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Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 3, Issue 1, 2014

Editor-in-Chief

Umer Sheikh, MSc. Advancing Physiotherapy (UK), MSc. APA (Ireland/Belgium), MCSP (UK), SRP (UK), MAACP (UK), BSPT (PU), MPPS (PK) - Woking, UK

Associate Editor

Adnan Khan, MSc (UK), MCSP (UK), MICSP (Ireland), MAACP (UK), BSPT (PU) Staffordshire, UK

International Advisory Board

Editorial Board

Muhammad Atif Chishti, MSc. Musculoskeletal Physiotherapy (UK), MCSP (UK), SRP (UK), MAACP (UK), BSPT (PU), MPPS (PK) Middlesborough, UK Sameer Gohir, MSc Sports Physiotherapy (UK), MSc APA (Ireland/Belgium), MCSP (UK), SRP (UK), MISCP (Ireland), MSHC (KSA) - London, UK Rashid Hafeez M.Phil (Physiotherapy), MSc. APA (Belgium/Ireland), BSPT (PK) Dr. Fariha Shah, DPT (USA) - Lahore, PK Mohammad Bin Afsar Jan, MSPT (AUS), BSPT (PK) - Peshawar, PK

Shumaila Umer Sheikh, MSc Paediatric Physiotherapy (UK), MSc APA (Belgium/Ireland), MISCP (Ireland), BSPT (PU) - West Byfleet, UK Muhammad Atif Khan, BSc, MSc, Pgd (Ortho med), ESP, Spinal Practitioner, Berkshire, UK Muhammad Asim Ishaque, MSc Musculoskeletal Physiotherapy (UK), MCSP (UK), SRP (UK), BSPT (PK) London, UK Dr Junaid Amin DPT (PK), BSPT (PK) KSA Shahbaz Iqbal MSc Physiotherapy (USA), tDPT (USA), McKenzie Cert.

Managing Editor

Beenish Zaman, tDPT (PK), BSPT (PK) Lahore, PK

This journal subscribes to the principles of the Committee on Publication Ethics http://publicationethics.org/

The Journal of Postgraduate Institute of Physiotherapy Visit the journal website at http://www.pgip.co.uk/jopsm

JOPSM Editorial Office | 4 Brantwood Drive, West Byfleet, Surrey, United Kingdom E-mail: info@pgip.co.uk


Journal of Physiotherapy & Sports Medicine (JOPSM) Volume 3, Issue 1, 2014 Table of Content

Editorial........................................................................................................................................01 Lower Extremity Muscle Activity during Squatting with Unstable Shoes.…….…………………………………………………………………………………………………………………..................03 Effects of low frequency electrical stimulation on fracture healing of long bones of lower limb……………………………………………………………………………………..……………………………………..……………..17 Reliability and validity of the three visual assessments of lower limb function comprising FootFAST: a repeated measure cohort study............................................…………………………………..26 A Pragmatic approach to the development of a therapeutic protocol for enhancing motor control and coordination in chronic stroke patients – Review Study .........................................................36 Effectiveness of Incentive Spirometry with and Without Deep Breathing Exercises In Post-Coronary Artery Bypass Grafting Physical Therapy Management……………………..………………………………………..49 Guidelines for Authors..................................................................................................................56

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy

JOPSM Editorial Office | 4 Brantwood Drive, West Byfleet, Surrey, United Kingdom E-mail: info@pgip.co.uk


[Editorial]

Thinking beyond Horizons Chishti Muhammad Atif1, Sheikh Umer Qaiser2

Physiotherapists in the UK are the first in

Physiotherapists will now be able to

the world to be able to independently

deliver more effective patient services,

prescribe medication to their patients.

give patients a better experience, free up

Indeed, it is a very historic event and

valuable GP time and promote the value of

shows recognition of our profession by

physiotherapy in managing care pathways.

other

health

professions.

Previously,

physiotherapists must refer a patient to a GP in order to get a prescription. Now practitioners can issue prescriptions after completing a training course and are able to prescribe medications in their specific

independent prescription and there are ongoing

misconceptions

regarding

independent prescription. We would like to clarify this in wider interest of profession. Independent prescribing is the process by

area. An independent prescriber is someone who is able to prescribe medicines on their own initiative

from

the

British

National

Formulary (BNF). Eight Physiotherapists who

There have been numerous queries about

have

trained

in

South

Bank

University in London have already started prescribing and imprinted their names in the history. These physiotherapists have

which a practitioner is responsible and accountable for the assessment, diagnosis and treatment of a patient’s condition and for

decisions

management

about

the

required,

clinical including

prescribing. Only GP’S and dentist were allowed

previously

to

prescribe

independently.

become pioneers after attended one of the

There

has

been

UK’s first independent prescribing courses

physiotherapists to be able to prescribe and

for physiotherapists and other allied health

the move comes after 10 years of

professionals.

campaigning by the Chartered Society of Physiotherapy.

growing

Advanced

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][Dec 2014]

need

for

practice

Page 1


[Editorial] physiotherapists are now able to prescribe

advanced practitioners in musculoskeletal,

any licensed medicine relevant to their

neurology and cardio respiratory fields and

particular scope of practice, and for a wide

now

range of conditions such as asthma,

prescription

neurological disorders, rheumatological

professional growth and recognition.

conditions, women’s health problems and pain. This means that physiotherapists will have similar prescribing responsibilities to nurses and pharmacists.

has to complete recognised independent course.

Not

all

the

physiotherapist will be able to prescribe, only

advanced

new will

era

of

lead

independent to

further

These extended roles on one side are a token of appreciation of continuous hard work of professionals but it does not undermine basic physiotherapist skills

To be eligible to prescribe, Physiotherapist prescription

this

physiotherapist

practitioners working in a specialist area

which are at the very heart of profession. I wish this new era will open the new horizons for our profession and hopefully other countries will follow the same foot step.

on completion of appropriate training will be able to prescribe. Essential elements include appropriate training and skillsbased recognition within the discipline and the broader health team, and the need to overtly demonstrate effectiveness and

Corresponding Author 1 Atif Chishti Extended Scope Practitioner Connect Physical Health, Essex 36 Apex Business Village Cramlington, Northumberland, NE23 7BF 2 ICATS Extended Scope Practitioner, Oxleas NHS Foundation Trust, UK

safety. The whole process will not only improve patient’s adherence to the treatment but will also improve their experience of health system through easy access to medicine and improve delay in patient care, quality of care and patient pathways. With the greater recognition comes the greater responsibility. Physiotherapist have

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy

proven record of working successfully as

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][Dec 2014]

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[Research Report]

Lower Extremity Muscle Activity during Squatting with Unstable Shoes Horsak Brian1,2, Hochhauser Manon1, Bruckner Johannes1, Brauneis Werner1,2, Wondrasch Barbara1,2, Figl-Hertlein Astrid1,2

Abstract: Objectives: In physiotherapy, squat exercises are commonly used to strengthen lower

extremity muscles. Wearing an unstable shoe construction can increase muscle activation during walking and running. However, little is known about their contribution to muscle activity when wearing them during squatting. The aim of this study was to assess changes of the mean activation of selected lower extremity muscles during squat exercises. Design: Controlled laboratory study using a repeated-measures, counterbalanced design. Setting: Twelve healthy subjects were recruited (6 men, 6 women; mean±SD: age, 25±7

years; height, 1.71±0.9 m; body mass, 65±10 kg). Main outcome measures: Mean activation of the vastus medialis, gluteus maximus, tibialis

anterior and gastrocnemius medialis of the dominant leg were monitored during three squat exercises using regular and unstable shoes. A two-way repeated-measures ANOVA was utilised to identify changes in mean activation between both test situations. Results: Muscle activation for all exercises increased for vastus medialis by 9% and for

tibialis anterior by 13% when using unstable shoes (p<0.05). The gluteus maximus and gastrocnemius medialis failed to reach significance. Conclusion: Even though vastus medialis, as part of one major muscle group to train with

squats, showed a slight increase, no changes were observed for gluteus maximus and gastrocnemius. Therefore, unstable shoes do not seem advantageous in increasing muscle activation during squatting.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] Keywords: biomechanics/lower extremity, electromyography, strength training, unstable shoes

Introduction

increases

Squatting and its variations are widely

material in the medio-lateral direction

used exercises to train lower extremity

(Figure 1).

muscles in physiotherapy and fitness training1–4. The main purpose of squat training is to develop strength in the lower extremities and the lower back. Healthy function of these muscles groups are a basic prerequisite for participating in sports activities and for activities of daily living. The double-leg squat exercise performed with and without an additional barbell (e.g. back squat) and variations of the single-leg squat are often used in physiotherapy and fitness practice. Major lower extremity muscles involved during these

squatting

quadriceps,

exercises

hamstrings,

are

the

gastrocnemius,

gluteus maximus as well as muscles encompassing the ankle and hip joints3,5.

instability through

its

soft

Research has suggested that such unstable shoe constructions produce changes in kinematics and kinetics, as well as changes in muscle activation patterns of the lower extremity during gait and standing6–8. One of the findings from recent research was, that wearing unstable shoes increases body sway in stance6,9. Due to this increased instability, important

a

continual

stabilizing

activation

lower

of

extremity

muscles is needed to maintain postural stability9. It has been shown that walking and standing in unstable shoes increases the activity of lower limb muscles (e.g. gastrocnemius,

vastus

lateralis

and

medialis and gluteus maximus) and, as a result, could provide a sufficient stimulus

In the past few years, unstable shoe

for training these muscles7,9. Based on

constructions

popular,

these results, it is suggested that unstable

especially for training lower extremity

shoes could be beneficial for training

muscles during walking and standing,

postural stability and strength7,9–11. There

hence during daily living. Masai Barefoot

is also a significant amount of evidence

Technology (MBT, Winterthur, CH) is

showing that training on unstable surfaces

such an unstable shoe construction. The

(e.g. wobble boards, soft pads) can

MBT shoe has a rounded sole providing

improve global knee function, as well as

instability

dynamic knee stability4,12,13.

became

in

the

more

anterior-posterior

direction and a cushioned heel, which

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] Additionally, it was hypothesised by Kornecki

Zschorlich14

and

the

squat exercises, when using an unstable

combination of strength exercises together

shoe construction and regular training

with training on unstable surfaces, hence

shoes.

greater instability during exercises, can

activities of the vastus medialis, gluteus

stress the neuromuscular system to a

maximus,

greater extent than traditional training

gastrocnemius medialis of the dominant

methods using more stable conditions.

leg

Based

wearing

electrodes. A repeated-measures analysis

unstable shoe constructions during squat

of variances (ANOVA) was utilised to

exercises

identify global changes in mean activation

on

this

information,

could

combination.

that

muscles during three different types of

This

be

a

may

beneficial

lead

to

an

increased difficulty for the neuromuscular

Electromyographic

tibialis

were

monitored

(EMG)

anterior

using

and

surface

amplitudes between the stable and unstable test situation.

system to maintain postural and dynamic joint stability and may lead to higher muscular

activation.

Therefore,

the

purpose of this study was to compare mean activation of selected lower extremity muscles during three different types of squat exercises using an unstable shoe construction and a regular pair of training shoes. It was hypothesised that using unstable shoe constructions compared to normal

shoes

increases

total

mean

activation of lower extremity muscles during exercises.

Subjects

Twelve healthy subjects were recruited for this study (6 men, 6 women; mean±SD: age, 25±7 years; height, 1.71±0.9 m; body mass, 65±10 kg) from the local University community as a sample of convenience. Subjects were included if they were able to safely perform all three investigated types of squat exercises. Subjects were excluded if

significant

musculoskeletal

or

neurological dysfunctions were existent or in case of any history of lower extremity injury or surgery within the last half year.

Methods

The dominant leg was determined by

Study design

asking the subjects to kick a soccer ball15.

A controlled laboratory study using a

Prior to participation, all subjects were

repeated-measure, counterbalanced design

informed about the testing procedures.

was used to evaluate mean activation

Subjects

patterns of selected

participation by reading and signing a

lower extremity

denoted

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

their

voluntary

Page 5


[Research Report] University approved informed consent

Conditioning Association3 and practiced

form. Rights of subjects were protected.

these exercises to the beat of a metronome (20 beats per minute) to familiarize

Data collection and processing

All data were captured in a single testing session. A repeated measures study design was used where independent variables included three variations of squat exercises (double-leg squat, wide double-leg squat and split squat) whilst wearing either an unstable shoe construction or regular training shoes. The MBT Mahuta model

themselves with each exercise. Prior to testing, subjects warmed up by using a stationary bike at submaximal speed for 5 minutes and practiced all three exercises, without load, for a few repetitions. All warm-up activities were supervised and monitored by the investigators to reduce the possible effect of fatigue.

was used in the unstable shoe condition

Subjects then performed all three squat

(Figure 1). The conventional street shoes

exercises (double-leg squat, wide double-

of the participants were used as the regular

leg squat and split squat) for the test

(control) shoes. Exclusion criteria for the

situations with both normal and unstable

regular shoe were: heeled shoes, open

shoes. Figure 2 shows how the split squat

shoes or sandals. Dependent variables

was performed. To account for possible

were defined as the total mean activity

fatigue effects between both test situations,

(ÂľV) for the selected lower extremity

half of the subjects started with the

muscles during squatting.

unstable shoe construction, the others

Ten days prior to the testing session, the subjectsâ&#x20AC;&#x2122; individual muscular endurance training loads were determined. The external load was determined were the subjects were able to perform a maximum of about 25 repetitions for the double-leg squat3. This load then was used for all exercises and test sessions. Subjects were instructed on how to perform all three squat

exercises

in

accordance

with

guidelines of the National Strength and

started with regular shoes. Each subject then performed six repetitions for each squat exercise and for each test situation to a metronome, set at 20 beats per minute, to ensure similar rates of motion among both test situations16. Subjects were instructed to flex the hip and knee joints at one beat, getting to the lowest squat position and then extending hip and knee joints again to get back to the starting position with the following beat. After a brief rest period this procedure was repeated until six trials

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] for each squat were captured. Between the

gastrocnemius medialis of the dominant

different squat exercises, rest periods of 5

leg

minutes were given to each subject to

recommendations18.

ensure that fatigue was not an issue.

electrode was placed at the centre of the

Furthermore, individual stance width, foot

patella. In general, electrodes were placed

progression angle and step length (for the

along the longitudinal axes of each muscle

split squat) for each subject were marked

having the electrode pair itself placed

on the floor and used to establish same

above the most prominent aspect of each

foot position within each subject when

muscle. Muscles were selected according

wearing regular and unstable shoes.

to their functional contribution to squat

according

to

the

SENIAM

One

reference

exercises. Raw EMG data were captured EMG is a valuable technique for studying human movement, evaluating mechanisms involving neuromuscular physiology, and diagnosing neuromuscular disorders17. In this study, EMG data were captured using pre-gelled

bipolar

Ag/AgCl

surface

electrode pairs (Blue Sensor SP, Ambu GmbH,

DE),

a

portable

4-channel

telemetry EMG system (MyoTrace 400, Noraxon, US ) and the software Myo Research (XP Master’s Edition 1.07). The EMG amplifier base gain was 1000 with a bandwidth frequency of 20 to 500 Hz, an input impedance of >100 MΩ and a CMR of >100 dB. Prior to electrode placement the skin was shaved, slightly abraded and disinfected with alcohol. The circle shaped electrodes, with a 3 mm sensor-diameter, 13 mm gel-area and an inter-electrode distance of 35 mm were placed in a bipolar configuration at the vastus medialis,

using a sampling rate of 1000 Hz. EMG signals were full wave rectified and smoothed using a RMS with a window length of 100 ms. The beginning and end of each repetition for each squat were manually determined by one assessor by assessing when muscle activity was at baseline during rest periods, when muscle activity began to rise during descent and reached activity of rest periods again after ascent.

Maximum

differences

in

determined time intervals among each subjects’ repetitions were typically less than 8% for each squat and shoe condition. Mean muscle activity was determined by calculating the mean amplitude value (µV) of each trial. The mean amplitude value of a selected analysis interval describes best the gross innervation input of a selected muscle for a given task, because it is less sensitive

to

duration

differences

of

gluteus maximus, tibialis anterior and

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] analysis intervals than the integrated EMG

activation amplitudes between both test

and therefore, is very applicable for

situations for all exercises. ANOVA was

comparison analysis19.

run separately for all four muscles. Data were analysed and processed using a

After electrode cables were secured using elastic adhesive tape to reduce movement artefacts, the investigator inspected the correct placement of the electrodes during standing and during a squat. Then raw EMG traces were inspected during rest and contraction for clear signals with minimal offset. Because EMG data were captured without removing electrodes or altering placement between both test sessions,

custom written programme in MatLab. Statistical analysis was conducted using IBM SPSS Statistics 19. The level of significance was set a priori at 0.05 for all analyses. Reliability of all mean muscle activity parameters, based on the data from three trials under each condition, were assessed using a two-way random effects model intraclass correlation coefficient (2,1) for absolute agreement (ICC).

subjects acted as their own control. Therefore, amplitude normalisation was not required

20,21

Results

. For all mean muscle

The values for ICC for the mean muscle

activity parameters, the data from three

activation showed very good agreement

trials under each condition were averaged

reliability of 0.89 (95%CI: 0.87 to 0.90).

for each subject and used for statistical

No significant interactions were found for

analysis. Because the signals of one

the ANOVA when comparing muscle

subject showed high signal artefacts, the

activities between the shoe conditions

data was not considered in the analysis.

across squat exercises. However, there was

Therefore analysis was performed using 11

a significant main effect for the shoe

subjects.

condition. When averaging across all squat

Statistical Analyses

A two-way repeated-measures ANOVA using two within-subject factors (squat exercise: double-leg squat, wide doubleleg squat and split squat; and test situation: with regular and unstable shoes) was utilised to identify total difference in mean

exercises, the average vastus medialis and tibialis

anterior

significant

activities

increase

when

showed

a

using

an

unstable shoe construction compared to the regular shoe condition, F(1,10)=14.034, p=0.004,

respectively

F(1,10)=18.200,

p=0.002. Total muscle activation increased for the vastus medialis 8.9% (95%CI:

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] 2.85% to 14.95%) from 245.8±104.1 µV

different types of squat exercises using an

to 268.3±113.8 µV when using unstable

unstable shoe construction and a normal

training shoes compared to regular shoe

pair of training shoes. It was hypothesised

constructions. The tibialis anterior showed

that the use of unstable shoe constructions

an increase of 12.6% (95%CI: 6.10% to

will increases the mean activation of lower

19.10%)

extremity muscles during squat exercises.

from

171.9±64.2

µV

to

192.8±71.6 µV when using an unstable shoe. Both the gluteus maximus and gastrocnemius medialis failed to reach

In this study an overall increase of muscle activity was found for the vastus medialis and tibialis anterior when wearing unstable

significance.

training shoes during squat exercises There were also significant exercise effects

compared to normal shoes. Both the

present for gluteus maximus, vastus

gluteus

maximus

medialis

medialis

failed

and

gastrocnemius

medialis,

and to

The

gastrocnemius

reach

statistical

F(1.023,10.23)=13.440, p=0.004, F(2,20)=

significance.

increased

muscle

6.961, p=0.005, F(2,20)=24,292, p=0.000.

activity, when using an unstable shoe construction, is in accordance with the data

Figure 3 and Tables 1 and 2 give an overview

of

statistical

analyses

and

descriptive statistics for all muscles and exercises in both test sessions.

of Maior et al.22 who also have found greater

muscle

activation

for

the

quadriceps when using an unstable surface. They found an increase of muscle activity

Discussion

for the vastus lateralis, rectus fermoris and

Research suggests that the combination of

vastus medialis of 21%, 18% and 16% and

strength

exercises

with

training

on

assumed that an unstable condition may be

unstable

surfaces

can

stress

the

incorporated in some periods of strength

neuromuscular system to a greater extent

training to increase quadriceps muscle

than traditional training methods using

activity. In contrast Li et al.23 did not

more stable conditions14,22. Therefore, the

observe

purpose of this study was to compare mean

activation when using unstable surfaces.

activation of the gluteus maximus, vastus

They examined muscle activities for the

medialis,

and

soleus, vastus lateralis, vastus medialis,

three

rectus femoris, biceps femoris, gluteus

gastrocnemius

tibialis medialis

anterior during

any

differences

in

muscle

maximus, gluteus medius and upper

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] lumbar erector spinae during a deep squat

shoe. This could in consequence increase

task on the Reebok Core Board in

the external plantarflexion moments which

comparison to stable conditions.

will need higher activation of the tibialis anterior to sustain stability.

Most studies assessing mean muscle activity during an exercise situation used

The unstable shoe construction used in this

soft pads or similar devices as unstable

study has, next to the rounded sole, a

surfaces22â&#x20AC;&#x201C;25.

best

cushioned heel, which increases instability

knowledge this study is the first using

by its soft material in the medio-lateral

unstable shoe constructions as unstable

direction. The increased muscle activation

surfaces. These shoes have a rocker

of the vastus medialis may be ascribed to

bottom, which provides instability in the

the medio-lateral instability induced by the

anterior-posterior and the medio-lateral

cushioned

directions. The increased activity of the

medialis is primary a major knee extensor.

tibialis anterior found in this study during

Several authors have observed increased

the squat exercises may be ascribed to this

muscle activation of the vastus medialis

anterior-posterior rounded shape of the

and/or vastus lateralis while walking with

unstable shoes. While performing the squat

unstable shoes, especially during first half

exercises and flexing/extending knee and

of stance phase7,10. This increase of muscle

hip joints, the unstable shoes decrease

activation as well as concomitant co-

stance stability in the anterior-posterior

contraction of these muscles may be

direction and, therefore, the plantarflexors

ascribed to the increased instability during

and dorsiflexors have to be higher

gait and therefore as a mechanism to

activated than with regular shoes, although

manage instability10,26. However, another

only the tibialis anterior showed

a

explanation for the increased activity of

significant increase. One reason for the

the vastus medialis during squatting could

gastrocnemius medialis failing to reach

be the rounded anterior-posterior shape of

significance could be the high variability

the unstable shoes. As mentioned above,

in the data, especially for the double leg

an evoked posterior shift of the center of

squat and the split squat (Figure 3).

mass may be present, resulting in the need

Another reason might be a provoked

for an increased knee extensor torque.

posterior shift of the centre of mass due to

Another muscle which is involved in

the rounded anterior-posterior shape of the

frontal knee plane alignment is the gluteus

To

the

authors`

heel,

even

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

though

vastus

Page 10


[Research Report] maximus27. Therefore, one would expect

when performing a squat. They found that

greater muscle activation when increased

a progressively increased trunk tilt tends to

medio-lateral stance instability is present,

increase muscle activity of the hamstrings

but no changes in muscle activity were

and decrease muscle activity of the

observed in this study. Whether or not this

quadriceps. Future studies therefore should

is in consequence of the partly high

consider

variability of the data or the inability of

position. The use of a metronome for

unstable shoes in increasing muscular

establishing quasi-similar rates of motion

activation cannot be distinguished.

among test situations may also have a lack

monitoring

hip

and

trunk

of accuracy in controlling motion speed This study is subject to several limitations. The use of young healthy subjects, in general, limits the application of the findings of this study to patients and clinical settings. However, findings can be used in the setting of prevention, health promotion and strength training. Although shoe order was counterbalanced to protect against order effects, exercise order was not

randomised.

This

could

have

introduced a fatigue effect for the different squat exercises. The purpose of this study was to investigate differences between two shoe

conditions

and

not

differences

between squat exercises, and therefore any effects may be considered as negligible. As highlighted by Lubahn et al.27 trunk lean and pelvis position can have an influence on the magnitude of muscle activation. This was also shown by Ohkoshi et al.28 who analysed anterior cruciate ligament loading for different

between all performed trials. Determining time intervals for squats manually as well as calculating mean activation over the concentric and eccentric phase of the entire squat cycle may also have been a limitation in this study. While depend parameters

seemed

to

introduced

variability

be

reliable,

could

have

eliminated some important differences. Another limiting factor in this study is the use of unnormalized EMG data to quantify differences between the two test situations. Even though, other authors20,29 have adopted similar methods in analysing muscle

intensities

it

may

be

more

advantageous for future studies to use normalized data. In addition future studies may

also

include

inverse

dynamic

approaches in combination with EMG. In respect to the limitations mentioned above, results of this study show that the use of unstable shoe constructions in

knee flexion angles and trunk positions

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] healthy subjects lead to a slight increase of

References

muscle activation of the vastus medialis (9%) and tibialis anterior (13%) when performing

squat

exercises.

Our

hypothesis that squatting in unstable shoes increases muscle activation of lower extremity muscles can only be supported to a certain extent. Even though vastus medialis as part of one major muscle group to train with squats, showed a slight increase, no changes were observed for gluteus

maximus

and

gastrocnemius.

Therefore, unstable shoes at this point of view do not seem advantageous in increasing

muscle

activation

during

squatting. Research needs to address the above mentioned limitations, as well as replicate and extend these findings. Future studies may also evaluate how other types of unstable shoes, as for example toning shoes30, can contribute to muscle activity during exercises.

Conclusion Results of this study show that the use of unstable shoe constructions in healthy subjects lead to a slight increase of muscle activation of the vastus medialis (9%) and tibialis anterior (13%) when performing squat exercises. However, the practical relevance of the relatively small increase of 9% and 13% EMG activity, although statistically significant, may be questioned.

1. Andersen LL, Magnusson SP, Nielsen M, Haleem J, Poulsen K, Aagaard P. Neuromuscular activation in conventional therapeutic exercises and heavy resistance exercises: implications for rehabilitation. Phys Ther. 2006;86(5):683–97. 2. Bade MJ. Early High Intensity Rehabilitation Following Total Knee Arthroplasty Improves Outcomes. J Orthop Sports Phys Ther. 2011;41(12):932–942. doi:10.2519/jospt.2011.3734. 3. Baechle TR, Roger WE. Essentials of strength training and conditioning. Champaign IL: Human Kinetics; 2008. 4. Risberg MA, Holm I, Myklebust G, Engebretsen L. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. Phys Ther. 2007;87(6):737–50. 5. Escamilla RF. Knee biomechanics of the dynamic squat exercise. Med Sci Sports Exerc. 2001;33(1):127–41. 6. Nigg B, Hintzen S, Ferber R. Effect of an unstable shoe construction on lower extremity gait characteristics. Clin Biomech Bristol Avon. 2006;21(1):82–88. 7. Romkes J, Rudmann C, Brunner R. Changes in gait and EMG when walking with the Masai Barefoot Technique. Clin Biomech Bristol Avon. 2006;21(1):75–81. 8. Taniguchi M, Tateuchi H, Takeoka T, Ichihashi N. Kinematic and kinetic characteristics of Masai Barefoot Technology footwear. Gait Posture. 2012;35(4):567–72. doi:10.1016/j.gaitpost.2011.11.025. 9. Landry SC, Nigg B, Tecante KE. Standing in an unstable shoe increases postural sway and muscle activity of selected smaller extrinsic foot muscles. Gait Posture. 2010;32(2):215–219. doi:10.1016/j.gaitpost.2010.04.018. 10. Buchecker M, Wagner H, Pfusterschmied J, Stöggl TL, Müller E. Lower extremity joint loading during level walking with Masai barefoot technology shoes in overweight males. Scand J Med Sci Sports. 2010;22(3):372–380. doi:10.1111/j.1600-0838.2010.01179.x. 11. Stewart L, Gibson JNA, Thomson CE. In-shoe pressure distribution in “unstable” (MBT) shoes and flat-bottomed training shoes: A comparative study. Gait Posture. 2007;25(4):648–651. doi:http://dx.doi.org/10.1016/j.gaitpost.2006.06.01 2. 12. Chmielewski TL, Rudolph KS, Snyder-Mackler L. Development of dynamic knee stability after acute ACL injury. J Electromyogr Kinesiol. 2002;12(4):267–74.

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[Research Report] 13. Williams GN, Chmielewski T, Rudolph K, Buchanan TS, Snyder-Mackler L. Dynamic knee stability: current theory and implications for clinicians and scientists. J Orthop Sports Phys Ther. 2001;31(10):546–66. 14. Kornecki S, Zschorlich V. The nature of the stabilizing functions of skeletal muscles. J Biomech. 1994;27(2):215–25. 15. Bisson EJ, McEwen D, Lajoie Y, Bilodeau M. Effects of ankle and hip muscle fatigue on postural sway and attentional demands during unipedal stance. Gait Posture. 2011;33(1):83–87. doi:10.1016/j.gaitpost.2010.10.001. 16. Bolgla LA, Uhl TL. Electromyographic analysis of hip rehabilitation exercises in a group of healthy subjects. J Orthop Sports Phys Ther. 2005;35(8):487–494. 17. Kamen G, Gabriel DA. Essentials of electromyography. Champaign, IL: Human Kinetics; 2010. 18. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development of recommendations for SEMG sensors and sensor placement procedures. J Electromyogr Kinesiol. 2000;10(5):361–74. 19. Konrad P. The ABC of EMG: A Practical Introduction to Kinesiological Electromyography. Noraxon Inc.: U.S.A; 2005. 20. Edwards L, Dixon J, Kent JR, Hodgson D, Whittaker VJ. Effect of shoe heel height on vastus medialis and vastus lateralis electromyographic activity during sit to stand. J Orthop Sports Phys Ther. 2008;3(2):1:7. doi:10.1186/1749-799X-3-2. 21. Soderberg GL, Knutson LM. A guide for use and interpretation of kinesiologic electromyographic data. Phys Ther. 2000;80(5):485–498. 22. Maior AS, Simão R, Freitas de Salles B, Miranda H, Costa PB. Neuromuscular activity during the squat exercise on an unstable platform. Braz J Biomotricity. 2009;3(2):121–129. 23. Li Y, Cao C, Chen X. Similar EMG Activities of Lower Limbs between Squatting on a Reebok Core Board and Ground. J Strength Cond Res. 2012;[Epub ahead of print]. doi:10.1519/JSC.0b013e318267a5fe. 24. Saeterbakken AH, Fimland MS. Muscle force output and electromyographic activity in squats with various unstable surfaces. J Orthop Sports Phys Ther. 2012;27(1):130–136. doi:10.1519/JSC.0b013e3182541d43. 25. Zemkova E, Jelen M, Kovacikova Z, Olle G, Vilman T, Hamar D. Power outputs in the concentric phase of resistance exercises performed in the interval mode on stable and unstable surfaces. J Strength Cond Res. 2012;26(12):3230– 6. doi:10.1519/JSC.0b013e31824bc197.

26. Horsak B, Baca A. Effects of unstable shoe construction on EMG and lower and upper extremity gait biomechanics. J Biomech. 2012;45, Supplement 1:222. doi:10.1016/S00219290(12)70223-3. 27. Lubahn AJ, Kernozek TW, Tyson TL, Merkitch KW, Reutemann P, Chestnut JM. Hip muscle activation and knee frontal plane motion during weight bearing therapeutic exercises. Int J Sports Phys Ther. 2011;6(2):92–103. 28. Ohkoshi Y, Yasuda K, Kaneda K, Wada T, Yamanaka M. Biomechanical analysis of rehabilitation in the standing position. Am J Sports Med. 1991;19(6):605–611. 29. Goryachev Y, Debbi EM, Haim A, Wolf A. The effect of manipulation of the center of pressure of the foot during gait on the activation patterns of the lower limb musculature. J Electromyogr Kinesiol. 2011;21:333–339. doi:10.1016/j.jelekin.2010.11.009. 30. Horsak B, Baca A. Effects of toning shoes on lower extremity gait biomechanics. Clin Biomech Bristol Avon. 2013;[Epub ahead of print]. doi:http://dx.doi.org/10.1016/j.clinbiomech.2013.0 1.009.

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[Research Report] Figures

Figure 1. Illustration of the unstable test shoe used in this study. The rounded shape of the sole and the soft heel material induce instability during walking and standing in both the anterior-posterior and medio-lateral directions.

Figure 2. Starting/End position (A), middle (B) and lowest position (C) of the split squat exercise.

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[Research Report]

Figure 3. Total mean muscle activation (A) and mean activation for each squat exercise (B) with 95%CI bounds when performing squats with stable and unstable shoes. Positive values indicate an increase when using the unstable shoe construction. * p<0.05

Tables Table 1. Two-way repeated measures ANOVA for mean (SD) muscle activation during exercises with regular and unstable training shoes EMG (ÂľV)

RS

US

Mean activity*

Mean activity*

GM

51.2 (37.6)

VM GMM TA

Two-way repeated ANOVA

50.9 (37.0)

Shoe effect n.s.

Exercise effect 0.004

Interaction effect n.s.

245.8 (104.1)

268.3 (113.8)

0.004

0.005

n.s.

55.1 (22.4)

58.5 (20.6)

n.s.

0.000

n.s.

171.9 (64.2)

192.8 (71.6)

0.002

n.s.

n.s.

Abbreviations: RS, regular training shoe; US, unstable training shoe; GM, gluteus maximus; VM, vastus medialis; GMM, gastrocnemius medialis; TA, tibialis anterior. n.s., not statistically significant (p>0.05). * Mean muscle activity for all three squat exercises.

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[Research Report] Table 2. Mean differences (95%CI: lower to upper bound) of muscle activity between both test situations for all three squat exercises EMG (%)

Difference (US - RS) DLS

SS

WDLS

GM

3.53 (-14.2 to 21.30)

3.90 (-4.40 to 12.20)

-2.17 (-12.40 to 8.10)

VM

9.65 (-2.69 to 21.99)

8.07 (-4.45 to 20.59)

14.50 (3.85 to 25.15)

GMM

21.83 (-4.66 to 48.32)

3.16 (-31.64 to 37.96)

33.10 (9.63 to 56.57)

TA

10.53 (-0.93 to 21.99)

21.20 (-8.09 to 50.49)

15.31 (4.86 to 25.76)

Abbreviations: RS, regular training shoe; US, unstable training shoe; GM, gluteus maximus; VM, vastus medialis; GMM, gastrocnemius medialis; TA, tibialis anterior; DLS, double-leg squat; SS, split squat; WDLS, wide double-leg squat.

Source of funding: This study was supported by the St. Poelten University of Applied Sciences.

Corresponding Author * Brian Horsak, 3100 St. Poelten, Matthias Corvinus StraĂ&#x;e 15, AT. E-mail: brian.horsak@fhstp.ac.at 1 Department of Physiotherapy, St. Poelten University of Applied Sciences 2 Institute for Sciences and Services in Health, St. Poelten University of Applied Sciences Š 2014 PGIP. All rights reserved.

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report]

Effects of low frequency electrical stimulation on fracture healing of long bones of lower limb Sandeep1, Paramjot2, Jagmohan3

ABSTRACT Aims: This study has been designed to see the fracture healing of long bones of lower limb

with low frequency electrical stimulation. Methods: Total 5 adult patients aged above 18 years with non infected fractures with simple,

fresh (< 7 days) traumatic diaphyseal fractures of both bones of leg managed conservatively were included in this study. Electrical stimulation was given to the patients from 0 week to 6 weeks. Radiological views and RUST scores were taken at 0,2 and 6 weeks. Findings: Fracture healing was seen at 2 and 6 weeks. Statistically significant results were

found at initial and final values with p values 0.0022.In all 5 patients, we were able to predict fate of fracture healing process by serial estimation of RUST levels. Conclusion: In the present study, statistically significant improvement in RUST score has

been found after 6 weeks of treatment. Keywords: Fracture, Capacitative Coupling, RUST

Introduction

organic matrix, known as osteoid and its continuous

subsequent mineralization, thus bridging

physiological process to achieve union1.

the gap between two bony fragments

This

is

(bridging callus). This fracture healing

characterized by the production of a new

process should be serially quantifiable /

Fracture

healing

process

of

is

a

fracture

union

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 17


[Research Report] measureable8. Till date, clinically validated

more advanced imaging techniques, such

method to measure healing progression is

as nuclear scintigraphy, is still limited to

not available. So a valid measurement for

only few centers in our country7.

bony union should be desired to measure the bony union process. Thus, the values yielded by measurement should be on a continuous numerical scale17. However till now, researchers have used an end point for completely healed fracture at a point of time without documenting the values signifying progress of union before that time2.

Presently,

commonly

fracture

assessed

healing

clinically

The development of alternative techniques to treat non-union or bone defects offers promising perspectives for a large number of patients. Physicians treating fractures have an increasing variety of options available, some of which can supersede harvest of bone autograft.

is

Physical methods are non-invasive and

and

have been shown to offer beneficial effects

radiologically. The probability of correct

in

radiological evaluation of the stage of

(mechanical

union in fractures of tibia has been shown

stimulation), and in the treatment of

to be only about fifty percent. So, the

hypertrophic nonunion and congenital

radiographic assessment is not an optimum

pseudoarthroses (electromagnetic fields).

method to assess the fracture healing, a

Heckman et al (1997) stated that these

fact borne out by a study on radiological

methods

evaluation of the stage of union in

especially since some have been shown to

6

the

healing

of

fresh

loading,

may

be

useful

fractures ultrasound

clinically,

fractures of tibia . None of the available

reduce substantially the costs of treatment.

measures of union will help in the early

These techniques are non invasive and

detection of problems in the bone healing

inexpensive. Moreover the enhancement of

process,

in

fracture healing is a major issue of health-

outcome i.e. bone union . As the routine

care; with potential benefit for millions of

methods of diagnosis available may not be

patients every year3. There are currently

able to identify the complications like

three different

delayed / nonunion early, so patients will

stimulation

have to suffer for a longer period.

current capacitively coupled and pulsed

Furthermore, it is sometimes hard to

electromagnetic fields.

resulting

into

problems

5

methods of electrical

devices

available:

direct

distinguish early, a delayed union from nonunion radiologically, and the use of

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 18


[Research Report] Direct current devices require surgical

is the need of the hour to explore the

implantation and extraction, necessitating

situation and see the effect of non invasive

two additional surgeries. With direct

methods such as low frequency current on

current devices, one would use a negative

fracture healing.

cathode directly over the impaired healing site. Capacitively coupled and pulsed electromagnetic

field

devices

utilize

electrodes that one places externally on the skin4. Onibere, R. & Khanna, A. (2009) stated that electrical stimulation (ES) is therefore an alternative, less invasive form of treatment which has shown great potential in management of complicated

We designed this prospective case series to analyze the correlation of low frequency electrical stimulation with progression of fracture healing process and to evaluate the relationship

between

low

frequency

electrical stimulation and fracture healing outcome.

Material and Methods

fractures. Various human randomized clinical and animal studies have shown ES

Setting- Experimental study.

to improve fracture healing time, since ES

Location- Department of Physiotherapy,

plays a significant role in the management

Gian Sagar College of Physiotherapy,

of large scale bone defects/fracture11. In a

Banur

prospective

Hospital Ludhiana Punjab India

study

performed

on

35

&

Christian

Medical

College

nonunions treated by stimulation with

Month –April 2012-August 2013

inductive coupling, Sedel et al (1981)

Year- 2012-2013

reported positive effects in 14. There is, to

Participant-Total 5 patients above 18

our

years of age

knowledge,

prospective,

however,

randomised

only

one

double-blind

Nature of sample-Convenience sampling

study which has been performed on the use

Research variables-

of EM for treating pseudarthroses.15

 Independent variable- low frequency electrical stimulation  Dependent variable-Fracture healing

Further independent research needs to be conducted

to

make

quantified

measurements in vivo, to ascertain the role of these techniques in improving the healing of fractures with identification of

Inclusion

  

Non infected fractures Fresh (< 7 days) traumatic diaphyseal fractures of both bones of leg Types of Fractures: Transversal fracture, longitudinal fracture and

the most effective non invasive method. It

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 19


[Research Report] 

middle or distal third of tibia are included. Only patients who previously were in good health and mobile were included in the material. The patients in the stimulated group have to consent to partaking in the experiment. All patients were to be follows by the same doctor and as far as possible receive a standard treatment.

of two cutaneous electrodes on the opposite sides of the bone to the stimulated. A power source will be attached to the patients cast will connected to the electrodes forming an electric field with the fracture site. Using potentials of 1 to 10V at frequencies between 20 and 200 KHz creates electric fields of 1 to 100 mV/cm which will be efficient for bone

Exclusion

stimulation.

   

Intervention: Treatment time will be 30

 

Open wounds Infected fractures, Bone grafted fractures Patients diagnosed with diabetes mellitus (type 1 & type 2) Patients receiving immunosuppressive drugs Those not willing for inclusion in study.

minutes -1 hour 3- × daily. And will be compared with R.U.S.T taken during these visit (monthly intervals). Follow ups were done at admission, after 2nd, 6th week counted from day of trauma and last sample at clinic radiological union or at 6th month.

Study Protocol: After obtaining ethical

clearance

from

departmental

research

review committee, all 5 patients were

Tool

The tool consists of three parts:

(reduction setting and above knee Bi

Part 1: Socio demographic profile and sample characteristics Part 2: Data collection sheet on assessment of fracture by radiological images (X-Ray CT Scans). Part 3: Rust score Clinical Examination: Gentle clinical

valled or long leg splints was applied) All

examination of the fracture site was done

were discharged after 24 – 48 hours with a

at 6th, 10th week, for the assessment of –

standard advice written on discharge card.

skin condition, abnormal mobility, and

We used following research tools in our

bony tenderness. Further, follow up and

study.

management

was

decided

by

the

investigator/

co-investigators

as

per

included in this study from 2012 to 2013. Informed consent was taken. After the recording of demographic characteristics, all 5 patients were managed conservatively

Testing

Procedures

Capacitative

progression of union.

coupling involves non- invasive placement

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[Research Report] Standard

each group, a hypothesis test of the same

plain radiographs of the affected leg

variable over time was carried out using

including knee and ankle joints (AP and

analysis of variance on the repeated

Lateral views) were done and separately

measures. Statistical analysis between

these were assessed by at least 02

groups was performed using a 95%

investigators for evidence of progression

confidence interval of mean. The 5% level

of bony union, if any (as per RUST

was considered significant. All the analysis

score)12. Radiological follow ups were

were done by using SPSS Software (15.0

done at 6, 10 weeks (Further, follow up

version).

and management was decided by the

Results and Discussion

Radiological

investigator/

Examination:

co-investigators

as

per Total 5 patients were enrolled and studied.

progression of union).

Paired t-test was applied on initial and Clinical bone union was defined as the

final.

stage in the healing process when the fracture site was painless (no tenderness), motionless (no abnormal mobility) with presence

of

transmitted

movements.

Radiographic bone was defined when bony callus was evident on at least 3 cortices in standard AP and Lateral views and with

Values

Initial value

Final Values

Mean

4.00

10.25

SD

0.00

1.26

SEM

0.00

0.63

N

5

4

RUST score more than six .The individual cortical scores ( anterior, posterior, medial and lateral) are added to provide a RUST value for a set of radiographs of 4 ( definitely not healed) to 12 (definitely

P value and statistical significance- P value is 0.0022. By conventional criteria, this difference is considered to be very statistically

healed) . Confidence interval:

The

mean

values,

serially

recorded

throughout the follow up period, were compared with others subjects in the same

The mean of Group One minus Group Two equals -6.25 95% confidence interval of this difference: From -8.25 to -4.25.

group at different time intervals. The data collected were entered in Microsoft Excel and were checked for any inconsistency. In

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] Intermediate values

injury. The control group was composed of 11 patients treated with a placebo unit.

t = 9.9340 df = 3 standard error of difference = 0.629

There were five cases of nonunion of the tibia in the active group and ten in the

Discussion

control group. Healing was achieved in In our study, changes in RUST score level

60% of the patients treated by capacitative

in 5 patients paralleled the process of

coupling stimulation at a mean of 21

fracture healing as documented by clinico-

weeks, while none of the control group

radiological evidences. Fracture healing

healed.11

was seen at 2nd and 6th week. Statistically significant results were found at initial and final values with p value 0.0022. In all 5 patients, we were able to predict the fate of fracture healing process by the serial estimation of RUST levels. We observed that RUST level at 6 week was correlated with future outcome of these fractures. We may predict the future outcome of these

Similar results were found in the review made by Griffin and Bayat in 201110. Direct current was found to be effective in enhancing bone healing in spinal fusion but only LOE-4 supported its use for nonunion. Eleven studies were retrieved for

capacitive

coupling

with

LOE-1

demonstrating its effectiveness for treating nonunion. The majority of studies utilized

fractures at as early as 6 week.

inductive coupling with LOE-1 supporting In

study

and

its application for healing osteotomies and

Hausman, these potentials could play a

nonunions. In vitro studies by Ryaby

role

demonstrate

in

conducted

by

the

Rubin

process

of

Although

the

healing by changes in growth factors and

study by Scott and King, suggests that

transmembrane signaling although no clear

there are some positive effects of the

mechanism has been defined13. In order to

treatment of nonunionby electromagnetic

mimic these effects, several investigators

stimulation, these results must be assessed

have proposed administering an exogenous

in

trials

electrical field at the site of the fracture.

with

According

mechanotransduction.12

larger

comparing

controlled this

clinical

treatment

that

to

ES

Trock,

enhances

bone

Electromagnetic

conventional autograft procedures. This

fields (EM) can be delivered by direct-

consisted of 23 patients with established

current

nonunion at a mean of 28 months after

electrodes (invasive), inductive coupling

stimulation

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

using

implanted

Page 22


[Research Report] produced by a time-varying magnetic field

Unit Head, Christian Medical College and

(non-invasive), or by capacitative coupling

Hospital, Ludhiana, Dr Uttam B George,

(non-invasive)

16

. Overall, the studies,

Professor And Head, Radio diagnosis,

although in favor of ES application in bone

Christian Medical College And Hospital,

repair, displayed variability in treatment

Ludhiana for the immense support.

regime,

primary

outcome

measures,

follow-up times, and study design, making critical evaluation and assessment difficult. Electrical stimulation shows promise in enhancement of bone healing; however, better-designed clinical studies will enable the optimization for clinical practice.

Conclusion In

the

present

study,

statistically

significant improvement in RUST score has been found after 6 weeks of treatment. Simple

diaphyseal,

fresh

traumatic

fractures, the serial measurement levels during the fracture healing process in combination

with

clinic-radiological

examination can be an additional, useful, reproducible, patient-clinical friendly and cost effective tool in predicting whether fractures

are

at

risk

of

developing

complications like delayed union/nonunion and in aiding the clinician to intervene properly at an appropriate.

Acknowledgement We are grateful to Dr Jagmohan Singh, Principal, College of Physiotherapy, Gian Sagar Medical College, Banur, Patiala, Dr

References 1. Davis B.J et al.Reliability of radiographs in defining union of internally fixed fractures injury .(2005);35(6): 557-561 2. Hammer R et al, Accuracy of radiological assessment of tibial shaft fractures in humans, Clin Orth Res.(1985);19(9):233-238 3. Heckman, J.D. and Sarasohn, Kahn. J. The economics of treating tibia fractures: the cost of delayed union. Bull Hosp Jt Dis (1997);56: 63-72. 4. Jeffrey C et al. Bone stimulation for non-union: What the evidence reveals.Podiatry Today(2011);Vol.24(9):52-57 5. Marsh D.Concepts of fracture union, delayed union and non-union, Clin Orthop (1998);35(5):2230 6. Mc Closkey E.V et alThe assessment of vertebral deformity: a method for use in population studies and clinical trials, Osteoporosis International (1993);3(3):138-147 7. McKibbin BThe biology of fracture healing in ling bones, J Bone Joint Surg Am.(1978); 60(B):150-162 8. Meller Yet al. Meneral and endocrine metabolism during fracture healing in dogs, ClinOrthop (1984); 187:289-295 9. Meister, K et al The role of bone grafting in the treatment of delayed unions and nonunions of the tibia. Orthop Rev(1990); 19:260-271. 10. Michelle, Griffin. & Ardeshir, Bayat. Electrical Stimulation in bone Healing: Critical Analysis by evaluating Levels of Evidence. 2011;11:34 11. R Onibere and A Khanna. The Role Of Electrical Stimulation In Fracture Healing. The Internet Journal of Orthopedic Surgery. (2008.) 11 (2) 12. Rubin, CT. and Hausman, MR. ‘The cellular basis of Wolff’s law: transduction of physical stimuli to skeletal adaptation’. Rheum Dis Clin North Am.(1998); 14:503-517. 13.Ryaby, JT.Clinical effects of electromagnetic and electric fields on fracture healing’ Clin Orthop .(1998);355:205-215. 14 Scott G and King JB. A prospective, doubleblind trial of electrical capacitive coupling in the treatment of non-union of long bones.J Bone Joint Surg Am.(1994);76(6):820-6.

Jeewan S. Prakash, Professor Orthopedics,

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] 15. Sedel et al. Acceleration of repair of nonunions by electromagnetic fields’ Rev Chir Orthop Reparatrice Appar(1981) 16. Trock, DH. Electromagnetic fields and magnets: investigational treatment for

musculoskeletal disorders Rheum Dis Clin North Am.(2002);6:. 51-62. 17. Wade R. and Richardson J.Outcome in fracture healing – a review, Injury.2001;32 (2) ,109-114

Graphs

(RUST) SCORE

RUST SCORE

12

10

10

8

8

6

6 (RUST) SCORE

4

4

RUST SCORE

2

2

0

0 0 week

2nd week

0week

6th week

Figure 1 Patient A Graph representing RUST scores

2nd week

6th week

Figure 2 Patient B Graph representing RUST score

RUST SCORE

14 12

12

10

10

8

RUST SCORE

8

6

6

4

4

2

2

0

RUST SCORE

0 0 week

2nd week

6thweek

Figure 3 Patient C Graph representing RUST

0 week

2nd week

6th week

Figure 4 Patient D Graph representing RUST score

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] 25

RUST SCORE

20

12 10

15

8

10

6

5

RUST SCORE

4

Series3 Series2 Series1

0

2 0 0 week

2nd week 6th week

Figure 5 Patient E Graph representing RUST score

Figure 6 Rust score showing variation in patients

Corresponding Author Sandeep Singh Saini College of Physiotherapy, CMCH,Ludhiana Email:sssainicmc@yahoo.co.in Contact-0161-2660044 1. Associate Professor,College of Physiotherapy, Christian Medical College And Hospital,Ludhian, India Contact Detail- 0161-2660044 Fax- 0161-2660044 email-sssainicmc@yahoo.co.in 2. Assistant Professor, College of Physiotherapy, Christian Medical College and Hospital, Ludhiana,India Contact Detail- 0161-2660044 Fax- 0161-2660044 email- dhillonphysio@gmail.com 3. Principal, College of Physiotherapy, Gian Sagar Medical College, Banur, India Contact Detail- 09417222468 email- jagmohansingh@rediffmail.com

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report]

Reliability and validity of the three visual assessments of lower limb function comprising FootFAST: a repeated measure cohort study Marian Baxter 1, David McBride, Paul Hendrick, Daniel Cury Ribeiro

ABSTRACT Objective: To investigate the reliability and validity of FootFAST; a novel screening tool. Design: Repeated measures cohort design. Setting: Primary care, three centers involved. Participants: Eighteen participants and eighteen assessors completed the study. Participants

had no previous injury in the last three months prior to data collection. Assessors were recruited from three professional groups: registered sports medicine practitioners, clinical physiotherapists, and New Zealand army medics. All had a minimum of three years clinical experience.

Assessors independently assessed participants according to the FootFAST

protocol on three separate occasions. Inter-rater and intra-rater reliability were investigated. Criterion based validity was assessed by comparing the results from the assessors to objective, software based measures.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 26


[Research Report] Outcome measures: Cohenâ&#x20AC;&#x2122;s weighted Kappa was used to evaluate the agreement for intra-

rater reliability and criterion based validity. Fleissâ&#x20AC;&#x2122; weighted Kappa was used to evaluate inter-rater agreement. Results: Inter-rater reliability scores of all three test components were K=0.450. Intra-rater

reliability ranged from K=0.890 to 0.940. Criterion based validity ranged from K=0.390 to 0.830. Conclusion: Agreements for all three tests were above the clinically acceptable minimum of

K=0.400 except for the criterion based validity scores of the heel raise test. The results support a continued use of the FootFAST protocol, providing the recommended amendments are made to the heel raise test. Keywords: Reliability, validity, injury risk, screening tool.

Introduction

Thus, the aim of the current study was to

The traditional, but informal, screening

add to knowledge by investigating the

tool utilized within the physiotherapy and

psychometric properties of a recently

sport medicine clinic involves a visual

developed

assessment of function which aims to

FootFAST (Foot Functional Assessment)

identify those who are at risk of overuse

9

injury

screening

tool:

, the three components of which are single

injury 1. For use as a formal screening test

leg stance, hindfoot angle and the heel

the psychometric properties of these

raise test. A recent report suggests that

assessments must be measured, and adhere

these three functional tests have reasonable

to a clinically acceptable level. Clinicians

validity in the identification of overuse

must

assessments

injury risk10. More specifically, FootFAST

justify their

was able to identify between those who did

practices, and the requirement for accuracy

and did not experience a lower limb

be

aware

limitations, be

of

the

able to

of the procedures must be emphasized Research

regarding

the

2, 3

.

psychometric

properties of such tests has been a comparatively recent appearance in the peer-reviewed literature 4. Studies of this nature are somewhat scarce, and the results of such tests have been highly varied, according to a recent review 4-8.

overuse injury during a three month basic fitness training program 10. Despite

this

psychometric

encouraging properties

of

result,

the

the

test,

specifically, inter and intra-reliability and criterion based validity of FootFAST, has not been assessed. Such knowledge is essential if FootFAST is going to be

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 27


[Research Report] recommended as a clinical screening tool.

A pilot test was conducted by the authors

This

the

in order to ensure a robust methodology,

psychometric properties of the three visual

and to calculate participant and assessor

assessments of function which comprise

numbers required for an 80% powered

FootFAST.

study

study

therefore

assesses

11

. Amendments were made to the

proposed methodology based on the

Methodology

findings in order to ensure that there was

Design

minimal ambiguity in the protocol and

A repeated measures cohort study.

instructions. The pilot study indicated that,

Participants, therapists, centers

The participants consisted of eighteen New Zealand army soldiers. None of the participants had a current injury, or had experienced an injury three months prior to

to detect an agreement with a 95% confidence interval width of less than Kappa = 0.200, eighteen assessors and eighteen participants were required.

data collection, that affected their normal

Procedure

ambulation. Participants were recruited

FootFAST consists of three tests which are

from

independently assessed by the practitioner

Burnham

Military

camp,

10

Christchurch, New Zealand.

. The first test is an assessment of

hindfoot angle, and involves a visual The

assessors

consisted

of

eighteen

clinically experienced practitioners, with a minimum of three years of clinical practice. Assessors were recruited from three professional groups, who represented practitioners who would typically use such a

tool:

physiotherapists

six from

musculoskeletal the

School

of

Physiotherapy, University of Otago, six sports medicine practitioners and six New Zealand army medics who were stationed at Burnham military camp during October

estimation of the angle of the hindfoot, as the patient stands in a neutral pose, facing away from the practitioner. The second test is an evaluation of a single leg stance performance. The practitioner assesses the performance

based

on

the

patientâ&#x20AC;&#x2122;s

steadiness, and how long they can maintain the posture. The final test is an assessment of a heel raise performance, which is similarly graded based on the stability

and

effectiveness

of

the

movement.

2012. Assessors were asked to score the tests according to the FootFAST protocol

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

10

.

Page 28


[Research Report] The procedure is described in detail in

camera view and perpendicular to the

Table 1, but to provide the material for the

floor. This distance was used for scalar

assessors the hindfoot angle was recorded

calibration of these images when they were

in a still image (both with and without

viewed within the computer assisted

anatomical markers), the single leg stance

design (CAD) software program- Silicon

and heel raise test were by video footage.

CoachTM.

The images were presented in randomized sequence on a DVD sent to each assessor; the sequence generated by the random function in Microsoft Excel, and was randomized again for the two further repeated assessments, giving three sets of scores from each assessor.

Once an initial image was captured, joint markers and anatomical reference marks were placed on the participant. These mark/ers were placed in similar locations as used by Davison et al

14

, and included:

one on each ankle malleolus, one on the lateral epicondyle of the tibia, one on the

Data collection

medial epicondyle of the fibula, one on the

Hindfoot angle. The participant was in

proximal head of the calcaneus, one on the

bare feet and wore clothing above knee

fusion point of the gastrocnemius muscle

level. The distance between the ischial

and the Achilles tendon, and two marks

tuberosities (identified through palpation)

2cm in length on the lateral and medial

was measured using a 1.5 meter measuring

borders of the calcaneus where they made

tape. Lines were drawn on the ground,

contact with the ground. The participant

perpendicular to the wall, the distance

was returned to the same position as

apart as measured between the ischial

described, and a second image was

tuberosities. The participant placed both

captured.

feet on these lines, with the line running through the middle of their heel and then under the second toe. Although this may not be indicative of typical stance, it minimizes parallax error as the heel is optimally aligned within the optical field of view. 12, 13

Single leg stance. All marks and markers

were removed from the participant. The environment was set up as follows: The RS ScanTM was placed in the center of the room so that the participant could not fall or use a wall for support. Cameras were placed on the medial side and to the front

A distance reference line 10cm in length

of the planted foot. To avoid parallax error

was drawn on the wall, within the field of

the cameras were placed as far from the

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 29


[Research Report] mat as possible (12.5m, the length of the

differences between scoring outcomes was

laboratory floor), and perpendicular to the

conducted during the pilot test. It was

mat. The foot and the lower half of the

determined that the reliability of assessors

shank were included in the field of view.

from all three clinical groups were not

The participants stood on the RS ScanTM

statistically different (p-values of 0.523 to

mat with their foot pointing parallel to

0.898), and therefore no distinction was

longest side, and were instructed to stand

made as regards occupation.

in their normal posture. When instructed to, the participant lifted one foot off the ground and attempted to remain balanced for as long as possible. Once the participant could no longer maintain balance the trial was accepted as being complete. There were no practice attempts and no repeated trials. Heel raise. The environment was the same

as that for single leg stance. When instructed to, participants lifted one foot off the ground and attempted to rise unto the toes of the planted foot. The participant was requested to; if possible, remain at their maximum height reached on their toes for about three seconds. Again, there was only one attempt allowed for this test and no repeated trials.

Statistical analysis

Linear weighted Cohen’s Kappa scores were used to assess intra-rater reliability and

criterion

based

validity.

Linear

weighted Fleiss’ Kappa test provided scores of inter-rater reliability. For intrarater reliability, each assessor (N=18) completed the entire FootFAST protocol on three occasions. Cohen’s weighted Kappa score was calculated to determine the within assessor agreement level. Criterion based validity was assessed by comparing the assessor scores with those obtained from software based technology. Cohen’s Kappa was used to determine the agreement level between the assessors and the relevant software for each of the three tests.

Data analysis

For all outcomes, the clinically acceptable

Results

minimum level of agreement was taken as

No Participant characteristics are presented

Kappa greater than 0.4, as described by

in

Table

2.

The

results

from

the

15

Sim and Wright .

calculations

Outcome measures

reliability, and criterion based validity are

Each of the three tests was analyzed independently.

A

p-value

test

of

inter

and

intra-rater

presented in Table 3.

for

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 30


[Research Report] The level of intra-rater agreement was

facilitated fine tuning of the protocol and

classified as ‘very high’ across all three

instructional material, also conducive to

tests (K=0.890 to 0.940). The level of

optimal levels of reliability and validity 18.

inter-rater agreements were consistently

The inclusion of experienced assessors

K=0.450 across all three tests, and met the

also tends to improve reliability 7,

clinically

main weakness was that the assessment

acceptable

minimum

of

K>0.400. The results of the criterion based

16

. The

was, to some extent, a simulation.

validity agreements scores ranged between poor and very good (K=0.390 to 0.830). The criterion based validity comparison for the heel raise test was below the

There were similar studies identified in the literature. Haight

7

also investigated the

inter-rater and intra-rater reliability, and criterion based validity of a visually based

acceptable minimum (K=0.390).

hindfoot angle assessment, and results

Discussion

were similar to those reported here (ICC =

Our principle finding was that inter and

0.56-0.65, ‘satisfactory’; ICC = 0.88-0.98,

intra-rater reliability and criterion based

‘excellent’;

validity of the three tests comprising

‘acceptable’ respectively). In their study,

FootFAST are at a clinically acceptable

two blinded assessors visually measured

level, the single exception being the

eighteen participants on two occasions,

criterion based validity assessment for the

and

heel raise test. Further to this, the narrow

assessments made using a goniometer.

95% confidence interval widths gained across all agreement scores (less than K=0.200) suggests that there is little variability in the results 11.

and

results

19

Trojian assessors)

were

(forty and

participants,

ICC

=

compared

with

participants,

Finnoff

three

0.64-0.95,

20

assessors)

two (thirty also

investigated the inter-rater reliability of a

A key strength of the current study was the

single leg balance test. Both previous

simplicity of

studies reported inter-rater reliability of

the

FootFAST

scoring

20

system, a factor previously shown to

‘high’ or better. Further, Finnoff

decrease variability5,

. The quality of

assessed intra-rater reliability and found an

the images presented is also important 5, 17;

ICC=0.88. There were some differences

and we achieved standardisation in terms

between the results of the current and

of field of view, lighting and proximity to

previous studies with respect to scoring-

the camera. The feasibility study further

Trojian

16, 17

19

required either a ‘pass’ or ‘fail’

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 31


[Research Report] outcome, and Finnoff

20

scored the tests

latter is a time-to-boundary assessment,

based on observable faults. Despite these,

which

the results of previous studies are in

spatiotemporal characteristics of postural

agreement with the results of the current

control,

study.

detecting postural unsteadiness

Dennis et al 21 performed an inter-rater and

is

used

and

has

to

quantify

been

the

validated 22,

in 23

,

however, further research is needed to identify its limitations.

intra-rater reliability assessment of a calf raise test, which is essentially the same as

Implications for clinical practice

the heel raise test investigated in the

Our findings support those of a previous

current study. They identified ICC>0.80

study

for both inter and intra-rater reliability,

the FootFAST tool are at a clinically

which is in agreement with the reliabilities

acceptable

reported in the current study (K=0.450 to

promise as a screening tool which can

0.940). Unfortunately, no previous studies

support injury prevention programmes.

of comparison were identified which

However, we do caution that the results

investigated the criterion based validity of

may only be generalizable to assessors

either single leg balance or the heel raise

with a minimum of three years of clinical

test.

experience, novice practitioners might not

10

, that psychometric properties of

level.

It

therefore

shows

be expected to give the same results 7. The knowledge that the heel raise test does not meet the minimum standard for

The one-on-one ‘digital’ assessment of a

criterion based validity highlights the

realistic patient achieved a high level of

potential need for further development of

ecological validity, however it was not a

the test. Although it is beyond the scope of

real-time assessment, thus diminishing the

the current paper to develop this further,

external validity of the investigation. A

there are a number of potential options to

‘real

explore in this regard: restructuring of the

benefits: it allows the practitioner to view

measurement process used within the test,

the patient from any number of angles;

considering why the test is used and how it

facilitates examination of the complete

is scored, investigating the criterion the

patient and provides the opportunity to

test is scored against, or perhaps changing

perform several other tests. Because of

the comparison for the criterion based

this, although our results are promising,

validity assessment. One option for the

we cannot be certain whether we could

life’

assessment

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

has

additional

Page 32


[Research Report] replicate these findings in a real life

the clinical setting to confirm the screening

setting. Previous research has indicated

properties

that the agreement between video and real-

prevention.

time

assessments

performed

physiotherapists is highly variable

by 24

. It

may be that because the assessors in the current trial were able to replay the images as many times as they wish, and utilise ‘pause’ and ‘slow time’ features, that the performances were easier to grade. Future research should be

directed towards

of

FootFAST

in

injury

Acknowledgement The authors wish to thank all volunteers from

the

Dunedin

School

of

Physiotherapy, the New Zealand Sports Medicine Society, and the New Zealand army for

their

time

and

effort

in

completing this study.

investigating these assumptions when FootFAST is performed under clinical conditions.

Conclusion Given the lack of reliable data, the justification

for

clinical

use

of

functionally-based assessments of injury risk has been somewhat controversial. The current investigation has contributed to an under-developed

area

of

research.

However, there is a need to investigate other functionally-based assessments of injury risk to find out which are suitable, which need revision, and which should be discontinued. In summary, we find support for the continued use of the hindfoot angle and the single leg balance test. We suggest that the heel raise test be revised to improve reliability and criterion based validity. Further research should be carried out in

References 1 Lawry GV. Systematic musculoskeletal examinations. California: McGraw-Hill 2012. 2 Whatman C. Physiotherapist agreement when visually rating movement quality during lower extremity functional screening tests. Physical Therapy in Sport. 2012; 13: 87-96. 3 Whatman C, Hume P, Hing W. The reliability and validity of physiotherapist visual rating of dynamic pelvis and knee alignment in young athletes. Physical Therapy in Sport. 2012; 14: 16874. 4 Baxter M, McBride DI, Cury-Ribeiro D, Hendrick P. Psychometric properties of lower limb and lower back injury risk assessment: A narrative review. Australian Conference of Science and Medicine in Sport. Phuket 2013. 5 Gabbe BJ. Reliability of common lower extremity musculoskeletal screening tests. Physical Therapy in Sport. 2004; 5: 90-97. 6 Frigg A, Nigg B, Davis E, Pederson B, Valderrabano V. Does alignment in the hindfoot radiograph influence dynamic foot-floor pressures in ankle and tibiotalocalcaneal fusion? Clinical Orthopaedics and Related Research. 2010; 468: 3362-70. 7 Haight HJ. Measuring standing hindfoot alignment: Reliability of goniometric and visual measurements. Archives of Physical Medicine and Rehabilitation. 2005; 86: 571-75. 8 Takala EP. Do functional tests predict low back pain? Spine (Philadelphia, Pa 1976). 2000; 25: 2126. 9 Baxter M, McBride DI, Milosavljevic S, Hendrick P. A background and justification of the novel injury risk assessment protocol: FootFAST.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] Australasian Podiatric Societies Annual Conference. Sydney 2011. 10 Baxter ML, Baxter DG, Baycroft C. Lower limb injuries in soldiers: Feasibility of reduction through implementation of a novel orthotic screening protocol. Military Medicine. 2011; 176: 291. 11 Donner A. Sample size requirements for reliability studies. Statistics in Medicine. 1987; 6: 441-48. 12 Garzia RP. Foundations of Binocular Vision: A Clinical Perspective. New York: McGraw Hill 2000. 13 Simpson JA, Weinar ESC. The Oxford English Dictionary. London: Clarendon Press 2002. 14 Davidson PL. Examination of interventions to prevent common lower-limb Injuries in the New Zealand defense force. Military Medicine. 2009; 174: 1196. 15 Sim J, Wright CC. The kappa statistic in reliabiltiy studies: use, interpretation and sample size requirements. Physical Therapy. 2005; 85: 257-68. 16 Murphy DR. Interexaminer reliability of the hip extension test for suspected impaired motor control of the lumbar spine. Journal of Manipulative and Physiological Therapeutics. 2006; 29: 374. 17 Eechaute C, Vaes P, Duquet W. The dynamic postural control is impaired in patients with chronic ankle instability: reliability and validity of the

multiple hop test. Clinical Journal of Sport Medicine. 2009; 19: 107-14. 18 Meijne W, Neerbos K, Aufdemkampe G, Van Der Wurff P. Intraexaminer and interexaminer reliability of the Gillet test. Journal of Manipulative and Physiological Therapeutics. 1999; 22: 4-9. 19 Trojian TH. Single leg balance test to identify risk of ankle sprains British Journal of Sports Medicine. 2006; 40: 610-13. 20 Finnoff JT, Peterson VJ, Hollman JH, Smith J. Intrarater and interrater reliability of the Balance Error Scoring System (BESS). Physical Medicine and Rehabilitation. 2009; 1: 50-54. 21 Dennis RJ, Finch CF, Elliot BC, Farhart PJ. The reliability of musculoskeletal screening tests used in cricket. Physical Therapy in Sport. 2008; 9: 9. 22 Hertel J. Time-to-boundary measures of postural control during single leg quiet standing. Journal of Applied Biomechanics. 2006; 22: 67. 23 Hertel J, Olmsted-Kramer LC. Deficits in timeto-boundary measures of postural control with chronic ankle instability. Gait and Posture. 2007; 25: 33-39. 24 Wiles C, Newcombe R, Fuller K, Jones A, Price M. Use of videotape to assess mobility in a controlled randomized crossover trial of physiotherapy in chronic multiple sclerosis. Clinical Rehabilitation. 2003; 17: 256-63.

Tables Test Number 1 Hindfoot angle

2 Single leg stance

3 Heel raise

Assessment outcome Ideal rearfoot alignment Slightly everted Excessive eversion Inverted rearfoot greater than 4 degrees Stable Mild instability Unstable Laterally unstable Grossly unstable Smooth transition Unstable Resisted Inversion

Score 0 1 2 3 0 1 2 3 4 0 1 2 3

Table 1 The FootFAST assessment

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 34


[Research Report] Variable Sex Age Height Weight Ethnicity

Range Male (N=18) 18 to 25 years 163 to 184cm 72 to 112kg Maori (N=9) Pacifica (N=1) Asian (N=2) European (N=6)

Table 2 Characteristics of participants included in this study (N=18)

Test

Hindfoot angle

Single leg stance

Heel raise

Linear weighted Cohen’s Kappa test scores for intrarater agreement (95% confidence interval) Linear weighted Fleiss’ Kappa scores for inter-rater agreement (95% confidence interval) Linear weighted Cohen’s Kappa test scores for criterion based validity assessments (95% confidence interval)

0.920 (0.881 to 0.958)

0.890 (0.839 to 0.941)

0.940 (0.860 to 1.000)

0.450 (0.399 to 0.502)

0.450 (0.418 to 0.481)

0.450 (0.400 to 0.499)

0.448 (0.375 to 0.521)

0.830 (0.750 to 0.911)

0.390 (0.305 to 0.445)

Table 3 Kappa test scores for intra and inter-rater reliability, and criterion based validity of the three tests comprising FootFAST. Corresponding Author Marian Baxter, Marian.Baxter@aoraki.ac.nz. Aoraki Polytechnic, 32 Arthur Street, Private Bag 902, Timaru 7940. Phone: 006436855722, 0064273782757. *David McBride: University of Otago. david.mcbride@otago.ac.nz **Paul Hendrick: University of Nottingham. Paul.Hendrick@nottingham.ac.uk ***Daniel Cury Ribeiro: University of Otago. daniel.ribeiro@otago.ac.nz The corresponding author receives a PhD scholarship from The FootScience Foundation NZ. All authors receive funding in the form of salaries from their respective educational institutions. © 2014 PGIP. All rights reserved

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 35


[Research Report]

A Pragmatic approach to the development of a therapeutic protocol for enhancing motor control and coordination in chronic stroke patients â&#x20AC;&#x201C; Review Study Shashank Ghai1*, Ishan Ghai2

Abstract: This review shall help to present an ideological therapeutic practice for management of patients suffering from stroke especially with chronic duration. This incorporates evaluating, execution and arrangements of different treatment and maneuvers applied in the treatment, in a significant order, so as to enhance and produce early rehabilitation. Various rehabilitative techniques for instance relaxation technique, inhibition technique, facilitation technique, mobilization maneuvers, proprioceptive facilitation techniques in a specific pattern, might produce an efficient and viable rehabilitative approach. Formulating a functional exercise regime, post initiation of these techniques, shall produce effective results, adding to the benefits in a better rehabilitation process. In addition to these techniques, a regular motivating approach with the patient, repetition of such techniques and exercise regimes on regular

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 36


[Research Report] intervals and encouraging the patient to perform the given activities, while verbalizing them, are very important and has been found to be extremely effective. The application of manual techniques, under guidance of a highly skilled physical therapist shall have proven productive results, extremely beneficial in rehabilitating stroke patients. Keywords:

Therapeutic,

Maneuvers,

Relaxation,

Inhibition,

Facilitation,

Mobilization,

Proprioceptive

Introduction:

a sudden initiation of neurological signs many worst

and symptoms as a result of interruption in

neurological ailment ever encountered, it

blood supply to definite regions in the

affects both the physical as well as the

brain. A stroke arises as a result of

mental aspect of the patient.. If this

cerebrovascular mishaps, which could be

condition is not attended immediately the

characterized as Ischemic or hemorrhagic.

patient is left with severe physical and

Roughly

mental disabilities, fully dependent on the

cerebrovascular mishaps are as a result of

family /society for its care. Further, as the

Ischemia, twenty percent occur as a result

time passes, the physical and mental

of hemorrhage and the remaining ten

condition of patient further deteriorates1. A

percent are of idiopathic origin3-5.

majority of patients fail to recover and lead

ď&#x201A;ˇ

Stroke

is

one

of

the

a normal healthy life. The stroke affects

Ischemic CVA - It arises from hypoxia

of a stroke and occurs due to hindrance

neurological disability suffered by the

in one of the vital cerebral arteries

adult population throughout the world. It is

middle, posterior and anterior cerebral

the prime cause for about twenty five

arteries or their minor perforating

percent of all accounted deaths in the

branches to deeper parts of the brain.

developed nations; also it is one of the

They may happen as an outcome of

major causative factors for permanent

thrombosis and those that resulted

disabilities, most prevalent among the

from a stroke, every year. Stroke stands for

all

blood supply. It is most common cause

be one of the most common reasons of

above the age of forty five years suffer

of

brain tissues as an outcome of scarce

on the entire family. Stroke is depicted to

hundred people, out of every one lakh,

percent

or diminished oxygen supply to the

not only the patient, but also has a bearing

elderly population2. Approximately four

seventy

from an embolus. ď&#x201A;ˇ

Hemorrhagic CVA â&#x20AC;&#x201C; This condition is triggered

by

subarachnoid

hemorrhage,

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

intra-cerebral, arterial-

Page 37


[Research Report] venous deformity and lacunar infarcts

develops

characteristic

patterns

of

8

resulting from irregular bleeding from

hypertonicity or spasticity . Spasticity, a

rupture of a cerebral vessel. The

motor

incidence of the hemorrhage is less

exaggerated deep tendon reflexes and

among people those are younger than

increased muscle tone. It develops from

forty five years of age, furthermore the

hyper-excitability of monosynaptic stretch

chances of stroke grows after sixty five

reflex.

years. The combined cause of intra

spasticity

cerebral hemorrhage includes vessel

resistance to passive stretching of the

malformation and changes in the

involved muscle, hyper-reflexia of deep

integrity of cerebral vessels brought on

tendon

by the properties by hypertension and

extremities in flexion or extension, co-

2, 5

ageing

.

disorder

is

Clinically,

characterized

the

presents

reflexes,

patient

with

by

with

increased

posturing

of

the

contraction of muscles, and stereotypical

Necessity for mobility is the key reasons

movement patterns which are called

for admitting of a patient to an In-patient

synergies. Other impairments may include

restoration department post stroke. A lot of

Sensory

the exertion is engaged in the patients to

impairments,

retain the ability to walk at least in the

respiratory impairments, Bowel bladder

7

home, prior to their discharge . Despite of these efforts majority of the survivors with initial paralysis of the leg do not retain the normal gait pattern, and roughly all other survivors are unable to walk without full physical assistance. The primary clinical manifestation in patients following stroke, is the spectrum of motor problems resulting from damage to the motor cortex. Initially, a patient may present with a state of low muscle tone or flaccidity. Flaccid muscles lack the ability to generate muscle contractions and coordinate movements. This condition of relative low muscle tone is usually transient, and the patient soon

impairments,

Communication

orofacial

impairments,

dysfunction etc9. Objective of Study

The objective of the review study is to enhance the rehabilitation process of a patient suffering from chronic stroke, specifically aiming towards for their speedy motor control and co-ordination10. Our effort shall be conceptualize an ideal exercise regime accompanied by various maneuvering

techniques,

approach

contributing a bit towards easing the suffering of stroke patients, expedite recovery leading to early rehabilitation, thereby paying back for betterment of our society2.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 38


[Research Report] Relaxation Therapy Maneuvers:

techniques are found to be most effective

Relaxation techniques (Diagram 1.0) are

in case of patients

exceptionally beneficial for promoting

spasticity8.

relaxation in the patients affected by

implemented in order to attain a lower

6

Various

presenting with methods

can

be

chronic stroke . The relaxation technique

tone. The main emphasis is on reflex

helps in reducing the mental stress the

inhibiting

patient suffers whilst he/she is affected by

development of righting and equilibrium

stroke;

the

reactions and the use of key points of

confidence and determination of a patient

control. Also, inhibition of muscle groups

it

helps

in

alleviating

7

patterns

of

activity,

the

towards the treatment .

by influencing the bias placed on muscle

It helps in reducing the spasticity the

spindles through the tendons of Golgi

patient

organ10.

encounters

as

a

clinical

manifestation of chronic stroke.

The goal of the therapy is to oppose the

It helps in reducing the stiffness, which

irregular postural reflex, the actions and

also serves as a clinical manifestation

also to facilitate normal motor patterns and

and arises as a result of immobilization

balance

reactions11.

and sustained spasticity.

activities

mainly

It helps in relaxation and strengthening

segments is important if the desired

of the respiratory component which

outcome is to change the tone more

also

distally. Movement must be superimposed

is

affected

as

a

-clinical

Commencing in

proximal

the body

manifestation of chronic stroke.

on the improved tonal state if carryover is

The relaxation component of the

to occur. Prolonged application of ice

therapeutic protocol can include deep

might be beneficial. Weight bearing is

breathing

another

techniques,

positioning, passive

appropriate

inhibitory

technique.

relaxed

Positioning a limb in an inhibitory pattern

suspension

is extremely important; Air splints could

hydrotherapy, movements,

useful

also

techniques etc.

be

employed

to

assist

with

positioning, tone reduction and sensory Inhibitory Therapy Maneuvers:

The further hypothesis of the proposed study

includes

implementation

and

awareness12, 13. Mobilization of Joints:

execution of Inhibitory techniques and

For refining the range of motion of the

positions

patient’s joint can be accomplished by use

(Diagram

2.0).

Inhibitory

of mobilization maneuvers, it also terms to [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 39


[Research Report] benefit as mobility exercises. In addition to

The

this, mobilizing the joints in the direction

implemented by stimulating:

of facilitation

ď&#x201A;ˇ

of Proprioceptive, neural

facilitation

Cutaneous

methods

receptors:

can

Quick

be

light

and muscular parts patterns has proven to

brushing, application of ice, brisk

be useful14. The range of the particular

stroking by manual touch, tapping etc.

grades of mobilization should be taken

Muscle

very carefully. These manipulations should

unexpected stretch, slow full stretch,

only be executed by a skilled physical

vibrations

therapist.

weight bearing and an approximation

spindle

receptors:

(Mechanical

Quick

vibrators),

of joints etc also executing Primitive Facilitation Therapy Methods

(spinal) or tonic (brain stem) reflexes

It is extremely important to perform facilitation techniques to prepare the patient for the performance of functional activities15. The facilitation techniques are based on the known physiological facts that skeleton-motor units with different enzyme profiles play a distinct role in the control of movement and posture, and how afferent input can influence different controls on these in the Central nervous system16. The Selection of appropriate afferent stimuli is important to exploit the potentiality of tissues to change at the molecular level. This facilitates attainment of motor goals, and helps to prevent perpetuation

of

abnormal

influences

imposed by pathological changes. These are implemented in order to reduce the protective muscle spasm, increase soft tissue range, and elicit normal postural reactions and to strengthen and activate the 17

weaker muscle groups .

are extremely beneficial18. Proprioception, Neural and Muscular Facilitation and Development:

Proprioception is well-defined as the perception of oneself in harmony to the atmosphere

(Diagram

3.0).

The

proprioceptive facilitation methods depend largely

on

stimulation

of

the

proprioceptors (special position sensing receptors) for growing the request made on the neuromuscular mechanism to attain and facilitate its reaction19. Management by these methods aims to summate the effects of facilitation to increase the reaction of the neuromuscular mechanism. Proprioceptive stimulation (Diagram 4.0) is mainly instigated to increase the demands made by intentional efforts, the initiation of some reflex reactions and physiological principles concerned with the interaction of antagonistic muscles are used in a few methods20. Resistance and

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 40


[Research Report] stretch are employed manually to muscles

An exercise regime (Diagram 4.0 – 8.0)

occupied to accomplish patterns of mass

involving simple practical activities of

movement and active instructions provide

day-to-day life is exceptionally vital for

encouragement to the patient’s intentional

teaching normal control and coordination

effort. Maximal resistance is measured to

to a patient27-29. The simple goal is to

be the most vital means for stimulating the

establish control of movement; such that

proprioceptors21. The methods concerned

the patient is able and self-assured in his

with its application are rudimentary.

skill to carry out those activities which are

Methods of emphasis are intended to

vital for freedom in day-to-day life. The

correct

the

intact sensory mechanism of sight, sound

neuromuscular feature of the body22. The

and touch can be utilized for prompt

numerous methods are cited as follows:

results29-31. The additional significant vital

incoordination

within

Movement on patterns (Diagram

issues are attentiveness, accuracy and

5.0, 6.0, 7.0, 8.0).

replications. The rapidity, replication and

Manual contact.

respite periods must be allotted rendering

Stretch stimulus and stretch reflex.

to the patient’s potential. The complication

Traction and approximation

in

Spoken instructions to the patient

progressively through the course of the

Consecutive

therapy.

timing

of

muscle

exercise

designs

should

intensify

contractions.

Other Employable Approaches:

Resistance.

Motivation is an extremely imperative

Reinforcement.

feature of the therapy. It should be

These procedures of the therapy, gain the

instigated

maximum amount of action which could

recovery. A patient suffering from stroke,

be accomplished at each voluntary effort

is not only affected physically, mentally

and the maximum possible number of

but emotionally also. The low down

replications of the activity to stimulate the

sentiment, subtle moral and breakdown is

response23-26. This procedure demonstrates

very common in such patients. It plays a

to be an effective means of gaining and

noteworthy

hastening the patient’s recovery.

rehabilitation of these problems. The

Employable Exercise Regimes:

during

role

the

in

progression

managing

of

the

therapists aim should be to not just employ physical exercise, but also to build an sensitive rapport with the patient, boosting

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 41


[Research Report] their morale and confidence of patients,

First and foremost the implementation

enabling better recovery and preparing

of the Relaxation techniques shall be

them to engage towards future recovery

extremely useful for reducing the

tasks30.

developed

Application of patient friendly

and

stiffness

among the chronic stroke patients3.

methods where the Physical therapist who remains consulted by a sociologist, clinical

spasticity

Followed by this regime, introduction

psychologist, furthermore, he/she conducts

of inhibitory techniques shall prove

a method on various groups of patients,

exceptionally beneficial, as deploying

inspiring them to together speak their

post relaxation techniques to the

actions and execute the actions as they do

patient, the developed spasticity and

so,

stiffness could be effectively reduced.

originally

comparatively

beginning

simplified

with

patterns

of

Inhibitory

techniques

implemented

exercise and during the advanced stages of

against the synergy patterns would not

recovery, continuing to more compound

only help in reducing the developed

and practical activities31. Replications of

spasticity, but also would help in

regime of actions, over sufficient periods

developing

of time, is anticipated, to influence change in muscle unit type so that they are more

movements 

32

the 32-33

functional

.

Later, with the introduction of the

suitable to the demands made upon them .

Facilitation

For example, the execution of Frenkel

Mobilization techniques on patients,

movements accomplished at consistent

might prove to be very useful, as the

intermissions with aggregated complexity.

manual mobilization when applied to

techniques

and

the

the affected joints, helps improve the

Probable outcome of this approach:

certain

range of motion at the patient’s joint,

techniques have been conceptualized for

in addition to maintaining the muscle

speedy rehabilitation of chronic stroke

mobility (as the already relaxed spastic

patients.

and stiff muscles would allow the joint

For

the

proposed

Based

research,

upon

my

practical

to move) 34.

experience in treating stroke patients, In this

review,

we

have

formulated

a

The Facilitation techniques on the

Hypothesis, by deploying various physical,

other hand might prove to be effective

sociological & psychological techniques to

when applied with the mobilization

rectify symptomatic manifestations, in the

techniques

patient’s, on one-to-one basis.

spasticity would exert less stress on the

because

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

the

reduced

Page 42


[Research Report]

opposite muscle group and hence its

touch, and hearing, to develop the

implementation would help develop

coordination. The replications are very

and strengthen the weaker muscle

significant; the intricacy, the sessions

groups35.

of exercise must be preceded slowly as

Proprioceptive drills are valuable at

the condition of the patient recovers36-

advanced phase, as during this period

39

the spasticity is reduced; after the

Replication of these procedures on a

mobilization, the range of motion

consistent

increases

significant.

and

the

facilitation

techniques help stimulate the weaker muscle(s)

hence

performing

the

proprioception at this stage might prove

to

be

most

is

extremely

Encouraging the patient at regular

treatment is essential. 

Dynamic involvement of the patient in

in

the management is extremely valuable,

improving the coordination patterns

furthermore making the patient speak

within the affected parts.

effective

interval

intervals during the course of the

functional activities that improve the

.

36

the

movement

accordingly

whilst

Presenting plain, functional exercise

accomplishing

regimes at this stage is valuable; the

treatment will deliver supplementary

main

benefits40-43.

module

unharmed

is

sensory

to

employ

aspects

the

2.

3.

4.

5.

throughout

the

vision,

References 1.

it

Adamson J, Beswick A, Ebrahim S. Is stroke the most common cause of disability? J Stroke Cerebrovasc Dis, 2004; 13(4):171-7. Wade DT, Hewer RL. Functional abilities after stroke: measurement, natural history and prognosis. J Neurol Neurosurg Psychiatry, 1987; 50(2):177-82. Post MW, Witte LP, Schrijvers AJ. Quality of life and the ICIDH: towards an integrated conceptual model for rehabilitation outcomes research. Clin Rehabil, 1999;13 (1): 5-15. Wade DT. Epidemiology of disabling neurological disease: how and why does disability occur? J Neurol Neurosurg Psychiatry, 1996; 61(3):242-9. Jackson D, Turner-Stokes L, Williams H, Das-Gupta R. Use of an integrated care pathway: a third round audit of the

management of shoulder pain in neurological conditions. J Rehabil Med, 2003; 35(6):265-70. 6. Langhorne P, Pollock A, Stroke Unit Trialists’ Collaboration. What are the components of effective stroke unit care? Age Ageing, 2002; 31(5):365-71. 7. Langhorne P, Stott DJ, Robertson L, MacDonald J, Jones L, McAlpine C, et al. Medical complications after stroke: a multicenter study. Stroke, 2000; 31(6):1223-9. 8. Bernhardt J, Thuy MNT, Collier JM, Legg LA. Very early versus delayed mobilization after stroke. Cochrane Database of Systematic Reviews, 2009; 1. 9. Chatterton HJ, Pomeroy VM, Gratton J. Positioning for stroke patients: a survey of physiotherapists’ aims and practices. Disabil Rehabil, 2001; 23(10):413-21. 10. Carr EK, Kenney FD. Positioning of the stroke patient: a review of the literature. Int J Nurs Stud, 1992; 29 (4): 355-69.

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[Research Report] 11. Borisova Y, Bohannon RW. Positioning to prevent or reduce shoulder range of motion impairments after stroke: a metaanalysis. Clin Rehabil., 2009; 23 (8): 6816. 12. Lehrer, Paul M.; David H. (FRW) Barlow, Robert L. Woolfolk, Wesley E. Sime. Principles and Practice of Stress Management, Third Edition, 2007; 46–47. 13. Irvine KN, Warber SL, Devine-Wright P, Gaston K . "Understanding Urban Green Space as a Health Resource: A Qualitative Comparison of Visit Motivation and Derived Effects among Park Users in Sheffield, UK". Int. J. Environ. Res. Public Health, 2013; 10 (1): 417–442. 14. Taub, E., Crago, J.E., Burgio, T. An operant approach to rehabilitation medicine: Overcoming learned non-use by shaping. Journal of the Experimental Analysis of Behaviour, 1994; 61, 281– 293. 15. Schrag A, Jahanshahi M, Quinn N. How does Parkinson’s disease affect quality of life? A comparison with quality of life in the general population. Mov Disord, 2000; 15:1112–1118. 16. Bloem BR, Beckley DJ, van Dijk JG, Zwinderman AH, Remler MP, Roos RA. Influence of dopaminergic medication on automatic postural responses and balance impairment in Parkinson’s disease. Mov Disord, 1996; 11:509 –521. 17. Keus SHJ, Bloem BR, Verbaan D. Physiotherapy in Parkinson’s disease: utilization and patient satisfaction. J Neurol, 2004; 251:680–687. 18. Goede CJ, de, Keus SH, Kwakkel G, Wagenaar RC. The effects of physical therapy in Parkinson’s disease: a research synthesis. Arch Phys Med Rehabil, 2001; 82:509 –515. 19. Hendriks HJM, Bekkering GE, van Ettekoven H, Brandsma JW, van der Wees PhJ, de Bie RA. Development and implementation of national practice guidelines: a prospect for continuous quality improvement in physiotherapy. Introduction to the method of guideline development. Physiotherapy, 2000; 86:535–547. 20. Deane KHO, Ellis-Hill C, Jones D, et al. Systematic review of paramedical therapies for Parkinson’s disease. Mov Disord, 2002; 17:984 –991. 21. Tetreault, P., Krueger, A., Zurakowski, D. & Gerber, C. Glenoid version and rotator cuff tears. Journal of Orthopaedic Research, 2004; 22 (1), 202–207.

22. Urquhart, D.M., Hodges, P.W. & Story, I.H. Postural activity of the abdominal muscles varies between regions of these muscles and between body positions. Gait and Posture, 2005; 22, 295–301. 23. Van Kan, P.L.E. & McCurdy, M. Role of primate magnocellular red nucleus neurons in controlling hand during reaching to grasp. The Journal of Neurophysiology, 2000; 85, 1461–1478. 24. Voight, M. & Thomson, B. The role of the scapula in the rehabilitation of shoulder injuries. Journal of Athletic Training, 2000; 35 (3), 364–372. 25. Willems, J.M., Jull, G.A. & Ng, J.K. An in vivo study of the primary and coupled rotations of the thoracic spine. Clinical Biomechanics, 1996; 11, 311–316. 26. Yue, G. & Cole, K.J. (1992) Strength increases from the motor program: Comparison of training with maximal voluntary and imagined muscle contractions. Journal of Neurophysiology, 1992; 67, 1114–1123. 27. Hakkennes S, Keating JL, Constraintinduced movement therapy following stroke: a systematic review of randomized controlled trial, Aust J Physiotherapy. 2005; 51(4): 221-31. 28. Asanuma, H. Experiments on functional role of peripheral input to motor cortex during voluntary movements in the monkey. J. Neurophysiol, 1984; 52(2):212-227. 29. Basmajian, JV. Motor learning and control: a working hypothesis. Arch Phys Med rehab, 1977; 58(l): 388-41. 30. Hellebrandt, FA. The physiology of motor learning. Cerebral Palsy Rev, 1958; 19:914. 31. Iriki, A- Long term potentiation in the motor cortex. Science, 1989; 245(4924): 1385-1387. 32. Janda, V. Muscles, central nervous motor regulation and bacak problems. In: Korr, I (ed) The Neurobiologic Mechanisms in Manipulative Therapy. Phenurn Press, London, 1978 33. Janda, V. Muscle weakness and inhibition in back pain syndromes In: Grieve, GP (ed) Physical Therapy of the Low Back. Churchill Livingstone, London, 1987. 34. Jarus, T. Motor learning and occupational therapy: the organization of practice. Am J Occup Ther, 1994; 48(9): 810-816. 35. Kabat, H, McLeon, M. Athetosis: neuromuscular dysfunction and treatment. Arch Phys Med, 1959; 40:285-292.

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[Research Report] 36. Knott, M. Neuromuscular facilitation in the treatment of rheumatoid arthritis. Phys Ther, 1964; 44:737-739. 37. Sady, SP, Wortman, M, and Blanke, D. Flexibility training: Ballistic, static, or proprioceptive neuromuscular facilitation? Arch Phys Med Rehab, 1982; 63: 251. 38. Scholz, JP, Campbell, SK. Muscle spindles and the regulation of movement. Phys Ther, 1980; 60:1416-1423. 39. Voss, DE. Everything is there before you discover it. Phys Ther, 1982; 62(11): 1617-1624. 40. Wardlaw, C. Evaluation and treatment of the movement system with proprioceptive

neuromuscular facilitation. Rehab Training Network Leaming Lab, 1997. 41. Bloem BR, van Vugt JP, Beckley DJ. Postural instability and falls in Parkinson’s disease. Adv Neurol, 2001; 87:209 –223. 42. Garrett NA, Brasure M, Schmitz KH, Schultz MM, Huber MR. Physical inactivity: direct cost to a health plan. Am J Prev Med, 2004; 27:304 –309. 43. Pressley JC, Louis ED, Tang MX, et al. The impact of comorbid disease and injuries on resource use and expenditures in Parkinsonism. Neurology, 2003; 60:87– 93.

Diagram 1.0

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[Research Report]

Diagram 2.0

Diagram 3.0

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report]

Diagram 4.0

Diagram 5.0

Diagram 6.0

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report]

Diagram 7.0

Diagram 8.0

2.

Corresponding Author *Corresponding Author Depâ&#x20AC;&#x2122;t. Of physiotherapy, Savig Healthcare Clinic New Delhi, India shashank_ghai@live.com Contact +9111- 47541414 shashank_ghai@live.com 1. Physiotherapist, Savig Healthcare Clinic, New Delhi, India. Research Scholar, Jacobs University gGmbh, Bremen, Germany. Š 2014 PGIP. All rights reserved.

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy

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[Research Report]

Effectiveness of Incentive Spirometry with and Without Deep Breathing Exercises In Post-Coronary Artery Bypass Grafting Physical Therapy Management Arooj Fatima*, Ashfaq Ahmed**, Filza Shoukat***, Halima Shoukat****, Mehreen Fatima*****

Abstract Background: Coronary artery bypass grafting (CABG) is a surgical procedure in which the

blocked coronary arteries are bypassed by the blood vessel grafts. Cardiac surgery is associated with an occurrence of respiratory complications. Chest physiotherapy techniques play an important role in preventing or treating post-operative respiratory complications in CABG patients. Study design: Randomized controlled trial. Objectives: To determine the efficacy of incentive spirometry with or without deep

breathing exercises in patients undergoing CABG. Interventions: One group had done incentive spirometry and other group had done incentive

spirometry and deep breathing exercises Randomisation: Out of 40 patients, 20 were randomly allocated into 2 groups by systematic

sampling.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 49


[Research Report] Results: Study includes 40 participants, Having 20 in each group. By applying paired t-test,

in subjects doing incentive spirometry only, the p-value for arterial oxygen tension (pO2), arterial carbon dioxide tension (pCO2) and oxygen saturation (SaO2) was found to be statistically significant (p=0.000, p=0.006 and p=0.000 respectively), while in subjects doing both incentive spirometry and deep breathing exercises, p-value for pO2and SaO2 was found to be significant (p=0.000, p=0.000), and for pCO2 it was insignificant (p=0.244). With the application of Analysis of Variance (ANOVA), p-value for pO2 and SaO2 was found to be insignificant (p=0.084 and p=0.125 respectively), and for pCO2, it is significant (p=0.015). Conclusion: In both groups, improvement in arterial blood gases and oxygen saturation is

observed without any significant difference between the groups. Both interventions are equally effective in the prevention and treatment of chest complications in patients which may occur after bypass surgery. Key words: CABG. Chest physiotherapy techniques. Deep breathing exercises. Incentive

spirometry.

Introduction

effusion, pulmonary edema or shortness of

The purpose of this study is to compare the

breath.4,5 Risk factors for the respiratory

efficacy of incentive spirometry and deep

complications

breathing

exercises

to

prevent

the

development of respiratory complications in patientsâ&#x20AC;&#x2122; undergone CABG surgery and to develop awareness in people about the significant role of chest physiotherapy in preventing post-op complications.

are

smoking,

advanced age or lung diseases.

obesity,

6,7

Chest physiotherapy techniques play an important role in preventing post-operative respiratory

complications

in

bypass

patients.8,9,10 About 1 million coronary artery bypass surgeries (CABG) are

Bypass grafting is a surgical procedure in

carried out in the world per annum. Most

which a graft is used to bypass the blocked

of the patients develop chest complications

coronary arteries to restore blood supply to

after surgery as a result of general

the ischemic myocardium.1 Respiratory

anesthesia

complications develop after surgery which

Mechanical devices such as incentive

affects

and

spirometer have been frequently used in

compliances.2,3 Complications may include

United States after thoracic surgery.11

lung collapse, respiratory failure, pleural

Deep breathing exercises are used in post-

their

lung

volumes

and

prolonged

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

bed

rest.

Page 50


[Research Report] CABG patients to improve pulmonary

the aid of any mechanical devices, have

ventilation and restore lung volume by

been done along with incentive spirometry.

opening

and

On 1st post-op day, supplemental oxygen

preventing lung collapse.12 The evidence

was administered by facemask at 6.0

for the advantageous effects of these

L/min. In subsequent days, in case of need

techniques is inconclusive.13

for supplemental oxygen, the evaluation

the

collapsed

alveoli

was performed after removing the source

Materials and Methods

of oxygen for ten minutes. The outcome

Inclusion criteria: Patients undergone

bypass surgeries, of either gender or age were included.

of lung diseases, tuberculosis of bones, arthritis,

osteoporosis,

neurological disorders, any previous chest surgery and unstable hemodynamics were excluded. Study

arterial blood gases (ABGs) and SaO2 by pulse oximetry on daily basis half an hour

Exclusion criteria: Patients with history

infective

measures are pO2, pCO2 measured by

setting:

after chest physiotherapy treatment by taking the blood sample. The instruments used in the study were the incentive spirometer, perfoma sheet and treatment bed. Statistical analysis: Using SPSS 20 data

Doctorâ&#x20AC;&#x2122;s Hospital &

Medical Centre, Lahore from July, 2013 -

has been recorded and analyzed and p-

Jan, 2014.

value

Group I consists of 20 patients who are

less

than

0.05

(p<0.05)

was

considered statistically significant. The

treated with incentive spirometry only. Group II consists of 20 patients who are

quantitative data has been presented in the

treated with incentive spirometry & deep

form of frequency tables and mean S.D.

breathing exercises. Participants received treatment twice daily

The qualitative data has been presented in form of frequencies and percentage.

for 20 minutes in ICU in each session. In Group I, patients inspire slowly until the

Repeated measure ANOVA test has been

desired level marked in the spirometer is

used to compare the interventions between

achieved. In Group II, three sets of ten

two groups. Paired t-test was used to

deep breaths through slow and uniform nasal inspiration, progressing to slow flow

observe the effects of these interventions.

until the total lung capacity (TLC), without

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] Results

By applying paired t-test, in subjects doing

The study involved 70% males (n=28) and

incentive spirometry only, the p-value for

30% females (n=12). About 62.5% were

arterial oxygen tension (pO2), arterial

smokers (n=25) and 37.5% non-smokers

carbon dioxide tension (pCO2) and oxygen

(n=15). All the patients had undergone off-

saturation (SaO2) was found to be

pump CABG surgery (n=40) and almost

statistically significant (p=0.000, p=0.006

97.5%

and

(n=39)

patients

developed

p=0.000

respectively),

while

in

respiratory complications after surgery. It

subjects doing both incentive spirometry

was calculated from the data that among

and deep breathing exercises, p-value for

the

developed

pO2and SaO2 was found to be significant

atelectasis (n=29), 15% pleural effusion

(p=0.000, p=0.000), and for pCO2 it was

(n=6), and 12.5% pulmonary edema (n=5)

insignificant (p=0.244).

total

patients,

72.5%

while no one developed pneumothorax.

With the application of Analysis of

It was observed that 77.5% (n=31) of the

Variance (ANOVA), p-value for pO2 and

patients usually involved both sides of

SaO2 was found to be insignificant

lungs and triple grafts are placed in 60%

(p=0.084 and p=0.125 respectively), and

patients (n=24). According to the data, it

for pCO2, it is significant (p=0.015).

was reported that upper lobes were spared in all the subjects, 60% (n=24) had secretions accumulated in their lower lobes, and 40% (n=16) had affected middle lobe of right lung.

were discharged on 5th post-op day, 22.5% (n=9) patients on 6th day, 15% (n=6) on 7th day while 15% (n=6) had more than 7 days stay in hospital. Patients who had incentive

The aim of the study is to find out the effectiveness of incentive spirometry with and without deep breathing exercises in preventing the chest complications in post-

Data shows that 47.5% (n=19) patients

done

Discussion

spirometry and

deep

breathing exercises had shorter hospital stay as compared to patients who had done incentive spirometry only.

CABG patients. In this study, incentive spirometry was used along with deep breathing exercises post-operatively

to

treat

chest

complications. This study reveals that both groups showed improvement in restoring the oxygen saturation and ABGs, but there is no significant difference in ABGs and oxygen saturation among the groups.

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] Respiratory complications develop as a

There is a limited data available regarding

result of general anesthesia or prolong

chest physiotherapy techniques used for

immobility after surgery which impairs the

the treatment of respiratory complications

lungs function by reducing the oxygen

after bypass surgery. There is not even a

saturation, lung volumes and capacities.2,3

single study that suggests the supremacy

After bypass surgery, many physiotherapy

of one therapy technique over another.

techniques have been used to improve

None of the above mentioned studies

oxygenation of lungs, to remove secretions

suggested the use of both deep breathing

from them and to reduce risk of pulmonary

exercises and incentive spirometry as an

complications.14,8 Some studies showed

important treatment option.

the effectiveness of these techniques in the prevention or treatment of complications. Studies

have

shown

that

chest

physiotherapy can improve lung functions by the use of deep breathing exercises

Conclusion Deep breathing exercises and incentive spirometry

are

preventing

and

complications

which help in clearing the lung fields.15

equally

in

effective

in

treating

the

lung

patients

undergoing

coronary artery bypass grafting, as they An RCT was conducted to compare the

improve ABGs and oxygen saturation. But

effects of breathing exercises or incentive

there is no significant difference among

spirometry with early mobilization in 49

the

bypass patients. Deep breathing exercises

complications.

or

incentive

spirometry

showed

groups

1.

Another trial of Freitas et. al. showed that

2.

incentive spirometry have no advantage over standard physical therapy.17 However, in a review by Pasquina et. al., it is

3.

concluded that there is lack of evidence advantages

of

chest

References

after the surgery.16

the

improving

no

beneficial effect over early mobilization

supporting

in

chest

physiotherapy after cardiac surgery.18 4.

Olendorf, D., et al. The Gale encyclopedia of medicine. 1999, Detroit, MI: Gale Research Vargas FS, Terra-Filho M, Hueb W, Teixeira LR, Cukier A, Light RW. Pulmonary function after coronary artery bypass surgery. Respir Med 1997;91:62933 Shapira N, Zabatino SM, Ahmed S, Murphy DM, Sullivan D, Lemole GM. Determinants of pulmonary function in patients undergoing coronary artery bypass operations. Ann Thorac Surg 1990;50:268-73 Rady MY, Ryan T, Starr NJ, Early onset of acute pulmonary dysfunction after cardiovascular surgery: Risk factors and

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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[Research Report] 5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

clinical outcome. Crit Care Med 1997;25:1831-9 Brooks-Brunn JA. Post-operative atelectasis and pneumonia: risk factors. American Journal of Critical Care 1995;4:340-9 Ferdinande P, Lauwers P, Van Buyten L, Van de Walle J. Pulmonary function tests before and after open heart surgery. Acta Anaesthesiol Belg 1980;31 Suppl;127-36 Jenkins SC, Moxham J. The effects of mild obesity on lung function. Respir Med 1991;85:309-11 Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson BI, Timmermans C, et al. the effect of incentive spirometry on post-operative pulmonary complications: a systematic review. Chest 2001;120:971-8 Pasquina P, Tramer MR, Walder B. Prophylactic respiratory physiotherapy after cardiac surgery: systematic review. 2003;327:1379 Innocenti D. An overview of the development of breathing exercises into speciality of physiotherapy for heart and lung conditions. Physiotherapy 1995;81:681-93 Crowe JM, Bradley CA, The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Phys Ther 1997;77:260-8 Hough A. Physiotherapy in respiratory care. An evidence-based approach to respiratory and cardiac management. 3rd ed. Cheltenham: Nelson Thornes Ltd;2001 Susan Jenkins , Susan Soutar , Barry Gray , Jane Evans and John Moxham The acute effects of respiratory manoeuvres in post-operative patients 1988, Vol. 4, No. 2, Pages 63-68 Morran, CG, Finaly, IG, Mathieson, M, et al Randomized controlled trial of physiotherapy for postoperative pulmonary complications.Br J Anaesth1983;55,1113-1117

15. Bartlett RH. Respiratory therapy to prevent pulmonary complications of surgery. Respir Care 1984;29:667-79 16. Dull JL, Dull WL. Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass? Phys Ther 1983;63:655-9 17. Freitas ERFS, Soares BGO, Cardoso JR, Atallah Ă N. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD004466 18. Pasquina P, Tramer MR, Walder B: Prophylactic respiratory physiotherapy after cardiac surgery: systematic review. BMJ 2003, 327(7428):1379

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 54


[Research Report] Variables

Mean

Standard deviation

PO2 (Day 1)

136

23.03778

PO2 (Day 4)

74.42

16.21608

SaO2 (Day 1)

98.525

1.67925

SaO2 (Day 4)

94.075

2.35761

PCO2 (Day 1)

42.3225

4.56809

PCO2 (Day 4)

40.075

3.49518

t

p-value

16.013

0.000*

9.214

0.000*

2.905

0.006*

Table 1 Paired Sample Test for Group I (n=20) given incentive spirometry *p-value <0.05 is considered significant

Variables

Mean

Standard deviation

PO2 (Day 1)

127.965

16.994

PO2 (Day 4)

70.805

10.89

SaO2 (Day 1)

97.900

1.997

SaO2 (Day 4)

95.400

2.036

PCO2 (Day 1)

40.855

4.033

PCO2 (Day 4)

39.615

3.402

t

pvalue

12.897

0.000*

4.291

0.000*

1.202

0.224*

Table 2 Paired Sample Test for Group II (n=20) given incentive spirometry and deep breathing exercises *p-value <0.05 is considered significant Corresponding Author *Dr. Arooj Fatima, Physical Therapist,Physiotherapy Lecturer at University of Lahore, Pakistan King Edward Medical University, Lahore, Pakistan 98-H, DHA-EME sector, Lahore, Pakistan aruj43@hotmail.com 0092-341-4391882 **Dr. Ashfaq Ahmed, Physical therapist ****Dr. Halima Shoukat, Physical Therapist Assisstant Professor at University Institute of Physical Physiotherapy lecturer Therapy, University of Lahore halima.shoukat@gmail.com *****Ms. Mehreen Fatima ashfaaqpt@gmail.com ***Dr. Filza Shoukat, Physical Therapist Bio-statician Physiotherapy lecturer mehreen.fatima@uipt.uol.edu.pk filzashoukat21@gmail.com Š 2014 PGIP. All rights reserved.

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

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Welcome to the Postgraduate Institute of Physiotherapy, we are the team of professional physiotherapists working in United Kingdom promoting and uplifting the physiotherapy profession in developing countries particularly in South Asia. Our well trained and qualified physiotherapists conduct postgraduate courses in various countries. The courses ranged from Musculoskeletal Manual Therapy to Sports Physiotherapy. The basic aim is to provide evidenced based way of practice and education to physiotherapy societies of developing nation so that they can uplift the profession and become the contributors to the profession. Date: 00/00/00

Time: 00:00

www.pgip.co.uk

Encouraging Better Education Ob j e ct ive s

Co ur se s:

Provision of education and training in 1. Spinal Examination and physiotherapy to the public at large Enabling patients to relieve or assist in relieving their own suffering/conditions To persons (professionally qualified or not) providing paid or voluntary care to any person in need of physiotherapy Promotion of research and the dissemination to the public at large of the results of research in the field of physiotherapy

Diagnostic Assessment 2. Management of Neck Disorders 3. Neurodynamics and Neuromatrix 4. Lumbar Spine 5. Cervical Spine 6. Treating Cervicogenic Headaches 7. Low back pain and evidence base approach 8. Spinal Manipulation 9. Evidence Based Practise 10. Clinical Reasoning 11. Professionalism, Empowerment and Autonomy 12. Sports Rehabilitation and injuryIPrevention


JOPSM June 2014 Volume 3, Issue 1  

The Journal of Physiotherapy & Sports Medicine (JOPSM) is peer-reviewed International open access journal for advancing research activities...

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