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

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Vol.1 No.4 2012

About Us: Scientific Research JournalCare and Educational Development Society.funded by the Dr. L. Sharma Medical Care and Educational Development Society.Multidisciplinary, Peer Reviewed,intended audiences of this journal are the professionals and students. The scope of journal is broad to cover the recent scientific research. The Journal publishes selebook reviews in the fields of Botany, Zoology,Environmental Sciences, Natural Sciences, Anthropology and any other branch of related sciences. Frequency: The issues will be regularly published Special Issue: Special issue based on specific themesexecutive committee of Society and the members of editorial of SRJI. Disclaimer:

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Scientific Research Journal of India (SRJI) is the official organ of Dr.Care and Educational Development Society. It was founded by Dr. Krishna N. Sharma.

Sharma Medical Care and Educational Development Society.Peer Reviewed, Open Access Journal of science. The of this journal are the professionals and students. The scope of journal

recent inventions/discoveries in structural and functional principles of

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

The issues will be regularly published quarterly.

Special issue based on specific themes may be published at the suggestion of the Dr. L. Sharma Medical Care and Educational Development

members of editorial of SRJI.

Information provided on the site is meant to complement and not replace any or information from a health professional. We do not make claims relating to the benefit or performance of a specific medical treatment, commercial product or service. All the papers published are claimed to be original by the authors. The editors, publisher, and reviewers will not be responsible for plagiarism.

Scientific Research Journal of India, Dr.L.Sharma Campus, Muhammadabad Gohana, Mau, U.P., India. Pin- 276403

Website: http://www.srji.co.cc [email protected]

9320699167, 8822485959, 9305835734

1


(SRJI) is the official organ of Dr. L. Sharma Medical It was founded by Dr. Krishna N. Sharma. It is

Sharma Medical Care and Educational Development Society. It is a Journal of science. The

of this journal are the professionals and students. The scope of journal in structural and functional principles of

short communication and Medical Sciences, Agricultural Sciences,

Environmental Sciences, Natural Sciences, Anthropology and any other branch of related

published at the suggestion of the Sharma Medical Care and Educational Development

Information provided on the site is meant to complement and not replace any advice

We do not make claims relating to the benefit or performance of a specific medical

All the papers published are claimed to be original by the authors. The editors,

This page is intentionally left blank

Vol.1 No.4 2012 Scientific Research Journal of India 3


Index

Editorial

Dr. Krishna N. Sharma

5

Comparison of Clinic and Home Based

Exercise Programs after Total Knee Arthroplasty: A Pilot Study

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

7

Electrical Muscle Stimulation (EMS) Improve Functional Independence in

Critically Ill Patients

Dharam Pani Pandey, Dr. Uday

Shankar Sharma, Dr. Ram Babu

19

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

Knee Arthroplasty

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

Physiotherapy 27

Comparison of the Effect of Isometric

Exercise of Upper Limb on Vitals between Young Males and Females

Pranjal Parmar 37

Paraplegia with Sacral Pressure ulcer

treated by Ultrasound therapy- A Single Case Report

Shanmuga Raju P., Ramalingam P. 50

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

Mandar Tilak Surgery 57

All-Oxide Solar Cells: The Way of the

Future

Akshay Vijay Dongarwar

Chemical Engineering 63




Editorial

Dear Readers,

I am very pleased to present the fourth issue of the Scientific Research

Journal of India (SRJI) as the next Editor in Chief. This multidisciplinary and

open access Journal of science is the official organ of Dr. L. Sharma Medical

Care and Educational Development Society. The previous issues had covered

three disciplines of science Physiotherapy, Agriculture, Anthropology and

Computer science. In this current issue we are covering two new branches of

science- Surgery, and Chemical Engineering. I would like to mention that this

journal is intended to publish selected original research articles, reviews, short

communications and book reviews etc. in the various fields of science like Botany,

Zoology, Medical Sciences, Agricultural Sciences, Environmental Sciences,

Natural Sciences, Anthropology and any other branch of related sciences and

we’ll be more than happy to recognize any of your works in these field too.

Your comments and suggestions are very valuable for us.

Happy Reading.

Regards,

Dr. Krishna N. Sharma

Editor in Chief




Comparison of Clinic and Home Based Exercise Programs after Total

Knee Arthroplasty: A Pilot Study

Bijender Sindhu PhD, PT*, Dr.Manoj Sharma, MBBS, MS(Ortho)**, Dr.Raj K Biraynia, MBBS,

D.Ortho***

Abstract: Sixteen patients (mean age, 68+-8 years) having primary total knee

arthroplasty were assigned randomly to two rehabilitation programs: (1) clinic-

based rehabilitation provided by outpatient physical therapists; or (2) home-

based rehabilitation monitored by periodic telephone calls from a physical

therapist. Both rehabilitation programs emphasized a common home exercise

program. Before surgery, and at discharge and follow up after surgery, no

statistically significant differences were observed between the clinic and the

home-based groups on any of the following measures: (1) total score on the Knee

Society clinical rating scale; (2) total score on the ILOA level of assistance (3)

total score on the Goniometry; (4) total score of VAScale. After primary total

knee arthroplasty, patients who completed a home exercise program (home-based

rehabilitation) performed similarly to patients who completed regular outpatient

clinic sessions in addition to the home exercises (clinic-based rehabilitation).

Additional studies need to determine which patients are likely to benefit most

from clinic-based rehabilitation programs.

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

Based Exercise Program

INTRODUCTION The aim of the arthroplasty is to resurface

the tibiofemoral joint to allow better

articulation and to reciprocate normal

kinematics of the knee (Palmer &

Cross,2004) Another aim of surgeons is to

correct valgus deformity through the

release of lateral structures (Elson &

Brenkel, 2006). The most common

approach is the medial parapatellar

approach. This has been shown to give

better radiological results, but more pain

in the short term than the minimally

invasive mid-vastus approach (Chen,

2006). Soft tissue and bony alignment can

be ensured using the Tensor/ Balancer

system (Winemaker, 2002). The Tensor/

Balancer system is important as

malalignment can lead to failure of the

operation (Winemaker,2002) Prostheses

consist of a femoral and tibial component.

The femoral or tibial component can be

cemented, hybrid (one component

cemented and the other uncemented) or

uncemented (Zavadak et al., 1995). The

type of prosthesis used depends on the

surgeons’ protocol.This question is

important because of time and cost

differences between these service delivery

settings. Clinic-based programs typically

are provided by outpatient physical

therapy clinics, and facilitate monitoring

the patient’s progress, modifying

individual programs, and providing patient

support and motivation. Home-based

programs, however, typically do not

require the patient to attend outpatient

clinic sessions or require attendance at a

minimum number of outpatient sessions,

and provide fewer opportunities for

monitoring or program modification.

Although usually developed by and taught

to patients by physical therapists, home-

based exercises typically are completed

independently by the patient at home.

The populations examined in those studies

have tended to be younger individuals

who otherwise were healthy, and with an

interest in returning to work or sporting

activities or both. The efficacy of clinic-

and home-based rehabilitation programs is

particularly important with respect to

elderly patients. Owing to the older age of

patients who have total knee arthroplasty,

the likelihood of complicating medical

conditions, the serious implications of

postoperative complications in this

population,and the medicolegal climate,

surgeons may be hesitant to prescribe non

clinically based rehabilitation programs

after hospital discharge. An often used

alternative to mandatory outpatient

physical therapy has been having all

patients complete a limited number of

clinic visits. Another alternative may be a

home-based program, monitored via

periodic telephone calls. Monthly phone



calls by therapist individuals were

associated with increased function in

patients with osteoarthritis. Although

caution must be exercised in generalizing

the findings of their study, home exercise

programs developed and monitored by

physical therapists via periodic phone

calls may provide an alternative to

mandatory clinic-based programs and to

requiring a defined number of clinic visits,

and a means to provide some monitoring

of patients during the early rehabilitation

phase.

Objective of the Study: Objective of the Study:

The purpose of the current study was to

compare two rehabilitation programs after

total knee arthroplasty: (1) clinic-based

rehabilitation delivered in outpatient

physical therapy clinics; and (2) home-

based rehabilitation monitored by a

physical therapist via periodic telephone

calls, on disease-specific, joint-specific,

and functional outcome measures.

MATERIAL AND METHODS

Inclusion and Exclusion Criteria

Patients were selected using the following

criteria: patients having primary unilateral

total knee arthroplasty as a result of

osteoarthritis, both male and female who

had a primary unilateral TKA, age 50-85.

Able to give independent informed

consent. Patients with rheumatoid arthritis

or major neurologic conditions were

excluded.

Randomization to Groups

At the time of primary total knee

arthroplasty, 32 patients were assigned

randomly to two rehabilitation programs

(1) clinic-based rehabilitation provided by

outpatient physical therapy clinics; or (2)

home-based rehabilitation, monitored by a

physical therapist via periodic telephone

calls.

Inpatient and Home Exercise.

Familiarization Period

All patients received standard inpatient

physical therapy twice daily, for 20

minutes on each occasion. Inpatient

physical therapy also included instruction

in a series of home exercises to be

completed daily after discharge, regardless

of the patient’s group assignment.

Ambulatory status on the surgical side

was weight bearing as tolerated on

discharge after surgery, at which time the

patient progressed to walking with walker.

Discharge criteria included the ability to

transfer independently, ambulate more

than 30 m using walker/crutches, and

ascend and descend at least five steps.

Medication given at discharge was pain

killer, nutrition’s and antibiotics.

Common Home Exercises (for both

groups)

The common home exercise program was

that developed for routine total knee

arthroplasty rehabilitation at the authors’

institution, and consisted of basic (Stage 1)

and more advanced (Stage 2) ROM and

strengthening exercises. Each patient

received Stages 1 and 2 booklets, which

included written and pictorial descriptions

of each exercise and educational

information on using ice, controlling

swelling, walking, and ROM. They were

instructed to complete the common home

exercises three times daily until their 8-

week follow up, at which time they were

advised to continue the home exercises at

least once daily, indefinitely. Home-Based

Group A physical therapist familiar with

the common home exercises telephoned

each patient in the home-based group at

least two times ask whether the patient

was having any problems with the

exercises, to remind them of the

importance of completing the exercises,

and to provide advice on wound care, scar

treatment, and pain control. During each

telephone call, which lasted approximately

10 minutes, the patient was asked when

and how often he or she wished to be

telephoned in the future. Patients also

were provided with a contact telephone

number to call if additional questions

arose.

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

Clinic-Based Group In addition to the common home exercises,

patients in the clinic-based group were

Variable Clinic-Based (n=16)

Home-Based(n=16)

Continuous variables: mean (standard deviation) Age (years) 65.2 (6.9)* 64.6 (7.8) Height (cm) 160.2 (9.6) 162.3 (11.1) Mass (kg) 86.4 (15.6) 85.5 (15.9) Disease duration (years) 9.8 (6.4) 9.2 (7.3) Discrete variables: frequency and percent of group (percent)

Gender—female 9 (56.25%) 5 (31.25%) Left replacement 6 (37.5%) 3 (18.75%) Contralateral knee involvement 8 (50%) 6 (37.50%) Contralateral hip involvement 3 (18.75%) 1 (6.25%) Ipsilateral hip involvement 1 (6.25%) 0 (0%)



required to attend outpatient physical

therapy after discharge to 8 weeks after

surgery, for as many as three sessions per

week, for approximately 1 hour per

session. Outpatient physical therapists

were provided with copies of the Stages 1

and 2 exercise booklets, and were asked to

use these exercises as the basic component

of their rehabilitation program. However,

they were not advised that the patient was

participating in a study comparing two

rehabilitation programs. Therapists were

permitted to modify or add exercises, use

therapeutic modalities (such as ice, heat,

and ultrasound), joint mobilizations, or

other measures as they deemed

appropriate. Patients in the clinic-based

group were requested to complete the

common home exercises at home only

twice on days that they attended clinic

sessions.

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

Assessments and Measurements

In conjunction with routine orthopaedic

clinic evaluations pre surgically, and at

discharge, 8 weeks after surgery, patients

completed a series of questionnaires and

functional tests that required

approximately 1 hour. Throughout the

study, these tests were conducted by two

experienced testers who were blinded as

to the patient’s group assignment, and

gave the test results directly to the study

coordinator. The following tests were

completed: (1) total score on the Knee

Society clinical rating scale; (2) total score

on the ILOA level of assistance (3) total

score on the Gonioetry; (4) total score of

VAScale. From a position of maximum

extension, the patient slid the heel of the

test leg toward the buttocks to a position

of maximum knee flexion. The knee angle

was measured using a goniometer and

scored as the average of three repetitions.

Non directional, t tests, and tests of the

significance of the difference between two

percentages were used to compare the

clinic- and home-based groups on pre

surgical descriptive measures, and to

compare the patients who were lost to, or

dropped out of the study with those who

remained in the study, on baseline

Eligibility

Randomization

Clinic Based Rehabilitation

Home Based Rehabilitation

Total Knee Arthroplasty Inpatient Physical Therapy Common Home Exercise

Hospital Discharge at 5-7 days

OPD 3 session /week at 1

hour

Atleast 1 telephonic call

by therapist

Stage 2 4 week follow up

Instruction common home exrecise

OPD 2 session /week at 1

hour

Atleast 1 telephonic call

by therapist

Stage 3 8 week follow up

Instruction common home exrecise

measures. Four-way analysis of variance

(ANOVA) were used to examine the

following four criterion variables(1) total

score on the Knee Society clinical rating

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

assistance (3) total score on the Gonioetry;

(4) total score of VAScale. After a

significant F-ratio, the Newman-Keuls

technique was used to compare selected

means.

Any patients who were removed from

their assigned group by the surgeons for

reasons related to the surgically treated

knee or medical conditions not related to

the surgically treated knee, or who

withdrew consent to participate, were

encouraged to continue with the home

exercises and any other therapies

prescribed, and to continue coming for

regular follow ups and testing. To take

into account that some patients were

removed or otherwise lost from their

group, but did continue to be tested at

their regular follow ups, two types of

analyses were completed: (1) a per

protocol analysis, which included all

patients who completed the study in their

assigned group; and (2) an intent to treat

analysis, in which all patients were

analyzed as having remained in their

assigned group, regardless of whether they

had completed the study in that group.

Analysis of variance tests were confined

to patients who had full data sets for the

three times of measurement (before

surgery, and discharge and 6 weeks after

surgery). In view of the number of

statistical tests computed and to minimize

the likelihood of Type 1 or alpha error, the

0.01 level was used to denote statistical

significance throughout analyses.

RESULT

Before surgery, no significant differences

were observed between the clinic- and the

home based groups on the demographic

variables shown in Table 1, or on any of

the nine criterion measures (p>0.01). No

statistically significant differences were

observed between the patients lost and

those who remained in the study (Table 2),

or between the patients lost to the two

groups on the baseline scores for any of

the four criterion measures, or for age,

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

stay in the hospital for the patients who

completed the study in their assigned

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

the home- and clinic-based groups,

respectively. On ANOVA tests, the per

protocol and the intent to treat analyses

produced identical results for all nine

criterion measures; no treatment, surgeon,

or prosthesis-related effects were observed

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

(averaged over treatment, surgeon) was

significant (p<0.01) (Figs 2, 3).

Subsequent analysis of the main effect for



time indicated that the scores before

surgery, at discharge after surgery, and 6

weeks after surgery differed significantly

from one another (p<0.01); with one

minor exception. Pain before surgery,

measured via Visual analog score, was

significantly greater than that at discharge

and 8 weeks after surgery (p<0.01),

whereas there was no statistically

significant difference (p>0.01) between

the pain scores at discharge and 8 weeks,

on the per protocol and the intent to treat

analyses.

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

DISCUSSION

After primary total knee arthroplasty,

patients who completed home-based

rehabilitation performed similarly to

patients who completed clinic-based

rehabilitation during the first 4 weeks after

surgery. That all four criterion measures in

the current study produced similar results

for the per protocol and the intent-to-treat

analyses suggests that these findings apply

across a spectrum of disease-specific,

joint-specific, and functional variables.

Overall, the additional patient monitoring,

adjustment of program, and motivational

support available through clinic-based

rehabilitation was not advantageous for

the population studied. These findings

were not confounded by any interactions

with surgeon, type of prosthesis or time

since surgery. The current results extend

those of previous studies of meniscectomy

5,7,10 and anterior cruciate ligament

reconstruction1,3,4,11 populations, and

corroborate a previous retrospective study

using a total knee arthroplasty sample.

Patients who were lost to their assigned

group were not included in the per

protocol analysis, but did raise concerns

Patient Losses Clinic Based (n=16)

Home Based (n=16)

Patients lost during the inpatient period (before hospital discharge)

Medical issues related to the surgically treated knee 2 1 Withdrawal of consent by the patient 1 2 Other medical issues 2 1 Totals 5 4 Patients lost after hospital discharge (Weeks 2–52 after surgery)

Medical issues related to the surgically treated knee 0 1 Withdrawal of consent by the patient 0 0 Other medical issues 1 1 Total losses 1 2

that the group comparisons may have been

affected (Table 2). Comparisons within

and between groups indicated

differences between patients lost and

remaining. In addition, when patients

had been lost to their assigned group, but

continued being tested at their normal

follow-ups and had complete data sets,

were returned to their assigned group for

the intent to treat analysis, results were the

same as for the per protocol analysis. For

these reasons, patient losses were not

considered to have significantly

the overall results of the current study.

Fig 2 A–C. Total scores for the (A) Range of Motion Knee Flexion(B) ILOA level of assistance (C) KSKS knee society knee score

Range of Motion (Knee Flexion)

ILOA Level of Assistance

0

20

40

60

80

100

PRE POST

0

5

10

15

20

25

30

35

PRE POST

comparisons may have been

Comparisons within

and between groups indicated no

differences between patients lost and those

addition, when patients who

had been lost to their assigned group, but

continued being tested at their normal

and had complete data sets,

to their assigned group for

treat analysis, results were the

r protocol analysis. For

losses were not

considered to have significantly affected

the overall results of the current study.

Range of Motion Knee Flexion

nee society knee score

Knee Society Knee Score

Visual analog Score

Between discharge and 8 weeks

more patients were removed from the

home-based group than from the clinic

based group for reasons related

of the surgically treated knee to

(Table 2). These patients then had

intensive outpatient physical therapy than

that provided by the clinic-based program.

Four patients in the clinic

were advised by their surgeon to continue

clinic-based rehabilitation after Week 12.

Although both groups of patients tended

to have poorer baseline scores on the

majority of objective measures,

scores were not consistently low across

the same measures and tended to b

1 standard deviation of the group mean.

The combination of poorer scores plus

HOME

CLINIC

HOME

CLINIC

0

10

20

30

40

50

60

70

80

PRE POST

0

5

10

15

20

25

PRE POST

Between discharge and 8 weeks, four

were removed from the

from the clinic-

r reasons related to failure

of the surgically treated knee to progress

(Table 2). These patients then had more

intensive outpatient physical therapy than

based program.

patients in the clinic-based group

eir surgeon to continue

after Week 12.

of patients tended

scores on the

majority of objective measures, their

scores were not consistently low across

the same measures and tended to be within

standard deviation of the group mean.

combination of poorer scores plus

HOME

CLINIC

HOME

CLINIC



subjective factors such as the patients’

attitudes, motivation, pain tolerance, and

home environment were considered in

making the decision to remove these

patients from their assigned group or to

continue clinic-based rehabilitation.

Additional studies are needed to document

psychosocial and demographic variables

to help identify patients who might derive

greatest benefit from clinic-based

rehabilitation programs.

The telephone calls to patients in the home

based group were completed by an

experienced physical therapist who had

been introduced to all of the patients

during their inpatient period. The

telephone calls focused on the home

exercises and did not introduce any new

exercises or provide unique treatment

guidance beyond that available from

similarly experienced therapists. Two

patients with potential major

problem ,such as unresolved swelling,

infection, and deep vein thrombosis, were

identified via the telephone calls and were

referred to the patient’s physician or

surgeon for treatment. Whether delayed

treatment of these conditions would have

resulted in major complications is unclear.

All of these patients completed the 8 week

study in their assigned group. As a result,

the telephone calls received by the home-

based group provided a form of minimally

supervised rehabilitation, which also

enabled some monitoring of the patient’s

medical status.

The major component of the current study

was the common home exercise program,

taught to all patients during their

hospitalization after surgery and at their 8

week follow up. Outpatient clinicians used

this program as the basis for their

treatments, and determined the number

and frequency of treatments, which

averaged 15+-20 sessions; whereas the

home-based group was monitored by

periodic telephone calls from a physical

therapist, which averaged 3+-1 calls

during the first 8 weeks after hospital

discharge. At hospital discharge, patients

in the home-based group indicated when

they wished to be telephoned, and again

did so during each telephone call. Pilot

study had indicated that virtually all

patients having primary total knee

arthroplasty had previous experience with

home exercise programs and that the

majority preferred to determine the

contact schedule themselves.

In addition to the phone calls, the follow-

ups at 4 and 8 weeks after surgery

included review of the home exercises.

That no patients in the home-based group

requested additional telephone calls after

4weeks and only three patients in the

clinic-based group phoned to ask

questions about the home exercises,

suggests all patients felt competent in

doing their home exercises. Although

passive ROM was examined by the

surgeons at each follow up, active ROM

was used to compare groups, to minimize

the extent to which pain tolerance and

motivation may have affected ROM.

Compliance with the home exercises was

considered high, with only two patients in

the home-based group and one patient in

the clinic-based group considered to have

been noncompliant at discharge and 4

after surgery (where compliance was

defined as completion of the home

exercises at least 90% of the time, as per

exercise log booklets). Exercise

compliance was discussed with the

patients before surgery and at each follow

up thereafter. The sample studied was

limited to elderly patients who agreed to

be assigned randomly to one of the two

rehabilitation programs. Approximately

10% of eligible patients refused to

participate for this reason. The extent to

which a home exercise program would be

effective for patients with a more

complicated history, more limited ROM,

or less motivation, needs to be determined.

CONCLUSION

The current study compared two

rehabilitation programs, where the basic

component of each program was a series

of common exercises to be completed

independently by all patients at home.

Because these exercises were developed

by and taught to the patients by physical

therapists, the current study might be

viewed as having compared two means of

providing physical therapy services; that is,

physical therapy monitored by telephone

calls (home-based) and physical therapy

monitored in person by outpatient physical

therapists (clinic-based). The current study

did not compare physical therapy versus

no physical therapy. There is no

significant difference in the data of study

but there is statistical difference in both

group. So this pilot studies shows that the

group of clinic based rehabilitation after

total knee arthroplasty having more better

prognosis than home based exercise group

ie. range of motion and functional ability

and pain.

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ACKNOWLEDGMENT:

The authors thank Dharam Pandey (MPT-neuro), Deepa Dabas (MSc-psycho) for assistance

throughout the study.

CORRESPONDENCE:

*Bijender Sindhu PhD,PT Research Student**Dr.Manoj Sharma, MBBS, MS(ortho)***Dr.Raj k Biraynia,

MBBS, D.ortho *School of Physical Therapy, Faculty of Medical Science, Singhania University**Department

of orthopedic surgery, Jaipur Golden Hospital *** Department of orthopedic surgery, Sarvodaya

Multispeciality Hospital. This study was not funded through a grant from the any organization.



Electrical Muscle Stimulation (EMS) Improve Functional Independence in

Critically Ill Patients

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

Abstract: Objective. This study was designed to investigate the effects of

electrical muscle stimulation (EMS) on strength of muscle groups stimulated and

improvement in functional independence in critically ill patients .Methods. 134

subjects were recruited among the patient admitted in multidisciplinary intensive

care units and randomly divided in to control and EMS group. Patients unable to

understand or speak English and or Hindi due to language barrier or cognitive

impairment prior to admission, unable to transfer from bed to chair at baseline

prior to hospital admission, Patient with known history of primary systemic

neuromuscular disease were excluded from study. Results. EMS group patients

achieved higher MRC scores than controls in knee extensors and ankle

dorsiflexors. Independence level was higher in EMS group Conclusions. EMS

application constitutes a promising means of muscle strength preservation and

early mobilization which can directly reflects the gain in functional independence

post ICU discharge in critically ill patients.

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

functional independence

INTRODUCTION Weakness that is acquired during

hospitalization for critical illness is

increasingly recognized as common and

important clinical problem. Weakness

acquired in the intensive care unit (ICU)

and related acquired neuromuscular

dysfunction occur in a large percentage of

critically ill patients1–3 and are associated

with increased morbidity and mortality.4,5

Critical illness polyneuromyopathy

(CIPNM) is an acquired neuromuscular

disorder observed in survivors of acute

critical illness. It is characterized by

profound muscle weakness and

diminished or absent deep tendon

reflexes1 and is associated with delayed

weaning from mechanical ventilation

suggesting a possible relation between

limb and respiratory neuromuscular

involvement. In addition, the syndrome is

associated with prolonged hospitalization

and increased mortality.3 The diagnosis of

CIPNM requires a reliable bedside muscle

strength examination and depends on

patient's cooperation and maximal effort.

Several risk factors have been identified

including systemic inflammatory response

and sepsis5, medications such as

corticosteroids6 and neuromuscular

blocking agents7, inadequate glycemic

control8, protracted immobility

hypoalbuminemia9, Gram-

bacteremia9 and severity of organ

dysfunction.10 Thus, looking for the

potentially reversible risk factors and

subsequent adjustment of therapy are so

far advocated as preventive measures to

decrease the risk of CIPNM.

A very few of studies available suggesting

the treatment and prevention of critical

illness myopathy these includes intensive

insulin therapy, optimal gycemic control

and minimized use of neuromuscular

blocking agents, high dose and prolong

use of corticosteroids.

OBJECTIVE OF THE STUDY

diminished or absent deep tendon

and is associated with delayed

weaning from mechanical ventilation2

suggesting a possible relation between

limb and respiratory neuromuscular

involvement. In addition, the syndrome is

associated with prolonged hospitalization

The diagnosis of

eliable bedside muscle

strength examination and depends on

patient's cooperation and maximal effort.4

Several risk factors have been identified

including systemic inflammatory response

, medications such as

and neuromuscular

, inadequate glycemic

, protracted immobility4,

-negative

and severity of organ

Thus, looking for the

potentially reversible risk factors and

subsequent adjustment of therapy are so

advocated as preventive measures to

A very few of studies available suggesting

the treatment and prevention of critical

illness myopathy these includes intensive

insulin therapy, optimal gycemic control

uromuscular

blocking agents, high dose and prolong

The objective of this study is to

investigate whether electrical muscle

stimulation (EMS) will improve

functional independence in critically ill

patients.

Our experimental Hypothesis was that

“EMS would beneficially affect muscle

functional status and will improve


patients.


Subjects:

The 134 subjects were recruited among

the patient admitted in multidisciplinary

intensive care units during the study

period.

Exclusion criteria:

Unable to understand or speak English

and or Hindi due to language barrier or

cognitive impairment prior to admission,

unable to independently transfer from bed

The objective of this study is to

investigate whether electrical muscle

stimulation (EMS) will improve


Our experimental Hypothesis was that

“EMS would beneficially affect muscle

functional status and will improve



The 134 subjects were recruited among

n multidisciplinary

intensive care units during the study

Unable to understand or speak English

and or Hindi due to language barrier or

cognitive impairment prior to admission,

unable to independently transfer from bed



to chair at baseline prior to hospital

admission (based on detail history taken

from caregivers. Patient with known

history of primary systemic

neuromuscular disease, vascular events,

organ transplant, intracranial process that

is associated with localizing weakness,

transferred from another ICU after >2

consecutive days of mechanical

ventilation, amputation of lower

extremities, any limitation of life support,

pregnancy, age under 18 years, obesity,

technical obstacles that did not allow the

implementation of EMS such as bone

fractures, skin lesions and, end-stage

malignancy were excluded from our study

Design of study:

The study employed a randomized single

blind controlled experimental study design

consisting of two group experimental

group and control group, Subjects were

randomly assigned ether to experimental

group or to control group everyday the

ICU patient admission register were

observed and with in 24 hour the

assessment were done , each time when a

patient met the criteria for inclusion a

random number were picked up between 1

to 10 using sealed envelope method if it

were an odd number than the subject were

assigned to experimental group similarly

if it even number were obtained the

subjects were assigned to control group.

Intervention:

EMS was implemented on knee extensors,

tibialis anterior and of both lower

extremities. Patients received daily

sessions. After skin cleaning, rectangular

electrodes (90 × 50 mm) were placed on

motor point of targeted muscle. The

stimulator (Unistim, HMS medical system)

delivered biphasic, symmetric impulses of

50 Hz, 100 µsec pulse duration, 12

seconds at intensities able to cause visible

contractions. The duration of the session

was 30 minutes each muscle group. EMS

sessions were continued until ICU

discharge, both group were getting routine

physiotherapy included the passive

movements, active assisted movements

and chest physiotherapy.

Outcome Measures:

Primary Outcome Measures were the

score of barthel index, it is reliable and

valid outcome measure used to assess

functional independence.

Secondary Outcome Measures were lower

extremity strength, at ICU discharge, of 2

bilateral muscle groups which were

stimulated measured by MMT using a

composite Medical Research Council

(MRC) score.

DATA ANALYSIS AND RESULTS

All continuous variables were presented

by mean. The statistical significance of P

value was set at 0.05. One-way repeated

measures analysis of variance (ANOVA)

was made to compare MRC Grading and

barthel index score between-group. Two

hundred and thirty-eight patients were

admitted to our multidisciplinary ICU

during the eight-month study period and

104 patients fulfilled the exclusion criteria

or stayed in the ICU less than 48 hours.

The study population consisted of 134

patients of which of these patients, 70

were randomly assigned to the EMS group

and 64 to the control group. 6 patients

from EMS group and 1 patient from

control died or were discharged from the

ICU before the second measurement.

MRC muscle grading score of muscle

group being stimulated were for left knee

extensors were control group mean 3.49

and EMS group mean 3.91 (p = 0.0187),

right knee extensors control group mean

3.69 and EMS group mean 3.87 (p =

0.0387). left ankle dorsiflexors control

group mean 3.78 and EMS group m

3.91 (p = 0.04), right ankle dorsiflexors

were observed as follows mean control

group mean 3.37 and EMS group mean

3.3.46 (p = 0.0587) found.

Barthel index score of control group was

(mean) 68.6 and EMS group (mean) 71.9

and found significant between groups (p =

0.010).

was made to compare MRC Grading and

group. Two

eight patients were

admitted to our multidisciplinary ICU

month study period and

104 patients fulfilled the exclusion criteria

or stayed in the ICU less than 48 hours.

The study population consisted of 134

hese patients, 70

were randomly assigned to the EMS group

and 64 to the control group. 6 patients

from EMS group and 1 patient from

control died or were discharged from the

ICU before the second measurement.

MRC muscle grading score of muscle

stimulated were for left knee

extensors were control group mean 3.49

and EMS group mean 3.91 (p = 0.0187),

right knee extensors control group mean

3.69 and EMS group mean 3.87 (p =

0.0387). left ankle dorsiflexors control


3.91 (p = 0.04), right ankle dorsiflexors

were observed as follows mean control


Barthel index score of control group was

(mean) 68.6 and EMS group (mean) 71.9

een groups (p =

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

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

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

DISCUSSION

The main finding of our randomized

controlled study is that EMS of lower

extremities seems to preserve the muscle

Graph 1: Showing the mean and significance level of two group of left and

Graph 2: Showing the mean and significance level of two group of left and

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

The main finding of our randomized

controlled study is that EMS of lower

extremities seems to preserve the muscle



strength of critically ill patients as

assessed with MRC muscle strength

grading system. EMS of lower extremities

applied to critically ill patients upon

admission is associated with a lesser

degree of muscle strength loss of these

patients as assessed with MRC muscle

strength grading system. barthel index

score were higher in EMS group and the

patient of EMS group were more

independent.

Electrical stimulation has been used to

increase strength and endurance in

partially and fully paralyzed muscle. It has

been used for peroneal nerve stimulation10,

11 the restoration of shoulder movement12,

recovery of tendonesis grip13, and in the

use of an upper arm prosthesis.14

Electrical muscle stimulation (EMS) has

been used as an alternative to active

exercise in patients with chronic heart

failure (CHF)15 and chronic obstructive

pulmonary disease (COPD).16, 17 Many of

these patients, even those who are

clinically unstable, experience severe

dyspnea on exertion, which can prohibit

the regular application of conventional

exercise training, considered necessary for

an integrated therapeutic approach. In a

recent systematic review, EMS

implementation in most of the selected

controlled clinical trials produced

significant improvements in muscle

strength, exercise capacity and disease-

specific health status.18 Recently, an study

identified an acute systemic effect exerted

by EMS on peripheral microcirculation of

critically ill patients.19 Specifically, after

performing a 45-minute session of EMS

on the lower extremities, an improvement

in the microcirculation of the thenar

muscle as assessed by near infrared

spectroscopy technique was observed.

EMS, as a possible substitute to aerobic

and resistance exercise training in severe

CHF and COPD patients, has been shown

to improve muscle performance, aerobic

exercise capacity, and disease-specific

health status.9-11

CONCLUSIONS

EMS exercise induces beneficial effects in

muscle strength of ICU patients. These

effects mainly concern muscle groups

directly stimulated, but there is also

evidence of effects in muscle groups not

stimulated. EMS application constitutes a

promising means of muscle strength

preservation and early mobilization which

can directly reflects the gain in functional

independence post ICU discharge in

critically ill patients.

Clinical relevance & limitation

EMS is an alternative method of exercise

causing minimal discomfort to patients

who are not able to perform any form of

physical exercise, as is often the case in

critically ill patients. It is a limitation of

this study that it did not evaluated the

follow up stage and upper extremities

function. Further studies are needed to

explore the possible role of EMS as a tool

for preserving the muscle strength and

gain in functional independence post ICU

discharge with longer follow up

evaluation, the muscle properties and

preventing CIPNM in critically ill patients

and to define which patients would benefit

most from this intervention.

REFERENCES:

1. De Jonghe B, Sharshar T,

Lefaucheur JP, Authier FJ,

Durand-Zaleski I, Boussarsar M, et

al; Groupe de Reflexion et d’Etude

des Neuromyopathies en

Reanimation. Paresis acquired in

the intensive care unit: a

prospective multicenter study.

JAMA 2002;288(22):2859–2867.

2. De Letter MA, Schmitz PI, Visser

LH, Verheul FA, Schellens RL,

Op de Coul DA, van der Meche

FG. Risk factors for the

development of polyneuropathy

and myopathy in critically ill

patients. Crit Care Med

2001;29(12):2281–2286.

3. Coakley JH, Nagendran K,

Yarwood GD, Honavar M, Hinds

CJ. Patterns of neurophysiological

abnormality in prolonged critical

illness. Intensive Care Med

1998;24(8):801–807.

4. Garnacho-Montero J, Madrazo-

Osuna J, Garcia-Garmendia JL,

Ortiz- Leyba C, Jimenez-Jimenez

FJ, Barrero-Almodovar A, et al.

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risk factors and clinical

consequences: a cohort study in

septic patients. Intensive Care Med

2001;27(8): 1288–1296.

5. Spitzer AR, Giancarlo T, Maher L,

Awerbuch G, Bowles A.

Neuromuscular causes of

prolonged ventilator dependency.

Muscle Nerve 1992;15(6):682–686.

6. Rudis MI, Guslits BJ, Peterson EL,

Hathaway SJ, Angus E, Beis S,

Zarowitz BJ. Economic impact of

prolonged motor weakness

complicating neuromuscular

blockade in the intensive care unit.

Crit Care Med 1996;24(10):1749–

1756.



7. Latronico N, Peli E, Botteri M.

Critical illness myopathy and

neuropathy. Curr Opin Crit Care

2005;11(2):126–132.

8. Bednarik J, Lukas Z, Vondracek P.

Critical illness polyneuromyopathy:

the electrophysiological

components of a complex entity.

Intensive Care Med

2003;29(9):1505–1514.

9. Van den Berghe G, Wouters P,

Weekers F, Verwaest C,

Bruyninckx F, Schetz M, et al.

Intensive insulin therapy in the

critically ill patients. N Engl J Med

2001;345(19):1359–1367.

10. Tennila A, Salmi T, Pettila V,

Roine RO, Varpula T, Takkunen O.

Early signs of critical illness

polyneuropathy in ICU patients

with systemic inflammatory

response syndrome or sepsis.

Intensive Care Med

2000;26(9):1360–1363.

11. Rabuel C, Renaud E, Brealey D,

Ratajczak P, Damy T, Alves A, et

al. Human septic myopathy:

induction of cyclooxygenase,

heme oxygenase and activation of

the ubiquitin proteolytic pathway.

Anesthesiology 2004;101(3):583–

590.

12. MacFarlane IA, Rosenthal FD.

Severe myopathy after status

asthmaticus (letter). Lancet

1977;2(8038):615.

13. Witt NJ, Zochodne DW, Bolton

CF, Grand’Maison F, Wells G,

Young GB, Sibbald WJ. Peripheral

nerve function in sepsis and

multiple organ failure. Chest

1991;99(1):176–184.

14. Knox AJ, Mascie-Taylor BH,

Muers MF. Acute hydrocortisone

myopathy in acute severe asthma.

Thorax 1986;41(5):411–412.

15. Hund E, Genzwurker H, Bohrer H,

Jakob H, Thiele R, Hacke W.

Predominant involvement of motor

fibres in patients with critical

illness polyneuropathy. Br J

Anaesth 1997;78(3):274–278.

16. Thiele RI, Jakob H, Hund E,

Tantzky S, Keller S, Kamler M, et

al. Sepsis and catecholamine

support are the major risk factors

for critical illness polyneuropathy

after open heart surgery. Thorac

Cardiovasc Surg 2000;48(3):145–

150.

17. Garnacho-MonteroJ, Amaya-Villar

R, Garcia-Garmendia JL,Madrazo-

Osuna J, Ortiz-Leyba C. Effect of

critical illness polyneuropathy on

the withdrawal from mechanical

ventilation and the length of stay

in septic patients. Crit Care Med

2005;33(2):349–354.

18. Bolton CF. Sepsis and the

systemic inflammatory response

syndrome: neuromuscular

manifestations. Crit Care Med

1996;24(8): 1408–1416.

ACKNOWLEDGMENT:

We would like also to acknowledge the support of all intensive care unit staff, consultants

and all the patients caregivers.

CORRESPONDENCE:

*Department Of Physiotherapy & Rehabilitation,BLK Super Speciality Hospital, Pusa Road, New Delhi, India.

**Sr. Consultant Neurologist, Department of Neurology, Jaipur Golden Hospital,2 institutional area, sector 3,

Rohini, New Delhi, India. ***Sr. Consultant Physician, Department of Internal, Medicine, Jaipur Golden

Hospital,2 institutional area, sector 3, Rohini, New Delhi, India.



A Comparative Study on Supervised Clinical Exercise versus Home Based

Exercise in Primary Unilateral Total Knee Arthroplasty

Bijender Sindhu PhD, PT*, Dr.Manoj Sharma, MBBS, MS(Ortho)**, Dr.Raj K Biraynia, MBBS,

D.Ortho***

Abstract: Objective. This study was designed to investigate the effects of

supervised clinical exercise and home Based Exercise in patient with unilateral

total knee arthroplasty in sub acute phase (after 5-6 weeks of discharge). To

assess the effect on function ability of patient after primary unilateral total knee

arthroplasty. To assess the effect on knee integrity (it include pain, ROM, knee

stability)of patient after primary unilateral total knee arthroplasty. Methods. 130

subjects were recruited from OPD physiotherapy among the patient discharge

from hospital and randomly divided into supervised clinic exercise and home

based exercise. Socio demographic and clinical data, pain, range of movement

(ROM) and function of TKA patients were collected on day of discharge (ie day 5

to 8 post operation). A self designed data capture sheet, the goniometer, VAS

(Visual Analogue Scale) and ILOA (Iowa Level of Assistance) KSKS (kne society

knee score)were used to measure data. Criteria for recruitment is patient having

primary unilateral total knee replacement, having a functional hip on operated

side, both male and female and age between 50 to 80 years. Able to follow simple

verbal commands. Patient excluded from study who are suffering from

Rheumatoid Arthritis, revision TKA, bilateral knee arthroplasty. Results. The

results indicate that there is significant difference between experimental group

(supervised clinical exercise) and Control group (home based exercise). For knee

integrity measured using the Knee Society Knee Score (p=0.017)and function

measured using the ILOA Scale (p= 0.018) and goniometry (p=>0.05). The

average age was 64 years in male and 66 years in females . There were 41%

males and 59% females. There is statistical difference between pain, range of

motion, Knee integrity, Knee functional outcomes of groups that receive post-

discharge outpatient physiotherapy as compared to those who do not attend

physiotherapy. Conclusions. After primary total knee arthroplasty, patients who

completed a home based exercise program (control group) performed similarly to

patients who completed regular outpatient clinic sessions in addition to the home

exercises (supervised clinic exercise ie. experimental group). Additional studies

need to determine which patients are likely to benefit most from clinic-based

rehabilitation programs. The overall aim of this study was to establish the early

post operative status of Total knee arthroplasty patient.

Key words: Supervised clinical exercise, Home based exercise, KSKS (knee

society knee score), ILOA (ILOA level of assistance)

INTRODUCTION Osteoarthritis is a leading cause of pain

and disability affecting joints (Marchet al

1999). Progressive loss of the articular

cartilage can result in joints that are

painful and inflamed. The joint becomes

stiffer and there is less stability in the joint

(Parmet et al 2003). These factors affect

the function of the joint which ultimately

impacts on patients’ functional ability and

their quality of life (March et al 1999).

Total knee arthroplasty has been found to

be effective in the management of pain

(Palmer & Cross, 2004), functional status

and quality of life in people suffering from

OA, rheumatoid arthritis (RA) and related

conditions (Zavadak et al., 1995).

Physiotherapists aim to prevent

contractures (Lenssen et al., 2006)

decrease pain and swelling and improve

knee and functional mobility in

preparation for discharge (Oldmeadow et

al.,2002. Post operative physiotherapy

aims to minimize the complications

following total knee replacements and to

rehabilitate the patient to full functional

recovery. Techniques such as cryotherapy,

strengthening and stretching exercises are

used (Zavadak et al 1995). Physiotherapy

in hospital also includes functional

techniques such as bed mobility, transfers,

ambulation and stair climbing. An

assumption can be made that if there is a

relationship between knee integrity and

function, physiotherapists may decide to

only work on improving function, or only

work on improving knee integrity

(improving knee range of motion,

reducing swelling, reducing pain and

improving muscle strength). Time could

then be better utilized on one aspect of

rehabilitation.

Early discharge can sometimes result in

transfer to an inpatient facility. A study by

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



demographic and socioeconomic factors

all affect the decision to discharge a

patient to an inpatient rehabilitation centre.

Objective of the Study:

To assess the effect on knee integrity (it

include pain, ROM and knee stability) and

knee function ability. To establish

pain,ROM of the operated knee and

functional level of TKA patients. To

establish socio-demographic factors and

clinical data of TKA patients on first

follow up. To establish the relationship

amongst supervised clinical exercise as

well as home based exercise and

postoperative functional status of TKA

patients. To study this procedure can be

clinically implemented.


Subjects: 130 subjects were recruited

from OPD physiotherapy among the

patient discharge from hospital and

randomly divided into supervised clinic

exercise and home based exercise.

Inclusion criteria:

Patient having primary unilateral total

knee replacement having a functional hip

on operated side .Both male and female

who had a primary unilateral TKA able to

give independent informed consent Patient

between the age of 50 to 80 years of age,

presented to the first follow-up session.

(This was around six to eight weeks post

operation who gave informed

constant).Able to follow simple verbal

commands

Exclusion criteria:

Any additional trauma to the lower limb,

inability to participate in the assessment

from a physical and cognitive point of

view such as dementia, confusion etc.

Inability of the patient to walk prior to the

TKA(with or without aid). Patient

suffering from Rheumatoid Arthritis.

Unwillingness to participate in the

assessments Revision TKA, Bilateral knee

arthroplasty. Inability of the patients to

walk prior to the total knee replacement

(with or without the aid of an assistive

device).

Design of study:

The study employed a randomized single

blind controlled experimental study design

consisting of two group experimental

group and control group, Subjects were

randomly assigned either to experimental

group or to control group everyday in

physiotherapy OPD before discharge ,

each time when a patient met the criteria

for inclusion a random number were

picked up between 1 to 10 using sealed

envelope method if it were an odd number

than the subject were assigned to

experimental group.

Intervention

Supervised clinical exercise: These are

exercise which are perfomed by patient

under the observation of a qualified

physiotherapist. Postoperative

rehabilitation usually consists of passive

and active knee mobilisation, quadriceps

strengthening and functional activities

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

flexion; hip and knee extension in neutral;

hip abduction; hip adduction to neutral;

ankle dorsi- and plantar flexion, static

quadriceps contraction and inner range

quadriceps contraction over a rolled up

towel. The physiotherapist performs anti-

inflammatory modalities on the patient

which include ultrasound, interferential

therapy, pulsed short wave diathermy,

transcutaneous electrical nerve stimulation

(TENS), laser, acutouch and heat or

cryotherapy. Myofascial release,

continuous passive mobilisation exercises,

stretching, strengthening exercises, gait

re-training, massage, patient education

and an exercise programme are also

prescribed.

Home based exercise: Home based

exercise group performed the exercise

which are explained and demonstrated by

physiotherapist in OPD at the time of

discharge to the patient for home, which

included isometric exercises for

quadriceps, knee range of motion,

strengthening exercise, effective use of

assistive devices and appliance, walking

pattern, safety & precaution, do’s and

dont’s.

Outcome Measures:

ILOA : The patients’ functional ability

was assessed using the Iowa Level of

Assistance (ILOA) Scale, which was first

described by Shields et al (1995). It was

shown to be reliable and valid.The best

overall result the patient is able to achieve

with this scale is zero. This indicates that

the patient was able to perform all five

tasks independently without the use of any

assistive device. The worst overall score

that could be achieved is fifty which

indicates that the patient was unable to

perform the tasks due to medical and

safety reasons and the assistive device

used for standing or mobilizing was a

walking frame.

KSKS: This rating system was developed

in 1989 by the American Knee Society to

provide an evaluation form for knee

integrity (Insall et al, 1989). The knee

assessment has three parameters which

measure pain, stability and range of

motion. The knee is given a score out of a

hundred. A well-aligned knee with no pain,

negligible instability and range of motion

of 125 degrees scores a hundred points

Goniometry: It is a measuring tool used to

assess the range of motion of a joint. It

can be used as an initial assessment and it



evaluate the patient’s progress (Rothstein

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

goniometric reliability and which

goniometer size was the most reliable in a

clinical setting.

DATA ANALYSIS AND RESULTS

All continuous variables were presented

by mean. The statistical significance of P

value was set at 0.05.

One-way repeated measures analysis of

variance (ANOVA) was made to compare

ILOA score, KSKS score, Goniometry

range between-groups.

130 subjects were recruited from OPD

physiotherapy among the patient

discharge from hospital and randomly

divided into supervised clinic exercise and

home based exercise. 19 patients not

fulfilled the inclusion criteria and four

patients due to prolonged hospital stay for

medical reasons, two patients for medical

conditions, two patient consented to the

socio demographic and clinical

questionnaire, but not to the goniometry

and Iowa Level of Assistance (ILOA)

testing, and therefore had to be excluded.

One patient refused to be tested · two

patient had been discharged before the

researcher had been able to collect data

(morning of day three).

The following results are presented:

Range of movement (ROM) of the

operated knee and functional level of

TKA patients, Knee integrity and Socio-

demographic factors and clinical data of

TKA patients, The relationship between

identified factors and postoperative

functional status of TKA patients in

relevance of level of assistance (ILOA) in

control group mean (home based exercise)

is11.94 and experimental group

(supervised clinical exercise) 10.01 (p=

0.018), KSKS in control group mean

(home based exercise) is74.72 and

experimental group (supervised clinical

exercise) 76.78 (p=0.017), goniometry in

control group mean (home based exercise)

is 88.06 and experimental group

(supervised clinical exercise) 95.52

(p=>0.05) found.

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

pre post

Home 30.46 88.06

Super 28.86 95.52

0.

50.

100.

150.

RO

M )

in d

eg

tre

e)

ROM Knee Flexion

pre post

Home 33.9 11.94

Super 32.9 10.1

0.

10.

20.

30.

40.

Lev

el

of

ass

iste

nce

ILOA

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

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

DISCUSSION

KSKS: 1. Pain: Fifty percent of the

patients had virtually no pain at six weeks

post operation. The other fifty percent had

pain that ranged from occasional to severe

pain Two patients (4%) had severe pain.

This indicates that the patients’ pain is not

being managed well at home after

discharge. They are perhaps not given

physiotherapy modalities which are

healing in reducing pain. Cryotherapy and

simultaneous exercise is more effective in

reducing pain than icing alone. Icing and

compression also helps to reduce pain in

patients post surgery. Transcutaneous

Electrical Nerve Stimulation (TENS)

causes a reduction of pain in 93% of

patients who undergo surgery and the

TENS group of patients consumed less

pain medication. Interferential therapy has

been shown to reduce pain in patients at

intervals of 24-hours, 48-hours, 72- hours

and at one to eight weeks post operation

(Hubbard and Denegar 2004; Jensen et al

1985; Jarit et al 2003).

2: Range of motion: People normally

require knee flexion of 45º to 105º during

various activities of daily living. To

demonstrate a normal gait pattern, 65º of

flexion is required. To ascend and descend

stairs, 90º of flexion is needed and to go

from sitting to standing, 105º of flexion is

required (Miner et al 2003). From the

results of the range of movement shows

that experimental group (mean=95.52) and

control group (mean=88.06), one can

assume that 51% of the patients (twenty

six patients) would not be able to go from

sitting to standing as they only had knee

flexion of 80º. However, from our sample

of 50-patients, 24-patients (49%) who had

90º-100 of knee flexion were able to go

from sitting to standing independently

without any assistance or assistive devices.

Patients with less than 95º of knee flexion

had worse Goniometry scores (p<.0001).

Only patients with a very stiff knee will

have function that is really affected by

ROM. Their study identified 95º of knee

flexion as a clinically meaningful cut-off

point above which ROM does not limit a

patient’s normal activities after TKR.

However the long-term effects of this

limitation of ROM could be detrimental to

pre post

Home 18.16 74.72

Super 18.52 76.78

0.

50.

100.

Kn

ee

in

teg

rity

&

fun

ctio

n

KSKS



the normal joints, because of the patients

over compensation when performing

activities of daily living.

3. Knee Stability and alignment: The

majority of the patients had normal

stability and alignment. This indicates that

the total score of the Knee Society Knee

Score in this sample is not really affected

by the components of stability and

alignment, but mainly by pain and ROM.

Malalignment of the prosthesis could

result in stiffness which although

uncommon is a disabling problem (Jerosh

and Aldawoudy 2007). Treatment of

malalignment could include manipulation

or revision arthroplasty (Bong and Di

Cesare 2004),which has been shown to be

successful in terms of post-operative

function(Miner et al 2003).

4. Knee Flexion contracture and extension

lag: A percentage of the patients in this

study had some degree of a flexion

contracture and some degree of an

extension lag at six weeks post operation.

This could indicate that attaining full knee

extension and flexion is not that important

when it comes to functional activities such

as going from sitting to standing, walking

and stair climbing, as these same patients

performed well when assessed using the

ILOA Scale. Functional range of motion is

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

As long as the extension lag and the

flexion contracture do not interfere with

this range of motion, the patient should

manage functionally. Patients also

compensate when performing activities by

using the other leg or their arms to assist

with transfers. The quality of the

movement being performed is not

important to the patient, what is of

importance is completing the movement

by any means possible. The long term

effect of poor ROM and poor quality of

movement is that the normal joints take

excess strain and over a prolonged period,

there is an increased risk of developing

pain and discomfort in the normal joints

due to osteoarthritis.

ILOA Score:

Most of the patients were able to go from

lying to sitting, sitting to standing and

walking 4.57 meters independently, with

minimal assistance. The patients scored

very well in these three categories. This

indicates that the ILOA Scale is not a

sensitive enough functional measuring

tool when used at six weeks post operation.

It measures basic functional ability, not

higher function. It was developed to

determine whether patients who had had

total hip and knee replacements were

ready to be discharged from hospital

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

physiotherapists in the hospital to ensure

that patients are able to perform basic

transfers so that they will be independent

at home, after they are discharged from

hospital. Five patient did not use an

assistive device to perform the five

functional tasks. She did however require

nearby supervision for the walking, stairs

and the speed test. Two patients used a

walking frame at six weeks after the

operation. Only one patient was unable to

climb the stairs even with maximal

assistance

CONCLUSIONS

The goal of a TKA is to provide the

patient with a stable and painless knee

with sufficient ROM to perform ADL’s

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

only focused on the long-term status of

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

study examined the short-term status. The

value of this is to furnish patients and the

therapist with knowledge of their acute

postoperative status and appropriate

rehabilitation programme that will

influence their prognosis. integrity which

was measured using the Knee Society

Knee Score and function as measured

using the ILOA Scale, six to eight weeks

post surgery on total knee replacement.

Research Recommendations:

A functional tool should be developed that

assesses the attainment of higher

functional milestones, as well as the

quality of the movement. If a more

sensitive functional assessment tool was

used, one that looked at higher functional

levels, a more accurate functional

evaluation of the knee replacement could

be determined.

REFERENCES:

1. De Jonghe B, Sharshar T,

Lefaucheur JP, Authier FJ, Durand-

Zaleski I, Boussarsar M, et al; Groupe

de Reflexion et d’Etude des

Neuromyopathies en Reanimation.

Paresis acquired in the intensive care

unit: a prospective multicenter study.

JAMA 2002;288(22):2859–2867.

2. de Letter MA, Schmitz PI, Visser

LH, Verheul FA, Schellens RL, Op de

Coul DA, van der Meche FG. Risk

factors for the development of

polyneuropathy and myopathy in

critically ill patients. Crit Care Med

2001;29(12):2281–2286.

3. Coakley JH, Nagendran K,

Yarwood GD, Honavar M, Hinds CJ.

Patterns of neurophysiological

abnormality in prolonged critical

illness. Intensive Care Med

1998;24(8):801–807.

4. Garnacho-Montero J, Madrazo-

Osuna J, Garcia-Garmendia JL, Ortiz-



Leyba C, Jimenez-Jimenez FJ,

Barrero-Almodovar A, et al. Critical

illness polyneuropathy: risk factors

and clinical consequences: a cohort

study in septic patients. Intensive Care

Med 2001;27(8): 1288–1296.

5. Spitzer AR, Giancarlo T, Maher L,

Awerbuch G, Bowles A.

Neuromuscular causes of prolonged

ventilator dependency. Muscle Nerve

1992;15(6):682–686.

6. Rudis MI, Guslits BJ, Peterson EL,

Hathaway SJ, Angus E, Beis S,

Zarowitz BJ. Economic impact of

prolonged motor weakness

complicating

neuromuscular blockade in the

intensive care unit. Crit Care Med

1996;24(10):1749–1756.

7. Latronico N, Peli E, Botteri M.

Critical illness myopathy and

neuropathy. Curr Opin Crit Care

2005;11(2):126–132.

8. Bednarik J, Lukas Z, Vondracek P.

Critical illness polyneuromyopathy:

the electrophysiological components

of a complex entity. Intensive Care

Med 2003;29(9):1505–1514.

9. Van den Berghe G, Wouters P,

Weekers F, Verwaest C, Bruyninckx F,

Schetz M, et al. Intensive insulin

therapy in the critically ill patients. N

Engl J Med 2001;345(19):1359–1367.

10. Tennila A, Salmi T, Pettila V,

Roine RO, Varpula T, Takkunen O.

Early signs of critical illness

polyneuropathy in ICU patients with


syndrome or sepsis. Intensive Care

Med 2000;26(9):1360–1363.

11. Rabuel C, Renaud E, Brealey D,

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

Human septic myopathy: induction of

cyclooxygenase, heme oxygenase and

activation of the ubiquitin proteolytic

pathway. Anesthesiology

2004;101(3):583–590.

12. MacFarlane IA, Rosenthal FD.

Severe myopathy after status

asthmaticus (letter). Lancet

1977;2(8038):615.

13. Witt NJ, Zochodne DW, Bolton

CF, Grand’Maison F, Wells G, Young

GB, Sibbald WJ. Peripheral nerve

function in sepsis and multiple organ

failure. Chest 1991;99(1):176–184.

14. Knox AJ, Mascie-Taylor BH,

Muers MF. Acute hydrocortisone

myopathy in acute severe asthma.

Thorax 1986;41(5):411–412.

15. Hund E, Genzwurker H, Bohrer H,

Jakob H, Thiele R, Hacke W.

Predominant involvement of motor

fibres in patients with critical illness

polyneuropathy. Br J Anaesth

1997;78(3):274–278.

16. Thiele RI, Jakob H, Hund E,

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

Sepsis and catecholamine support are

the major risk factors for critical

illness polyneuropathy after open heart

surgery. Thorac Cardiovasc Surg

2000;48(3):145–150.

17. Garnacho-MonteroJ, Amaya-Villar

R, Garcia-Garmendia JL,Madrazo-

Osuna J, Ortiz-Leyba C. Effect of

critical illness polyneuropathy on the

withdrawal from mechanical

ventilation and the length of stay in

septic patients. Crit Care Med

2005;33(2):349–354.

18. Bolton CF. Sepsis and the


syndrome: neuromuscular

manifestations. Crit Care Med

1996;24(8): 1408–1416.

19. Latronico N, Fenzi F, Recupero D,

Guarneri B, Tomelleri G, Tonin P, et

al. Critical illness myopathy and

neuropathy. Lancet 1996;

347(9015):1579–1582.

ACKNOWLEDGMENT:

The authors thank Dharam Pandey (MPT-neuro), Deepa Dabas (MSc-psycho) for assistance

throughout the study.

CORRESPONDENCE:

*Bijender Sindhu PhD,PT Research Student**Dr.Manoj Sharma, MBBS, MS(ortho)***Dr.Raj k Biraynia,

MBBS, D.ortho *School of Physical Therapy, Faculty of Medical Science, Singhania University**Department

of orthopedic surgery, Jaipur Golden Hospital *** Department of orthopedic surgery, Sarvodaya

Multispeciality Hospital. This study was not funded through a grant from the any organization.



Comparison of the Effect of Isometric Exercise of Upper Limb on Vitals

between Young Males and Females

Pranjal Parmar. BPT*

Abstract: Background and objective: studies on gender difference in

cardiovascular responses to isometric exercises have been numerous and

confliction the objective of this study was to determine if cardiovascular response

to upper extremities isometric exercises differ between apparently healthy male

and female subjects. Method: 60 young adults age between 18 to 22 years were

included in study. These consisted of 30 males and 30 females. The baseline

cardiovascular parameters (HR, SBP, DBP & MAP) were recorded. After two

sets of three isometric upper limbs for 3 minutes these parameters recorded at the

end of exercise and after recovery. Results:An increase in HR ,SBP , DBP&MAP

was seen in both groups after exercise .the result showed group B had more

increase in HR,SBP,DBP and MAP as compared to group A and significant rise

in MAP &SBP in group B. Conclusion: Isometric exercise of upper limb can lead

to increase in SBP, DBP, MAP &HR among apparently healthy males & females.

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

in both but more in males as compared to females.

Keywords: Isometric Exercises, Cardiovascular Measures

INTRODUCTION Exercise, a common physiological stress,

can elicit cardiovascular abnormalities not

present at rest and can be used to

determine the adequacy of cardiac

function.1 The isometric contractions are

seen in various exercises like pushing or

lifting heavy load where net displacement

of load is not, but the rising tension can be

felt in contracting muscles.3 It imposes

greater pressure than volume load on left

ventricle in relation to the body ability to

supply oxygen.4 The metabolic demands

of the exercising muscles increases,

depending upon intensity of exercises and

are met with various changes in

circulatory and respiratory system.13

The effect of isometric exercises on vitals

in between males and females may vary

with substantial anatomical, physiological

and morphological differences that exist

between men and women which may

affect their exercise capacity and influence

magnitude of response to exercise.5

The average isometric strength estimate is

generally 30% greater in men than in

women in different muscle group. Gender

difference in cardiovascular response to

static exercise is believed to be due to

differences in sympathetic –

parasympathetic or adrenal interactions at

cardiac level.

The larger the muscle group that is

involved in isometric tension the greater

the cardiovascular response.6

Response To Exercise:7

When you exercise or take part in a

strenuous sport you will notice several

changes taking place in your body:

a. Your heart beats stronger and faster

b. Your breathing quickens and deepens

c. Your body temperature increases

d. You start to sweat

e. Your muscles begin to ache

1. Heart beats stronger and faster:

During exercise it is mainly adrenaline

that produces changes in the heartbeat.

Adrenaline is a hormone which causes the

heart rate to quicker.

2. Breathing quickens and deepens:

You breathe quicker so as to get more

oxygen into the lungs. An efficient heart

can then transport this to the working

muscles. Training can be of great benefit

to the Respiratory System. The capacity of

the lungs is increased, which allows more

oxygen to be taken in per breath.

3. Temperature rises:

When we exercise, our muscles are

working and they generate heat, so our

body temperature rises. Body temperature

is regulated by heat radiating from the

skin and water evaporating by sweating.

When we shiver, our muscles are working

to produce heat in order to raise our body

temperature.

4. Start to sweat:

As we have just seen, some of our energy

is turned into heat. The body will tolerate

a small rise in temperature, but very soon

we begin to sweat. If the conditions are

hot, we sweat more and produce less urine.

We also lose salt as well as body heat and

water. We have to replace the salt so that

the body stays the same, otherwise we will

get cramp.

5. Muscles begin to ache:

As we now know, in order to work,

muscles need energy. Energy comes from



food, which is mainly converted to

glucose. To work more efficiently muscles

also need plenty of oxygen. Glucose and

oxygen are brought to the muscles in the

blood. Wastes such as carbon dioxide are

carried away in the blood. This process of

getting energy is called respiration.

Glucose + Oxygen = Energy + CO2 +

Water

When muscles do extra work more

Glucose and Oxygen are needed, so more

blood must flow to the muscles.

Eventually it becomes impossible to get

enough oxygen to the muscles, so they use

a different method of getting energy.

Glucose is still used, but now there is a

waste product called lactic acid, which

makes muscle ache, & muscles.

Acute Cardiovascular Response to

Exercise:

As exercise intensity increases, heart rate,

stroke volume, and cardiac output increase

to get more blood to the tissues. More

blood forced out of the heart during

exercise allows for more oxygen and

nutrients to get to the muscles and for

waste to be removed more quickly. Blood

flow distribution changes from rest to

exercise as blood is redirected to the

muscles and systems that need it.

CLINCAL SIGNIFICANCE

Vitals response to exercise has been used

as major criteria in exercise prescription

for both patient and healthy population.

Thus for prescribing isometric exercise,

repetitions and frequency it would be

helpful and prevent the adverse effect on

vitals. The study would also be helpful in

prescribing exercises for those with

cardiovascular compromise. It would help

to determine the safety limits of the

exercise.

OBJECTIVES:

1. To analyze if there is any change in

vitals as a result of isometric exercises of

upper limb

2. To compare the response of upper limb

isometric exercises in young male and

female.

METHODOLOGY

Research Design: An quasi-Experimental

(comparative) study. Sample Size: 60

normal individuals. Sample Population:

60 young adults between 18 to 22 yrs.

Group A: 30 normal individuals (females)

Group B: 30 normal individuals(males)

Type of Sampling: Convenient sampling

with random assignment. Duration of

Study: one month. Study Set Up:

Physiotherapy OPD of a tertiary care

hospital.

Inclusion Criteria:

• No previous history of known

cardiovascular condition.

• Normal values of vitals at rest.

• No neurological defecit in upper

limb.

• Sex – both male and female.

• Willingnessof patient.

Exclusion Criteria:

• Fracture of upper limb bones.

• Cervical vertebrae or scapula

fracture.

• Neurogenic deficit.

• Congenital anomalies.

• Previous exercise training

• Any disability limiting to upper

limb exercise.

• Psychiatric patients.

• Non-willing patients.

Outcome Measures:

• Heart rate of patient at rest,

immediately post exercise and 3

minutes after exercise

• Blood pressure i.e. systolic and

diastolic blood pressure at rest,

immediately postexercise and 3

minutes after exercise.

• Mean arterial pressure was

calculated from the above data.

PROCEDURE

60 individuals were selected according to

the inclusion and exclusion criteria. The

need of the study and treatment

intervention was explained to the

individuals and their written consent was

taken from them. 60 individuals were

assigned into two groups, group A and

group B, 30 patients in each group.

Procedure details of group A and group B:

Pre-measures: Heart rate and blood

pressure was measured using an electronic

sphygmomanometer in standing position.

Reading was noted.

Individual position: standing position.

Therapist position: on the individual side

in stride standing position.

Procedure: Participants in upstanding

position performed 3 upper extremities

isometric exercises i.e. 2 sets of each

exercise for each 30 second each thus total

duration of exercise for 3 minutes.

1. The exercise are pushing against the

wall with outstretched arms and were

instructed to exert maximal tension on

wall.8

2. Hands clasped together and brought to

manubrosternal level to chest while

shoulders are 60 70 degree abducted and

participants were instructed to maximally

generate tension by pressing opposite

hands against each other.8

3. Both palms on wall with participants

standing ahead arms extended and were

asked to push the wall without coming

behind and keeping elbow straight.8

Participants were instructed to avoid

valsalva maneuver by not holding breath

Vol.1 No.4

Thereafter participants were asked to rest

for 10 minutes before leaving.

measures: Heart rate and blood pressure

was measured immediately after exercise

and 3 minutes after exercise.

were comfortable after the treatment

session.

DATA ANALYSIS AND RESULT

The data collected was entered in excel

sheet and statistical analysis

using SPSS software. Heart rate and blood

pressure are objective data hence can be

considered for statistical analysis.

isan interval data hence pre and post

parmeters was statistically analysed using

paired t-test, and difference in paramate

between two groups was statistically

analysed using unpaired t-

Table No.1

Mean age (yrs)of study group

Group Number A 30 B 30

Rest Post exercise

Value -5.46072 -10.1411P

value 1.64e-05 3.14e

2012 Scientific Research Journal of India


Thereafter participants were asked to rest

for 10 minutes before leaving. Post-

Heart rate and blood pressure

was measured immediately after exercise

s after exercise. All patients

were comfortable after the treatment

DATA ANALYSIS AND RESULT

The data collected was entered in excel

sheet and statistical analysis was done

Heart rate and blood

pressure are objective data hence can be

considered for statistical analysis. This

isan interval data hence pre and post

parmeters was statistically analysed using

test, and difference in paramaters

between two groups was statistically

- test.

Table No.1

)of study group

Age (yrs) 20.23 20.16

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

Table 2 Rest

Group A (females)

117.8

Group B (males)

123.6

Table 3 Value P

Group

A

-1.6912 3.47e

10

Group

B

-1.3678 3.17e

12

Table 4

Table 2 shows mean of systolic blood

pressure at rest in group A is 117.8 and

group B IS 123.6 ,post exercise in group

A is 123.28 and group B is 134.58 and

recovery in group A is 120.45and group B

is 128.95.

20.1

20.15

20.2

20.25

MEAN AGE OF POPULATION

Post exercise

Recovery

10.1411 -10.0176 3.14e-09 2.19e-11

Scientific Research Journal of India 41


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

Table 2 Post

exercise Recovery

123.28 120.45

134.58 128.95

Table 3 P value Significance

3.47e-

10

Difference is

significant.

3.17e-

12

Difference is

significant.

Table 4

Table 2 shows mean of systolic blood


group B IS 123.6 ,post exercise in group

A is 123.28 and group B is 134.58 and

in group A is 120.45and group B

MEAN AGE OF POPULATION

MEAN AGE

OF

POPULATION

Table 3 shows p value by paired t test in

group A and group B and difference is

statically significant.

Table 4 shows p value by unpaired t test in

group A and group B at rest, post exercise

and recovery and difference is statically

significant.

The graph shows mean of males and females of systolic blood pressure at rest ,

post exercise and recovery.

.

0

50

100

150

REST POST

EXERCISE

RECOVERY

SYSTOLIC BLOOD PRESSURE

0

0.05

0.1

0.15

0.2

102106110114118122126130


0

0.05

0.1

0.15

108112116120124128132136140

SYSTOLIC BLOOD PRESSURE - POST EXERCISE



Table 4 shows p value by unpaired t test in

group A and group B at rest, post exercise

difference is statically

The graph shows mean of males and females of systolic blood pressure at rest ,

post exercise and recovery.

The above graph shows distribution of

systolic blood pressure in males and

females at rest, post exercise and recovery.

Diastolic Blood Pressure

Table 5 Rest Post

exerciseGroup A (Females)

75.6 84.25

Group B (Males)

80 96.50

Table 6

Value P value Group

A -1.345 3.95e-

15 Group

B -1.236 3.21e-

08 Table 7

Rest Post exercise

Value -5.78263 -14.6703P

value 1.1e-06 3.14e-09

Table 5 shows mean of diastolic blood


group B is 80, at post exercise in group A

is 84.25 and in group B is 96.50 and at

recovery in group A is 80.20 and group B

is 83.60.

RECOVERY


SYSTOLIC BLOOD PRESSURE - REST

Female

Male

POST EXERCISE

Female

Male

0

0.05

0.1

0.15

0.2

0.25

0.3

108110112114116118120122124126128



systolic blood pressure in males and

exercise and recovery.

Diastolic Blood Pressure

Post exercise

Recovery

84.25 80.20

96.50 83.60

Significance Difference is significant.

Difference is significant.

Post exercise

Recovery

14.6703 -4.4098 09 1.58e-07

Table 5 shows mean of diastolic blood


exercise in group A

is 84.25 and in group B is 96.50 and at


128130132

SYSTOLIC BLOOD PRESSURE - RECOVERY

Female

Male





statistically significant.

Table 7 shows p value by unpaired t test at

rest, post exercise and recovery in group

A and group B and difference is

statistically significant

The above graph shows mean of males

and females of diastolic blood pressure at

rest, post exercise and recovery.


diastollic blood pressure between males

and females at rest, post exercise and

recovery.

Mean Arterial Pressure

Table 8

Rest Post exercise

Recovery

Group A (Females)

89.66 97.26 93.61

Group B (Males)

94.53 109.19 98.71

Table 9 Value P value Significance

Group A

-1.327 5.78e-10

Difference is significant

Group B

-1.784 4.08e-12

Difference is significant.

Table 10

Table 8 shows mean of mean arterial

pressure at rest in group A is 89.66 and in

group B is 94.53,at post exercise in group

A is 97.26and in group B is 109.19 and at


is 98.71.


group A and group B difference is


Table 10 shows p value by unpaired t test

at rest, post exercise and recovery in

group A and group and difference is


020406080

100120

DIASTOLIC BLOOD PRESSURE

FEMALES

MALES

0

0.1

0.2

68 70 72 74 76 78 80 82 84 86 88

DIASTOLIC BLOOD PRESSURE - REST

Female

Male

0

0.1

0.2

74767880828486889092949698100102

DIASTOLIC BLOOD PRESSURE - POST EXERCISE

Female

Male

0

0.1

0.2

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

DIASTOLIC BLOOD PRESSURE - RECOVERY

Female

Male

Rest Post exercise

Recovery

Value -7.001 -9.57881 -7.17096 P value 1.16e-

09 1.91e-11 2.06e-09

The above graph shows mean of mean

arterial pressure at rest, post exercise and

recovery between group A and group B.


mean arterial pressure between males and

females at rest, post exercise and recovery.

Heart Rate

Table 11 Rest Post

exercise Recovery

Group A (Females)

72.6 80.40 76.40

Group B (Males)

74.4 82.95 78.65

Table 12

Value P value Significance Group

A 0.00615 0.015E-

04 Difference is significant

Group B

0.00322 0.14E-05

Difference is significant

Table 13 Rest Post

exercise Recovery

Value 0.00123 0.00808 0.00055 P

value 0.012e-

06 0.080e-

05 0.055e-06

Table 11 shows mean of heart rate at rest

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

at post exercise in group A is 80.40 and in

group B is 82.95 and at recovery in group

A is 76.40 and in group B is 78.65.




Table 13 shows p value by unpaired t test

at rest, post exercise and recovery in



020406080

100120

MEAN ARTERIAL PRESSURE

FEMALES

MALES

0

0.05

0.1

0.15

0.2

80 90 100

MEAN ARTERIAL PRESSURE -REST

Female

Male

0

0.05

0.1

86889092949698100102104106108110112114116118

MEAN ARTERIAL PRESSURE - POST EXERCISE

Female

Male

0

0.05

0.1

0.15

0.2

82 84 86 88 90 92 94 96 98 100102104106

MEAN ARTERIAL PRESSURE - RECOVERY

Female

Male



Heart Rate

The above graph shows mean of heart rate

in males and females at rest, post exercise

and recovery.


heart rate between males and females at

rest, post exercise and recovery.

DISCUSSION

The study investigated the gender

difference in cardiovascular response to

upper extremities isometric exercise

among apparently young healthy subjects.

60 participants were included in the study.

They were divided into two groups, group

A and group B. Group A included female

gender and group B included male gender.

BP, HR and MAP were taken as outcome

measure. These measures were taken pior,

immediately after test and 3 minutes after

study. The data collected was statistically

analysed. The result showed group B had

more increase in HR,SBP ,DBP AND

MAP as compared to group A and there

was significant rise in MAP and SBP in

group B. The average isometric strength

estimate is generally about thirty percent

greater in men than in women in different

muscle groups . Upon initiating isometric

tension, increases in heart rate, systolic

blood pressure, and diastolic blood

pressure occur. Mitchell and associates

and Seals et al suggested that

cardiovascular responses to isometric

exercise are greater when larger muscle

groups are involved. While heart rate

responses to sustained submaximal static

contractions tend not to be significantly

0

20

4060

80

100

FEMALES

MALES

0

0.05

0.1

0.15

0.2

65 70 75 80

HEART RATE - REST

Female

Male

0

0.05

0.1

0.15

68 78 88

HEART RATE - RECOVERY

Female

Male

0

0.05

0.1

0.15

72 82 92

HEART RATE - POST EXERCISE

Female

Male

different before, during, or after exercise,

blood pressure responses to this exercise

are significantly elevated before, during,

and after exercise Gender differences in

cardiovascular responses to static exercise

are believed to be due to differences in

sympathetic-parasympathetic or adrenal

interactions at the cardiac level. The

finding of this study revealed that there

was no significant gender difference in

vitals of participants at baseline which

was statistically significant. The data

collected reveals that post exercise heart

rate, systolic blood pressure ,diastolic

blood pressure and mean arterial pressure

were higher than pre exercise values and

was statistically significant in both groups

ie group A and group B.

When values of recovery i.e. 3 minutes

after exercise when compared it was

almost same in both groups but when

compared to values at rest it was much

greater than recovery values.

The result between the two was calculated

using unpaired t test. Therefore upper

extremities isometric exercise had

significant effect on heart rate, systolic

blood pressure, diastolic blood pressure

and mean arterial blood blood pressure.

When values of group A and group B at

post exercise were compared it was seen

that male participants (group B) had

higher post exercise MAP and SBP had

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

These result indicate that more blood is

pumped by left ventricle into aorta in

response to upper extremities isometric

exercise among males than females; while

myocardial oxygen uptake & measure of

oxygen consumption of heart muscles of

female participants in response to upper

extremities isometric exercises is higher

than that of males.

The tissues working hard during exercise

and also after the completion of exercise

require more oxygen than normal to pay

off this oxygen debt incurred during the

exercise. These results in increase in blood

supply to active muscles to supply this

extra amount of blood. At rest, muscles

receive approximately 20% of total blood

flow but during exercise blood flow to

muscles increase to 80 -85% .

Generally ,longer the duration of exercise

greater the role the cardiovascular system

plays in metabolism and performance

during exercise bout.eg an 1T00 meter

walk (little or no cardiovascular

involvement) versus a marathon(maximal

involvement).9

It has reported that release of adrenaline

and lactic acid into the blood result

increase in a heart rate.

The isometric exercises does not increase

the oxygen demand to the extend raised by

isotonic exercise thus DBP does not rise

much in isometric exercise The isometric

exercise results in pressure overload on



heart. The myocardial oxygen

consumption (mvo2) also increase due to

exercise . Higher ventricular contraction is

evoked among males leading to increase

in systolic blood pressure.

This indicates that the males have higher

myocardial oxygen demand during

isometric exercise predisposing them to

greater risk of ischemia if developing

cardiovascular risk, factor compromising

the coronary blood flow.10

It has been seen males have higher plasma

levels of all three catecholoamines out of

which plasma levels of epinephrine are

higher as compared to females .this results

in increase in MAP immediately at of

exercise.

The findings supports the results of

previous investigators than upon initiation

isometric tension increase heart rate,

systolic blood pressure and diastolic blood

pressure occur.12 The result of

investigations have been reported at best

inconsistent and do not follow definite

pattern.12

However during the recovery period the

vitals were decreased as compared to

immediately post exercise in both genders.

However the vitals were not the same as

they were at rest prior to commmencent of

exercise.

The result of study is supported by the

articles “Gender difference in

cardiovascular response to upper

extremities isometric exercise in

normotensive subjects.” By Cembada and

“Gender differences in cardiovascular

response to isometric in seated and supine

positions” by Don Melrose. The proposed

mechanisms attempting to explain gender

differences in cardiovascular responses to

isometric exercise have been numerous

and conflicting. Sanchez et al. found

differences in adrenergic patterns between

genders in response to isometric exercise

and support the study. Ettinger and

associates demonstrated attenuated

increases in blood pressure and muscle

sympathetic nerve activity compared with

men. In data also derived from static

exercise as well as temperature and

psychological stressors, Jones et al found

that gender did not influence sympathetic

neural reactivity to stressors such as

isometric handgrip exercise

Changes in posture often experienced

during exercise or sporting activities have

also been shown to elicit various

circulatory adaptations. Sagiv et al. and

Borst et al. both noted changes in

cardiovascular regulation as a result of

postural changes. Relatively fewer studies

have investigated the cardiovascular

adaptations to exercise performed when

posture does not change during the time

course of the positions.

A further study can be made:

• Comparison of vitals for larger

muscles groups to smaller muscles

group in upper limb isometric

exercises.

• Comparison of vitals in isometric

exercise for upper limb versus

lower limb.

The result can be used as

• It can be used for prescription of

exercise in those with

cardiovascular crompromise and

elderly patients.

• It can be used to determine the

safety limits during exercise

regimen.

CONCLUSION

The above study gives following

conclusion:

1. Isometric exercises of upper limb can

lead to increase in systolic blood

pressure ,diastolic blood pressure ,mean

arterial pressure and heart rate among

apparently healthly males and females.

2. This was more preannounced in males

than females .Systolic blood pressure

(SBP) and Mean arterial pressure (MAP)

increased in both but more males as

compared to females

LIMITATION

1. The participants in study were young

and elderly or middle aged participants

were not included in these study.

2. All the subjects who were included in

the study were students.

3. The participants nutritional status or

BMI were not considered while selection.

4. The occupation or lifestyle of

participants was not considered.

5. The muscle mass or bulk of upper limb

was not considered.

REFERENCES:

1. Journal of Exercise Physiology

Online. Volume 8, number 5,

august 2005.

2. Therapeutic Exercise, Carolyn

Kisner & Lynn Allen Collby.Pg

No 168,5th Edition

3. Sports Fitness Advisor, Fleck

st&kramerwj(2004).

4. Husketh Mount, pg no 92-96,lord

street,merseyside, england.

5. Effect of exercise .stending

lenderg 2004

6. Gender difference in

cardiovascular response to

isometric exercise.gatzke 2005

7. Circulation, amercian heart

association,2007pg no 3 &4

8. Clinical Orthopaedic

rehabilitation ,2nd editions brent

brotzman,pg no 138-142



9. Cardiovascular system and

exercise physiology,aulter &amer

suleman

10. International journal of biomedical

reserach,srinath galag & ravipati

sarath volume 2,november 2011



isometric exercise of upper

limbs,howden et clf 2006.



isometric exercise,gatzke

13. The essential guide to building

muscles by phil daviee.

CORRESPONDENCE:

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

Email: [email protected]

Paraplegia with Sacral Pressure ulcer treated by Ultrasound therapy- A

Single Case Report

Shanmuga Raju P. MPT *, Ramalingam P. MS, FICA, MAMS

Abstract: Pressure ulcers are important and common complications after

paraplegia. The use of therapeutic ultrasound as an adjunct to wound healing has

gained interest in recent years. An twenty five year old male reported with a two

months history of a grade two, non healing, sacral pressure ulcer. Ultrasound

therapy (UST) is simple, safe, without side effects, bedside procedure, inexpensive

with positive wound healing results for difficult to treat non healing pressure sore.

I hope that this article will encourage other wound care specialists to engage in

further research in this area.

Key Words: Paraplegia, Sacral pressure ulcer; Continuous mode of ultrasound

therapy; wound healing.

INTRODUCTION Pressure Ulcer, also called as Decubitus

ulcers, was first seriously studied by

“Jean- Martin Charcot”, a clinician in the

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

serious health issue, very painful, a

significant physiological challenge, can

shorten the life of patient, an emotional

and financial burden to the patient.

Pressure sore are important and common

complications after paraplegia. An

estimated 50 – 80% of individuals

suffering from spinal cord injury develop

pressure ulcer at least once in their life

time (9). Pressure ulcer are treated by

using wound dressings, relieving pressure

on the wound, Water beds/ Alpha bed by

treating concurrent conditions which may

delay healing and by the use of physical

therapy such as electrical stimulation,

laser therapy and ultrasound (1).

Ultrasound is now the most frequently

used electrophysical agent worldwide,

used at least daily for patient treatment by

the majority of physiotherapists (4-5).The

aim of this study to investigate the effect

of ultrasound (US) therapy in sacral



pressure ulcer with paraplegia. Limited

clinical research is available and no

consensus exists regarding the efficacy of

ultrasound for treating pressure ulcer,

particularly full thickness pressure ulcers.

CASE REPORT

A twenty five year old man presented with

a two months history of a grade two, non

healing sacral pressure ulcer. He was a

former. He had history of fall from height.

His past medical history, complete

paralysis of both lower limbs, loss of

sensation, urinary and bladder

incontinence, loss of mobility and sacral

pressure ulcer for past one month. His

medical problems included spinal cord

injury and severe depression. He had

become unable to walk since two months

and was carried either in bed or in his

wheelchair. He was diagnosed as a case of

D11, and D12 wedge compression of

spine with traumatic paraplegia (American

spinal cord injury association impairment

score: A- no motor or sensory function in

the sacral segments) and sacral pressure

ulcer. Five month back, he underwent

placement of spinal fixation rods and

plates from D11 to L1 level. A thoraco

Lumbar-sacral corset was fabricated for

him. Routine hematology and

biochemistry investigations were within

normal limits. He received antibiotics and

vitamin supplements. He was referred to

department of physical medicine and

rehabilitation OPD, CAIMS, Karimnagar

on February 26th, 2011.

On physical examination, he is bed ridden

and was unable to sit without support in

the chair, had sustained the sacral pressure

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

depth ranging from 10mm, grade II

sacrum ulcer with necrotic slough

according to European pressure ulcer

Advisory panel (EPUAP) wound

classification system (Figure.1). His

albumin count 2.4 g/dL, haemoglobin 11.0

g/dL, temperature was 38 degree Celsius.

There was no evidence of osteomyelitis.

He was put on conservative treatment,

consisting of water bed mattress, bed

postioning, regular pressure relief, daily

saline water dressing and appropriate

antibiotics.

OUTCOMES EVALUATED

Wound measurements and digital

photographs of wound beds were obtained

weekly. Wound dimension monitored and

depth measurements were obtained using

a sterile, cotton-tip applicator and ruler

(Steven JK et al, 2007). Wound surface

area was determined using Bates-Jenes

wound assessment tool.

ULTRASOUND THERAPY

INTERVENTION

On February 2011, Continuous mode of

ultrasound therapy (Electroson 709,

Chennai) treatment was performed in

sacral pressure ulcer region. The

following protocols are applied:

ultrasound machine with frequency of 3

MHz and spatial average intensity 0.8

w/cm2 sound head, in conjunction with a

coupling media of aquasonic ultrasound

transmission gel was used. Ultrasound

was applied to the outer surface, and edge

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

treatment of CUS therapy, we splashed

each wound by oxygen spray. Sacrum

ulcer was cleaned using 2% hydrogen

peroxide. The standard normal saline

(Nacl) dressing was done. Ultrasound

treatment time was 10 minutes per session

6 days a week, for six weeks. At the end

of third week there was marked

improvement in pressure ulcer i.e size,

floor and wound margin reduced. There

was no pus discharge after treatment (Fig.

3). A healthy granulation tissue was noted

(Fig. 4). The patient made good progress

and wound was completely healed within

42 days (Fig. 5).

Table: 1 Parameter of Ultrasound

therapy treatment (McDiarmid etal, 1985)

• Ultrasound frequency: 3 MHz

• Spatial average temporal peak

intensity: 0.8 W/cm2

• Pulse duration: 2 ms

• Duty factor: 0.2

• Spatial temporal average radiating

surface area: 5.2 cm2

• Duration of treatment: 10 minutes

per session for sacral pressure

ulcer

• Duration of treatment: 6 weeks

RESULT

The indolent pressure ulcer, apart from

routine therapy, continuous mode

ultrasound therapy enhanced the healing

of pressure ulcer in six weeks.

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



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

Fig: 3 three weeks after the treatment of CUST

Fig: 4 Fifth weeks after CUST, the wound size are decreased for sacral ulcer

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

DISCUSSION

The purpose of the study was to assess the

effect of ultrasound therapy in healing of

sacrum pressure ulcer in patients with

paraplegia. Infected sores heal more

slowly than clean sores while no effect of

ultrasound clean sores were observed

ultrasound therapy appeared to improve

the rate of healing of infected sores. It is

non thermal effect produced by ultrasound

that are most significant in the stimulation

of tissue repair (Dyson, 1976). Paul et al

(1960) ultrasound was effective in

relieving congestion, cleansing necrotic

areas and promoting healing with healthy,

non-adherent skin approaching normal

thickness. Cyclic vibration effect of

ultrasound might induced a form of micro

massage which by reducing edema, might

facilitate repair, their requires further

investigations. It is also stimulate protein

synthesis infact ultrasound initiates two

processess which results in release of

energy tissue: Surface cavitation (creation

and dissipation of tiny bubbles in the

tissues) and acoustic microstreaming that

is movement of fluids along acoustic

boundaries, such as cell membrane. This

biophysical effect that are non-thermal

alternations in cellular protein synthesis

and release, blood flow and vascular

permeability, angiogenesis, and collagen

content and alignment by various workers

it as quoted as follows: 1. General protein

and collagen synthesis by fibroplasts

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

Fibroplast mobility (Miller etal, 1978). 3.

Fibroblast ultrastructure (Dyson and Pond,

1970). 4. Permeability of fibroblast

membrane (Harvey etal, 1975). 5.

Lysosomal fragilty (Tayor and Pond,

1972). 6. Tensile strength and elasticity of

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

Modification of contraction in skin

wounds (Dyson et al, 1981).

With this parameters of ultrasound

treatment (frequency 3 MHz, Intensity 0.8

W/cm2, Pulse duration 2 ms, Duty cycle

0.2, effective radiating surface area 5.2

cm2, Duration of treatment 10 minute

per/session, Duration of frequency 6

weeks) pressure ulcer healed in time

without side effects. Our case study

showed that continuous mode of

ultrasound therapy treatment enhances

healing of sacral pressure ulcer. This case

study confirmed that continuous UST has

a positive effect on pressure ulcer with

paraplegia (Fig.5). No complications were

observed with application of the

continuous ultrasound. Further studies are

needed to evaluate the efficacy of

ultrasound therapy in pressure ulcers in

spinal cord injury in a large number of

patients.

CONCLUSION

Continuous mode of ultrasound therapy

was effective in the treatment of patient

with grade II pressure ulcer in young

paraplegic patient. Ultrasound therapy

treatment of pressure ulcer is less

expensive, more comfortable and can

enhance wound healing process without

side effects and complication.

REFERENCES:

1. Sella EJ, Barrette C. Staging of

charcot neuro arthropathy along

the medial column of the foot in

the diabetic patient. J. Foot Ankle

Surg. 1999, 38; 34-40.

2. Levine JM. Historical perspective

on pressure ulcers: The decubitus

ominosus of Jean- Martin Charcot.



J Am. Geriatr. Soci, 2005, 53;

1248- 1251.

3. Levine JM. Historical perspective:

The neuropathic theory of skin

ulceration. J. Am.Geriatr.Soci,

1992; 40, 1281.

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

Therapeutic ultrasound rate of

usage, knowledge of use, and

opinions on dosimetry. Physiother

Singapore 1999; 2: 69-83.

5. Chipchase LS, Trinkle D.

Therapeutic Ultrasound: Clinician

usage and perception of efficacy.

HongKong Physio Ther J. 2003;

21: 5-13.

6. Ali Akbari S, Flemming K,

Cullum NA, Wollina U.

Therapeutic Ultrasound for

pressure ulcers, (2009). The

Cohrane collaboration, John wiley

and Son ltd, p:1-18.

7. Paul BJ, Lafratta CW, Dawson AR

etal. Use of ultrasound in the

treatment of pressure sores in

patients with spinal injury. Arch

phys Med Rehabil, 1960; 41; 438-

440.

8. Callam MJ, Dale Jj, Harpel DR,

etal. A controlled trial weekly

ultrasound therapy in chronic leg

ulceration, Lancet. 1987; ii; 204-

206.

9. Saad A, Williams A. Effect of

therapeutic ultrasound on the

activity of the mononuclear

phagocyte system in vivo.

Ultrasound Med Biol, 1986; 12;

145-150.

10. Steven JK, David AL, Andrea JB,

Jenny LM, Julie AB, Karen LA.

Expedited wound healing with

Non-contact, Low frequency

ultrasound therapy in chronic

wounds: A retrospective analysis.

Adv. Skin and wound care, 2008,

vol: 21 (9); 416-23.

11. Arthro PJ, Thyme B, Warring

(2002). A Calibration study of the

ultrasound unit, Phys Ther, 82;

257-263.

12. Ankrom MA, Benneh RG, Sprigle

S, et al. Pressure related deep

tissue injury under intact skin and

the current pressure ulcer staging

systems. Adv. Skin Wound care,

2005; 18 (1); 35-45.

13. McDiarmid T, Burns PN, Lewith

GT, Machin D. Ultrasound and the

treatment of pressure sores,

Physiotherapy, 1985; 71; 66-70.

14. Dyson M. Role of ultrasound in

wound healing. In: Mcculloch JM.

Kloth LC, Feeder JA, eds. Wound

Healing. Alteratives in

Management, 2nd ed, Philadelphia

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

15. Sari AA etal. Therapeutic

ultrasound for pressure ulcers.

Cochrane Database of systemic

reviews. 2009 (4).

16. TerRiet G, Kessels AG,

Knipschild P (1996). A

randomized clinical trial of

ultrasound in the treatment of

pressure sores. Phys Ther 76;

1301-1311.

17. Whatson GW, Milani JC, Dean LS.

Pressure sore profile: cost and

management, ASIA, Abstracts

Digest, 1987; 115-119.

18. Houghton PE, Kincaid CB,

Campell KE, et al. Photographic

assessment of the appearance of

chronic pressure and leg ulcers.

Ostomy / Wound Management.

2000; 46(4); 20-30.

ACKNOWLEDGMENT:

I thank the men who participated in this trial. I would also like to thank chairman Sri. C.

Lakshmi Narasimha Rao, Prof. V. Suryanarayana Reddy, Director, Chalmeda Anand Rao

Institute of Medical Sciences, Karimnagar for his support and encouragement of this study.

CORRESPONDENCE:

*Asst. Professor & I/C Head, Department of Physical Medicine and Rehabilitation Chalmeda Anand Rao

Institute of Medical Sciences Karimnagar -505001, Andhra Pradesh, INDIA. Mobile: 08790544270, Fax: 0878-

2285318. E-mail: [email protected]



Arterio-Enteric Fistula: A Case Report

Anil Degaonkar*, Nikhil Bhamare**, Mandar Tilak***

Abstract: Gastro-intestinal (GI) bleeding may originate anywhere from oral

cavity to anus from the innocuous one like peptic ulcers to capricious lesion like

ca colon.Classically if the cause of bleeding is somewhere below the ligament of

Treitz, the stools are maroon or bright red in colour and it is described as lower

GI bleeding or hematochezia. Arterioenteric fistula signifies a rare but important

cause of massive lower GI bleeding .The vexing problem lies in proper and timely

diagnosis of this condition.A keen clinical acumen and proper use of tests lead to

accurate diagnosis and prompt treatment and can be lifesaving for the patient by

treating significant ongoing bloodloss. We wish to report such a case of an

arterio-enteric fistula between artery of broad ligament of uterus and terminal

ileum diagnosed and successfully treated at our institute .

Keywords: Arterioenteric fistula, massive GI bleed, rare cause

INTRODUCTION Arterioenteric fistula is a anomalous

communication between artery &

gastrointestinal tract. It is a rare cause of

massive lower GI bleeding with the

dreaded aortoenteric fistula leading to

massive and many times fatal GI bleed.

CASE REPORT

A 28 yr lady presented with complains

of recurrent per rectal bleeding and severe

anemia. She had undergone exploration

for ectopic pregnancy 1 month back at a

private hospital..On 8th post operative day

she had complained of three episodes of

per rectal bleeding which was associated

with giddiness and profound weakness.

Her sigmoidoscopy had been done and no

abnormality was detected.Patient had been

transfused, stabilised and subsequently

discharged .She whad been stable for the

next 20 days and now presented with

above complains of recurrent per rectal

bleeding and severe anemia. Patient was

investigated. Hematological investigations

showed low haemoglobin hb-5 gm% with

reticulocytosis. Platelets were adequate

and bleeding and clotting time was normal.

Serum Beta hCG was elevated .Upper GI

scopy showed no abnormality. O

colonoscopy only significant finding

observed was presence of blood clots near

caecum. USG was suggestive of

heterogeneous mass in right adnexa with

left ovarian cyst. CT confirmed the

ultrasound findings.

Pt was transfused with 3 pints of PCV.

Her condition improved and she remained

stable for next 8 days .On 9th day she

developed three episodes of massive per

rectal bleed and went into hypovolemic

shock. Her pulse rate was 146/min, BP

90/60 mm of hg. Patient was pale and

dehydrated. She did not have an

hematemesis and ryle’s tube aspirate was

clear. Due to absence of hematemesis and

pain in epigastrium upper GI bleeding was

less likely. Also patient had a history of

abdominal exploration. Thus an

arterioenteric fistula was suspected.

Advanced investigation modalities like

angiography and technicium99 labelled

rbc scan was unavailable at our institute.

Hence a decision for emergency

next 20 days and now presented with

above complains of recurrent per rectal

ere anemia. Patient was

investigated. Hematological investigations

5 gm% with

reticulocytosis. Platelets were adequate

and bleeding and clotting time was normal.

Serum Beta hCG was elevated .Upper GI

scopy showed no abnormality. On

colonoscopy only significant finding

observed was presence of blood clots near

caecum. USG was suggestive of

heterogeneous mass in right adnexa with

left ovarian cyst. CT confirmed the

Pt was transfused with 3 pints of PCV.

ition improved and she remained

stable for next 8 days .On 9th day she

developed three episodes of massive per

rectal bleed and went into hypovolemic

shock. Her pulse rate was 146/min, BP

90/60 mm of hg. Patient was pale and

dehydrated. She did not have any

hematemesis and ryle’s tube aspirate was

clear. Due to absence of hematemesis and

pain in epigastrium upper GI bleeding was

less likely. Also patient had a history of

abdominal exploration. Thus an

arterioenteric fistula was suspected.

tion modalities like

angiography and technicium99 labelled

rbc scan was unavailable at our institute.

Hence a decision for emergency

exploratory laparotomy after proper

resuscitation of the patient was taken.

On exploratory laparotomy there was

evidence of adherent ileum to the

posterior aspect of the broad lig. of

uterus (site at which the gestational sac

of previous ectopic was present.) Ileum

was separated from adhesion site. Erosion

of ileum wall with bleeder at site of

adhesion to broad ligament was found.

The site of adhesion on the broad ligament

showed necrosis.

Fig.1: Involved Ileal Segment

Thus this was a case of arterioenteric

fistula between the adherent ileum and a

branch of the ovarian artery supplying the

broad ligament. All bowel adhesions were

separated. The bleeder as ligated

hysterectomy was done. Adherent and

eroded segment of ileum was resected.

Intra-operative enteroscopy both

antegrade and retrograde was done in the

ileum to rule out any othe site of GI bleed.

Ileo-ileal anastomosis was done.

Postoperatively the patient was monitored

in surgical intensive care unit. Patient

exploratory laparotomy after proper

resuscitation of the patient was taken.

On exploratory laparotomy there was

f adherent ileum to the

posterior aspect of the broad lig. of

uterus (site at which the gestational sac

of previous ectopic was present.) Ileum

was separated from adhesion site. Erosion

of ileum wall with bleeder at site of

ad ligament was found.

The site of adhesion on the broad ligament

Involved Ileal Segment

Thus this was a case of arterioenteric

fistula between the adherent ileum and a

branch of the ovarian artery supplying the

ll bowel adhesions were

separated. The bleeder as ligated

hysterectomy was done. Adherent and

eroded segment of ileum was resected.

operative enteroscopy both

antegrade and retrograde was done in the

ileum to rule out any othe site of GI bleed.

ileal anastomosis was done.

Postoperatively the patient was monitored

in surgical intensive care unit. Patient

Vol.1 No.4 2012

received 3 blood transfusions. Patient’s

general condition improved steadily and

patient was discharged on 14th post

operative day.

Gross observation of resected specimen of

ileum and uterus with broad ligament as

well as histopathological analysis

suggested a arterio-enteric fistul between

the ileum and the broad ligament of the

uterus.

Fig.2. & 3: Resected specimen of uterus

(gross)

DISCUSSION

The causes of lower GI bleeding shows a

geographical variation, wit colonic

diverticulitis and vascular ectasia of colon

are the most common causes in the West.

Idiopathic ulcerative colitis, acute colitis,

colonic polyps, solitary rectal ulcer,

colonic carcinoma, ileal and colonic



received 3 blood transfusions. Patient’s

general condition improved steadily and

patient was discharged on 14th post

tion of resected specimen of

ileum and uterus with broad ligament as

well as histopathological analysis

enteric fistul between

the ileum and the broad ligament of the

esected specimen of uterus

The causes of lower GI bleeding shows a

geographical variation, wit colonic

diverticulitis and vascular ectasia of colon

are the most common causes in the West.1

Idiopathic ulcerative colitis, acute colitis,

colonic polyps, solitary rectal ulcer,

colonic carcinoma, ileal and colonic

tuberculosis, non steroidal anti

inflammatory drug enteropathy and

enteric fever are the major causes of lower

GI bleeding in India.

sources and other colonic pathologies like

small bowel diverticular disease,

inflammatory bowel diseases, neoplasia of

small and large bowel, angiodysplasia,

aorto-enteric fistula, ischaemic and

radiation colitis are uncommon causes but

pose a challenge to the clinician in making

correct preoperative diagnosis.

It is imperative to localize the source of

bleeding preoperatively for successful

treatment. Only rarely does laparotomy

need to be performed in emergency

without knowledge of the s

hemorrhage.5 The diagnostic work

should be done as soon as the resuscitation

is over and the general condition stabilizes.

The first step is nasogastric aspiration and

upper gastrointestinal endoscopy

(esophago-gastroduodenoscopy) to rule

out upper GI hemorrhage since peptic

ulcer bleeding may be the cause of

hematochezia and malena. Proctoscopy

and sigmoidoscopy (rigid or flexible) are

relatively simple procedures to exclude

hemorrhage below the peritoneal

reflection such as bleeding internal

hemorrhoids, rectal polyps and growths.

Colonoscopy, visceral angiography and

abdominal scintigraphy with 99m Tc

labeled RBCs are three useful tests for

59


tuberculosis, non steroidal anti-

inflammatory drug enteropathy and

enteric fever are the major causes of lower

GI bleeding in India.2,3 Small bowel

sources and other colonic pathologies like

small bowel diverticular disease,

inflammatory bowel diseases, neoplasia of

small and large bowel, angiodysplasia,

enteric fistula, ischaemic and

radiation colitis are uncommon causes but

a challenge to the clinician in making

correct preoperative diagnosis.3,4

It is imperative to localize the source of

bleeding preoperatively for successful

treatment. Only rarely does laparotomy

need to be performed in emergency

without knowledge of the site of

The diagnostic work-up

should be done as soon as the resuscitation

is over and the general condition stabilizes.

The first step is nasogastric aspiration and

upper gastrointestinal endoscopy

gastroduodenoscopy) to rule

er GI hemorrhage since peptic

ulcer bleeding may be the cause of

hematochezia and malena. Proctoscopy

and sigmoidoscopy (rigid or flexible) are

relatively simple procedures to exclude

hemorrhage below the peritoneal

reflection such as bleeding internal

orrhoids, rectal polyps and growths.

Colonoscopy, visceral angiography and

abdominal scintigraphy with 99m Tc

labeled RBCs are three useful tests for

localization.5 Colonoscopy may be most

useful if the bleeding has stopped or at

least slowed substantially.

Selective visceral angiography is very

useful if the patient is having active

bleeding to locate exact site of bleeding.

Abdominal scintigraphy with 99m Tc

labeled RBC infusion is helpful in

delineating the site of bleeding when

bleeding is intermittent and at a rate below

that which is detectable by angiography.

In case the above facilities are not at hand,

a combination of sigmoidoscopy and air

contrast barium enema may be tried if

patient’s general condition permits.6 We

have searched the literature on the subject

and have come across some pathological

conditions leading to fistula formation

between aorta and the intestine.7,8

Abdominal aortic aneurysm and infective

aortitis may lead to primary aorto-enteric

fistula but in most of the cases the

bleeding occurs due to erosion of aortic

vascular prosthesis through the wall of

distal duodenam due to prolonged contact

between prosthetic graft and a fixed

segment of intestine (secondary aorto-

enteric fistula). Bleeding may occur due

to dehiscence of the anastomosis with

bleeding into the bowel lumen from the

edges of the eroded intestine.7

The intestine may take blood supply from

the anterior abdominal wall due to

adhesion formation as seen sometimes as

a sequele of mesenteric venous thrombosis,

malignancies and fungal infection. A case

has been reported where mucomycosal

invasion took place into the iliac artery

causing severe haemorrhage, in a case of

non Hodgkin’s lymphoma receiving

chemotherapy.8 In this case, the cause of

arterio-enteric fistula formation was due to

continued trophoblastic activity of

incompletely removed gestational sac &

as the syncytiotrophoblast has invading

property.9 It has eroded the ileum &

fistula is formed between uterine artery of

broad ligament & terminal ileum.

Monitoring of trophoblastic activity can

be done by estimation of serum beta HCG

levels.10

In the above case report we have

presented a case of arterio-enteric fistula

between ileum and broad ligament of the

uterus. This is a very rare pathology and

has seldom been reported. We hypothesize

that the ectopic pregnancy and exploratory

laparotomy for the same probably created

a inflamed and eroded surface on the

broad ligament where ileum adhered. The

ileal wall was further eroded .The

inflammatory process exposed a artery on

the broad ligament and this adhered to the

ileum cresting the arterioenteric fistula.



REFERENCES:

1. DeMarkles MP, Murphy JR. Acute

lower gastrointestinal bleeding.

Med Clin North Am 1993 Sep;

77(5):1085-100.

2. Goenka MK, Kochhar R, Mehata

SK. Spectrum of lower

gastrointestinal hemorrhage: an

endoscopic study of 166 patients.

Indian J Gastroenterology 1993

Oct; 12(4):129-31.

3. Anand AC, Patnaik PK, Bhalla VP,

Choudhary, et al. Massive lower

intestinal bleeding – a decade of

experience. Trop Gastroenterol

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

4. Miller LS, Barbarvech C,

Friedman LS. Less frequent causes

of lower gastrointestinal bleeding.

Gastroenterol Clin North Am

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

5. Gracia Osogobio S, Remes Troche

JM, et al. Surgical treatment of

lower digestive tract hemorrhage –

Experience at the Institute

Nacional de ciencias Medicas Y

Nutricion Salvador Zubiran.Rev

Invest Clin 2002 Mar-Apr;

52(2):119-24.

6. Mark HB, Robert B, Mark B.

Merk Manual Diagnosis and

Therapy. Seventeenth Edition Sec

– 3, Ch-22. Gastrointestinal

Bleeding.

7. Kahhlke V, Brossmanm J, Klomp

HJ. Lethal hemorrhage caused by

aortoenteric fistula following

endovascular stent implant.

Cardiovasc Intervent. Radiol 2002

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

8. Mir N, Edmonson R, Yeghen T,

Rashid H. Gastrointestinal

mucormycosis complicated by

arterio-enteric fistula in a patient

with non-Hodgkin’s lymphoma.

Clin Lab Haematology 2000

Feb;22(1):441-4.

9. Datta; textbook of

gynaecology;6th edtn;chapter

2;page no.23

10. Datta; textbook of

gynaecology;6th edtn;chapter

15;page no.186.

CORRESPONDENCE:

*Assistant Professor Surgery, Dr. Shankarrao Chavan Govt Medical College, Nanded, Maharashtra;

**Resident 3rd yr General Surgery, Dr. Shankarrao Chavan Govt Medical College, Nanded, Maharashtra;

***Assistant Professor Surgery, Dr. Shankarrao Chavan Govt Medical College, Nanded, Maharashtra. E-mail

id: [email protected] Mob no: 09975033726



All-Oxide Solar Cells: The Way of the Future

Akshay Vijay Dongarwar*

Abstract: We as a world are looking at our globe depleting of its natural

resources. The quantity of coal presently available can lead us through for twenty

more years at maximum considering the growing demand for high quality coal

and natural resources and to suffice the growing population and bettering

lifestyle. Again, on one side we have cut throat technological advancement in the

silicon valley and the mobile world and on other, we have fairly advanced

technologies for bringing in better, faster, more efficient and cheaper solutions to

the environmental concerns. The question is basically inspired from this ever

daunting situation. Can’t we have a cheap and highly effective solar energy

treatment plant which can actually reach poor countries and help them get over

their energy crisis without undergoing high-end processing in posh labs like is

done for silicon cells? Even in one of the fastest growing economies of world,

India, silicon processing is not done by any industry commercially to make solar

cells. All the pre-processed cells are imported and further distributed because of

the complexity in the process. Also, being cheap and easily available, it must have

a huge life like silicon cells have. So, it should possess the best of silicon while

eliminating the negatives. Can we find an alternative to conventional solar cells

that can reach out to everyone?

Keywords: All Oxide Solar Cell

THE QUESTION We as a world are looking at our globe

depleting of its natural resources. The

quantity of coal presently available can

lead us through for twenty more years at

maximum considering the growing

demand for high quality coal and natural

resources and to suffice the growing

population and bettering lifestyle. Again,

on one side we have cut throat

technological advancement in the silicon

valley and the mobile world and on other,

we have fairly advanced technologies for

bringing in better, faster, more efficient

and cheaper solutions to the

environmental concerns. The question is

basically inspired from this ever daunting

situation.

Can’t we have a cheap and highly

effective solar energy treatment plant

which can actually reach poor countries

and help them get over their energy crisis

without undergoing high-end processing

in posh labs like is done for silicon cells?

Even in one of the fastest growing

economies of world, India, silicon

processing is not done by any industry

commercially to make solar cells. All the

pre-processed cells are imported and

further distributed because of the

complexity in the process. Also, being

cheap and easily available, it must have a

huge life like silicon cells have. So, it

should possess the best of silicon while

eliminating the negatives. Can we find an

alternative to conventional solar cells that

can reach out to everyone?

HYPOTHESIS

A cavity of metal m2 (W2) with thin

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

inner surface, with a pin hole is kept at the

focus of the solar concentrator coinciding

the pinhole and focus. Pinhole is covered

with transparent glass to protect inner

polish of cavity from atmospheric reaction.

Such cavity behaves as metal-metal

junction solar cell (termed M-M cavity

solar cell).

But using nanowires and nanotubes

increases the functionality further as

diffraction light rays occurs. Again, using

metal oxide makes further sense as they

are chemically under thermodynamic

equilibrium. Another approach is used

which is of titanium dioxide for photo-

sensitization.

RESEARCH

The main challenge with producing a solar

cell with whole new materials is the

availability of photo sensitive materials

and their production. I had prepared a

project for the prestigious “KVPY”

scholarship, where I tried to theoretically

explain the use of metal-metal junction

cavity cell for emitting electrons. The

same research is used here, but with some

changes to make it further effective and to

eliminate short-comings. Here, I present

an all-oxide solar cell fabricated from

vertically oriented zinc oxide nanowires

and cuprous oxide nanoparticles. It

consists of vertically oriented n-type zinc

oxide nanowires, surrounded by a film

constructed from p-type cuprous oxide

nanoparticles. The idea behind using

metal oxides is to eliminate the effects of

atmosphere. Oxides being benign, are safe



from environmental contamination. The

use of cuprous oxide as solar cells is a

very well studied since last 20 years.

Adding another metal-oxide film seemed

difficult at first as the oxides are already

in stable states and to make use of metal-

metal junction films, we had to change the

physical properties to excite them. But,

with the knowledge of photo-electricity

(diffusion) that I had acquired in the

recent months made me think a step

further and the idea of using nanowires

and nano-particles that respond better to

incident light seemed possible.

In the second part, I used titanium dioxide,

another successful oxide to take in the

solar light and convert them into

electricity (Research done by Dr. M.

Graetzel ). The cell was not taken as it

was. I just used pure titanium dioxide dust

here as polyphyrine derivatives. I did not

use dyes as is done in Graetzel cell but

instead let the oxide in white colour. Its

property of reflecting back visible range

light was later used and sorted out with

design. Being from an engineering

background, I designed a model, that

could make use of both these oxide films

efficiently and expected to get a desired

output of >12% efficiency.

EXPERIMENT

Zn oxide film preparation:

5 mM solution of zinc acetate dihydrate in

absolute ethanol was prepared. Two drops

of this solution were placed onto an

indium tin oxide (ITO) coated glass

substrate (Thin Film Devices, ~40-50

Ω/square). The substrate was then rinsed

with absolute ethanol and blown dry with

nitrogen. The dropcasting, rinsing and

drying was repeated four times per

substrate. The substrates were then

annealed in air at 350°C for 30 minutes,

converting the Zn(OAc)2 into ZnO, and

then cooled to room temperature. This

process was then repeated a second time

to ensure a conformal layer of ZnO.

The nanowires were then grown by

placing the seeded substrate in an aqueous

solution containing 25 mM zinc nitrate

hexahydrate, 25 mM

hexamethylenetetraamine, and 5 mM

polyethyleneimine at 90°C. The substrate

was suspended upside-down to prevent

any larger ZnO aggregates from

accumulating on the surface. Typical

growth times ranged from 30-60 minutes,

yielding wires that averaged from 400-

1000 nm in length and 30-50 nm in

diameter. After the growth, the nanowire

arrays were rinsed thoroughly with

deionized water, then annealed at 400°C

for 30 minutes to remove any residual

organics on the nano wire surface.

The Cu2O nanoparticles (NPs) were

prepared as follows:

A solution of copper (I) acetate (0.5 g),

trioctylamine (15 mL) and oleic acid (Alfa

Aesar, 99%, 4 mL) was flushed with

nitrogen, then rapidly heated to 180°C

under nitrogen flow. The solution was

maintained at this temperature for 1 hour,

then was quickly increased to 270°C and

held for one additional hour, ultimately

producing a burgundy colloidal solution,

which are metallic copper nanoparticles.

The solution was cooled to room

temperature, at which point absolute

ethanol was added to precipitate the

nanoparticles. The supernatant was

removed and the nanoparticles were

redispersed in hexane and then exposed to

air. After 12 hours, the burgundy solution

turned into deep green, indicating the

oxidation of the copper nanoparticles into

Cu2O. The Cu2O nanoparticles underwent

further cleaning by repeated precipitation

with ethanol. Finally, the nanoparticles

were dispersed in toluene for dropcasting

onto the ZnO nanowire arrays.

The processing required no posh research

labs and could be done without much

efforts.

The titanium oxide film is prepared the

usual Graetzel cell way. Except, we do not

use dye. The main motto was to simplify

the process. Dying induces lot of

complexity and we want the process to

remain easy.

DATA

The complete experiment was done by

using the available technologies at

disposal. Instead of using the paraboloid

sun-tracking reflector concentrator, a fine

beam of SODIUM VAPOUR LAMP was

used to create a similar effect. The metal-

metal oxide junction solar cell and the

titanium oxide cell were tested over a long

period of time to get accurate readings.

The cuprous oxide-zinc oxide junction

cells were studied first as they formed the

key research. A fine layer of the junction

nanoparticles was taken and placed in a

small glass box. The glass was designed in

such a way that it didnt let the incident



light get out and caused multiple internal

reflections, thereby reproducing the effect

as we see in the model. The input currents

and output currents were first measured

for a silicon solar cell of known efficiency.

It gave the total losses caused due to

atmosphere and other resistances in the

wire. Considering the same,the silicon

solar cell was replaced by the meta-metal

junction cell. Calculating the output

currents for same input current given t

sodium vapour lamp and subtracting the

effects of losses previously calculated, the

efficiency was calculated to be

The details of the experiment are given as

follows

There were mainly 2 methods employed

to double check the results

1) V-A meter, where voltage of input was

noted and then the output current. Thus

the power of cell was measured.

2) A solar cell's energy conversion

efficiency (eff), is the percentage of

incident light energy that actually ends up

as electric power. This is calculated at the

maximum power point, Pm, divided by

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

under standard test conditions (STC) and

thesurface area of the solar cell (Ac in m2).

eff=P/EA

Similar procedure was carried out for

Titanium dioxide cell.

The net efficiency was found out as

12.2374%

OBSERVATION

The observations of the experiment that I

performed are listed below

For the Metal-metal oxide junction cell:

Sr No

Voltage (V)

Output Current (mA)

1 11.5 100

2 10.6 99

3 11.4 100

Max power point 1.146 w

Light irradiance 1000 w/m^2

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

Efficiency=11.9374

For the titanium dioxide cell

Sr No

Voltage (V)

Output current (mA)

1 10.2 100

2 10.3 100

3 10.2 99

Max power point 1.0243

Light irradiance 1000w/m^2

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

Efficiency= 10.6697

Now, we observe that the efficiency of the

proposed cells with the given design

comes out to be quite more than that of the

silicon cells. Thus, one coupling the cells,

the efficiency will increase further.

Here, an interesting trend observed is that

the maximum power point doesn't change

much for a considerable change of input

voltage in case of metal-metal oxide

junction cells. The reason is unknown.

CONCLUSION

Thus, as the results showcase, using some

of the most common oxides and some

simple primary treatment processes

coupled with engineering ideas, we were

able to increase the efficiency of solar

energy harnessing devices by an

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

that is under lab conditions).

Thus, the basic idea of trying to use the

metal oxides arising from a simple urge to

use environmentally inert materials turns

out to be a revolutionary alternative for

the conventional silicon solar cells. The

trait that make the idea highly successful

is that the processing is very easy and can

be done on a commercial level with some

material engineering guidance. Also, it

turns out to be a relief for countries like

India and other developing countries as

importing silicon cells was never cheap.

Hence, here, with technologically

advanced institutes in the nation like IITs

and NITs the implementation and

bettering the scope of the idea can be done.

A major issue was designing.

• How could we make most of the

sunlight. The answer came with

the paraboloid concentrator.

• How could we use it at all times

during the day? The secret lied

with the solar tracking device

which had become pretty common.

• How would we place the cells to

get output from both? The design

came to me by instincts. After a

host of designs, the most suitable

and easy to construct was used.

• Titanium di-oxide reflects back the

visible light. I offered a solution in

the design.

• At some places, the solar energy is

directly used for heating purposes.

Thus a band filter can be employed

to filter out the harmful ultraviolet

and infra-red light.

CORRESPONDENCE:

*29, Nelco Housing Society, Near Nagarjuna Trust Hospital, Khamla-Nagpur-440025. Contact- +91

9175017645, Email-id: [email protected]



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

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