) total score on the Knee Society clinical rating scale; (2) total score on the ILOA level of assistance (3) total score on the Gonioetry; (4) total score of VAScale. From a position of maximum

sessions.

extension, the patient slid the heel of the Eligibility

test leg toward the buttocks to a position

Randomization Clinic Based Rehabilitation

Home Based Rehabilitation

Total Knee Arthroplasty Inpatient Physical Therapy Common Home Exercise Hospital Discharge at 5-7 days Atleast 1 telephonic call by therapist

OPD 3 session /week at 1 hour

Stage 2 4 week follow up Instruction common home exrecise

of maximum knee flexion. The knee angle was measured using a goniometer and scored as the average of three repetitions.

Non directional, t tests, and tests of the significance of the difference between two percentages were used to compare the clinic- and home-based groups on pre

Atleast 1 telephonic call by therapist Stage 3 8 week follow up Instruction common home exrecise

OPD 2 session /week at 1 hour

surgical descriptive measures, and to compare the patients who were lost to, or dropped out of the study with those who remained in the study, on baseline http://www.srji.co.cc

measures. Four-way analysis of variance

three times of measurement (before

(ANOVA) were used to examine the

surgery, and discharge and 6 weeks after

following four criterion variables(1) total

surgery). In view of the number of

score on the Knee Society clinical rating

statistical tests computed and to minimize

scale; (2) total score on the ILOA level of

the likelihood of Type 1 or alpha error, the

assistance (3) total score on the Gonioetry;

0.01 level was used to denote statistical

(4) total score of VAScale. After a

significance throughout analyses.

significant F-ratio, the Newman-Keuls technique was used to compare selected

RESULT

means.

Before surgery, no significant differences

Any patients who were removed from

were observed between the clinic- and the

their assigned group by the surgeons for

home based groups on the demographic

reasons related to the surgically treated

variables shown in Table 1, or on any of

knee or medical conditions not related to

the nine criterion measures (p>0.01). No

the surgically treated knee, or who

statistically significant differences were

withdrew consent to participate, were

observed between the patients lost and

encouraged to continue with the home

those who remained in the study (Table 2),

exercises

therapies

or between the patients lost to the two

prescribed, and to continue coming for

groups on the baseline scores for any of

regular follow ups and testing. To take

the four criterion measures, or for age,

into account that some patients were

height, and weight (p>0.01). Length of

removed or otherwise lost from their

stay in the hospital for the patients who

group, but did continue to be tested at

completed the study in their assigned

their regular follow ups, two types of

group was 5.1+-1.5 and 5.2+-1.7 days for

analyses were completed: (1) a per

the

protocol analysis, which included all

respectively. On ANOVA tests, the per

patients who completed the study in their

protocol and the intent to treat analyses

assigned group; and (2) an intent to treat

produced identical results for all nine

analysis, in which all patients were

criterion measures; no treatment, surgeon,

analyzed as having remained in their

or prosthesis-related effects were observed

assigned group, regardless of whether they

(p>0.01), and only the main effect for time

had completed the study in that group.

(averaged over treatment, surgeon) was

Analysis of variance tests were confined

significant

to patients who had full data sets for the

Subsequent analysis of the main effect for

and

any

other

home-

and

clinic-based

(p<0.01)

(Figs

groups,

2,

3).

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

13

time indicated that the scores before

and 8 weeks after surgery (p<0.01),

surgery, at discharge after surgery, and 6

whereas

weeks after surgery differed significantly

significant difference (p>0.01) between

from one another (p<0.01); with one

the pain scores at discharge and 8 weeks,

minor exception. Pain before surgery,

on the per protocol and the intent to treat

measured via Visual analog score, was

analyses.

there

was

no

statistically

significantly greater than that at discharge

Patient Losses

Clinic (n=16)

Patients lost during the inpatient period (before hospital discharge) Medical issues related to the surgically treated knee Withdrawal of consent by the patient Other medical issues Totals Patients lost after hospital discharge (Weeks 2â&#x20AC;&#x201C;52 after surgery) Medical issues related to the surgically treated knee Withdrawal of consent by the patient Other medical issues Total losses

Based

Home (n=16)

2 1 2 5

1 2 1 4

0 0 1 1

1 0 1 2

Based

Table 2. Number of Patients Lost From Each Group and Reason for Loss

DISCUSSION

support available through clinic-based

After primary total knee arthroplasty,

rehabilitation was not advantageous for

patients

the population studied. These findings

who

completed

home-based to

were not confounded by any interactions

clinic-based

with surgeon, type of prosthesis or time

rehabilitation during the first 4 weeks after

since surgery. The current results extend

surgery. That all four criterion measures in

those of previous studies of meniscectomy

the current study produced similar results

5,7,10 and anterior cruciate ligament

for the per protocol and the intent-to-treat

reconstruction1,3,4,11 populations, and

analyses suggests that these findings apply

corroborate a previous retrospective study

across a spectrum of disease-specific,

using a total knee arthroplasty sample.

joint-specific, and functional variables.

Patients who were lost to their assigned

Overall, the additional patient monitoring,

group were not included in the per

adjustment of program, and motivational

protocol analysis, but did raise concerns

rehabilitation patients

who

performed completed

similarly

http://www.srji.co.cc

that the group comparisons may have been

Knee Society Knee Score

affected (Table 2). Comparisons within and

between

groups

indicated

no

differences between patients lost and those remaining. In addition, when patients who had been lost to their assigned group, but continued being tested at their normal

80 70 60 50 40 30 20 10 0

HOME CLINIC

PRE

POST

follow-ups and had complete data sets, were returned to their assigned group for

Visual analog Score

the intent to treat analysis, results were the

25

same as for the perr protocol analysis. For

20

these reasons, patient losses were not

15

considered to have significantly affected

10

the overall results of the current study.

HOME CLINIC

5 0 PRE

Fig 2 Aâ&#x20AC;&#x201C;C. Total scores for the (A) Range of Motion Knee Flexion (B) ILOA level of assistance (C) KSKS knee nee society knee score

POST

Between discharge and 8 weeks, weeks four more patients were removed from the home-based group than from the clinicclinic

Range of Motion (Knee Flexion)

based group forr reasons related to failure

100

of the surgically treated knee to progress

80

(Table 2). These patients then had more

60 40

HOME

intensive outpatient physical therapy than

CLINIC

that provided by the clinic-based based program.

20

Four patients in the clinic-based clinic group

0 PRE

POST

were advised by their eir surgeon to continue clinic-based rehabilitation after Week 12.

ILOA Level of Assistance

Although both groups of patients tended 35 30 25 20 15 10 5 0

to have poorer baseline scores on the majority of objective measures, their HOME CLINIC

scores were not consistently low across the same measures and tended to be b within

PRE

POST

1 standard deviation of the group mean.

The combination of poorer scores plus

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

15

subjective factors such as the patients’

enabled some monitoring of the patient’s

attitudes, motivation, pain tolerance, and

medical status.

home environment were considered in

The major component of the current study

making the decision to remove these

was the common home exercise program,

patients from their assigned group or to

taught

continue

rehabilitation.

hospitalization after surgery and at their 8

Additional studies are needed to document

week follow up. Outpatient clinicians used

psychosocial and demographic variables

this program as the basis for their

to help identify patients who might derive

treatments, and determined the number

greatest

and

clinic-based

benefit

from

clinic-based

to

all

patients

frequency of

during

treatments,

their

which

rehabilitation programs.

averaged 15+-20 sessions; whereas the

The telephone calls to patients in the home

home-based group was monitored by

based group were completed by an

periodic telephone calls from a physical

experienced physical therapist who had

therapist, which averaged 3+-1 calls

been introduced to all of the patients

during the first 8 weeks after hospital

during

The

discharge. At hospital discharge, patients

telephone calls focused on the home

in the home-based group indicated when

exercises and did not introduce any new

they wished to be telephoned, and again

exercises or provide unique treatment

did so during each telephone call. Pilot

guidance beyond that available from

study had indicated that virtually all

similarly experienced therapists. Two

patients

patients

major

arthroplasty had previous experience with

problem ,such as unresolved swelling,

home exercise programs and that the

infection, and deep vein thrombosis, were

majority

identified via the telephone calls and were

contact schedule themselves.

referred to the patient’s physician or

In addition to the phone calls, the follow-

surgeon for treatment. Whether delayed

ups at 4 and 8 weeks after surgery

treatment of these conditions would have

included review of the home exercises.

resulted in major complications is unclear.

That no patients in the home-based group

All of these patients completed the 8 week

requested additional telephone calls after

study in their assigned group. As a result,

4weeks and only three patients in the

the telephone calls received by the home-

clinic-based

based group provided a form of minimally

questions about the home exercises,

supervised

suggests all patients felt competent in

their

inpatient

with

period.

potential

rehabilitation,

which

also

having

primary

preferred

to

group

total

determine

phoned

to

knee

the

ask

http://www.srji.co.cc

doing their home exercises. Although

CONCLUSION

passive ROM was examined by the

The

surgeons at each follow up, active ROM

rehabilitation programs, where the basic

was used to compare groups, to minimize

component of each program was a series

the extent to which pain tolerance and

of common exercises to be completed

motivation may have affected ROM.

independently by all patients at home.

Compliance with the home exercises was

Because these exercises were developed

considered high, with only two patients in

by and taught to the patients by physical

the home-based group and one patient in

therapists, the current study might be

the clinic-based group considered to have

viewed as having compared two means of

been noncompliant at discharge and 4

providing physical therapy services; that is,

after surgery (where compliance was

physical therapy monitored by telephone

defined as completion of the home

calls (home-based) and physical therapy

exercises at least 90% of the time, as per

monitored in person by outpatient physical

exercise

therapists (clinic-based). The current study

log

compliance

booklets).

was

Exercise

discussed

with

the

current

study

compared

two

did not compare physical therapy versus

patients before surgery and at each follow

no

up thereafter. The sample studied was

significant difference in the data of study

limited to elderly patients who agreed to

but there is statistical difference in both

be assigned randomly to one of the two

group. So this pilot studies shows that the

rehabilitation programs. Approximately

group of clinic based rehabilitation after

10% of eligible patients refused to

total knee arthroplasty having more better

participate for this reason. The extent to

prognosis than home based exercise group

which a home exercise program would be

ie. range of motion and functional ability

effective

and pain.

for

patients

with

a

more

physical

therapy.

There

is

no

complicated history, more limited ROM, or less motivation, needs to be determined.

REFERENCES: 1. Beard DJ, Dodd CAF: Home or supervised rehabilitation following anterior

cruciate

reconstruction:

A

controlled trial. J Orthop Sports Phys Ther 27:134â&#x20AC;&#x201C;143, 1998.

ligament randomized

2. 2Bellamy

N,

Buchanan

WW,

Goldsmith CH, Campbell J, Stitt

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

17

LW: Validation study of WOMAC: A health status instrument for measuring patient

clinically

relevant

antirheumatic

important

outcomes

drug

therapy

7. Jokl P, Stull PA, Lynch JK, Vaughan V: Independent home

to

exercise

versus

in

rehabilitation

supervised following

patients with osteoarthritis of hip

arthroscopic

knee

surgery:

or knee. J Rheumatol 15:1833–

prospective

randomized

1840, 1988.

Arthroscopy 5:298–305, 1989.

A

trial.

3. De Carlo MS, Sell KE: The effects

8. Mahomed NN, Koo See Lin MJ,

of the number and frequency of

Levesque L, Lan S, Bogoch ER:

physical therapy treatments on

Determinants and outcomes of

selected outcomes of treatment in

inpatient

patients

rehabilitation following elective

with

anterior cruciate

and

versus

knee

home-based

ligament reconstruction. J Orthop

hip

replacement.

Sports Phys Ther 26:332–339,

Rheumatol 27:1753–1758,2000.

J

1997.

9. Rene J, Weinberge M, Mazzuca 4. Fischer DA, Tewes DP, Boyd JL,

SA,

Brandt

KD,

Katz

BP:

et al: Home based rehabilitation

Reduction of joint pain in patients

for

anterior

cruciate

ligament

with knee osteoarthritis who have

Clin

Orthop

received monthly telephone calls

reconstruction.

from lay personnel and whose

347:194–199, 1998.

medical treatment regimens have 5. Forster DP, Frost CEB: Costeffectiveness physiotherapy

of

outpatient

after

remained stable. Arthritis Rheum 35:511–515, 1992.

medial

menisectomy. BMJ 284:485–487,

10. Seymour N: The effectiveness of physiotherapy

1982.

after

medial

menisectomy. Br J Surg 56:518– 6. Insall JN, Dorr L, Scott RD, Scott WN:

Rationale

of

the

Knee

Society clinical rating system. Clin Orthop 248:13–14, 1989.

520, 1969.

11. Treacy SH, Baron OA, Brunet ME, Barrack RL: Assessing the need http://www.srji.co.cc

for

extensive

supervised

12. Ware JE, Sherbourne CD: The

following

Medical Outcomes Study Short

arthroscopic reconstruction. Am J

Form (SF-36). Med Care 3:473,

Orthop 26:25â&#x20AC;&#x201C;29, 1997.

1992. Clinical Orthopaedics 234

rehabilitation

Kramer et al and Related Research

ACKNOWLEDGMENT: The authors thank Dharam Pandey (MPT-neuro), Deepa Dabas (MSc-psycho) for assistance throughout the study.

CORRESPONDENCE: *Bijender Sindhu PhD,PT Research Student**Dr.Manoj Sharma, MBBS, MS(ortho)***Dr.Raj k Biraynia, MBBS, D.ortho *School of Physical Therapy, Faculty of Medical Science, Singhania University**Department of orthopedic surgery, Jaipur Golden Hospital *** Department of orthopedic surgery, Sarvodaya Multispeciality Hospital. This study was not funded through a grant from the any organization.

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

19

Electrical Muscle Stimulation (EMS) Improve Functional Independence in Critically Ill Patients Dharam Pani Pandey PT*, Dr. Uday Shankar Sharma**,Dr. Ram Babu*** Abstract: Objective. This study was designed to investigate the effects of electrical muscle stimulation (EMS) on strength of muscle groups stimulated and improvement in functional independence in critically ill patients .Methods. 134 subjects were recruited among the patient admitted in multidisciplinary intensive care units and randomly divided in to control and EMS group. Patients unable to understand or speak English and or Hindi due to language barrier or cognitive impairment prior to admission, unable to transfer from bed to chair at baseline prior to hospital admission, Patient with known history of primary systemic neuromuscular disease were excluded from study. Results. EMS group patients achieved higher MRC scores than controls in knee extensors and ankle dorsiflexors. Independence level was higher in EMS group Conclusions. EMS application constitutes a promising means of muscle strength preservation and early mobilization which can directly reflects the gain in functional independence post ICU discharge in critically ill patients.

Key words: Electrical muscle stimulation, muscle strength, CIPNM, CIM, functional independence

INTRODUCTION Weakness that is hospitalization

for

acquired critical

during

illness

is

critically ill patients1–3 and are associated with increased morbidity and mortality.4,5

increasingly recognized as common and

Critical

important clinical problem. Weakness

(CIPNM) is an acquired neuromuscular

acquired in the intensive care unit (ICU)

disorder observed in survivors of acute

and

critical illness. It is characterized by

related

acquired

neuromuscular

dysfunction occur in a large percentage of

profound

illness

polyneuromyopathy

muscle

weakness

and

http://www.srji.co.cc

diminished

or

absent

deep

tendon

The

objective

of

this

study is

to

reflexes1 and is associated with delayed

investigate

weaning from mechanical ventilation2

stimulation

suggesting a possible relation between

functional independence in critically ill

limb

patients.

and

respiratory

neuromuscular

whether

electrical

muscle

will

improve

(EMS)

involvement. In addition, the syndrome is associated with prolonged hospitalization and increased mortality.3 The diagnosis of CIPNM requires a reliable eliable bedside muscle strength examination and depends on patient's cooperation and maximal effort.4 Several risk factors have been identified including systemic inflammatory response and

sepsis5,

medications

corticosteroids6

and

such

as

neuromuscular

7

blocking agents , inadequate glycemic control8,

hypoalbuminemia9, bacteremia9

immobility4,

protracted

and

Gram--negative severity

of

organ

Our experimental Hypothesis was that â&#x20AC;&#x153;EMS would beneficially affect muscle

dysfunction.10 Thus, looking for the

functional

status

and

will

improve

potentially reversible risk factors and

functional independence in critically ill

subsequent adjustment of therapy are so

patients.

far advocated as preventive measures to decrease the risk of CIPNM.

MATERIAL AND METHODS

A very few of studies available suggesting

Subjects:

the treatment and prevention of critical illness myopathy these includes intensive insulin therapy, optimal gycemic control and minimized use of neuromuscular uromuscular blocking agents, high dose and prolong use of corticosteroids.

The 134 subjects were recruited among the patient admitted inn multidisciplinary intensive care units during the study period.

Exclusion criteria: Unable to understand or speak English and or Hindi due to language barrier or

OBJECTIVE OF THE STUDY

cognitive impairment prior to admission, unable to independently transfer from bed

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

21

to chair at baseline prior to hospital

EMS was implemented on knee extensors,

admission (based on detail history taken

tibialis

from caregivers. Patient with known

extremities.

history

systemic

sessions. After skin cleaning, rectangular

neuromuscular disease, vascular events,

electrodes (90 × 50 mm) were placed on

organ transplant, intracranial process that

motor point of targeted muscle. The

is associated with localizing weakness,

stimulator (Unistim, HMS medical system)

transferred from another ICU after >2

delivered biphasic, symmetric impulses of

consecutive

days

mechanical

50 Hz, 100 µsec pulse duration, 12

ventilation,

amputation

of

lower

seconds at intensities able to cause visible

extremities, any limitation of life support,

contractions. The duration of the session

pregnancy, age under 18 years, obesity,

was 30 minutes each muscle group. EMS

technical obstacles that did not allow the

sessions

implementation of EMS such as bone

discharge, both group were getting routine

fractures, skin lesions and, end-stage

physiotherapy

malignancy were excluded from our study

movements, active assisted movements

Design of study:

and chest physiotherapy.

The study employed a randomized single

Outcome Measures:

blind controlled experimental study design

Primary Outcome Measures were the

consisting of two group experimental

score of barthel index, it is reliable and

group and control group, Subjects were

valid outcome measure used to assess

randomly assigned ether to experimental

functional independence.

group or to control group everyday the

Secondary Outcome Measures were lower

ICU patient admission register were

extremity strength, at ICU discharge, of 2

observed and with in 24 hour the

bilateral muscle groups which were

assessment were done , each time when a

stimulated

patient met the criteria for inclusion a

composite Medical Research Council

random number were picked up between 1

(MRC) score.

of

primary

of

anterior and

of both

lower

received

daily

Patients

were

continued

included

until

the

ICU

passive

measured by MMT using a

to 10 using sealed envelope method if it were an odd number than the subject were

DATA ANALYSIS AND RESULTS

assigned to experimental group similarly

All continuous variables were presented

if it even number were obtained the

by mean. The statistical significance of P

subjects were assigned to control group.

value was set at 0.05. One-way repeated

Intervention:

measures analysis of variance (ANOVA) http://www.srji.co.cc

was made to compare MRC Grading and barthel index score between-group. group. Two hundred and thirty-eight eight patients were admitted to our multidisciplinary ICU during the eight-month month study period and 104 patients fulfilled the exclusion criteria or stayed in the ICU less than 48 hours.

The study population consisted of 134 patients of which of these hese patients, 70

Graph 1: Showing the mean and significance level of two group of left and right knee extensor.

were randomly assigned to the EMS group and 64 to the control group. 6 patients from EMS group and 1 patient from control died or were discharged from the ICU before the second measurement.

MRC muscle grading score of muscle group being stimulated were for left knee extensors were control group mean 3.49 and EMS group mean 3.91 (p = 0.0187), right knee extensors control group mean 3.69 and EMS group mean 3.87 0.0387). left ankle dorsiflexors

Graph 2: Showing the mean and significance level of two group of left and right ankle dorsiflexors.

(p = control

group mean 3.78 and EMS group mean m 3.91 (p = 0.04), right ankle dorsiflexors were observed as follows mean control group mean 3.37 and EMS group mean 3.3.46 (p = 0.0587) found.

Barthel index score of control group was (mean) 68.6 and EMS group (mean) 71.9 and found significant between een groups (p =

Graph 3: Showing the mean and significance level functional independence level as assessed on barthel index.

0.010).

DISCUSSION The main finding of our randomized controlled study is that EMS of lower extremities seems to preserve the muscle

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

23

strength of critically ill patients as

specific health status.18 Recently, an study

assessed with MRC muscle strength

identified an acute systemic effect exerted

grading system. EMS of lower extremities

by EMS on peripheral microcirculation of

applied to critically ill patients upon

critically ill patients.19 Specifically, after

admission is associated with a lesser

performing a 45-minute session of EMS

degree of muscle strength loss of these

on the lower extremities, an improvement

patients as assessed with MRC muscle

in the microcirculation of the thenar

strength grading system. barthel index

muscle as assessed by near infrared

score were higher in EMS group and the

spectroscopy technique was observed.

patient

EMS, as a possible substitute to aerobic

of

EMS

group

were

more

independent.

and resistance exercise training in severe

Electrical stimulation has been used to

CHF and COPD patients, has been shown

increase

in

to improve muscle performance, aerobic

partially and fully paralyzed muscle. It has

exercise capacity, and disease-specific

been used for peroneal nerve stimulation10,

health status.9-11

11

strength

and

endurance

the restoration of shoulder movement12,

recovery of tendonesis grip13, and in the

CONCLUSIONS

prosthesis.14

EMS exercise induces beneficial effects in

Electrical muscle stimulation (EMS) has

muscle strength of ICU patients. These

been used as an alternative to active

effects mainly concern muscle groups

exercise in patients with chronic heart

directly stimulated, but there is also

failure (CHF)15 and chronic obstructive

evidence of effects in muscle groups not

pulmonary disease (COPD).16, 17 Many of

stimulated. EMS application constitutes a

these patients, even those who are

promising means of muscle strength

clinically unstable,

experience severe

preservation and early mobilization which

dyspnea on exertion, which can prohibit

can directly reflects the gain in functional

the regular application of conventional

independence post ICU discharge in

exercise training, considered necessary for

critically ill patients.

an integrated therapeutic approach. In a

Clinical relevance & limitation

recent

EMS

EMS is an alternative method of exercise

implementation in most of the selected

causing minimal discomfort to patients

controlled

clinical

produced

who are not able to perform any form of

significant

improvements

muscle

physical exercise, as is often the case in

strength, exercise capacity and disease-

critically ill patients. It is a limitation of

use

of

an

upper

systematic

arm

review,

trials in

http://www.srji.co.cc

this study that it did not evaluated the

discharge

with

longer

follow up stage and upper extremities

evaluation, the muscle properties and

function. Further studies are needed to

preventing CIPNM in critically ill patients

explore the possible role of EMS as a tool

and to define which patients would benefit

for preserving the muscle strength and

most

from

follow

this

up

intervention.

gain in functional independence post ICU

REFERENCES: Sharshar

T,

4. Garnacho-Montero J, Madrazo-

Authier

FJ,

Osuna J, Garcia-Garmendia JL,

Durand-Zaleski I, Boussarsar M, et

Ortiz- Leyba C, Jimenez-Jimenez

al; Groupe de Reflexion et d’Etude

FJ, Barrero-Almodovar A, et al.

des

Critical

1. De

Jonghe

Lefaucheur

B, JP,

Neuromyopathies

en

illness

Reanimation. Paresis acquired in

risk

the

a

consequences: a cohort study in

study.

septic patients. Intensive Care Med

intensive

prospective

care

unit:

multicenter

JAMA 2002;288(22):2859–2867.

2. De Letter MA, Schmitz PI, Visser

factors

polyneuropathy: and

clinical

2001;27(8): 1288–1296.

5. Spitzer AR, Giancarlo T, Maher L,

LH, Verheul FA, Schellens RL,

Awerbuch

Op de Coul DA, van der Meche

Neuromuscular

FG.

the

prolonged ventilator dependency.

development of polyneuropathy

Muscle Nerve 1992;15(6):682–686.

Risk

factors

for

G,

Bowles

A.

causes

of

and myopathy in critically ill patients.

Crit

Care

Med

Hathaway SJ, Angus E, Beis S,

2001;29(12):2281–2286.

3. Coakley

JH,

Nagendran

6. Rudis MI, Guslits BJ, Peterson EL,

K,

Zarowitz BJ. Economic impact of

Yarwood GD, Honavar M, Hinds

prolonged

CJ. Patterns of neurophysiological

complicating

abnormality in prolonged critical

blockade in the intensive care unit.

illness.

Crit Care Med 1996;24(10):1749–

Intensive

1998;24(8):801–807.

Care

Med

1756.

motor

weakness

neuromuscular

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

7. Latronico N, Peli E, Botteri M. Critical

illness

myopathy

and

25

Anesthesiology 2004;101(3):583– 590.

neuropathy. Curr Opin Crit Care 12. MacFarlane IA, Rosenthal FD.

2005;11(2):126–132.

Severe 8. Bednarik J, Lukas Z, Vondracek P. Critical illness polyneuromyopathy: the

myopathy

asthmaticus

after

(letter).

status Lancet

1977;2(8038):615.

electrophysiological

components of a complex entity.

Intensive

Care

Med

13. Witt NJ, Zochodne DW, Bolton CF, Grand’Maison F, Wells G, Young GB, Sibbald WJ. Peripheral

2003;29(9):1505–1514.

nerve function 9. Van den Berghe G, Wouters P, Weekers

F,

Verwaest

C,

multiple

organ

in

sepsis

failure.

and Chest

1991;99(1):176–184.

Bruyninckx F, Schetz M, et al.

Intensive insulin therapy in the

14. Knox

AJ,

Mascie-Taylor

BH,

critically ill patients. N Engl J Med

Muers MF. Acute hydrocortisone

2001;345(19):1359–1367.

myopathy in acute severe asthma.

Thorax 1986;41(5):411–412.

10. Tennila A, Salmi T, Pettila V, Roine RO, Varpula T, Takkunen O. Early signs of critical illness polyneuropathy in ICU patients with

systemic

response

inflammatory

syndrome

Intensive

Care

or

sepsis.

Med

11. Rabuel C, Renaud E, Brealey D, Ratajczak P, Damy T, Alves A, et Human

induction

septic of

Jakob H, Thiele R, Hacke W. Predominant involvement of motor fibres in patients with critical illness

polyneuropathy.

Br

J

Anaesth 1997;78(3):274–278.

2000;26(9):1360–1363.

al.

15. Hund E, Genzwurker H, Bohrer H,

myopathy:

cyclooxygenase,

heme oxygenase and activation of the ubiquitin proteolytic pathway.

16. Thiele RI, Jakob H, Hund E, Tantzky S, Keller S, Kamler M, et al.

Sepsis

and

catecholamine

support are the major risk factors for critical illness polyneuropathy after open heart surgery. Thorac http://www.srji.co.cc

Cardiovasc Surg 2000;48(3):145–

in septic patients. Crit Care Med

150.

2005;33(2):349–354.

17. Garnacho-MonteroJ, Amaya-Villar R, Garcia-Garmendia JL,Madrazo-

18. Bolton

CF.

Sepsis

and

the

Osuna J, Ortiz-Leyba C. Effect of

systemic inflammatory response

critical illness polyneuropathy on

syndrome:

the withdrawal from mechanical

manifestations. Crit Care Med

ventilation and the length of stay

1996;24(8): 1408–1416.

neuromuscular

ACKNOWLEDGMENT: We would like also to acknowledge the support of all intensive care unit staff, consultants and all the patients caregivers.

CORRESPONDENCE: *Department Of Physiotherapy & Rehabilitation,BLK Super Speciality Hospital, Pusa Road, New Delhi, India. **Sr. Consultant Neurologist, Department of Neurology, Jaipur Golden Hospital,2 institutional area, sector 3, Rohini, New Delhi, India. ***Sr. Consultant Physician, Department of Internal, Medicine, Jaipur Golden Hospital,2 institutional area, sector 3, Rohini, New Delhi, India.

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

27

A Comparative Study on Supervised Clinical Exercise versus Home Based Exercise in Primary Unilateral Total Knee Arthroplasty Bijender Sindhu PhD, PT*, Dr.Manoj Sharma, MBBS, MS(Ortho)**, Dr.Raj K Biraynia, MBBS, D.Ortho***

Abstract: Objective. This study was designed to investigate the effects of supervised clinical exercise and home Based Exercise in patient with unilateral total knee arthroplasty in sub acute phase (after 5-6 weeks of discharge). To assess the effect on function ability of patient after primary unilateral total knee arthroplasty. To assess the effect on knee integrity (it include pain, ROM, knee stability)of patient after primary unilateral total knee arthroplasty. Methods. 130 subjects were recruited from OPD physiotherapy among the patient discharge from hospital and randomly divided into supervised clinic exercise and home based exercise. Socio demographic and clinical data, pain, range of movement (ROM) and function of TKA patients were collected on day of discharge (ie day 5 to 8 post operation). A self designed data capture sheet, the goniometer, VAS (Visual Analogue Scale) and ILOA (Iowa Level of Assistance) KSKS (kne society knee score)were used to measure data. Criteria for recruitment is patient having primary unilateral total knee replacement, having a functional hip on operated side, both male and female and age between 50 to 80 years. Able to follow simple verbal commands. Patient excluded from study who are suffering from Rheumatoid Arthritis, revision TKA, bilateral knee arthroplasty. Results. The results indicate that there is significant difference between experimental group (supervised clinical exercise) and Control group (home based exercise). For knee integrity measured using the Knee Society Knee Score (p=0.017)and function measured using the ILOA Scale (p= 0.018) and goniometry (p=>0.05). The average age was 64 years in male and 66 years in females . There were 41% males and 59% females. There is statistical difference between pain, range of motion, Knee integrity, Knee functional outcomes of groups that receive post-

http://www.srji.co.cc

discharge outpatient physiotherapy as compared to those who do not attend physiotherapy. Conclusions. After primary total knee arthroplasty, patients who completed a home based exercise program (control group) performed similarly to patients who completed regular outpatient clinic sessions in addition to the home exercises (supervised clinic exercise ie. experimental group). Additional studies need to determine which patients are likely to benefit most from clinic-based rehabilitation programs. The overall aim of this study was to establish the early post operative status of Total knee arthroplasty patient.

Key words: Supervised clinical exercise, Home based exercise, KSKS (knee society knee score), ILOA (ILOA level of assistance)

INTRODUCTION Osteoarthritis is a leading cause of pain

aims to minimize the complications

and disability affecting joints (Marchet al

following total knee replacements and to

1999). Progressive loss of the articular

rehabilitate the patient to full functional

cartilage can result in joints that are

recovery. Techniques such as cryotherapy,

painful and inflamed. The joint becomes

strengthening and stretching exercises are

stiffer and there is less stability in the joint

used (Zavadak et al 1995). Physiotherapy

(Parmet et al 2003). These factors affect

in

the function of the joint which ultimately

techniques such as bed mobility, transfers,

impacts on patientsâ&#x20AC;&#x2122; functional ability and

ambulation

their quality of life (March et al 1999).

assumption can be made that if there is a

Total knee arthroplasty has been found to

relationship between knee integrity and

be effective in the management of pain

function, physiotherapists may decide to

(Palmer & Cross, 2004), functional status

only work on improving function, or only

and quality of life in people suffering from

work

OA, rheumatoid arthritis (RA) and related

(improving

conditions (Zavadak et al., 1995).

reducing swelling, reducing pain and

Physiotherapists contractures

aim

(Lenssen

to et

al.,

hospital

on

also

and

includes

stair

improving knee

functional

climbing.

knee

range

of

An

integrity motion,

prevent

improving muscle strength). Time could

2006)

then be better utilized on one aspect of

decrease pain and swelling and improve

rehabilitation.

knee

in

Early discharge can sometimes result in

preparation for discharge (Oldmeadow et

transfer to an inpatient facility. A study by

al.,2002. Post operative physiotherapy

Bozic et al. (2006), states that clinical,

and

functional

mobility

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India who

29

demographic and socioeconomic factors

operation

gave

informed

all affect the decision to discharge a

constant).Able to follow simple verbal

patient to an inpatient rehabilitation centre.

commands

Objective of the Study: To assess the effect on knee integrity (it

Exclusion criteria:

include pain, ROM and knee stability) and

Any additional trauma to the lower limb,

knee

establish

inability to participate in the assessment

pain,ROM of the operated knee and

from a physical and cognitive point of

functional level of TKA patients. To

view such as dementia, confusion etc.

establish socio-demographic factors and

Inability of the patient to walk prior to the

clinical data of TKA patients on first

TKA(with

or

follow up. To establish the relationship

suffering

from

amongst supervised clinical exercise as

Unwillingness

well

and

assessments Revision TKA, Bilateral knee

postoperative functional status of TKA

arthroplasty. Inability of the patients to

patients. To study this procedure can be

walk prior to the total knee replacement

clinically implemented.

(with or without the aid of an assistive

function

as

ability.

home

based

To

exercise

without

aid).

Rheumatoid to

participate

Patient Arthritis. in

the

device).

MATERIAL AND METHODS Subjects: 130 subjects were recruited

Design of study:

from OPD physiotherapy among the

The study employed a randomized single

patient

and

blind controlled experimental study design

randomly divided into supervised clinic

consisting of two group experimental

exercise and home based exercise.

group and control group, Subjects were

discharge

from

hospital

randomly assigned either to experimental Inclusion criteria:

group or to control group everyday in

Patient having primary unilateral total

physiotherapy OPD before discharge ,

knee replacement having a functional hip

each time when a patient met the criteria

on operated side .Both male and female

for inclusion a random number were

who had a primary unilateral TKA able to

picked up between 1 to 10 using sealed

give independent informed consent Patient

envelope method if it were an odd number

between the age of 50 to 80 years of age,

than

presented to the first follow-up session.

experimental group.

the

subject

were

assigned

to

(This was around six to eight weeks post http://www.srji.co.cc

Intervention

assistive devices and appliance, walking

Supervised clinical exercise: These are

pattern, safety & precaution, doâ&#x20AC;&#x2122;s and

exercise which are perfomed by patient

dontâ&#x20AC;&#x2122;s.

under the observation of a qualified physiotherapist.

Postoperative

Outcome Measures:

rehabilitation usually consists of passive

ILOA : The patientsâ&#x20AC;&#x2122; functional ability

and active knee mobilisation, quadriceps

was assessed using the Iowa Level of

strengthening and functional activities

Assistance (ILOA) Scale, which was first

(Lenssen et al., 2006). Hip and knee

described by Shields et al (1995). It was

flexion; hip and knee extension in neutral;

shown to be reliable and valid.The best

hip abduction; hip adduction to neutral;

overall result the patient is able to achieve

ankle dorsi- and plantar flexion,

static

with this scale is zero. This indicates that

quadriceps contraction and inner range

the patient was able to perform all five

quadriceps contraction over a rolled up

tasks independently without the use of any

towel. The physiotherapist performs anti-

assistive device. The worst overall score

inflammatory modalities on the patient

that could be achieved is fifty which

which include ultrasound, interferential

indicates that the patient was unable to

therapy, pulsed short wave diathermy,

perform the tasks due to medical and

transcutaneous electrical nerve stimulation

safety reasons and the assistive device

(TENS), laser, acutouch and heat or

used for standing or mobilizing was a

cryotherapy.

walking frame.

Myofascial

release,

continuous passive mobilisation exercises,

KSKS: This rating system was developed

stretching, strengthening exercises, gait

in 1989 by the American Knee Society to

re-training, massage, patient education

provide an evaluation form for knee

and an exercise programme are also

integrity (Insall et al, 1989). The knee

prescribed.

assessment has three parameters which

Home based exercise: Home based

measure pain, stability and range of

exercise group performed the exercise

motion. The knee is given a score out of a

which are explained and demonstrated by

hundred. A well-aligned knee with no pain,

physiotherapist in OPD at the time of

negligible instability and range of motion

discharge to the patient for home, which

of 125 degrees scores a hundred points

included

for

Goniometry: It is a measuring tool used to

motion,

assess the range of motion of a joint. It

strengthening exercise, effective use of

can be used as an initial assessment and it

quadriceps,

isometric knee

exercises

range

of

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

31

evaluate the patient’s progress (Rothstein

TKA patients, Knee integrity and Socio-

et al 1983). Rothstein et al (1983) assessed

demographic factors and clinical data of

goniometric

TKA patients, The relationship between

reliability

and

which

goniometer size was the most reliable in a

identified

factors

and

postoperative

clinical setting.

functional status of TKA patients in relevance of level of assistance (ILOA) in

DATA ANALYSIS AND RESULTS

control group mean (home based exercise)

All continuous variables were presented

is11.94

by mean. The statistical significance of P

(supervised clinical exercise) 10.01 (p=

value was set at 0.05.

0.018), KSKS in control group mean

One-way repeated measures analysis of

(home

variance (ANOVA) was made to compare

experimental group (supervised clinical

ILOA score, KSKS score, Goniometry

exercise) 76.78 (p=0.017), goniometry in

range between-groups.

control group mean (home based exercise)

130 subjects were recruited from OPD

is

physiotherapy

(supervised

among

the

patient

discharge from hospital and randomly

patients due to prolonged hospital stay for medical reasons, two patients for medical

demographic

and

exercise)

is74.72

experimental

clinical

group

exercise)

and

group 95.52

ROM Knee Flexion

conditions, two patient consented to the socio

and

experimental

(p=>0.05) found.

ROM )in degtree)

fulfilled the inclusion criteria and four

based

88.06

divided into supervised clinic exercise and home based exercise. 19 patients not

and

150.

100.

50.

0. pre

post

Home

30.46

88.06

Super

28.86

95.52

clinical

questionnaire, but not to the goniometry and Iowa Level of Assistance (ILOA) testing, and therefore had to be excluded.

Graph 1: Showing the mean and significance level of range of motion of two group of supervised and home based exercise.

One patient refused to be tested · two

40.

30.

researcher had been able to collect data (morning of day three).

The following results are presented: Range of movement (ROM) of the

Level of assistence

patient had been discharged before the

ILOA

20.

10.

0. pre

post

Home

33.9

11.94

Super

32.9

10.1

operated knee and functional level of http://www.srji.co.cc

Graph 2: Showing the mean and significance level of IOLA(level of assistance) of two group of supervised and home based exercise.

been shown to reduce pain in patients at intervals of 24-hours, 48-hours, 72- hours and at one to eight weeks post operation

Knee integrity & function

(Hubbard and Denegar 2004; Jensen et al

KSKS

100.

1985; Jarit et al 2003).

2: Range of motion: People normally

50.

require knee flexion of 45º to 105º during

0. pre

post

various activities of daily living. To

Home

18.16

74.72

demonstrate a normal gait pattern, 65º of

Super

18.52

76.78

Graph 3: Showing the mean and significance level of KSKS (knee society knee score) of two group of supervised and home based exercise.

KSKS: 1. Pain: Fifty percent of the patients had virtually no pain at six weeks post operation. The other fifty percent had pain that ranged from occasional to severe pain Two patients (4%) had severe pain.

This indicates that the patients’ pain is not being managed well at home after discharge. They are perhaps not given modalities

which

are

healing in reducing pain. Cryotherapy and simultaneous exercise is more effective in reducing pain than icing alone. Icing and compression also helps to reduce pain in patients post surgery. Transcutaneous Electrical

stairs, 90º of flexion is needed and to go from sitting to standing, 105º of flexion is required (Miner et al 2003). From the results of the range of movement shows

DISCUSSION

physiotherapy

flexion is required. To ascend and descend

Nerve

Stimulation

(TENS)

causes a reduction of pain in 93% of patients who undergo surgery and the TENS group of patients consumed less pain medication. Interferential therapy has

that experimental group (mean=95.52) and control group (mean=88.06), one can assume that 51% of the patients (twenty six patients) would not be able to go from sitting to standing as they only had knee flexion of 80º. However, from our sample of 50-patients, 24-patients (49%) who had 90º-100 of knee flexion were able to go from sitting to standing independently without any assistance or assistive devices.

Patients with less than 95º of knee flexion had worse Goniometry scores (p<.0001).

Only patients with a very stiff knee will have function that is really affected by ROM. Their study identified 95º of knee flexion as a clinically meaningful cut-off point above which ROM does not limit a patient’s normal activities after TKR. However the long-term effects of this limitation of ROM could be detrimental to

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

33

the normal joints, because of the patients

this range of motion, the patient should

over

manage

compensation

when

performing

functionally.

Patients

also

activities of daily living.

compensate when performing activities by

3. Knee Stability and alignment: The

using the other leg or their arms to assist

majority of the patients had normal

with

stability and alignment. This indicates that

movement

the total score of the Knee Society Knee

important to the patient, what is of

Score in this sample is not really affected

importance is completing the movement

by the components of stability and

by any means possible. The long term

alignment, but mainly by pain and ROM.

effect of poor ROM and poor quality of

Malalignment of the prosthesis could

movement is that the normal joints take

result

although

excess strain and over a prolonged period,

uncommon is a disabling problem (Jerosh

there is an increased risk of developing

and Aldawoudy 2007). Treatment of

pain and discomfort in the normal joints

malalignment could include manipulation

due to osteoarthritis.

or revision arthroplasty (Bong and Di

ILOA Score:

Cesare 2004),which has been shown to be

Most of the patients were able to go from

successful in terms of post-operative

lying to sitting, sitting to standing and

function(Miner et al 2003).

walking 4.57 meters independently, with

4. Knee Flexion contracture and extension

minimal assistance. The patients scored

lag: A percentage of the patients in this

very well in these three categories. This

study had some degree of a flexion

indicates that the ILOA Scale is not a

contracture and some degree of an

sensitive enough functional measuring

extension lag at six weeks post operation.

tool when used at six weeks post operation.

This could indicate that attaining full knee

It measures basic functional ability, not

extension and flexion is not that important

higher function. It was developed to

when it comes to functional activities such

determine whether patients who had had

as going from sitting to standing, walking

total hip and knee replacements were

and stair climbing, as these same patients

ready to be discharged from hospital

performed well when assessed using the

(Shield et al 1995). It is the role of

ILOA Scale. Functional range of motion is

physiotherapists in the hospital to ensure

between 45º and 105º (Miner et al 2003).

that patients are able to perform basic

As long as the extension lag and the

transfers so that they will be independent

flexion contracture do not interfere with

at home, after they are discharged from

in

stiffness

which

transfers.

The

being

quality

of

the

performed

is

not

http://www.srji.co.cc

hospital. Five patient did not use an

therapist with knowledge of their acute

assistive device to perform the five

postoperative

status

functional tasks. She did however require

rehabilitation

programme

nearby supervision for the walking, stairs

influence their prognosis. integrity which

and the speed test. Two patients used a

was measured using the Knee Society

walking frame at six weeks after the

Knee Score and function as measured

operation. Only one patient was unable to

using the ILOA Scale, six to eight weeks

climb the stairs even with maximal

post surgery on total knee replacement.

assistance

Research Recommendations:

and

appropriate that

will

A functional tool should be developed that CONCLUSIONS

assesses

the

The goal of a TKA is to provide the

functional milestones, as well as the

patient with a stable and painless knee

quality of the movement. If a more

with sufficient ROM to perform ADL’s

sensitive functional assessment tool was

(Gandhi et al., 2006). As many studies

used, one that looked at higher functional

only focused on the long-term status of

levels,

TKA patients (Aarons et al., 1996), this

evaluation of the knee replacement could

study examined the short-term status. The

be determined.

a

attainment

more

of

accurate

higher

functional

value of this is to furnish patients and the

REFERENCES: 1.

De

Jonghe

B,

Sharshar

T,

polyneuropathy

and

myopathy

in

Lefaucheur JP, Authier FJ, Durand-

critically ill patients. Crit Care Med

Zaleski I, Boussarsar M, et al; Groupe

2001;29(12):2281–2286.

de

Reflexion

Neuromyopathies

et

d’Etude

en

des

Reanimation.

3.

Coakley

JH,

Nagendran

K,

Paresis acquired in the intensive care

Yarwood GD, Honavar M, Hinds CJ.

unit: a prospective multicenter study.

Patterns

JAMA 2002;288(22):2859–2867.

abnormality illness.

2. de Letter MA, Schmitz PI, Visser

of in

neurophysiological prolonged

Intensive

Care

critical Med

1998;24(8):801–807.

LH, Verheul FA, Schellens RL, Op de Coul DA, van der Meche FG. Risk

4. Garnacho-Montero J, Madrazo-

factors

Osuna J, Garcia-Garmendia JL, Ortiz-

for

the

development

of

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

35

FJ,

9. Van den Berghe G, Wouters P,

Barrero-Almodovar A, et al. Critical

Weekers F, Verwaest C, Bruyninckx F,

illness polyneuropathy: risk factors

Schetz M, et al. Intensive insulin

and clinical consequences: a cohort

therapy in the critically ill patients. N

study in septic patients. Intensive Care

Engl J Med 2001;345(19):1359–1367.

Leyba

C,

Jimenez-Jimenez

Med 2001;27(8): 1288–1296.

10. Tennila A, Salmi T, Pettila V, 5. Spitzer AR, Giancarlo T, Maher L,

Roine RO, Varpula T, Takkunen O.

Awerbuch

Early

G,

Bowles

A.

signs

of

critical

illness

Neuromuscular causes of prolonged

polyneuropathy in ICU patients with

ventilator dependency. Muscle Nerve

systemic

1992;15(6):682–686.

syndrome or sepsis. Intensive Care

inflammatory

response

Med 2000;26(9):1360–1363.

6. Rudis MI, Guslits BJ, Peterson EL, Hathaway SJ, Angus E, Beis S,

11. Rabuel C, Renaud E, Brealey D,

Zarowitz BJ. Economic impact of

Ratajczak P, Damy T, Alves A, et al.

prolonged

Human septic myopathy: induction of

motor

weakness

cyclooxygenase, heme oxygenase and

complicating neuromuscular

blockade

in

the

activation of the ubiquitin proteolytic

intensive care unit. Crit Care Med

pathway.

1996;24(10):1749–1756.

2004;101(3):583–590.

7. Latronico N, Peli E, Botteri M.

12. MacFarlane IA, Rosenthal FD.

Critical

Severe

illness

myopathy

and

Anesthesiology

myopathy

after

(letter).

status

neuropathy. Curr Opin Crit Care

asthmaticus

Lancet

2005;11(2):126–132.

1977;2(8038):615.

8. Bednarik J, Lukas Z, Vondracek P.

13. Witt NJ, Zochodne DW, Bolton

Critical illness polyneuromyopathy:

CF, Grand’Maison F, Wells G, Young

the electrophysiological components

GB, Sibbald WJ. Peripheral nerve

of a complex entity. Intensive Care

function in sepsis and multiple organ

Med 2003;29(9):1505–1514.

failure. Chest 1991;99(1):176–184.

http://www.srji.co.cc

14. Knox AJ, Mascie-Taylor BH,

17. Garnacho-MonteroJ, Amaya-Villar

Muers

R,

MF.

Acute

hydrocortisone

Garcia-Garmendia

JL,Madrazo-

myopathy in acute severe asthma.

Osuna J, Ortiz-Leyba C. Effect of

Thorax 1986;41(5):411–412.

critical illness polyneuropathy on the withdrawal

from

mechanical

15. Hund E, Genzwurker H, Bohrer H,

ventilation and the length of stay in

Jakob

septic

H,

Thiele

R,

Hacke

W.

patients.

Crit

Predominant involvement of motor

2005;33(2):349–354.

fibres in patients with critical illness

18.

polyneuropathy.

systemic

Br

J

Anaesth

Bolton

CF.

Sepsis

inflammatory

syndrome:

1997;78(3):274–278.

manifestations.

16. Thiele RI, Jakob H, Hund E,

Care

Med

and

the

response

neuromuscular Crit

Care

Med

1996;24(8): 1408–1416.

Tantzky S, Keller S, Kamler M, et al.

Sepsis and catecholamine support are

19. Latronico N, Fenzi F, Recupero D,

the major risk factors for critical

Guarneri B, Tomelleri G, Tonin P, et

illness polyneuropathy after open heart

al. Critical illness myopathy and

surgery.

neuropathy.

Thorac

Cardiovasc

2000;48(3):145–150.

Surg

Lancet

1996;

347(9015):1579–1582.

ACKNOWLEDGMENT: The authors thank Dharam Pandey (MPT-neuro), Deepa Dabas (MSc-psycho) for assistance throughout the study.

CORRESPONDENCE: *Bijender Sindhu PhD,PT Research Student**Dr.Manoj Sharma, MBBS, MS(ortho)***Dr.Raj k Biraynia, MBBS, D.ortho *School of Physical Therapy, Faculty of Medical Science, Singhania University**Department of orthopedic surgery, Jaipur Golden Hospital *** Department of orthopedic surgery, Sarvodaya Multispeciality Hospital. This study was not funded through a grant from the any organization.

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

37

Comparison of the Effect of Isometric Exercise of Upper Limb on Vitals between Young Males and Females Pranjal Parmar. BPT*

Abstract: Background and objective: studies on gender difference in cardiovascular responses to isometric exercises have been numerous and confliction the objective of this study was to determine if cardiovascular response to upper extremities isometric exercises differ between apparently healthy male and female subjects. Method: 60 young adults age between 18 to 22 years were included in study. These consisted of 30 males and 30 females. The baseline cardiovascular parameters (HR, SBP, DBP & MAP) were recorded. After two sets of three isometric upper limbs for 3 minutes these parameters recorded at the end of exercise and after recovery. Results:An increase in HR ,SBP , DBP&MAP was seen in both groups after exercise .the result showed group B had more increase in HR,SBP,DBP and MAP as compared to group A and significant rise in MAP &SBP in group B. Conclusion: Isometric exercise of upper limb can lead to increase in SBP, DBP, MAP &HR among apparently healthy males & females.

It is more proannounced in males as compared to females. SBP &MAP increased in both but more in males as compared to females.

Keywords: Isometric Exercises, Cardiovascular Measures

INTRODUCTION Exercise, a common physiological stress,

seen in various exercises like pushing or

can elicit cardiovascular abnormalities not

lifting heavy load where net displacement

present at rest and can be used to

of load is not, but the rising tension can be

determine

cardiac

felt in contracting muscles.3 It imposes

function.1 The isometric contractions are

greater pressure than volume load on left

the

adequacy

of

http://www.srji.co.cc

ventricle in relation to the body ability to

During exercise it is mainly adrenaline

supply oxygen.4 The metabolic demands

that produces changes in the heartbeat.

of the exercising muscles increases,

Adrenaline is a hormone which causes the

depending upon intensity of exercises and

heart rate to quicker.

are

2. Breathing quickens and deepens:

met

with

various

changes

in

circulatory and respiratory system.13

You breathe quicker so as to get more

The effect of isometric exercises on vitals

oxygen into the lungs. An efficient heart

in between males and females may vary

can then transport this to the working

with substantial anatomical, physiological

muscles. Training can be of great benefit

and morphological differences that exist

to the Respiratory System. The capacity of

between men and women which may

the lungs is increased, which allows more

affect their exercise capacity and influence

oxygen to be taken in per breath.

magnitude of response to exercise.5

3. Temperature rises:

The average isometric strength estimate is

When we exercise, our muscles are

generally 30% greater in men than in

working and they generate heat, so our

women in different muscle group. Gender

body temperature rises. Body temperature

difference in cardiovascular response to

is regulated by heat radiating from the

static exercise is believed to be due to

skin and water evaporating by sweating.

differences

â&#x20AC;&#x201C;

When we shiver, our muscles are working

parasympathetic or adrenal interactions at

to produce heat in order to raise our body

cardiac level.

temperature.

The larger the muscle group that is

4. Start to sweat:

involved in isometric tension the greater

As we have just seen, some of our energy

the cardiovascular response.6

is turned into heat. The body will tolerate

Response To Exercise:7

a small rise in temperature, but very soon

When you exercise or take part in a

we begin to sweat. If the conditions are

strenuous sport you will notice several

hot, we sweat more and produce less urine.

changes taking place in your body:

We also lose salt as well as body heat and

a. Your heart beats stronger and faster

water. We have to replace the salt so that

b. Your breathing quickens and deepens

the body stays the same, otherwise we will

c. Your body temperature increases

get cramp.

d. You start to sweat

5. Muscles begin to ache:

e. Your muscles begin to ache

As we now know, in order to work,

1. Heart beats stronger and faster:

muscles need energy. Energy comes from

in

sympathetic

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

39

food, which is mainly converted to

Vitals response to exercise has been used

glucose. To work more efficiently muscles

as major criteria in exercise prescription

also need plenty of oxygen. Glucose and

for both patient and healthy population.

oxygen are brought to the muscles in the

Thus for prescribing isometric exercise,

blood. Wastes such as carbon dioxide are

repetitions and frequency it would be

carried away in the blood. This process of

helpful and prevent the adverse effect on

getting energy is called respiration.

vitals. The study would also be helpful in

Glucose + Oxygen = Energy + CO2 +

prescribing exercises for those with

Water

cardiovascular compromise. It would help

When muscles do extra work more

to determine the safety limits of the

Glucose and Oxygen are needed, so more

exercise.

blood

must

flow

to

the

muscles.

Eventually it becomes impossible to get

OBJECTIVES:

enough oxygen to the muscles, so they use

1. To analyze if there is any change in

a different method of getting energy.

vitals as a result of isometric exercises of

Glucose is still used, but now there is a

upper limb

waste product called lactic acid, which

2. To compare the response of upper limb

makes muscle ache, & muscles.

isometric exercises in young male and female.

Acute

Cardiovascular

Response

to

Exercise:

METHODOLOGY

As exercise intensity increases, heart rate,

Research Design: An quasi-Experimental

stroke volume, and cardiac output increase

(comparative) study. Sample Size: 60

to get more blood to the tissues. More

normal individuals. Sample Population:

blood forced out of the heart during

60 young adults between 18 to 22 yrs.

exercise allows for more oxygen and

Group A: 30 normal individuals (females)

nutrients to get to the muscles and for

Group B: 30 normal individuals(males)

waste to be removed more quickly. Blood

Type of Sampling: Convenient sampling

flow distribution changes from rest to

with random assignment. Duration of

exercise as blood is redirected to the

Study:

muscles and systems that need it.

Physiotherapy OPD of a tertiary care

one

month.

Study

hospital.

CLINCAL SIGNIFICANCE

Inclusion Criteria:

http://www.srji.co.cc

Set

Up:

•

No previous history of known

intervention

cardiovascular condition.

individuals and their written consent was

•

Normal values of vitals at rest.

taken from them. 60 individuals were

•

No neurological defecit in upper

assigned into two groups, group A and

limb.

group B, 30 patients in each group.

•

Sex – both male and female.

Procedure details of group A and group B:

•

Willingnessof patient.

Pre-measures: Heart rate and blood

•

Fracture of upper limb bones.

•

Cervical

vertebrae

or

scapula

Reading was noted.

Therapist position: on the individual side

Neurogenic deficit.

•

Congenital anomalies.

•

Previous exercise training

•

Any disability limiting to upper

in stride standing position.

Procedure: Participants in upstanding

•

Psychiatric patients.

•

Non-willing patients.

exercise for each 30 second each thus total duration of exercise for 3 minutes.

1. The exercise are pushing against the

Outcome Measures:

wall with outstretched arms and were

Heart rate of patient at rest, immediately post exercise and 3 minutes after exercise

instructed to exert maximal tension on wall.8 2. Hands clasped together and brought to

Blood pressure i.e. systolic and diastolic blood pressure at rest, immediately postexercise and 3 minutes after exercise. arterial

position performed 3 upper extremities isometric exercises i.e. 2 sets of each

limb exercise.

Mean

the

Individual position: standing position.

•

•

to

sphygmomanometer in standing position.

fracture.

•

explained

pressure was measured using an electronic

Exclusion Criteria:

•

was

manubrosternal level to chest while shoulders are 60 70 degree abducted and participants were instructed to maximally generate tension by pressing opposite

pressure

was

calculated from the above data.

hands against each other.8 3. Both palms on wall with participants standing ahead arms extended and were

PROCEDURE

asked to push the wall without coming

60 individuals were selected according to the inclusion and exclusion criteria. The need

of

the

study

and

treatment

behind and keeping elbow straight.8 Participants were instructed to avoid valsalva maneuver by not holding breath

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

Thereafter participants were asked to rest

41

MEAN AGE OF POPULATION

for 10 minutes before leaving. Post-

20.25

measures: Heart rate and blood pressure

20.2

was measured immediately after exercise

20.15

MEAN AGE OF POPULATION

20.1

and 3 minutess after exercise. All patients were comfortable after the treatment session.

The above graph shows mean age of group A and group B.

DATA ANALYSIS AND RESULT The data collected was entered in excel sheet and statistical analysis was done using SPSS software. Heart rate and blood pressure are objective data hence can be considered for statistical analysis. This isan interval data hence pre and post

Group A (females) Group B (males)

Table 2 Rest Post exercise 117.8 123.28 123.6

134.58

Recovery 120.45 128.95

parmeters was statistically analysed using paired t-test, test, and difference in paramaters paramate Rest

Post exercise -5.46072 -10.1411 10.1411 1.64e-05 3.14e-09 3.14e

Recovery Value

Value -10.0176 P 2.19e-11 value between two groups was statistically

Group

analysed using unpaired t-- test.

B

Table 3 P value

-1.6912 3.47e3.47e

A

10

Group

-1.3678 3.17e3.17e 12

Significance Difference is significant.

Difference is significant.

Table 4 Table No.1 Mean age (yrs)of )of study group Group A B

Number 30 30

Age (yrs) 20.23 20.16

Table 2 shows mean of systolic blood pressure at rest in group A is 117.8 and group B IS 123.6 ,post exercise in group A is 123.28 and group B is 134.58 and recovery in group A is 120.45and group B is 128.95.

http://www.srji.co.cc

Table 3 shows p value by paired t test in group A and group B and difference is statically significant.

Table 4 shows p value by unpaired t test in group A and group B at rest, post exercise

0.3SYSTOLIC BLOOD PRESSURE - RECOVERY 0.25 0.2 0.15 Female 0.1 Male 0.05 0

and recovery and difference is statically

108 110 112 114 116 118 120 122 124 126 128 128 130 132

significant.

The above graph shows distribution of 150

SYSTOLIC BLOOD PRESSURE

systolic blood pressure in males and females at rest, post exercise and recovery.

100

Diastolic Blood Pressure 50 0 REST

POST EXERCISE

RECOVERY

The graph shows mean of males and females of systolic blood pressure at rest , post exercise and recovery. .

0.2 SYSTOLIC BLOOD PRESSURE - REST 0.15 0.1

Female

0.05

Group A (Females) Group B (Males)

Group A Group B

Male

0 102106110114118122126130

0.15SYSTOLIC BLOOD PRESSURE - POST EXERCISE 0.1 Female 0.05 Male 0

Value P value

Table 5 Rest Post exercise 75.6 84.25 80

96.50

Recovery 80.20 83.60

Table 6 P value Significance 3.95e- Difference is 15 significant.

-1.236 3.21e- Difference is 08 significant.

Table 7 Rest Post Recovery exercise -5.78263 -14.6703 14.6703 -4.4098 1.1e-06 3.14e-09 09 1.58e-07 Value -1.345

Table 5 shows mean of diastolic blood pressure at rest in group A is 75.6 and group B is 80, at post exercise in group A

108112116120124128132136140

is 84.25 and in group B is 96.50 and at recovery in group A is 80.20 and group B is 83.60.

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

43

Table 6 shows p value by paired t test in

The above graph shows distribution of

group A and group B and difference is

diastollic blood pressure between males

statistically significant.

and females at rest, post exercise and

Table 7 shows p value by unpaired t test at

recovery.

rest, post exercise and recovery in group A and group B and difference is

Mean Arterial Pressure

statistically significant

Group A (Females) Group B (Males)

DIASTOLIC BLOOD PRESSURE 120 100 80 60 40 20 0

FEMALES

Rest

and females of diastolic blood pressure at

0.2

Value P value

0

-7.001 1.16e09

Post exercise -9.57881 1.91e-11

Recovery 93.61 98.71

Significance Difference is significant Difference is significant.

Recovery -7.17096 2.06e-09

Table 8 shows mean of mean arterial

DIASTOLIC BLOOD PRESSURE - REST

0.1

109.19

Table 9 P value 5.78e10 -1.784 4.08e12 Table 10

The above graph shows mean of males

rest, post exercise and recovery.

94.53

Value -1.327

Group A Group B

MALES

Table 8 Rest Post exercise 89.66 97.26

Female

pressure at rest in group A is 89.66 and in

Male

group B is 94.53,at post exercise in group

68 70 72 74 76 78 80 82 84 86 88

A is 97.26and in group B is 109.19 and at recovery in group A is 93.61 and group B

0.2

DIASTOLIC BLOOD PRESSURE - POST EXERCISE

0.1

Female

0

Male 74767880828486889092949698100 102

is 98.71.

Table 9 shows p value by paired t test in group A and group B difference is statistically significant.

0.2 DIASTOLIC BLOOD PRESSURE - RECOVERY 0.1

Female

0

Male 70 72 74 76 78 80 82 84 86 88 90 92

Table 10 shows p value by unpaired t test at rest, post exercise and recovery in group A and group and difference is statistically significant.

http://www.srji.co.cc

The above graph shows distribution of mean arterial pressure between males and

MEAN ARTERIAL PRESSURE

females at rest, post exercise and recovery.

120 100 80 60 40 20 0

Heart Rate FEMALES MALES

Group A (Females) Group B (Males)

Table 11 Rest Post exercise 72.6 80.40

76.40

74.4

78.65

82.95

Recovery

Table 12 The above graph shows mean of mean arterial pressure at rest, post exercise and

Group A

recovery between group A and group B. Group B 0.2MEAN ARTERIAL PRESSURE -REST 0.15 0.1

Female

0.05

Male

Value P value

0 80

90

100

Value 0.00615

P value Significance 0.015E- Difference 04 is significant 0.00322 0.14E- Difference 05 is significant Table 13 Rest Post Recovery exercise 0.00123 0.00808 0.00055 0.012e0.080e- 0.055e-06 06 05

Table 11 shows mean of heart rate at rest 0.1 MEAN ARTERIAL PRESSURE - POST EXERCISE 0.05 0

Female

at post exercise in group A is 80.40 and in

Male

group B is 82.95 and at recovery in group

86889092949698 100 102 104 106 108 110 112 114 116 118

A is 76.40 and in group B is 78.65.

0.2 MEAN ARTERIAL PRESSURE - RECOVERY 0.15 0.1 0.05

in group A is 72.6 and in group B is 74.4,

Female Male

0 82 84 86 88 90 92 94 96 98 100102104106

Table 12 shows p value by paired t test in group A and group B and difference is statistically significant.

Table 13 shows p value by unpaired t test at rest, post exercise and recovery in group A and group B and difference is statistically significant.

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

45

The above graph shows distribution of

Heart Rate

heart rate between males and females at

100 80 60 40 20 0

rest, post exercise and recovery.

FEMALES MALES

DISCUSSION The

study

investigated

the

gender

difference in cardiovascular response to The above graph shows mean of heart rate

upper

in males and females at rest, post exercise

among apparently young healthy subjects.

and recovery.

60 participants were included in the study.

extremities

isometric

exercise

They were divided into two groups, group HEART RATE - REST

0.2

A and group B. Group A included female gender and group B included male gender.

0.15 0.1

Female Male

0.05

BP, HR and MAP were taken as outcome measure. These measures were taken pior, immediately after test and 3 minutes after

0 65

70

75

study. The data collected was statistically

80

analysed. The result showed group B had more increase in HR,SBP ,DBP AND HEART RATE - RECOVERY

0.15

MAP as compared to group A and there was significant rise in MAP and SBP in

0.1 0.05

Female

group B. The average isometric strength

Male

estimate is generally about thirty percent greater in men than in women in different

0 68

78

88

muscle groups . Upon initiating isometric tension, increases in heart rate, systolic blood

HEART RATE - POST EXERCISE

0.15

pressure,

and

diastolic

blood

pressure occur. Mitchell and associates 0.1 Female 0.05

Male

and

Seals

et

al

suggested

that

cardiovascular responses to isometric exercise are greater when larger muscle

0 72

82

92

groups are involved. While heart rate responses to sustained submaximal static contractions tend not to be significantly http://www.srji.co.cc

different before, during, or after exercise,

These result indicate that more blood is

blood pressure responses to this exercise

pumped by left ventricle into aorta in

are significantly elevated before, during,

response to upper extremities isometric

and after exercise Gender differences in

exercise among males than females; while

cardiovascular responses to static exercise

myocardial oxygen uptake & measure of

are believed to be due to differences in

oxygen consumption of heart muscles of

sympathetic-parasympathetic or adrenal

female participants in response to upper

interactions at the cardiac level. The

extremities isometric exercises is higher

finding of this study revealed that there

than that of males.

was no significant gender difference in

The tissues working hard during exercise

vitals of participants at baseline which

and also after the completion of exercise

was statistically significant. The data

require more oxygen than normal to pay

collected reveals that post exercise heart

off this oxygen debt incurred during the

rate, systolic blood pressure ,diastolic

exercise. These results in increase in blood

blood pressure and mean arterial pressure

supply to active muscles to supply this

were higher than pre exercise values and

extra amount of blood. At rest, muscles

was statistically significant in both groups

receive approximately 20% of total blood

ie group A and group B.

flow but during exercise blood flow to

When values of recovery i.e. 3 minutes

muscles increase to 80 -85% .

after exercise when compared it was

Generally ,longer the duration of exercise

almost same in both groups but when

greater the role the cardiovascular system

compared to values at rest it was much

plays in metabolism and performance

greater than recovery values.

during exercise bout.eg an 1T00 meter

The result between the two was calculated

walk

using unpaired t test. Therefore upper

involvement) versus a marathon(maximal

extremities

involvement).9

isometric

exercise

had

(little

or

no

cardiovascular

significant effect on heart rate, systolic

It has reported that release of adrenaline

blood pressure, diastolic blood pressure

and lactic acid into the blood result

and mean arterial blood blood pressure.

increase in a heart rate.

When values of group A and group B at

The isometric exercises does not increase

post exercise were compared it was seen

the oxygen demand to the extend raised by

that male participants (group B) had

isotonic exercise thus DBP does not rise

higher post exercise MAP and SBP had

much in isometric exercise The isometric

level than females (group A) (p<0.05)

exercise results in pressure overload on

Vol.1 ● No.4 ● 2012 heart.

The

myocardial

Scientific Research Journal of India oxygen

extremities

47

isometric

exercise

in

consumption (mvo2) also increase due to

normotensive subjects.” By Cembada and

exercise . Higher ventricular contraction is

“Gender differences in cardiovascular

evoked among males leading to increase

response to isometric in seated and supine

in systolic blood pressure.

positions” by Don Melrose. The proposed

This indicates that the males have higher

mechanisms attempting to explain gender

myocardial

during

differences in cardiovascular responses to

isometric exercise predisposing them to

isometric exercise have been numerous

greater risk of ischemia if developing

and conflicting. Sanchez et al. found

cardiovascular risk, factor compromising

differences in adrenergic patterns between

the coronary blood flow.10

genders in response to isometric exercise

It has been seen males have higher plasma

and support the study. Ettinger and

levels of all three catecholoamines out of

associates

which plasma levels of epinephrine are

increases in blood pressure and muscle

higher as compared to females .this results

sympathetic nerve activity compared with

in increase in MAP immediately at of

men. In data also derived from static

exercise.

exercise as well as temperature and

The findings supports the results of

psychological stressors, Jones et al found

previous investigators than upon initiation

that gender did not influence sympathetic

isometric tension increase heart rate,

neural reactivity to stressors such as

systolic blood pressure and diastolic blood

isometric handgrip exercise

oxygen

occur.12

demand

demonstrated

attenuated

of

Changes in posture often experienced

investigations have been reported at best

during exercise or sporting activities have

inconsistent and do not follow definite

also

pattern.12

circulatory adaptations. Sagiv et al. and

However during the recovery period the

Borst et al. both noted changes in

vitals were decreased as compared to

cardiovascular regulation as a result of

immediately post exercise in both genders.

postural changes. Relatively fewer studies

However the vitals were not the same as

have

they were at rest prior to commmencent of

adaptations to exercise performed when

exercise.

posture does not change during the time

The result of study is supported by the

course of the positions.

articles

A further study can be made:

pressure

“Gender

cardiovascular

The

result

difference

response

to

in

been

shown

investigated

to

the

elicit

various

cardiovascular

upper http://www.srji.co.cc

•

•

Comparison of vitals for larger

pressure ,diastolic blood pressure ,mean

muscles groups to smaller muscles

arterial pressure and heart rate among

group in upper limb isometric

apparently healthly males and females.

exercises.

2. This was more preannounced in males

Comparison of vitals in isometric

than females .Systolic blood pressure

exercise for upper limb versus

(SBP) and Mean arterial pressure (MAP)

lower limb.

increased in both but more males as compared to females

The result can be used as •

It can be used for prescription of exercise

•

in

those

with

LIMITATION

cardiovascular crompromise and

1. The participants in study were young

elderly patients.

and elderly or middle aged participants

It can be used to determine the

were not included in these study.

safety

2. All the subjects who were included in

limits

during

exercise

the study were students.

regimen.

3. The participants nutritional status or BMI were not considered while selection.

CONCLUSION The

above

study

gives

following

4.

The

occupation

or

lifestyle

of

conclusion:

participants was not considered.

1. Isometric exercises of upper limb can

5. The muscle mass or bulk of upper limb

lead

was not considered.

to

increase

in

systolic

blood

REFERENCES: 1. Journal of Exercise Physiology Online. Volume 8, number 5,

Exercise,

Carolyn

Kisner & Lynn Allen Collby.Pg No 168,5th Edition 3. Sports

of

Fitness

Advisor,

st&kramerwj(2004).

4. Husketh Mount, pg no 92-96,lord street,merseyside, england.

cardiovascular

.stending

difference

in

response

to

isometric exercise.gatzke 2005 7. Circulation,

Fleck

exercise

lenderg 2004 6. Gender

august 2005.

2. Therapeutic

5. Effect

amercian

heart

association,2007pg no 3 &4 8. Clinical

Orthopaedic

rehabilitation ,2nd editions brent brotzman,pg no 138-142

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012 9. Cardiovascular

system

Scientific Research Journal of India and

exercise physiology,aulter &amer suleman

exercise

reserach,srinath galag & ravipati sarath volume 2,november 2011 difference

cardiovascular

response

of

upper

limbs,howden et clf 2006.

12. Gender

10. International journal of biomedical

11. Gender

isometric

49

cardiovascular

difference response

in to

isometric exercise,gatzke 13. The essential guide to building

in

muscles by phil daviee.

to

CORRESPONDENCE: * Consultant Physiotherapist, Bhagwan Mahaveer Medical Centre, M.G. Road, Goregaon (W), Mumbai.

Email: pranjalparmar38@yahoo.in

http://www.srji.co.cc

Paraplegia with Sacral Pressure ulcer treated by Ultrasound therapy- A Single Case Report Shanmuga Raju P. MPT *, Ramalingam P. MS, FICA, MAMS Abstract: Pressure ulcers are important and common complications after paraplegia. The use of therapeutic ultrasound as an adjunct to wound healing has gained interest in recent years. An twenty five year old male reported with a two months history of a grade two, non healing, sacral pressure ulcer. Ultrasound therapy (UST) is simple, safe, without side effects, bedside procedure, inexpensive with positive wound healing results for difficult to treat non healing pressure sore.

I hope that this article will encourage other wound care specialists to engage in further research in this area.

Key Words: Paraplegia, Sacral pressure ulcer; Continuous mode of ultrasound therapy; wound healing.

INTRODUCTION Pressure Ulcer, also called as Decubitus

time (9). Pressure ulcer are treated by

ulcers, was first seriously studied by

using wound dressings, relieving pressure

“Jean- Martin Charcot”, a clinician in the

on the wound, Water beds/ Alpha bed by

19th Century (1-3). Pressure ulcer is a

treating concurrent conditions which may

serious health issue, very painful, a

delay healing and by the use of physical

significant physiological challenge, can

therapy such as electrical stimulation,

shorten the life of patient, an emotional

laser therapy and ultrasound (1).

and financial burden to the patient.

Ultrasound is now the most frequently

Pressure sore are important and common

used electrophysical agent worldwide,

complications

An

used at least daily for patient treatment by

estimated 50 – 80% of individuals

the majority of physiotherapists (4-5).The

suffering from spinal cord injury develop

aim of this study to investigate the effect

pressure ulcer at least once in their life

of ultrasound (US) therapy in sacral

after

paraplegia.

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

51

pressure ulcer with paraplegia. Limited

department of physical medicine and

clinical research is available and no

rehabilitation OPD, CAIMS, Karimnagar

consensus exists regarding the efficacy of

on February 26th, 2011.

ultrasound for treating pressure ulcer,

On physical examination, he is bed ridden

particularly full thickness pressure ulcers.

and was unable to sit without support in the chair, had sustained the sacral pressure

CASE REPORT

ulcer. He has bedsore of 6.2 X 4.0 cm, the

A twenty five year old man presented with

depth ranging from 10mm, grade II

a two months history of a grade two, non

sacrum

healing sacral pressure ulcer. He was a

according to European pressure ulcer

former. He had history of fall from height.

Advisory

His

classification

past

medical

history,

complete

ulcer

with

panel

necrotic

(EPUAP)

system

slough

wound

(Figure.1).

His

paralysis of both lower limbs, loss of

albumin count 2.4 g/dL, haemoglobin 11.0

sensation,

bladder

g/dL, temperature was 38 degree Celsius.

incontinence, loss of mobility and sacral

There was no evidence of osteomyelitis.

pressure ulcer for past one month. His

He was put on conservative treatment,

medical problems included spinal cord

consisting of water bed mattress, bed

injury and severe depression. He had

postioning, regular pressure relief, daily

become unable to walk since two months

saline water dressing and appropriate

and was carried either in bed or in his

antibiotics.

urinary

and

wheelchair. He was diagnosed as a case of D11, and D12 wedge compression of

OUTCOMES EVALUATED

spine with traumatic paraplegia (American

Wound

spinal cord injury association impairment

photographs of wound beds were obtained

score: A- no motor or sensory function in

weekly. Wound dimension monitored and

the sacral segments) and sacral pressure

depth measurements were obtained using

ulcer. Five month back, he underwent

a sterile, cotton-tip applicator and ruler

placement of spinal fixation rods and

(Steven JK et al, 2007). Wound surface

plates from D11 to L1 level. A thoraco

area was determined using Bates-Jenes

Lumbar-sacral corset was fabricated for

wound assessment tool.

him.

Routine

hematology

measurements

and

digital

and

biochemistry investigations were within

ULTRASOUND

normal limits. He received antibiotics and

INTERVENTION

THERAPY

vitamin supplements. He was referred to http://www.srji.co.cc

On February 2011, Continuous mode of

•

Pulse duration: 2 ms

ultrasound

709,

•

Duty factor: 0.2

Chennai) treatment was performed in

•

Spatial temporal average radiating

sacral

therapy

pressure

following

(Electroson

ulcer

protocols

region. are

The applied:

surface area: 5.2 cm2 •

Duration of treatment: 10 minutes

ultrasound machine with frequency of 3

per session for sacral pressure

MHz and spatial average intensity 0.8

ulcer

w/cm2 sound head, in conjunction with a

•

Duration of treatment: 6 weeks

coupling media of aquasonic ultrasound transmission gel was used. Ultrasound

RESULT

was applied to the outer surface, and edge

The indolent pressure ulcer, apart from

of sacral ulcer region (Fig. 2). Before the

routine

treatment of CUS therapy, we splashed

ultrasound therapy enhanced the healing

each wound by oxygen spray. Sacrum

of pressure ulcer in six weeks.

therapy,

continuous

mode

ulcer was cleaned using 2% hydrogen peroxide. The standard normal saline (Nacl) dressing was done. Ultrasound treatment time was 10 minutes per session 6 days a week, for six weeks. At the end of

third

week

there

was

marked

improvement in pressure ulcer i.e size, floor and wound margin reduced. There was no pus discharge after treatment (Fig. 3). A healthy granulation tissue was noted (Fig. 4). The patient made good progress and wound was completely healed within 42 days (Fig. 5).

Table:

1

Parameter

of

Ultrasound

therapy treatment (McDiarmid etal, 1985) •

Ultrasound frequency: 3 MHz

•

Spatial average temporal peak intensity: 0.8 W/cm2

Fig: 1 On assessment, the sacral pressure ulcer presented as non- healing grade II pressure ulcer measuring 6.2 x 4.0 cm with erythema.

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

Fig: 2 the full thickness of sacral ulcer was treated with continuous mode ultrasound therapy (CUST)

53

Fig: 5 After six week of treatment, picture showing that sacral pressure ulcer are completely healed.

DISCUSSION The purpose of the study was to assess the effect of ultrasound therapy in healing of sacrum pressure ulcer in patients with paraplegia.

Infected sores heal more

slowly than clean sores while no effect of ultrasound clean sores were observed ultrasound therapy appeared to improve Fig: 3 three weeks after the treatment of CUST

the rate of healing of infected sores. It is non thermal effect produced by ultrasound that are most significant in the stimulation of tissue repair (Dyson, 1976). Paul et al (1960)

ultrasound

was

effective

in

relieving congestion, cleansing necrotic areas and promoting healing with healthy, non-adherent skin approaching normal thickness. Cyclic vibration effect of ultrasound might induced a form of micro massage which by reducing edema, might Fig: 4 Fifth weeks after CUST, the wound size are decreased for sacral ulcer

facilitate repair, their requires further investigations. It is also stimulate protein synthesis infact ultrasound initiates two http://www.srji.co.cc

processess which results in release of

cm2, Duration of treatment 10 minute

energy tissue: Surface cavitation (creation

per/session, Duration of frequency 6

and dissipation of tiny bubbles in the

weeks) pressure ulcer healed in time

tissues) and acoustic microstreaming that

without side effects. Our case study

is movement of fluids along acoustic

showed

boundaries, such as cell membrane. This

ultrasound therapy treatment enhances

biophysical effect that are non-thermal

healing of sacral pressure ulcer. This case

alternations in cellular protein synthesis

study confirmed that continuous UST has

and release, blood flow and vascular

a positive effect on pressure ulcer with

permeability, angiogenesis, and collagen

paraplegia (Fig.5). No complications were

content and alignment by various workers

observed

it as quoted as follows: 1. General protein

continuous ultrasound. Further studies are

and collagen synthesis by fibroplasts

needed to evaluate the efficacy of

(Harvey etal, 1975, Webster etal. 1980). 2.

ultrasound therapy in pressure ulcers in

Fibroplast mobility (Miller etal, 1978). 3.

spinal cord injury in a large number of

Fibroblast ultrastructure (Dyson and Pond,

patients.

1970).

4.

membrane

Permeability (Harvey

of

etal,

that

continuous

with

mode

application

of

of

the

fibroblast 1975).

5.

CONCLUSION

Lysosomal fragilty (Tayor and Pond,

Continuous mode of ultrasound therapy

1972). 6. Tensile strength and elasticity of

was effective in the treatment of patient

scar tissue (Dyson et al, 1979). 7.

with grade II pressure ulcer in young

Modification

paraplegic patient. Ultrasound therapy

of

contraction

in

skin

treatment

wounds (Dyson et al, 1981).

of

pressure

ulcer

is

less

ultrasound

expensive, more comfortable and can

treatment (frequency 3 MHz, Intensity 0.8

enhance wound healing process without

W/cm2, Pulse duration 2 ms, Duty cycle

side

With

this

parameters

of

effects

and

complication.

0.2, effective radiating surface area 5.2

REFERENCES: 1. Sella EJ, Barrette C. Staging of charcot neuro arthropathy along

2. Levine JM. Historical perspective

the medial column of the foot in

on pressure ulcers: The decubitus

the diabetic patient. J. Foot Ankle

ominosus of Jean- Martin Charcot.

Surg. 1999, 38; 34-40.

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

J Am. Geriatr. Soci, 2005, 53;

55

8. Callam MJ, Dale Jj, Harpel DR, etal. A controlled trial weekly

1248- 1251.

ultrasound therapy in chronic leg 3. Levine JM. Historical perspective: The neuropathic theory of skin ulceration.

J.

ulceration, Lancet. 1987; ii; 204206.

Am.Geriatr.Soci, 9. Saad A, Williams A. Effect of

1992; 40, 1281.

therapeutic 4. Goh AC, Chock B, Wong WP et al.

activity

ultrasound

of

the system

on

the

mononuclear

Therapeutic ultrasound rate of

phagocyte

in

vivo.

usage, knowledge of use, and

Ultrasound Med Biol, 1986; 12;

opinions on dosimetry. Physiother

145-150.

Singapore 1999; 2: 69-83.

10. Steven JK, David AL, Andrea JB, D.

Jenny LM, Julie AB, Karen LA.

Therapeutic Ultrasound: Clinician

Expedited wound healing with

usage and perception of efficacy.

Non-contact,

HongKong Physio Ther J. 2003;

ultrasound

21: 5-13.

wounds: A retrospective analysis.

5. Chipchase

LS,

Trinkle

Low therapy

frequency in

chronic

Adv. Skin and wound care, 2008, 6. Ali

Akbari

Cullum

S,

NA,

Flemming

K,

Wollina

U.

vol: 21 (9); 416-23.

for

11. Arthro PJ, Thyme B, Warring

The

(2002). A Calibration study of the

Cohrane collaboration, John wiley

ultrasound unit, Phys Ther, 82;

and Son ltd, p:1-18.

257-263.

Therapeutic pressure

Ultrasound

ulcers,

(2009).

12. Ankrom MA, Benneh RG, Sprigle 7. Paul BJ, Lafratta CW, Dawson AR

S, et al. Pressure related deep

etal. Use of ultrasound in the

tissue injury under intact skin and

treatment of pressure sores in

the current pressure ulcer staging

patients with spinal injury. Arch

systems. Adv. Skin Wound care,

phys Med Rehabil, 1960; 41; 438-

2005; 18 (1); 35-45.

440.

http://www.srji.co.cc

13. McDiarmid T, Burns PN, Lewith

16. TerRiet

G,

Kessels

GT, Machin D. Ultrasound and the

Knipschild

P

treatment

randomized

clinical

of

pressure

sores,

AG,

(1996). trial

A of

ultrasound in the treatment of

Physiotherapy, 1985; 71; 66-70.

pressure sores. Phys Ther 76; 14. Dyson M. Role of ultrasound in

1301-1311.

wound healing. In: Mcculloch JM. Kloth LC, Feeder JA, eds. Wound Healing.

Alteratives

in

17. Whatson GW, Milani JC, Dean LS. Pressure sore profile: cost and

Management, 2nd ed, Philadelphia

management,

Pa: FA Davis co; 1995; 319-345.

Digest, 1987; 115-119.

15. Sari

AA

etal.

Therapeutic

18. Houghton

ASIA,

PE,

Abstracts

Kincaid

CB,

ultrasound for pressure ulcers.

Campell KE, et al. Photographic

Cochrane Database of systemic

assessment of the appearance of

reviews. 2009 (4).

chronic pressure and leg ulcers.

Ostomy / Wound Management.

2000; 46(4); 20-30.

ACKNOWLEDGMENT: I thank the men who participated in this trial. I would also like to thank chairman Sri. C. Lakshmi Narasimha Rao, Prof. V. Suryanarayana Reddy, Director, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar for his support and encouragement of this study.

CORRESPONDENCE: *Asst. Professor & I/C Head, Department of Physical Medicine and Rehabilitation Chalmeda Anand Rao Institute of Medical Sciences Karimnagar -505001, Andhra Pradesh, INDIA. Mobile: 08790544270, Fax: 08782285318. E-mail: shanmugampt@rediffmail.com

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

57

Arterio-Enteric Fistula: A Case Report Anil Degaonkar*, Nikhil Bhamare**, Mandar Tilak***

Abstract: Gastro-intestinal (GI) bleeding may originate anywhere from oral cavity to anus from the innocuous one like peptic ulcers to capricious lesion like ca colon.Classically if the cause of bleeding is somewhere below the ligament of Treitz, the stools are maroon or bright red in colour and it is described as lower GI bleeding or hematochezia. Arterioenteric fistula signifies a rare but important cause of massive lower GI bleeding .The vexing problem lies in proper and timely diagnosis of this condition.A keen clinical acumen and proper use of tests lead to accurate diagnosis and prompt treatment and can be lifesaving for the patient by treating significant ongoing bloodloss. We wish to report such a case of an arterio-enteric fistula between artery of broad ligament of uterus and terminal ileum diagnosed and successfully treated at our institute .

Keywords: Arterioenteric fistula, massive GI bleed, rare cause

INTRODUCTION Arterioenteric fistula is a anomalous

anemia. She had undergone exploration

communication

&

for ectopic pregnancy 1 month back at a

gastrointestinal tract. It is a rare cause of

private hospital..On 8th post operative day

massive lower GI bleeding with the

she had complained of three episodes of

dreaded aortoenteric fistula leading to

per rectal bleeding which was associated

massive and many times fatal GI bleed.

with giddiness and profound weakness.

between

artery

Her sigmoidoscopy had been done and no CASE REPORT

abnormality was detected.Patient had been

A 28 yr lady presented with complains

transfused, stabilised and subsequently

of recurrent per rectal bleeding and severe

discharged .She whad been stable for the http://www.srji.co.cc

next 20 days and now presented with

exploratory

above complains of recurrent per rectal

resuscitation of the patient was taken.

bleeding and severe ere anemia. Patient was

On exploratory laparotomy there was

investigated. Hematological investigations

evidence off

showed low haemoglobin hb-55 gm% with

posterior aspect of the broad lig. of

reticulocytosis. Platelets were adequate

uterus (site at which the gestational sac

and bleeding and clotting time was normal.

of previous ectopic was present.) Ileum

Serum Beta hCG was elevated .Upper GI

was separated from adhesion site. Erosion

scopy

O On

of ileum wall with bleeder at site of

finding

adhesion to broad ad ligament was found.

observed was presence of blood clots near

The site of adhesion on the broad ligament

caecum.

showed necrosis.

showed

colonoscopy

no

only

USG

abnormality. significant

was

suggestive

of

laparotomy

adherent

after

ileum

proper

to the

heterogeneous mass in right adnexa with left ovarian cyst. CT confirmed the ultrasound findings.

Pt was transfused with 3 pints of PCV. Her condition ition improved and she remained stable for next 8 days .On 9th day she developed three episodes of massive per rectal bleed and went into hypovolemic

Fig.1: Involved Ileal Segment

shock. Her pulse rate was 146/min, BP

Thus this was a case of arterioenteric

90/60 mm of hg. Patient was pale and

fistula between the adherent ileum and a

dehydrated.

an any

branch of the ovarian artery supplying the

hematemesis and ryleâ&#x20AC;&#x2122;s tube aspirate was

broad ligament. All ll bowel adhesions were

clear. Due to absence of hematemesis and

separated.

pain in epigastrium upper GI bleeding was

hysterectomy was done. Adherent and

less likely. Also patient had a history of

eroded segment of ileum was resected.

abdominal

Intra-operative operative

arterioenteric

She

did

not

exploration.

an

bleeder

as

enteroscopy

ligated

both

antegrade and retrograde was done in the

Advanced investigation tion modalities like

ileum to rule out any othe site of GI bleed.

angiography and technicium99 labelled

Ileo-ileal ileal anastomosis was done.

rbc scan was unavailable at our institute.

Postoperatively the patient was monitored

Hence

in surgical intensive care unit. Patient

decision

was

Thus

The

suspected.

a

fistula

have

for

emergency

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

59

received 3 blood transfusions. Patientâ&#x20AC;&#x2122;s

tuberculosis,

non

steroidal

anti anti-

general condition improved steadily and

inflammatory

drug

enteropathy

and

patient was discharged on 14th post

enteric fever are the major causes of lower

operative day.

GI bleeding in India.2,3 Small bowel

tion of resected specimen of Gross observation

sources and other colonic pathologies like

ileum and uterus with broad ligament as

small

well

analysis

inflammatory bowel diseases, neoplasia of

suggested a arterio-enteric enteric fistul between

small and large bowel, angiodysplasia,

the ileum and the broad ligament of the

aorto-enteric enteric

uterus.

radiation colitis are uncommon causes but

as

histopathological

bowel

diverticular

fistula,

disease,

ischaemic

and

pose a challenge to the clinician in making correct preoperative diagnosis.3,4 It is imperative to localize the source of bleeding preoperatively for successful treatment. Only rarely does laparotomy need to be performed in emergency without

knowledge

of

the

s site

of

hemorrhage.5 The diagnostic work-up work should be done as soon as the resuscitation is over and the general condition stabilizes.

The first step is nasogastric aspiration and upper

gastrointestinal

endoscopy

Fig.2. & 3: Resected esected specimen of uterus

(esophago-gastroduodenoscopy) gastroduodenoscopy) to rule

(gross)

out upper er GI hemorrhage since peptic ulcer bleeding may be the cause of

DISCUSSION

hematochezia and malena. Proctoscopy

The causes of lower GI bleeding shows a

and sigmoidoscopy (rigid or flexible) are

geographical

relatively simple procedures to exclude

variation,

wit

colonic

diverticulitis and vascular ectasia of colon

hemorrhage

below

are the most common causes in the West.1

reflection

Idiopathic ulcerative colitis, acute colitis,

hemorrhoids, orrhoids, rectal polyps and growths.

colonic polyps, solitary rectal ulcer,

Colonoscopy, visceral angiography and

colonic carcinoma, ileal and colonic

abdominal scintigraphy with 99m Tc

such

as

the bleeding

peritoneal internal

labeled RBCs are three useful tests for http://www.srji.co.cc

localization.5 Colonoscopy may be most

adhesion formation as seen sometimes as

useful if the bleeding has stopped or at

a sequele of mesenteric venous thrombosis,

least slowed substantially.

malignancies and fungal infection. A case

Selective visceral angiography is very

has been reported where mucomycosal

useful if the patient is having active

invasion took place into the iliac artery

bleeding to locate exact site of bleeding.

causing severe haemorrhage, in a case of

Abdominal scintigraphy with 99m Tc

non

labeled RBC infusion is helpful in

chemotherapy.8 In this case, the cause of

delineating the site of bleeding when

arterio-enteric fistula formation was due to

bleeding is intermittent and at a rate below

continued

that which is detectable by angiography.

incompletely removed gestational sac &

In case the above facilities are not at hand,

as the syncytiotrophoblast has invading

a combination of sigmoidoscopy and air

property.9 It has eroded the ileum &

contrast barium enema may be tried if

fistula is formed between uterine artery of

patientâ&#x20AC;&#x2122;s general condition permits.6 We

broad

have searched the literature on the subject

Monitoring of trophoblastic activity can

and have come across some pathological

be done by estimation of serum beta HCG

conditions leading to fistula formation

levels.10

between aorta and the intestine.7,8

In the above case report we have

Abdominal aortic aneurysm and infective

presented a case of arterio-enteric fistula

aortitis may lead to primary aorto-enteric

between ileum and broad ligament of the

fistula but in most of the cases the

uterus. This is a very rare pathology and

bleeding occurs due to erosion of aortic

has seldom been reported. We hypothesize

vascular prosthesis through the wall of

that the ectopic pregnancy and exploratory

distal duodenam due to prolonged contact

laparotomy for the same probably created

between prosthetic graft and a fixed

a inflamed and eroded surface on the

segment of intestine (secondary aorto-

broad ligament where ileum adhered. The

enteric fistula). Bleeding may occur due

ileal wall was further eroded .The

to dehiscence of the anastomosis with

inflammatory process exposed a artery on

bleeding into the bowel lumen from the

the broad ligament and this adhered to the

edges of the eroded intestine.7

ileum cresting the arterioenteric fistula.

The intestine may take blood supply from the anterior abdominal wall due to

Hodgkinâ&#x20AC;&#x2122;s

lymphoma

trophoblastic

ligament

&

receiving

activity

terminal

of

ileum.

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

61

REFERENCES: 1. DeMarkles MP, Murphy JR. Acute lower

gastrointestinal

bleeding.

Invest

Clin

2002

Mar-Apr;

52(2):119-24.

Med Clin North Am 1993 Sep; 6. Mark HB, Robert B, Mark B.

77(5):1085-100.

Merk 2. Goenka MK, Kochhar R, Mehata SK.

Spectrum

gastrointestinal

of

lower

hemorrhage:

an

Manual

Diagnosis

and

Therapy. Seventeenth Edition Sec –

3,

Ch-22.

Gastrointestinal

Bleeding.

endoscopic study of 166 patients.

Indian J Gastroenterology 1993

7. Kahhlke V, Brossmanm J, Klomp HJ. Lethal hemorrhage caused by

Oct; 12(4):129-31.

aortoenteric 3. Anand AC, Patnaik PK, Bhalla VP,

fistula

following

stent

implant.

endovascular

Choudhary, et al. Massive lower

Cardiovasc Intervent. Radiol 2002

intestinal bleeding – a decade of

May-Jun:25(3):205-7.

experience.

Trop

Gastroenterol 8. Mir N, Edmonson R, Yeghen T,

2001 Jul-Sep;22(3):131-4.

Rashid 4. Miller

LS,

Barbarvech

C,

H.

Gastrointestinal

mucormycosis

complicated

by

Friedman LS. Less frequent causes

arterio-enteric fistula in a patient

of lower gastrointestinal bleeding.

with non-Hodgkin’s lymphoma.

Gastroenterol

Clin

Clin

North

Am

Lab

Haematology

Feb;22(1):441-4.

1994 Mar;23(1):21-52.

5. Gracia Osogobio S, Remes Troche

9. Datta;

textbook

JM, et al. Surgical treatment of

gynaecology;6th

lower digestive tract hemorrhage –

2;page no.23

Experience

at

the

2000

of

edtn;chapter

Institute

Nacional de ciencias Medicas Y Nutricion Salvador Zubiran.Rev

10. Datta;

textbook

gynaecology;6th

of

edtn;chapter

15;page no.186.

http://www.srji.co.cc

CORRESPONDENCE: *Assistant Professor Surgery, Dr. Shankarrao Chavan Govt Medical College, Nanded, Maharashtra; **Resident 3rd yr General Surgery, Dr. Shankarrao Chavan Govt Medical College, Nanded, Maharashtra; ***Assistant Professor Surgery, Dr. Shankarrao Chavan Govt Medical College, Nanded, Maharashtra. E-mail id: i.mandar@hotmail.com Mob no: 09975033726

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

63

All-Oxide Solar Cells: The Way of the Future Akshay Vijay Dongarwar* Abstract: We as a world are looking at our globe depleting of its natural resources. The quantity of coal presently available can lead us through for twenty more years at maximum considering the growing demand for high quality coal and natural resources and to suffice the growing population and bettering lifestyle. Again, on one side we have cut throat technological advancement in the silicon valley and the mobile world and on other, we have fairly advanced technologies for bringing in better, faster, more efficient and cheaper solutions to the environmental concerns. The question is basically inspired from this ever daunting situation. Canâ&#x20AC;&#x2122;t we have a cheap and highly effective solar energy treatment plant which can actually reach poor countries and help them get over their energy crisis without undergoing high-end processing in posh labs like is done for silicon cells? Even in one of the fastest growing economies of world, India, silicon processing is not done by any industry commercially to make solar cells. All the pre-processed cells are imported and further distributed because of the complexity in the process. Also, being cheap and easily available, it must have a huge life like silicon cells have. So, it should possess the best of silicon while eliminating the negatives. Can we find an alternative to conventional solar cells that can reach out to everyone?

Keywords: All Oxide Solar Cell

THE QUESTION We as a world are looking at our globe

demand for high quality coal and natural

depleting of its natural resources. The

resources and to suffice the growing

quantity of coal presently available can

population and bettering lifestyle. Again,

lead us through for twenty more years at

on

maximum

technological advancement in the silicon

considering

the

growing

one

side

we

have

cut

throat

http://www.srji.co.cc

valley and the mobile world and on other,

polish of cavity from atmospheric reaction.

we have fairly advanced technologies for

Such cavity behaves as metal-metal

bringing in better, faster, more efficient

junction solar cell (termed M-M cavity

and

solar cell).

cheaper

solutions

to

the

environmental concerns. The question is

But using nanowires and nanotubes

basically inspired from this ever daunting

increases the functionality further as

situation.

diffraction light rays occurs. Again, using

Canâ&#x20AC;&#x2122;t we have a cheap and highly

metal oxide makes further sense as they

effective solar energy treatment plant

are chemically under

which can actually reach poor countries

equilibrium. Another approach is used

and help them get over their energy crisis

which is of titanium dioxide for photo-

without undergoing high-end processing

sensitization.

thermodynamic

in posh labs like is done for silicon cells?

Even in one of the fastest growing

RESEARCH

economies

silicon

The main challenge with producing a solar

processing is not done by any industry

cell with whole new materials is the

commercially to make solar cells. All the

availability of photo sensitive materials

pre-processed cells are imported and

and their production. I had prepared a

further

project

of

world,

distributed

India,

because

of

the

for the prestigious

â&#x20AC;&#x153;KVPYâ&#x20AC;?

complexity in the process. Also, being

scholarship, where I tried to theoretically

cheap and easily available, it must have a

explain the use of metal-metal junction

huge life like silicon cells have. So, it

cavity cell for emitting electrons. The

should possess the best of silicon while

same research is used here, but with some

eliminating the negatives. Can we find an

changes to make it further effective and to

alternative to conventional solar cells that

eliminate short-comings. Here, I present

can reach out to everyone?

an all-oxide solar cell fabricated from vertically oriented zinc oxide nanowires

HYPOTHESIS

and

cuprous

oxide

nanoparticles.

It

A cavity of metal m2 (W2) with thin

consists of vertically oriented n-type zinc

polish of metal m1 (W1, W1<W2) on

oxide nanowires, surrounded by a film

inner surface, with a pin hole is kept at the

constructed from p-type cuprous oxide

focus of the solar concentrator coinciding

nanoparticles. The idea behind using

the pinhole and focus. Pinhole is covered

metal oxides is to eliminate the effects of

with transparent glass to protect inner

atmosphere. Oxides being benign, are safe

Vol.1 ● No.4 ● 2012

Scientific Research Journal of India

65

from environmental contamination. The

5 mM solution of zinc acetate dihydrate in

use of cuprous oxide as solar cells is a

absolute ethanol was prepared. Two drops

very well studied since last 20 years.

of this solution were placed onto an

Adding another metal-oxide film seemed

indium tin oxide (ITO) coated glass

difficult at first as the oxides are already

substrate (Thin Film Devices, ~40-50

in stable states and to make use of metal-

Ω/square). The substrate was then rinsed

metal junction films, we had to change the

with absolute ethanol and blown dry with

physical properties to excite them. But,

nitrogen. The dropcasting, rinsing and

with the knowledge of photo-electricity

drying was repeated four times per

(diffusion) that I had acquired in the

substrate.

recent months made me think a step

annealed in air at 350°C for 30 minutes,

further and the idea of using nanowires

converting the Zn(OAc)2 into ZnO, and

and nano-particles that respond better to

then cooled to room temperature. This

incident light seemed possible.

process was then repeated a second time

In the second part, I used titanium dioxide,

to ensure a conformal layer of ZnO.

another successful oxide to take in the

The nanowires were then grown by

solar

into

placing the seeded substrate in an aqueous

electricity (Research done by Dr. M.

solution containing 25 mM zinc nitrate

Graetzel ). The cell was not taken as it

hexahydrate,

was. I just used pure titanium dioxide dust

hexamethylenetetraamine,

here as polyphyrine derivatives. I did not

polyethyleneimine at 90°C. The substrate

use dyes as is done in Graetzel cell but

was suspended upside-down to prevent

instead let the oxide in white colour. Its

any

property of reflecting back visible range

accumulating on the surface. Typical

light was later used and sorted out with

growth times ranged from 30-60 minutes,

design.

engineering

yielding wires that averaged from 400-

background, I designed a model, that

1000 nm in length and 30-50 nm in

could make use of both these oxide films

diameter. After the growth, the nanowire

efficiently and expected to get a desired

arrays

output of >12% efficiency.

deionized water, then annealed at 400°C

light

and

Being

convert

from

an

them

The

larger

were

substrates

were

25

ZnO

rinsed

then

mM and

5

aggregates

thoroughly

mM

from

with

for 30 minutes to remove any residual EXPERIMENT

organics on the nano wire surface.

Zn oxide film preparation:

http://www.srji.co.cc

air. After 12 hours, the burgundy solution turned into deep green, indicating the oxidation of the copper nanoparticles into Cu2O. The Cu2O nanoparticles underwent further cleaning by repeated precipitation with ethanol. Finally, the nanoparticles were dispersed in toluene for dropcasting onto the ZnO nanowire arrays.

The processing required no posh research labs and could be done without much efforts.

The titanium oxide film is prepared the usual Graetzel cell way. Except, we do not use dye. The main motto was to simplify the

process.

Dying

induces

lot

of

The Cu2O nanoparticles (NPs) were

complexity and we want the process to

prepared as follows:

remain easy.

A solution of copper (I) acetate (0.5 g), trioctylamine (15 mL) and oleic acid (Alfa

DATA

Aesar, 99%, 4 mL) was flushed with

The complete experiment was done by

nitrogen, then rapidly heated to 180째C

using

under nitrogen flow. The solution was

disposal. Instead of using the paraboloid

maintained at this temperature for 1 hour,

sun-tracking reflector concentrator, a fine

then was quickly increased to 270째C and

beam of SODIUM VAPOUR LAMP was

held for one additional hour, ultimately

used to create a similar effect. The metal-

producing a burgundy colloidal solution,

metal oxide junction solar cell and the

which are metallic copper nanoparticles.

titanium oxide cell were tested over a long

The

period of time to get accurate readings.

solution

was

cooled

to

room

the

available

technologies

at

temperature, at which point absolute

The cuprous oxide-zinc oxide junction

ethanol was added to precipitate the

cells were studied first as they formed the

nanoparticles.

was

key research. A fine layer of the junction

removed and the nanoparticles were

nanoparticles was taken and placed in a

redispersed in hexane and then exposed to

small glass box. The glass was designed in

The

supernatant

such a way that it didnt let the incident

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

67

light get out and caused multiple internal reflections, thereby reproducing the effect

OBSERVATION

as we see in the model. The input currents

The observations of the experiment that I

and output currents were first measured

performed are listed below

for a silicon solar cell of known efficiency.

For the Metal-metal oxide junction cell:

It gave the total losses caused due to

Sr No

Voltage (V)

wire. Considering the same,the silicon

1

11.5

Output Current (mA) 100

solar cell was replaced by the meta-metal

2

10.6

99

3

11.4

100

atmosphere and other resistances in the

junction cell. Calculating the output currents for same input current given t sodium vapour lamp and subtracting the effects of losses previously calculated, the efficiency was calculated to be The details of the experiment are given as follows There were mainly 2 methods employed to double check the results 1) V-A meter, where voltage of input was

Max power point 1.146 w Light irradiance 1000 w/m^2 Area is 12*8cm^2 or 0.0096 m^2 Efficiency=11.9374

For the titanium dioxide cell Sr No

Voltage (V)

1

10.2

Output current (mA) 100

2

10.3

100

3

10.2

99

noted and then the output current. Thus the power of cell was measured.

2) A solar cell's energy conversion efficiency (eff), is the percentage of incident light energy that actually ends up as electric power. This is calculated at the

Max power point 1.0243

maximum power point, Pm, divided by

Light irradiance 1000w/m^2

the input light irradiance (E, in W/m2)

Area is 12*8 cm^2 or 0.0096 m^2

under standard test conditions (STC) and

Efficiency= 10.6697

thesurface area of the solar cell (Ac in m2). eff=P/EA

Now, we observe that the efficiency of the

Similar procedure was carried out for

proposed cells with the given design

Titanium dioxide cell.

comes out to be quite more than that of the

The net efficiency was found out as

silicon cells. Thus, one coupling the cells,

12.2374%

the efficiency will increase further. http://www.srji.co.cc

Here, an interesting trend observed is that

importing silicon cells was never cheap.

the maximum power point doesn't change

Hence,

much for a considerable change of input

advanced institutes in the nation like IITs

voltage in case of metal-metal oxide

and

junction cells. The reason is unknown.

bettering the scope of the idea can be done.

here,

NITs

the

with

technologically

implementation

and

A major issue was designing.

•

CONCLUSION

How could we make most of the

Thus, as the results showcase, using some

sunlight. The answer came with

of the most common oxides and some

the paraboloid concentrator.

simple

primary

treatment

processes

•

How could we use it at all times

coupled with engineering ideas, we were

during the day? The secret lied

able to increase the efficiency of solar

with the solar tracking device

energy

which had become pretty common.

harnessing

devices

by

an

outstanding ~6-7% (results show 4.3% but

•

How would we place the cells to

that is under lab conditions).

get output from both? The design

Thus, the basic idea of trying to use the

came to me by instincts. After a

metal oxides arising from a simple urge to

host of designs, the most suitable

use environmentally inert materials turns

and easy to construct was used.

out to be a revolutionary alternative for

•

Titanium di-oxide reflects back the

the conventional silicon solar cells. The

visible light. I offered a solution in

trait that make the idea highly successful

the design.

is that the processing is very easy and can

•

At some places, the solar energy is

be done on a commercial level with some

directly used for heating purposes.

material engineering guidance. Also, it

Thus a band filter can be employed

turns out to be a relief for countries like

to filter out the harmful ultraviolet

India and other developing countries as

and

infra-red

light.

CORRESPONDENCE: *29, Nelco Housing Society, Near Nagarjuna Trust Hospital, Khamla-Nagpur-440025. Contact- +91 9175017645, Email-id: adongarwar@gmail.com

Vol.1 â&#x2014;? No.4 â&#x2014;? 2012

Scientific Research Journal of India

69

Call for Papers Scientific Research Journal of India (SRJI) globally welcomes research scholars & scientists from different fields of science like Botany, Zoology, Medical Sciences, Agricultural Sciences, Environmental Sciences, Natural Sciences, Anthropology etc to contribute their researches in this Open Access Publication. ::For full detail kindly visit:: http://www.srji.co.cc

http://www.srji.co.cc

This page is intentionally left blank