Scientific Research Journal of India (SRJI) Vol- 2, Issue- 4, Year- 2013

Scientific Research Journal of India (Multidisciplinary, Peer Reviewed, Open Access, Journal of science)

ISSN: 2277-1700 Vol: 2, Issue: 4, Year: 2013

Editor in Chief (Current Issue)

Dr. Gayatri Ajay Upadhyay (PT)

Executive Editor

Dr. Krishna N. Sharma

Editors

Dr. Popiha Bordoloi

Dr. Kuki Bordoloi (PT)

Dr. Sudeep Kale (PT)

Dr. Waqar Naqvi (PT)

Dr. Piyush Jain (PT)

Junior Editor

Mrityunjay Sharma

Office Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403

Website http://srji.drkrishna.co.in

URL Forwarded to http://sites.google.com/site/scientificrji

Email [email protected]

Contact +91-9839973156

Declaration: The contents of the articles and the views expressed therein are the sole responsibility of the authors, and the

editorial board will not be held responsible for the same.

Copyright © 2013 Scientific Research Journal of India

All rights reserved.

CONTENTS

Title Author/s Department Page

Editorial Dr. Gayatri Ajay Upadhyay

(PT) i

EFFECTS OF TASK RELATED

SITTING TRAINING ON

BALANCE IN HEMIPLEGIC

PATIENTS

Dr. Vivek H. Ramanandi Physiotherapy 1

EFFECTIVENESS OF

CONVENTIONAL PHYSICAL

THERAPY & C.P.M UNIT FOR

FUNCTIONAL REHABILITATION

AFTER TOTAL KNEE

ARTHROPLASTY

Amit Murli Patel Physiotherapy 10

EFFECTIVENESS OF

SUPERVISED GRADED

REPETITIVE ARM

SUPPLEMENTARY PROGRAM

ON ARM FUNCTION IN

SUBJECTS WITH STROKE

Dr.Harsha Tummala,

Dr.V.Srikumari, Dr. K.

Madhavi

Physiotherapy 31

EFFECTIVENESS OF CORE

STRENGTHENING EXERCISES

TO REDUCE INCIDENCE OF

SIDE STRAIN INJURY IN

MEDIUM PACE BOWLERS

Omkar P.Padhye, Subin

Solomen, Pravin Aaroon Physiotherapy 41

A COMPARATIVE STUDY OF

STANDING BALANCE

PERFORMANCE BETWEEN OA

KNEE PATIENTS COMPARED

WITH NORMAL AGE MATCHED

CONTROLS

Alagappan Thiyagarajan.T,

Prem Karthik .GS Physiotherapy 53

THE EFFECTS OF BIT VERSUS

MCIMT ON FUNCTIONAL

PERFORMANCE OF UPPER

Dr. Bhatri Pratim Dowarah Physiotherapy 64

ISSN: 2277-1700 ● Website: http://srji.drkrishna.co.in ● URL Forwarded to: http://sites.google.com/site/scientificrji

iv

EXTREMITY IN CHRONIC

HEMIPARESIS

RARE PRESENTATION OF TYPE

1 DIABETES MELLITUS AS

DIABETIC KETOACIDOSIS

COMPLICATING INTO ACUTE

PANCREATITIS: A CASE

REPORT

Srinivas Madoori, Kapil C,

Mangath Bhukya, Sandeep

Chilumoju

Medicine 73

CASE REPORT VERY LARGE

SUPPURATIVE PERICARDIAL

EFFUSION CAUSED BY GROUP

“A” Β – HEMOLYTIC

STREPTOCOCCUS: IN THE

ANTIBIOTIC ERA.

Dr. J. Rajendra Kumar, Dr.

Mamta B. Kumbhare, Dr. P.

Shanmuga Raju, Dr. M.

Manjusha, Dr. M. Sumanth,

Dr.Ch. Rachna

Medicine 79

TECHNICAL SOFTWARE

PROJECT MANAGER VS NON

TECHNICAL SOFTWARE

PROJECT MANAGER

Zunera Jalil, Nazia

Tabbasum

Computer

Science 91

i

FROM EDITOR IN CHIEF - AN ERA OF OPEN ACCESS RESEARCH

BEGINS

The key to sustained progress in this age of internet and free access to information is to make society at large

avail with the open access articles. There are many primary sources of archives, manuscripts and collections

often hindered by private ownership which permits either on a highly selective basis or not at all. Based on

these facts we support open access scripts which involves dissemination of high quality researches. Open

access journals make it easy for us to access new techniques and thereby benefit society at large. Through this

journal we will try and provide updated information which will include high quality scientific publications

that will profoundly influence PTs education.

“The excitement of learning separates youth from old age. As long as you’re learning, you’re not old,” and

research articles comes from inquisitive questions that posits in our mind.

Dear Readers! Welcome to this issue of the Scientific Research Journal of India (SRJI), I hope that you are

pleased with the contents. I am.

In this issue: Like previous issue this is also a multidisciplinary and open access journal that contains total 6

papers in Physiotherapy, 2 paper of Medicine and 1 from Computer Science. I hope you’ll find these papers

informative.

Be aware that the journal also has a website, http://srji.drkrishna.co.in where subscribers can access the full

content and also submit papers for future publication.

Please send me informal comments directly, or formal letters we can publish, about the journal. I welcome

new ideas about topics (content) and process. Let me know your thoughts.

Thanks for the opportunity, and stay tuned for future editions.

-Gayatri Ajay Upadhyay, M.P.T. (Neuro)

1

EFFECTS OF TASK RELATED SITTING TRAINING ON BALANCE IN

HEMIPLEGIC PATIENTS

Dr. Vivek H. Ramanandi M.P.T.(Neuro)*

ABSTRACT

Introduction and purpose of study: The ability to balance in sitting is commonly impaired after stroke. Sitting

ability is critical to several ADL. So here we tried “To evaluate the efficacy of a 2-week task related sitting

training program in improving patients’ sitting balance.” Materials and methodology: This randomized

placebo-controlled study included 31 subjects who had first stroke within last 6 months and were able to sit.

Subjects with orthopaedic, visual, cognitive-perceptual and other neurological deficits were excluded. The

group “A” (n=16) participated in a standardized training program involving practice of reaching beyond

arm’s length along with the conventional therapy. The group “B” (n=15) received a sham training. Subjects

were tested before and after the completion of 2 weeks training using t-BBS (Total Berg’s balance scale

score) and FRD (Functional reach distance). Results & Conclusion: This study provides strong evidence of

the efficacy of task related sitting training in improving the ability to balance during seated reaching activities

as well as other activities of ADL.

Keywords:

Stroke, Task related sitting training, Balance, Rehabilitation.

INTRODUCTION Sitting involves not only the ability to


2

maintain the seated posture, but also the

ability to reach for a variety of objects located

both within and beyond arm’s length [1]. Poor

sitting ability is a common problem after

stroke [2,3,4]. Recovery of sitting after stroke is

important for individuals because sitting is a

skill that is critical to independent living [5,6,7].

Furthermore, sitting ability has been shown to

be a useful prognostic indicator of outcome for

this population [3,8,9,10]. The disability

associated with poor sitting arises primarily

because of muscle weakness and loss of

dexterity and also because of tendency to

adapt behaviour to avoid threats to balance. In

particular, it has been shown that in

comparison to healthy individuals, individuals

after stroke are slower and do not load their

affected foot or activate the muscle of their

affected leg sufficiently when reaching beyond

arm’s length in sitting [1].

Balance is defined as “The ability to

maintain the body’s center of mass over the

base of support with minimal postural sway

[11].” The normal control of balance is known

to emerge as a result of integration of inputs

from the vestibular, visual and somato-sensory

systems. Balance forms “The foundation for

all voluntary motor skills [12].” Most studies

have measured balance impairments (i.e.

postural sway, weight distribution or related

parameters) rather than balance disability (i.e.

static or dynamic balance while performing a

task) [13].

Intervention to train balance is a common

focus of rehabilitation after stroke. Previous

work has demonstrated the efficacy of a sitting

training protocol in individuals who had

suffered stroke [1,14]. They found that

individuals who were trained specifically to

improve their sitting by focusing on

appropriate loading of the affected foot were

able to reach further and faster. In addition,

these individuals were able to increase the

load taken through the affected foot and

increased the consistency of activation of

muscles in the affected leg. However, it is not

known whether this sitting training protocol is

feasible and effective in improving trunk

control and balance abilities associated with

functions of daily living. The research

questions for this study were:

1. “Does completion of 2-week sitting

training protocol improve balance ability

associated with sitting?”

2. “Does completion of a 2-week sitting

training protocol improve sitting ability

and quality?”

Background

Trunk control is having predictive value

on comprehensive ADL function in stroke

patients which implies that early assessment

and management of trunk control after stroke

should be emphasized [9]. Sitting involves not

only the ability to maintain the seated posture,

but also the ability to reach for a variety of

objects located both within and beyond arms’

length [1]. Due to larger base of support, sitting

Scientific Research Journal of India ● Volume: 2, Issue: 4, Year: 2013

3

does not present same threat to stability as

standing. During seated reaching activities

muscle activation depends upon the level of

support provided to feet. In both cases (i.e.

whether feet are supported on ground or not),

trunk muscles are active to stabilize the upper

body as it moves about over the base of

support [14].

Dean and Shepherd found out that

individuals who were trained specifically to

improve their sitting by focusing on

appropriate loading of the affected foot were

able to reach further and faster. Previous work

has demonstrated the efficacy of a sitting

training protocol in individuals who had

suffered a stroke 2-17 years back [1]. Dean CM

et al concluded that the sitting training is both

feasible and improving sitting ability, sitting

quality and standing up early after stroke [14].

Cho G, Lee S & Woo Y compared

improvements in the conventional physical

therapy group & task related circuit groups

and found out more improvement in task

related training group [15].

Functional neuroimaging studies suggest

that the gains produced in stroke patients by

task oriented training are associated with

increased activity in ipsilateral 1o sensorimotor

cortex and redistribution of activity in several

areas of sensorimotor network [16]. Leipert et al [17], Nelles et al. [18] and Jang et al. [19]

suggested that recovery of trunk function

following stroke is associated with increased

activation of paretic trunk muscles by

unaffected hemisphere, suggesting role of

uncrossed pathways which are unaffected, in

recovery of trunk function.

Methods

This randomized placebo controlled study was

done at thedepartment of physical medicine

and rehabilitation, Govt. hospital, Ahmedabad,

Gujarat. Subjects were selected through

convenient sampling. After having the

informed consent of 31 subjects (M: 17, F: 14)

and fulfilment of inclusion criteria systematic

randomization was done and the subject were

assigned to the particular group according to

their sequence of approach i.e. 1st, 3rd, 5th, 7th

in group A and 2nd , 4th , 6th, 8th in group B .

Group A participated in a standardized

training program involving practice of

reaching beyond arm’s length for 10 sessions

in 2 weeks for 30 minutes daily along with the

conventional therapy. The subjects reached

with the unaffected hand to pick up and drink

water from a glass under 3 reach direction

conditions: Forward, 45o towards the

unaffected side and 45o across the body

towards affected side. Subject sat on the

height adjustable stool with each foot resting

completely on floor. Seat height was adjusted

to 100% of lower leg length. The target (i.e.

Glass) was kept at height adjusted to 75% of

shoulder height. The training was advanced by

increasing number of repetitions and

complexity of task over 2 weeks’ period. Each

participant performed 250-350 reaches per

session and average 3000 reaches over 2


4

weeks.

Group B received a sham training involving

cognitive-manipulative tasks within arm’s

length for same duration. It was added to

avoid any effect due to placebo. Subject

performed task while sitting n completely

supported position and arm resting upon the

table.

Figure 1: Schematic diagram showing seated reachout

performance

Workspace was confined to 50% of arm

length. This minimized any perturbations to

balance. Training was progressed over the 2-

week period by increasing the number of

repetitions and cognitive difficulty of

cognitive-manipulative tasks. Thus this

training was unlikely to lead improvements in

sitting balance and FRD.

Both groups participated in training protocols

that were standardized in relation to amount of

practice. As a minimum, each participant in

the control group spent approximately the

same amount of time in the sitting position

and performed an equivalent number of

reaches as those in experimental group.

Both the groups were given conventional

stroke rehabilitation including measures for

[20]:

• Improving muscle force

• Improving ROM

• Reducing muscle tone

• Improving sensory function

• Improving flexibility and joint

integrity

• Training functional activities e.g. sit to

stand, standing, transfers, gait etc.

Results and discussion

Both of the groups showed clinically

significant improvement in t-BBS and FRD

when compared for within group and between

group comparisons.

Table:1 The Mean t-BBS before and after

intervention

Group Pre Post W-

value

“p”

Value

A 33.31

+ 7.55

44.37

+ 6.11

136 <0.0001

B 34.80

+ 5.33

44.20

+ 5.68

120 <0.0001

Table:2 The Mean FRD(inches) before and

after intervention

Group Pre Post t- “p”


5

value Value

A 10.08

+3.02

12.80

+2.52

10.07

9

<0.0001

B 10.08

+2.95

11.33

+2.43

5.173 <0.0001

Table : 3 The mean of differences of t-BBS

between the groups

N Mean SD SE

A 16 11 2.280 0.5701

B 15 9.4 1.724 0.4451

Table : 4 The mean of differences of FRD

(inches) between the groups

N Mean SD SE

A 16 2.72 1.079 0.269

B 15 1.25 0.933 0.241

33.31 34.8

44.37 44.2

0

10

20

30

40

50

Group A Group B

Pre

Post

Figure 2 : Comparison of t-BBS

10.088 10.087

12.811.33

0

5

10

15

Group A Group B

Pre

Post

Figure 3: Comparison of FRD

11

9.4

8.5

9

9.5

10

10.5

11

11.5

Group A Group B

Figure 4: Mean of differences in t-BBS

2.72

1.25

0

0.5

1

1.5

2

2.5

3

Group A Group B

Figure 5: Mean of differences in FRD

Results of within group analysis for the

present study showed extremely significant

improvement in t-BBS and FRD (p<0.0001)

for both the groups.

Results of between the group analysis

showed more improvements in FRD

(p<0.0003) and t-BBS (p<0.03) in group A as

compared to group B.

Both the groups improved significantly in

both the outcome measures but FRD showed

statistically significant improvements as


6

compared to t-BBS.

Previous studies by Dean CM et al [14];

Cheng P.T. et al [21] and Dean CM and

Shepherd RB [1] suggest that the sitting

training protocol is both feasible and effective

in improving sitting and standing up early

after stroke and somewhat effective 6 months

later. Many studies have proven efficacy of

task related training in improving the ability to

balance during seated reaching activities after

stroke as well as improved sit to stand task

along with less mediolateral sway when rising

and sitting down.

Studies by Chen IC, Cheng PT. Chen Cl

et al (2002) [22]; Cheng PT, Wu SH, Liaw MY

(2001) [21] and Mudie MH, Radwan S et al

(2002) [23] proved improvements in symmetry

of weight bearing and distribution by task

related training after stroke. Cho G, Lee S &

Woo y (2004) [15] proved improvements in

symmetry of weight bearing distribution by

task related training after stroke. Salbach NM,

Mayo NE, et al (2005) [24] has proved efficacy

of task oriented walking interventions in

improving balance self-efficacy during self-

initiated gait activities. The results of the

present study showing improvements in

functional activities, sitting quality and

functional reach performance by the sitting

training along with the conventional therapy is

in accordance with results of above mentioned

studies.

Studies by Dean CM et al (2007) [14]

concluded that individuals who were trained

specifically to improve their sitting by

focusing on appropriate loading of the affected

foot were able to reach further and faster.

They were able to increase the load taken

through the affected foot and increased the

consistency of activation of muscles in the

affected leg. The carry over to standing up was

observed. Shepherd and Gentile (1994) [25]

showed biomechanical similarities between

reaching in sitting and the pre-extension phase

of standing, which supports the carry over

effects of seated reaching training to sit to

stand and walking. During sitting training,

subjects practiced moving their trunk forward

rapidly over the centre of mass whilst loading

their legs. Although these components were

practiced with the intention of improving

sitting ability, they are also critical

components of biomechanics of early phase of

sit to stand activity.

Present study supports the concept of

specificity of training, which has been

discussed in relation to the able bodied

subjects by Rutherford OM (1988) [26] and

proposed as a means of rehabilitating the

movement disabled by Carr and Shepherd [27,28]. The results of present study showing

better improvements in the seated balance

outcomes can be explained on the basis of the

same mechanism as proposed by above

mentioned case studies.

Functional neuroimaging studies suggest

that the functional gains produced in stroke

patients by task related training are associated


7

with increased activity in ipsileisonal primary

sensory motor cortex and re-distributon of

activity in several areas of sensorimotor

network. This view is supported by the studies

of Leipert et al (2000) [17], Nelles et al (2001) [18] and Jang et al (2003) [19]. Fujiwara et al

(2001) [16] used transcranial magnetic

stimulation and suggested that recovery of

trunk function following stroke is associated

with increased activation of paretic trunk

muscles by the unaffected hemisphere,

suggesting role of compensatory activation of

uncrossed pathways in recovery of trunk

function.

The study have implications for

rehabilitation, demonstrating that the stroke

patients can improve their performance in

functions of daily living by inclusion of short

task related seated reach training that takes

into account normative biomechanics related

to trunk and lower limb function. It can be

included in treatment intervention at an early

stage of rehabilitation when there is greatest

potential for neuroplasticity.

Limitations:

1. Smaller sample size.

2. Lack of long term follow ups to

confirm persistence of interventional

gains.

3. Exclusion of subjects who were not

able to sit and reach.

4. Lack of training for seated reach

training on dynamic surface.

Conclusion

Task related sitting training is an effective

measure of improving balance not only in

sitting but also during other functional

activities when given with conventional

treatment. It should be included early in

treatment to gain maximum outcome benefits

in short training period.

REFERENCES

[1] Dean CM, RB shepherd: Task-related training improves performance of seated reaching tasks after stroke: a

randomized controlled trial. Stroke 1997;28:722-728 .

[2] Dean CM, Mackey FH: Motor assessment scale scores as a measure of rehabilitation outcome following stroke.

Australian Journal of Physiotherapy 1992; 38: 31-35.

[3] Morgan P: The relationship between sitting balance and mobility outcome in stroke. Australian Journal of

Physiotherapy 1994; 40: 91-96.

[4] Harley C, Boyd JE, Cockburn J, Collin C, Haggard P, Wann JP, and Wade DT: Disruption of sitting balance

after stroke: Influence of spoken output. Journal of Neurology, Neurosurgery and Psychiatry 2006; 77: 647-676.

[5] Dean CM, Shepherd RB, Adams R: Optimizing sitting balance after stroke: from science to the clinic. Canadian

Journal of Rehabilitation 1998; 11: 193-194.

[6] Dean CM, Shepherd RB and Adams R: Sitting balance I: trunk-arm coordination and the contribution of the

lower limbs during self paced reaching in sitting. Gait and Posture 1999a; 10: 135-146.


8

[7] Dean CM, Shepherd RB and Adams R: Sitting balance II: reach direction and thigh support affect the

contribution of lower limbs when reaching beyond arms’ length in sitting. Gait and Posture 1999b; 10: 147-153.

[8] Loewen SC, Anderson BA: Predictors of stroke outcome using objective measurement scales. Stroke 1990; 21:

78-81.

[9] Sandin KJ, Smith BS: The measure of balance in sitting in stroke rehabilitation prognosis. Stroke 1990; 21: 82-

86.

[10] Van de Port IG, Kwakkel G, Shepers VP, Lindeman E: Predicting mobility outcome one year after stroke: a

prospective cohort study. Journal of Rehabilitation Medicine 2006; 30: 218-223.

[11] Shumway-Cook A, et al:Postural sway biofeedback : its effects in reestablishing stance stability in hemiplegic

patients. Arch Phys Med rehabilitation 1988; 69: 395-40.

[12] Massion J, Woollacott MH, In: Brainstein A, Brandt T & Woollacott M, Editors. Clinical disorders of balance,

posture and gait. London: Arnold; 1996: pp.1-18.

[13] Tyson SF, Hanley M, CHillala J, Selley A and Raymond CT: Balance disability after stroke. Phys ther 2006;

86(1): pp. 30-38.

[14] Dean CM, Channon EF, Hall JM. Sitting training early after stroke improves sitting ability and quality and

carries over to standing up but not to walking: a randomized controlled trial. Australian Journal of Physiotherapy.

2007; 53: 97-102.

[15] Cho G, Lee S & Woo Y. The effects of task related circuit program on functional improvements in stroke

patients. KAUTPT vol.11 no.3, 2004.

[16] Fujiwara T, Sonoda S, Okajima Y, Chino N. The relationship trunk function and findings of transcranial

magnetic stimulation among patients with stroke. J Rehabil Med 2001; 33:249-55.

[17] Leipert J, Graef S, Uhde I, Leidner O, Weiller C. Training induced changes of motor cortex representations in

stroke patients. Acta Neurol Scand 2000 a ;101: 321-326.

[18] Nelles G, Jentzen W, Juepetner M, Muller S, Diener HC. Arm training induced brain plasticity studied with

serial positron emission tomography. Neuroimage 2001; 13: 1146-1154.

[19] Jang SH, Kim YH, Cho SH, Lee JH, Park JW, Kwon YH. Cortical reorganization induced by task oriented

training in chronic hemiplegic stroke patients. Neuroreport 2003b; 14: 137-141.

[20] Susan B O’Sullivan, Thomas J Schmitz: Physical Rehabilitation, 5thedi.; Chapter !8- Stroke. Pp 705-776. Jaypee

publication.

[21] Cheng PT, Wu SH, Liaw MY, Wong AM, Tang FT. symmetrical body weight distribution training in stroke

patients and its effects on fall prevention. Arch Phys Med Rehabil 2001;82(12): 1650-1654.

[22] Chen IC, Cheng PT, Chen CL, Chen SC, Chung CY et al. effects of balance training on hemiplegic stroke

patients. Cheng Gung Medical Journal. 2002; Sep: 25(9):583-590.

[23] Mudie MH, Winzeler Mercay U, Radwan S, Lee L. Training symmetry of weight distribution after stroke: a

randomized controlled pilot study comparing task related reach, Bobath & feedback training approaches. Clin rehabil

2002; 16(6): 582-592.

[24] Salbach NM, Mayo NE, Robichaud-Ekstrand S, Hanley JA, Richards CL, Wood-dauphinee S. The effects of task

oriented walking intervention on improving balance self efficacy poststroke: a randomized controlled trial. J Am Geriatr

Soc 2005; 53(4): 576-582.

[25] Shepherd RB, Gentile AM. Sit to stand: functional relationship between upper and lower body segments. Human

Movement Sciences 1994; 13: 817-840.


9

[26] Rutherford OM. Muscular coordination & strength training implications for injury rehabilitation. Sports Med

1988; 5: 196-202.

[27] Carr JH, Shepherd R. A Motor Relearning Programme for Stroke. 2nd ed. Oxford, UK: William Heinmann

Medical Books; 1987.

[28] Carr JH, Shepherd RB. A motor learning model for stroke rehabilitation. Physiotherapy. 1989; 89: 372-380.

CORRESPONDENCE

* Lecturer, Pioneer Physiotherapy College, Vadodara, Gujarat, India. [email protected]

10

EFFECTIVENESS OF CONVENTIONAL PHYSICAL THERAPY & C. P.M

UNIT FOR FUNCTIONAL REHABILITATION AFTER TOTAL KNEE

ARTHROPLASTY

Amit Murli Patel, MPT (Orthopaedics)*

ABSTRACT

Background and Purpose: This randomized clinical trial was conducted to compare the effectiveness of 3 in-

hospital rehabilitation programs with and without continuous passive motion (CPM) for range of motion

(ROM) in knee flexion and knee extension, functional ability, and length of stay after primary total knee

arthroplasty (TKA). Subjects: Eighty-one subjects who underwent TKA for a diagnosis of osteoarthritis were

recruited. Methods: All subjects were randomly assigned to 1 of 3 groups immediately after TKA: a control

group, which received conventional physical therapy intervention only; experimental group 1, which received

conventional physical therapy and 35 minutes of CPM applications daily; and experimental group 2, which

received conventional physical therapy and 2 hours of CPM applications daily. All subjects were evaluated

once before TKA and at discharge. The primary outcome measure was active ROM in knee flexion at

discharge. Active ROM in knee extension, Timed “Up & Go” Test results, Western Ontario and McMaster

Universities Osteoarthritis Index questionnaire scores, and length of stay were the secondary outcome

measures. Results: The characteristics of and outcome measurements for the subjects in the 3 groups were

similar at baseline. No significant difference among the 3 groups was demonstrated in primary or secondary

outcomes at discharge. Discussion and Conclusion: The results of this study do not support the addition of

CPM applications to conventional physical therapy in rehabilitation programs after primary TKA, as applied

in this clinical trial, because they did not further reduce knee impairments or disability or reduce the length of


11

the hospital stay.

Key Words: Continuous Passive Motion, Osteoarthritis, Knee Arthroplasty, Rehabilitation

INTRODUCTION

The biological concept of continuous

passive motion (CPM) unit was introduced by

RB Salter in the late 1970s. He demonstrated

that CPM for rabbit knees after cartilage injury

enhanced cartilage healing and regeneration

compared with pro-longed articular rest.1,2

Later, his research focused on the effects of

CPM on a variety of injuries in rabbits and in

clinical applications for human subjects.3

Coutts et al4 first initiated CPM use

immediately after total knee arthroplasty

(TKA). Their reasoning was based on Salter’s

research and the postulate that CPM enhanced

collagen tissue healing with better fiber

orientation, avoiding cross-linking and thus

generating better movement restoration.4,5

The effectiveness of postoperative

CPM applications has been studied in a large

variety of protocols after TKA. Knee flexion

range of motion (ROM) was usually the

primary outcome measure, evaluating either

short-term effectiveness (measured at the end

of the hospital stay) or long-term effectiveness

(measured 2–12 months after TKA). Most

authors6,15 agree on the lack of efficacy of

long-term CPM for knee flexion ROM;

however, there is still controversy regarding

its short-term effectiveness. Many researchers

have reported significant knee flexion ROM

gains of between 7 and 22 degrees (relative to

results for control groups)4,9,10,13,17 or faster

knee flexion recovery during the hospital

stay.4,12,17,19 In these studies, duration of CPM

applications could vary from 10 hours to 24

hours per day and were performed during 2 to

7 days after TKA.4,9,10,12,17,19 In the majority of

these studies, subjects’ knees in the control

group were immobilized for 2 to 7 days,

whereas subjects in the experimental groups

received early postoperative CPM

applications.4,9,13,17 These results cannot be

applied to contemporary practice, because a

long period of immobilization is no longer

recommended after TKA, and early movement

is always promoted in the TKA population. In

addition, description and standardization of

knee flexion measurements have been

neglected in many experiments, and only a

few studies have provided detailed

methodology.6,9,15,20,21 Other research-

ers6,8,11,18,20,22,25 have concluded that CPM

applications do not provide any additional

gains in knee flexion at the end of the hospital

stay. In a large proportion of these studies,

knee flexion exercises in the control group

began when CPM applications were initiated

in the experimental groups.6,11,20,22,24,25

However, either knee flexion ROM

measurements were performed 11–22 days


12

after TKA18,19,22,23,25 or CPM application

parameters were not applicable for actual

practice.8,11,24

Besides knee flexion ROM, length of stay

(LOS) and function also have been used to

measure CPM efficacy after TKA. In some

studies, LOS was reduced by 2 to 5 days in

groups receiving CPM applications. However

discharge criteria other than knee flexion

ROM were not always clear enough to make

inferences about the influence of CPM on

LOS.4,15,17,18,22,26 In some studies,8,10,14,20,23

function was measured with questionnaires at

various times, between 6 weeks and 2 years,

after surgery. Comparable results on these

questionnaires were observed for groups

receiving and groups not receiving CPM

applications.

At Shivam Orthopaedic Hospital, the

effectiveness of CPM applications was

questioned when rehabilitation protocols after

TKA were revised. The applications were

performed for 35 minutes per day every day

until discharge. The question was to decide

whether or not to maintain these low-intensity

CPM applications or whether to add

applications of moderate intensity as part of

the rehabilitation protocols after TKA. The

purpose of this single-blind randomized

clinical trial was to compare the effectiveness

of 3 in hospital rehabilitation programs with

various intensities of CPM applications for

knee flexion ROM, functional ability, and

LOS after primary TKA. Our hypothesis was

that when CPM applications were performed

in conjunction with conventional physical

therapy, there would be no additional benefit

in terms of knee flexion ROM, functional

ability, or LOS, compared with results

obtained with conventional physical therapy

alone.

METHOD

Subjects

This study was conducted between December

2011 and May 2013 at Shivam Hospital,

where over 150 TKAs are performed every

year. Subjects were asked to participate if they

had a diagnosis of knee osteoarthritis, were

expecting primary TKA, were ambulatory, and

were literate. Subjects with previous major

lower-limb surgery, such as contralateral TKA

or total hip arthroplasty, were included, as

long as the previous surgery had occurred at

least 12 months before the current TKA.

Exclusion criteria were: (1) medical conditions

or diseases that could interfere with test

performance, (2) collaboration or

comprehension problems, (3) neuromuscular

or neurodegenerative disease, (4) concurrent

intervention during surgery that could interfere

with outcomes (eg: collateral ligament repair),

(5) infection of the affected knee, and (6) any

major health complication during the hospital

stay (eg: pulmonary embolism, heart attack,

problems with scar healing).

Recruitment

The eligibility of subjects was verified on the

basis of their medical files obtained from the


13

orthopedic surgeon’s waiting list. Subjects

were asked to participate when they attended

their routine preoperative medical visit. All

participants signed an informed consent form.

Study Design

All subjects were assessed twice by an

experienced Physiotherapist: once at the

preoperative visit, 2 to 4 weeks before TKA,

for baseline measurements and again at

discharge, 7 or 8 days after TKA.

Randomization

After surgery, all subjects were randomly

assigned to one of the following 3 groups: (1)

a control group (CTL), which received

conventional physical therapy intervention

only, without CPM applications; (2)

experimental group 1 (EXP1), which received

conventional physical therapy intervention and

CPM applications for 35 minutes daily (low

intensity); and (3) experimental group 2

(EXP2), which received conventional physical

therapy intervention and CPM applications for

2 consecutive hours daily (moderate intensity).

Two strata were created for an equivalent

distribution of subjects with and subjects

without previous major surgery of the lower

limbs in the 3 groups. One set of

prenumbered, sealed envelopes was prepared

for each stratum, and subjects were assigned

to the group specified in the envelope.

Measures

For each participant, anthropometric, personal,

and clinical characteristics were reported,

including sex, age, weight, height, social

status, comorbid conditions, previous disease

or surgeries, and time from the onset of

symptoms. A questionnaire also was

administered to measure the frequency and

intensity of physical activity usually

performed by the subjects.27The same

measurements were taken at baseline and at

discharge. The primary outcome was maximal

active ROM in knee flexion in a seated

position. The secondary outcomes were active

ROM in knee extension, Timed “Up & Go”

Test (TUG) results, and Western Ontario and

McMaster Universities Osteoarthritis Index

(WOMAC) questionnaire scores. The

theoretical LOS and the real LOS also were

reported. All assessments at discharge were

performed at the same time of day, that is, in

the morning before physiotherapy

interventions, if those were still needed.

Maximal active ROM in knee flexion. The

ROM measurement was taken with a 1-

degree-increment goniometer. Its center of

rotation was placed in line with the center of

the knee, the fixed arm aligned with the

greater trochanter and the mobile arm aligned

with the lateral malleolus. The criterion

validity and the intratester and intertester

reliability of data obtained with the

goniometer have been demonstrated to be

high.28,31 To maximize reliability, the subject’s

position was standardized30,32 as follows: the

subject was seated on an adjustable table, the


14

foot of the affected leg was placed on a cloth,

and the contralateral foot was placed on an

7.6-to 15.2-cm-high (3- to 6-in-high) bench.

Subjects were asked to actively bend their

knee by sliding their foot backward to the

maximum ROM tolerated.

Maximal active ROM in knee extension.The

same procedure was applied for the extension

movement, except that subjects were lying

supine on the adjustable table and had to

actively slide their foot forward on a wooden

board to the maximum ROM tolerated.

Two trials were performed for both ROM

measurements. If the difference between those

trials was more than 5 degrees, a third trial

was performed and the mean of the 2 closest

ROM measurements was registered. All

evaluators were required to participate in a

standardization session for the entire

procedure of ROM measurements.

TUG.This functional test records the time

required toget up from a chair with armrests,

walk 3 m, turn around, walk back to the chair,

and sit down. Our chair seat was 46 cm in

height, and permanent painted lines on the

floor delimited the 3 meter walkway. The

standardized procedure included a

demonstration for the subject and 2 trials with

walking aids if necessary. Good correlation

with the Berg Balance Scale, walking speed,

and the Barthel Index has established the

validity of TUG scores.33 Intratester and

intertester reliability and responsiveness also

have been shown to be high for this test.33,34

WOMAC.The WOMAC questionnaire is a

self-administered, activity-based, and lower-

limb specific questionnaire that contains 24

items covering pain (n = 5), stiffness (n = 2),

and functional difficulty (n = 17). Excellent

validity and reliability have been shown with

many populations and specifically with TKA

and total hip arthroplasty populations.35,38 The

visual analog scale and the French version

were used. At discharge, several questions

regarding functional difficulty were excluded

from the original form getting in and out of the

car and the bath, shopping, and managing light

or heavy household work as subjects were

unable to attempt these tasks at the early

postoperative stage.

LOS.The real length of each subject’s hospital

stay wasrecorded. This measure was

dependent on other factors: organic

complications or disease, difficulties in the

organization of support at home, or delayed

transportation to home. Therefore, a

theoretical LOS also was recorded. It was

defined as the time needed to reach discharge

criteria for the knee condition. Those criteria

were obtaining independence and security in

transferring, in walking with aids, and in

managing stairs; furthermore, the subject had

to demonstrate good progression in recovery

of active ROM in knee flexion, which had to

be approximately 75 degrees at discharge.

Finally, the scar had to be healing

appropriately.


15

Interventions

CPM. Subjects in both experimental groups

receivedone daily CPM session, beginning on

the second day after TKA until discharge or

day 7 or 8. Nurses installed the CPM device,

and the procedure was standardized. Teaching

sessions were organized, and written and

audio-video instructions were provided.

Identical installations were performed for both

groups: subjects lay supine in their bed, and

the CPM device was placed under the affected

leg with the knee extended. For stability, one

strap surrounded the subject’s thigh, another

strap surrounded the subject’s lower leg, and

the apparatus was prevented from sliding

down by the edge of the bed. In the first group

(EXP1), CPM was used for 35 minutes

continuously, including a 5-minute warm-up

period. In the second group (EXP2), CPM was

used for 2 consecutive hours, including a 5-

minute warm-up period. This 2-hour

application was performed in the evening in

order to avoid interfering with all other

daytime medical and rehabilitation activities.

On the second day after TKA, 35 to 45

degrees of flexion was reached with CPM for

all subjects in both groups. From the third day

after TKA to the end of the clinical trial,

increments of ROM in flexion were

determined by the physical therapist on the

basis of the maximal ROM in knee flexion

obtained during the conventional

physiotherapy intervention. All information

regarding ROM and duration of CPM

applications and the reasons for disparity

between the prescribed and the actual

applications were recorded every day.

Conventional physical therapy

intervention.At Shivam Hospital, a

standardized clinical procedure is followed

after TKA. All subjects in the 3 groups

received the same daily (including weekends)

conventional physiotherapy intervention,

which was supervised by a Physiotherapist.

On the first day after surgery, respiratory and

circulatory exercises were encouraged.

Isometric knee extensor muscle exercises were

performed, and extension knee alignment was

maintained in a splint. On the second day, the

splint was removed. Active and passive knee

flexion, abduction and adduction of the hip in

the horizontal plane, and knee extensor muscle

exercises were performed. Next, teaching for

transferring and walking with the appropriate

device was begun. Functional exercises with

weight bearing were added on day 4.

Management of stairs, if needed, was

performed on day 6 or 7 before discharge. All

subjects had to practice exercises and walk on

their own in addition to the supervised

sessions. The detailed content of each

supervised session, such as the type and the

number of exercises, was recorded by the

physical therapist.

Co-interventions.The number and content of

the occupational therapist’s visits and

information about daily medications were


16

collected from each subject’s medical chart.

Details on the surgery protocol and the type of

prosthesis were available for all subjects a few

weeks after surgery. This information was

used to verify the comparability of the groups

regarding the type of surgery.

Adherence to intervention.In EXP1 and

EXP2, thenumber of CPM applications

planned, the number of CPM applications

received, their duration, and the ROM

progression were recorded. The number of

conventional physiotherapy sessions planned,

the number of conventional physiotherapy

sessions received, and their content also were

recorded in the 3 groups.

Sample Size

A consensus was reached between orthopedic

surgeons and physical therapists with respect

to the criterion for the maintenance of CPM

applications as part of the recovery program

after TKA: for active ROM in knee flexion, a

minimum effect size of 10 degrees was

established. This value corresponds to the

mean difference between the control group

(CTL) and either of the experimental groups

(EXP1 or EXP2). On the basis of the relevant

literature and subject files reviewed over 6

months, the estimated standard deviation of

the primary outcome was 10 to 12 degrees.

With a two-sided (type I) error level of .05 and

a statistical power of 80%, the sample size for

each group was estimated to be 26 subjects.39

DATA ANALYSIS

A first analysis was based on the intention-to-

treat principle. Demographic and clinical

characteristics of the subjects and baseline

measurements were compared between groups

by use of analysis of variance (ANOVA) for

continuous variables and chi-square tests for

categorical data. The nonparametric Kruskal-

Wallis test was used when data were not

normally distributed. At discharge, the

primary and secondary outcomes were

compared between groups by use of ANOVA

or the Kruskal-Wallis test when necessary.

Pain, stiffness, functional difficulty, and total

WOMAC questionnaire scores were

transformed to a percentage of the total score

available for questions answered in each

category. The 95% confidence interval of the

group differences was calculated for each

variable. Adherence to interventions in each

group was analyzed by comparing their

content, their frequency, and their duration.

Finally, a second analysis was carried out

according to the per-protocol principle;

subjects showing 75% participation in

interventions were included. The SPSS

version 10 statistical program* was used for

all analyses.

RESULTS

From December 2011 and May 2013, 98

subjects were evaluated at baseline (Fig. 1); 82

of them were randomly assigned to 1 of 3

groups: 27 were assigned to CTL, 26 were

assigned to EXP1, and 28 were assigned to


17

EXP2. One subject was excluded after being

randomly assigned by mistake; his

preoperative diagnosis was infection, not

osteoarthritis, as specified in the inclusion

criteria. For the main analysis (intention-to-

treat principle), 81 subjects were considered.

Personal characteristics, comorbid conditions,

physical activity levels, and measurement

outcomes at baseline were similar in the 3

groups (Tab. 1).

No significant difference was found among

the 3 groups for surgery characteristics, such

as patella resurfacing (CTL, 85%; EXP1,

69%; and EXP2, 64%; P .19) or postero-

cruciate-substituting prosthesis (CTL, 22%;

EXP1, 27%; and EXP2, 7%; P .15).

Primary Outcome


the 3 groups in active ROM in knee flexion (P

.33) (Tab. 2, Fig. 2).

Secondary Outcomes


the 3 groups in active ROM in knee extension

in TUG duration, or in total and subscale

WOMAC questionnaire scores. Both real LOS

and theoretical LOS were similar among the 3

groups (Tab. 2). Similar results for primary

and second-ary outcomes were found with

analysis by the per-protocol principle when

only subjects showing 75% adherence to

interventions were included.

Figure 1.


18

Subject enrollment, distribution, and participation in interventions. CTL control group, EXP1 experimental group 1, EXP2 experimental group 2, CPM continuous passive motion, Doppler deep vein thrombosis diagnosis test

Adherence to Interventions

Adherence to the CPM applications was very

high; only one subject in the EXP1 group and

3 subjects in the EXP2 group did not receive

75% of the planned interventions (Fig. 1). The

mean numbers of CPM applications were

similar (P .14) in both experimental groups:

EXP1, 4.9 applications (SD= 0.9), and EXP2,

4.5 applications (SD = 1.4). The percentages

of subjects who received CPM applications

daily were comparable between the groups

(Fig. 3). The mean durations of CPM

applications were 35.7 minutes (SD 2.5) in

EXP1 and 118.9 minutes (SD 7.6) in EXP2

(Fig. 3). Daily ROM progressions were similar

in both groups. Adherence to conventional

physiotherapy interventions also was very

high; 3 subjects in CTL and 1 subject in EXP1

did not receive 75% of the physical therapy

interventions (Fig. 1). The mean numbers of

physical therapy sessions were similar among

the 3 groups (P .24): CTL, 5.7 (SD = 1.0);

EXP1, 6.0 (SD = 1.0); and EXP2, 6.0 (SD =

0.7). Exercises performed and percentages of

subjects performing specific exercises were

comparable.

Co-interventions

In the first 36 hours after TKA, all subjects

had an intravenous analgesic perfusion that

they used as needed. Afterward, the analgesic

medication was adjusted according to pain and

discomfort requirements. Subjects in the 3

groups received similar numbers of visits from

the occupational therapist (P .87): CTL, 2.6

(SD = 1.8); EXP1, 2.7 (SD = 0.8); and EXP2,

2.8 (SD = 1.4).

Complications

One subject in each group developed a knee

hematoma; superficial vein thrombosis was

present in one subject each in CTL and EXP1,

and deep vein thrombosis (DVT) occurred in

one subject in EXP2. Scar bleeding was seen

in one subject in CTL, 2 subjects in EXP1, and

no subjects in EXP2. Three subjects in CTL

and 3 subjects in EXP1 had pulmonary or

cardiac problems, and only 1 subject in EXP2

had these problems. No subject was required

to undergo knee manipulation under

anesthesia before discharge.

DISCUSSION

Our results confirm that adding CPM

applications of low or moderate intensity to

conventional physiotherapy interventions has

no short term effect on active ROM in knee

flexion. Moreover, CPM applications did not

have any additional effect on secondary

outcome measurements, including active

ROM in knee extension, TUG results,

WOMAC questionnaire scores, and LOS.


19

Figure 2.

(Top) Mean and standard deviation of active range of

motion in knee flexion in each group (CTL control

group, EXP1 experimental group 1, EXP2 experimental

group 2) at discharge. (Bottom) Ninety-five percent

confidence interval for intergroup differences at

discharge: 0° means no difference among groups; the

dotted vertical lines illustrate the range of differences

not considered clinically important.

Our results confirm those of other studies in

which CPM applications did not have any

additional effect on knee flexion

ROM.6,8,11,18,20,22,25 Agreement also was

reached for the mean knee flexion ROM at

discharge. In some studies,11,20,24 this ROM

varied from 62.7 to 76.5 degrees 7 to 10 days

after TKA, all groups taken into account. In

studies supporting the efficacy of CPM

applica-tions,9,10,16,40,41 similar ranges of

knee flexion (70°– 82°) were observed 7 days

after surgery. When the mean knee flexion

ROM was found to be greater (86°–93°) at

discharge, the LOS also was longer, reaching

15 to 20 days.12,13,15,18,19 In our clinical

trial, the mean knee flexion ROM at discharge

for the entire population of subjects (N = 81)

was 80.8 degrees (SD = 11.5) for a mean LOS

of 8 days (SD = 2). One of the adverse effects

that could occur with CPM applications is an

increased lack of active or passive ROM in

knee extension. However, only a few

studies10,11,14 demonstrated a significant

decrease in knee extension ROM at discharge

in the experimental groups using CPM

applications. In all of these studies, the

duration of applications was 20 hours per day.

In our study, active knee extension was not

found to be decreased in groups receiving

CPM applications (CTL, – 8°; EXP1, –7°; and

EXP2, – 6.5°). Nevertheless, in all 3 groups,

there was a lack of knee extension of about 7.2

degrees (SD = 0.7). Comparable ROMs (– 4°

to –10°) have been observed at discharge (5–

14 days after TKA) in other studies, regardless

of study duration or the protocol

used.6,9,17,20,25,40 Difficulties in

performing knee extension may be explained

by extensor muscle weakness, stiffness in

flexor muscles, knee swelling, pain, or a

combination of these impairments, given the

acute-stage condition.

Table 1. Subject Characteristics and Outcome Measurements at Baseline.a


20

Characteristic CTL (n=27) EXP1 (n=26) EXP2

(n=28) p

Men, n (%) 13 (48.1) 10 (38.5) 15 (53.6) .53

Age, y, X (SD) 67.1 (7.6) 69.6 (6.7) 68.4 (7.4) .47

Weight, kg, X (SD) 85.8 (15.6) 79.3 (9.4) 80.7 (16.6) .22

Height, m, X (SD) 1.7 (0.1) 1.6 (0.1) 1.6 (0.1) .42

Live alone, n (%) 6 (22.2) 10 (38.5) 11 (39.3) .32

Duration of symptoms, y, X (SD) 8.6 (7.9) 8 (6.2) 11 (8.2) .30

Affected side, left, n (%) 15 (55.6) 19 (73.1) 12 (42.9) .08

Physical activity, none, n (%) 12 (44.4) 11 (42.3) 14 (50.0) .84

Comorbid conditions, n (%)

Hypertension 17 (63.0) 13 (50.0) 18 (64.3) .50

Cardiac problems 6 (22.2) 7 (26.9) 8 (28.6) .86

Pulmonary problems 3 (11.1) 2 (7.7) 2 (7.1) .85

Diabetes 5 (18.5) 5 (19.2) 5 (17.9) .99

Cancer 1 (3.7) 4 (15.4) 5 (17.9) .24

Outcomes, X (SD)

Flexion, ° 115.8 (11.5) 117.1 (7.9) 118.8 (9.7) .53

Extension, ° - 7.1 (5.6) - 8.8 (4.0) - 6.9 (3.8) .25

TUG duration, s 16.4 (12.3) 17.2 (11.3) 16.9 (5.9) .96

WOMAC score, %, X (SD)

Pain 51.5 (20.7) 52.5 (17.0) 48.9 (17.9) .77

Stiffness 61.1 (28.0) 66.5 (23.7) 62.4 (24.7) .73

Incapacity 55.2 (21.8) 51.2 (18.4) 53.7 (20.6) .77

Total 55.0 (20.7) 52.8 (16.5) 53.4 (18.9) .91

a TUG_Timed “Up & Go” Test, WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index, CTL = control group, EXP1 = experimental group 1, EXP2 = experimental


21

group 2. Table 2. Primary and Secondary Outcome Measurements at Discharge a

Parameter Outcomes b Intervention effects c

CTL (n=27)

EXP1 (n=26)

EXP2 (n=28)

P (Analysis of

Variance)

CTL-EXP1

CTL-EXP2

EXP1-EXP2

Flexion, ° 80.4 (11.8)

78.7 (10.6)

83.3 (11.9)

.33 1.7

( - 5.8,9.2)

-2.9

(-10.3, 4.5)

-4.6

(-12.1, 2.9)

Extension, ° - 8.0 (3.5)

- 7.0 (3.7)

- 6.5 (3.7)

.30 - 1

( - 3.4,1.4)

-1.5

(-3.9, 0.8)

-0.5

(-2.9, 1.9)

TUG duration, s 41.9 (21.4)

50.7 (22.6)

52.3 (34.9)

.33 - 8.7

(-26.8, 9.2)

-10.4

(-28.0, 7.3)

-1.6

(-19.6, 16.4)

WOMAC score, %, X (SD)

Pain 39.8 (24.8)

36.8 (15.6)

27.7 (17.1)

.07 3.0

(-9.9,15.9)

12.1

(-0.6, 24.9)

9.1

(-3.8, 22)

Stiffness 53.8 (26.1)

59.3 (19.3)

50.1 (24.1)

.36 -5.4

(-20.8,

10.0)

3.8

(-11.5, 19.0)

9.2

(-6.2, 24.6)

Functional Difficulty 33.0 (22.7)

40.0 (20.2)

31.0 (23.9)

.32 -7.0

(-21.7, 7.7)

1.9

(-12.6, 16.5)

8.9

(-5.7, 23.6)

Total 37.1 (22.6)

41.2 (17.6)

32.2 (20.6)

.28 -4.1

(-17.5,

4.9

(-8.4,

9.0

(-4.4,


22

9.3) 18.1) 22.4)

LOS

Real 7.8 (2.0)

8.1 (2.0)

8.0 (2.1)

.83 -0.3

(-1.7, 1.0)

-0.2

(-1.5, 1.1)

0.2

(-1.2, 1.5)

Theoretical 7.5 (1.4)

7.9 (1.6)

7.6 (1.8)

.71 -0.4

(-1.4, 0.7)

-0.2

(-1.2, 0.9)

0.2

(-0.8, 1.3)

a TUG_Timed “Up & Go” Test, WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index, LOS = limits of agreement, CTL = control group, EXP1 = experimental group 1, EXP2 = experimental group 2. b Reported as X (SD). c Reported as mean differences between groups (95% confidence interval).

One could surmise that subjects who received

additional CPM applications would have

decreased functional abilities because they

remained inactive during the duration of CPM

interventions. To our knowledge, no study

with CPM applications has measured

functional abilities at discharge. All

assessments of functional abilities were

performed 6 weeks to 2 years after TKA.

However, at these postoperative periods, no

adverse effect of CPM applications on

functional abilities was found.8,10,14,20,23 In

our study, functional abilities, as measured by

the TUG and the WOMAC questionnaire,

were comparable among the 3 groups at

discharge. The mean TUG duration for all

subjects in the 3 groups was 48.2 seconds (SD

= 27.2), 3 times longer than that at baseline

(16.8 seconds, SD = 9.8). Furthermore, 81.5%

of our subjects (CTL, 85.2%; EXP1, 76%; and

EXP2, 88.9%) were using a walker for

ambulating; therefore, walking speed was

decreased. In a previous study not involving

CPM applications, Walsh et al42 evaluated

functional performance at 1 week after TKA,

and their results showed that TUG duration

was only twice that measured at baseline.

However, the subjects in that study seemed to

have greater preoperative functional abilities,

as suggested by their superior performance on

the TUG (12.9 seconds, SD = 0.7). In

addition, the majority of their subjects used a

cane (78%) instead of a walker.42 In our

study, WOMAC questionnaire scores were

comparable among the 3 groups. However, it

is important to note that the results may have

been influenced by the withdrawal of several

nonrelevant items from the functional

difficulty subscale, because the subjects were

not exposed to these during the early


23

postoperative stage. This methodological

choice may have reduced the validity of the

corresponding subscale and the total score on

the WOMAC questionnaire. There is a need to

develop and validate an appropriate functional

outcome measure for the weeks immediately

after TKA.

Differences in WOMAC pain component

scores were close to significance at discharge

(P .07). A secondary analysis of the 5 items of

this pain component revealed a significant

difference between CTL subjects and subjects

who received moderate intensity CPM

applications for the fourth item, which

evaluates the intensity of pain at rest

(ANOVA, P .003; Tukey honestly significant

difference post hoc test, P .002; 95%

confidence interval for intergroup differences

7.4%–37.7%). For the other items, pain in

managing stairs (item 1), in walking (item 2),

at night (item 3), or in the sit-to-stand activity

(item 5), no difference among groups was

found, even for pain at night, when subjects

were also in a resting position. One may

question the validity of this finding. That is, is

it the result of chance, or does it actually

reflect the effect of intervention for subjects

who received moderate-intensity CPM

applications?

In the past 10 years, preestablished discharge

criteria have evolved concurrently with

decreasing LOS, which now varies between 5

and 10 days after TKA.8,20,24,43,46

Therefore, the 90 degree knee flexion

discharge criterion was modified to a smaller

ROM, and functional ability was emphasized

to accelerate discharge.46,47 In some

studies,8,20,24 the mean knee flexion ROM at

discharge varied from 63 degrees to 80

degrees for an LOS between 5 and 10 days

after TKA. In our study, one of our discharge

criteria in addition to independence in

functional activities was active ROM in knee

flexion, which had to be approximately 75.5

degrees. Eighty-three percent of our subjects

reached more than 70 degrees of knee flexion

at discharge (CTL, 81%; EXP1, 81%; and

EXP2, 86%). Others were allowed to return

home because they had reached the functional

independence goal and because they continued

to be partially supervised for their exercises.

All subjects were discharged with home-

supervised physiotherapy interventions. In our

clinical trial, when all groups were taken into

account, real LOS and theoretical LOS were 8

days (SD = 2) and 7.6 days (SD = 1.6) after

TKA, respectively. The slight difference

between the 2 LOS measures was mostly

attributable to delays in transportation for

subjects living in outlying regions.

Deep vein thrombosis can develop in 40% to

80% of subjects after TKA. This proportion

decreases with prophylactic anticoagulant

therapy.48 ,51 There is controversy

concerning the effect of CPM on DVT. Many

authors did not find any difference in DVT

with CPM applications,13,14,20,21,52


24

whereas others found less DVT in CPM

application groups, although this finding may

have been attributable to the fact that their

control subjects were immobilized.4,15,19,53

In our study, a majority of subjects received

anticoagulant therapy, and the same very small

proportions of side effects, including DVT,

were observed in the 3 groups.

Our choice of CPM application duration could

be criticized. Indeed, many protocols with

various CPM application durations have been

studied, for instance, 1 hour 3 times per day,22

2 hours 3 times per day,20 comparison of

moderate and intensive durations of 5 and 20

hours per day,21 mean applications between 4

and 8 hours,6 and applications as long as 20

hours per day for 1 to 6 days after

TKA.8,11,23 None of these studies

demonstrated any additional effect of CPM

applications on knee flexion. Adherence to

CPM interventions was reported in 2 studies

and was less than the prescribed duration.6,20

For example, Beaupre´ et al20 reported an

adherence of 1.7 hours 1.8 times per day,

which was less than the prescribed application

of 2 hours 3 times per day. In this case, 61%

of subjects missed the morning session

because of interference with other activities.20

In our study, the 35 minute duration in EXP1

corresponded to the usual length of the CPM

application in our rehabilitation practice after

TKA. The 2 hour CPM application was added

to the research protocol to explore the effect of

a more intense, yet still feasible, CPM

intervention. This second group (EXP2)

received the CPM application in the evening

to avoid interference with other postoperative

activities routinely per-formed during the

hospital stay. This 2 hour duration was chosen

on the basis of a consensus among the health

care professionals (orthopedic surgeons,

physiotherapists, and nurses) involved in

rehabilitation after TKA. We determined that

CPM applications could not be any longer

than 2 hours in the acute-care context after

TKA because subjects had daily conventional

physiotherapy interventions, occupational

therapy visits, nursing care, and radiographic

and medical assessments. Furthermore,

subjects needed time to achieve all of their

rehabilitation goals, in addition to knee

flexion, such as independence and security in

transferring and in walking with aids, before

being discharged and sent home.


25

Figure 3.

Adherence to continuous passive motion (CPM)

interventions. (Top) Percentages of subjects in

experimental group 1 (EXP1) and experimental group 2

(EXP2) who received CPM applications for each day of

the clinical trial. (Bottom) Mean duration (in minutes)

of daily CPM applications for each experimental group.

Our study has many factors that contribute to

the validity of the results. First, our 3 groups

were comparable at baseline in terms of

personal and clinical characteristics and

outcome measurements. Second, there was a

high degree of adherence to interventions.

Only 1 subject in EXP1 (4%) and 3 subjects in

EXP2 (11%) did not receive 75% of the

planned CPM applications. Three subjects in

CTL (11%) and 1 subject in EXP1 (4%) did

not receive 75% of the conventional physical

therapy interventions. Third, all subjects in the

3 groups began CPM mobilization and knee

flexion exercises at the same time after TKA

to avoid a delayed exposure to knee movement

in CTL. Furthermore, the levels of co-

interventions were comparable among the

groups. Finally, in this study, considering the

variability observed and the pre-established

parameters ( error 5% and effect size in active

knee flexion of 10° among groups), the

calculated statistical power was high (86%).

This study has some limitations. The

conclusions of this study are limited to

populations and CPM application protocols

similar to those described in our clinical trial.

In specific situations, such as when important

restrictions in knee flexion are present before

TKA or after knee manipulation, CPM

application efficacy still needs to be tested.

CONCLUSION

The results of this study suggest that adding

CPM applications to conventional physical

therapy interventions does not favor better

knee flexion ROM. Furthermore, the results

indicate that CPM applications do not have

any additional effect on knee extension ROM,

functional ability, or LOS. Therefore, we

believe that CPM should not be routinely used

during in-hospital rehabilitation programs

after primary TKA for people with

osteoarthritis.

26

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CORRESPONDENCE


30

* Senior Physical therapist, Ahmedabad, Gujarat


31

EFFECTIVENESS OF SUPERVISED GRADED REPETITIVE ARM

SUPPLEMENTARY PROGRAM ON ARM FUNCTION IN SUBJECTS W ITH

STROKE

Dr.Harsha Tummala, MPT (Neurology)*, Dr.V.Srikumari , MPT (Neuro), PhD.**, Dr. K.Madhavi,

MPT (CT), PhD., ***

ABSTRACT

PURPOSE: The aim of the present study is to evaluate the effect of supervised GRASP protocol in improving

arm function in subjects with stroke. DESIGN: A RCT, Prospective-exp-design with pre test-post-test design.

SETTING: College of physiotherapy OPD, General ward of Sri Venkateswara Institute of Medical Sciences

(SVIMS), Tirupati. SUBJECTS: 30 subjects divided into 2 groups, control group (n=15) & experimental

group (n= 15). INTERVENTION: For experimental group: Conventional physiotherapy with Supervised

GRASP protocol for upper limb (In the presence of therapist or caregiver). For control group:Conventional

physiotherapy with home program exercises with printed GRASP material. DURATION: 6 weeks, 5days in a

week. OUTCOME MEASURES: (1) The Chedoke Arm and Hand Activity Inventory-9 (CAHAI) was used to

evaluate the performance of the paretic upper limb in the completion of activities of daily living (ADL). (2)

The Box and Block test (B&BT) to measure upper limb functional performance of basic manual dexterity. (3)

Isometric grip strength of the paretic hand was tested using a jammer hand grip dynamometer. RESULTS:

According to the obtained values, the pre and post test values of CAHAI-9, B&BT and grip strength had an

extremely significant effect with p value < 0.0001 in both control and experimental group. On comparing the

results between the groups: The experimental group CAHAI-9, (p-value is 0.0001) and B&BT (p-value is


32

0.0020) is considered very significant comparing to control group. The grip strength (p-value is 0.0005) is

considered extremely significant than the control group. CONCLUSION: After 6 weeks of intervention

program, both the supervised and unsupervised groups had a greater improvement in arm function with

GRASP protocol; but, supervised group had a better improvement in ADL performance, manual dexterity and

grip strength when compared to unsupervised group. Hence this study recommends the supervised GRASP

protocol for improving arm functions in subjects with stroke.

KEY WORDS: Stroke, Upper limb, GRASP, CAHAI, ADL

INTRODUCTION

Among all the neurological diseases

of adult life, stroke or cerebrovascular

accident (CVA) clearly ranks first in

frequency and importance. It is a leading

cause of disability among adults in developed

countries and it may persist for lifelong and

limits independence and quality of life [1].

Approximately 20 million people each year

will suffer from stroke and of these 5 million

will not survive [2]. The incidence of stroke

in developing countries will grow

approximately 30% between 2000 and 2025.

In 2005 it accounts for 5.7million deaths

worldwide and it is estimated that this

number will climb to 6.3 million in 2015 and

7.8 million in 2030.

Although most of the stroke survivors regain

independent ambulation, many have

difficulty in performing activities of daily

living (ADL) especially their self care and

house hold duties [3] . More than 70% of

individuals experience upper-limb paresis

after stroke [4]. The functional limitation in

upper extremity is one of the most common

disabling deficits after stroke. Use of upper

limb is vital to the completion of many

activities of daily living (ADL), as well as to

socialization and health-related quality of life [5, 6].

According to the theory learned non-use

repeated disappointments in attempts to use

the affected arm in acute phase can lead to

negative reinforcement of using the affected

arm. The individual learns not to use the

affected extremity[7, 8]. This compensation has

been show to hinder recovery of function in

the upper limb and suppression of movement.

The restraint and training techniques

appeared to be effective because they

successfully overcame the learned non-use [9].

Greater amounts of upper extremity

therapy during rehabilitation can improve the

ability to use one’s arms and hands In the

rehabilitation treatment for the paretic upper

limb, it is apparent that increased treatment

intensity using repetitive task oriented

methods improves motor and functional

recovery compared to facilitative approaches

[10].

Thus, a novel method which is


33

practical, inexpensive and well-received by

the patients and clinicians are needed to

deliver greater amounts of therapy with a

focus on improving functional tasks of upper

extremity. One of such method is Graded

Repetitive Arm Supplementary Program

(GRASP)

GRASP is mostly used as a home

based exercise program which serves as a

complement to the regular physical therapy.

It is a self-directed arm and hand exercise

program which is supervised by a therapist,

but done independent by the patient (and

with their family if possible). But the

effectiveness of any home based exercise

regimen is not clearly studied because of the

adherence to the program and patient

motivation. So, this needs to supervise by the

therapist or a caregiver. The need of this

study is to find out the importance of

therapist supervision in implementing

GRASP program to stroke subjects.

Material and methodology: Subjects were

recruited from the college of Physiotherapy

OPD & General ward of Sri Venkateswara

Institute of Medical Sciences (SVIMS),

Tirupati, India.

Materials: Hand gripper, ball, light rubber

weight (half kg), clothe pegs, Lego-pieces,

paper clips &target board, Jammer hand grip

dynamometer & Box and block test kit.

CAHAI materials : plastic jar & lid,

telephone, scale(30 cms), pencil, water

glasses(2), hand towel, tooth paste and tooth

brush, knife, fork, thera putty,

Inclusion criteria: Stroke subjects with 40

to70 years of age; both males and females;

with active scapular elevation (shoulder

shrug) against the gravity; voluntary control

grading of 2 and 3 ;MAS score between 1 to

2 and Fugl-Meyer Upper Limb Motor

Impairment Scale score between 26 and 45.

Exclusion criteria: Stroke subjects with

unstable cardiovascular status; MMSE below

20; Cognitive deficits; Musculo-skeletal

disorders; Receptive aphasia & Non co-

operative patients.

OUTCOME MEASURES: The Chedoke

Arm and Hand Activity Inventory-9

(CAHAI) were used to evaluate the

performance of the paretic upper limb in the

completion of activities of daily living

(ADL).

1. The Box and Block test to measure

upper limb functional performance of

basic manual dexterity.

2. Isometric grip strength of the paretic

hand was tested using a hand grip

dynamometer.

All the subjects were selected on the

basis of inclusion criteria; were divided into

2 groups; Control group & experimental

group with 15 subjects in each group. The

subjects participated in this study voluntarily

after signing the consent form. The


34

demographic data, baseline measurements

were collected from both the groups and the

purpose of the study was explained to all the

subjects. All the three outcome

measurements are measured initially before

the intervention and after 6weeks of

intervention in both the groups.

Table 1: Demographic & Clinical

characteristics of sample at baseline.

Variable’s

Control

group

(n=15)

Experi-

mental

group

(n=15)

Sex, n 9M / 6F 8M /7F

Age (mean), yrs 56.5 54.2

Side of paresis, n 8R/7L 10R/5L

Fugl-meyer arm

score, max=66

(mean ± SD)

34.6

(4.6)

35.2 (6.2)

CAHAI-9,

max=63,(mean±SD

)

25.8(8.5) 23.4(6.9)

B&BT, (mean±SD) 10.2(5.0) 10.6(4.8)

Grip strength,

(mean±SD), kg

3.2(1.1) 3.5(0.88)

INTERVENTION

Experimental Group: Conventional

physiotherapy + Supervised GRASP protocol

for upper extremity. (In the presence of

therapist or caregiver.)

Control Group: Conventional physiotherapy

+ Home program exercises with printed

GRASP material (Telugu and English

versions)

Conventional physiotherapy: Stretching’s

to spastic group of muscles of upper

limb;Electrical stimulation to weaker group

of muscles of upper limb;Strengthening

exercises to arm and hand;Free exercises and

active movements to upper limbs &Weight

bearing exercises to upper limb.

STATISTICAL ANALYSIS:

Statistical analysis was done using

‘Graph pad instant 3’ version software. For

this purpose the data was entered into

Microsoft Excel spread sheet, tabulated and

subjected to statistical analysis.

To compare the pre and post

treatment effect within the group paired

sample t test was used, and to compare the

pre and post test treatment effect between the

groups unpaired t-test was used.

RESULTS:

Results of control group: (Refer table: 2)

CAHAI-9 result: The p-value is < 0.0001


35

which shows there is a extremely significant

difference. The t-test value is 21.767 with 14

degrees of freedom. It is observed that the post

intervention had shown significant impact on

the subjects.

B&BT result: The p-value is < 0.0001 which

shows there is a extremely significant




the subjects.

Grip strength result: The p-value is < 0.0001





the subjects.

Table 2: Analysis of control group with pre and post intervention:

Parameter Mean SD t-value DF P -

value

CAHAI-9

Pre 25.866 8.676 21.767 14 <0.0001

Post 29.666 9.005

B&BT

Pre 10.866 3.523 9.057 14 <0.0001

Post 12.933 3.674

Grip strength

Pre 2.967 1.274 9.727 14 <0.0001

Post 3.9 1.339

Results of experimental group :( Refer table: 3)

CAHAI-9 result: The p-value is < 0.0001





the subjects.

B&BT result: The p-value is < 0.0001 which

shows there is a extremely significant




the subjects.

Grip strength result: The p-value is < 0.0001





the subjects.

36

Table 3: Analysis of Experimental group with pre and post intervention

Parameter mean SD t-value DF p- value

CAHAI-9

Pre 23.466 6.906 13.266

14

<0.0001

Post 37.93 3.955

B&BT

Pre 10.666 4.865 18.806

14

<0.0001

Post 18.666 5.394

Grip strength

Pre 3.4 1.256 12.426

14

<0.0001

Post 5.9 1.429

COMPARISON BETWEEN THE GROUPS:

CAHAI Results: To compare the results of

between the group of control & experimental

groups, the unpaired t-test was selected. The

p-value is 0.0030, the difference is considered

very significant. The values of CAHAI are

improved in control group as well as

experimental group, but the improvement is

more is experimental group.

B&BT Results: The p-value is 0.0020, the

difference is considered very significant. The

values of B&BT are improved in control

group as well as experimental group, but the

improvement is more is experimental group.

Grip strength results: The p-value is 0.0005,

the difference is considered extremely

significant. The values of B&BT are improved

in control group as well as experimental

group, but the improvement is more is

experimental group.

Table 4: Comparison of between the groups of control and experimental group


37

Para-meter

Mean

S.D

t-value

df

p-value

CAHAI-9 Experimental 37.93 3.955

3.255

28 0.0030

Control 29.666 9.005

B&BT Experimental 18.666 5.394

3.402

28 0.0020

Control 12.933 3.674

Grip

strength

Experimental 5.9 1.429

3.955

28 0.0005

Control 3.9 1.339

DISCUSSION:

The results of the present study

revealed that there is a significant difference in

both control and experimental group which

indicates that GRASP protocol is effective in

improving arm function in stroke subjects.

Our intervention techniques (GRASP)

are based on the repetitive task oriented

practice which contains 3 designed principles;

such as, skill acquisition of functional tasks,

active participation training and individualized

adaptive training. All these 3 principles are

helped in improving arm function with

GRASP protocol. The task oriented training is

emerging as the dominant and most effective

approach to motor rehabilitation of upper

extremity function after stroke[11].

And these task oriented exercises are

based on the concrete task rather than abstract

task. Subjects showed a superior motor

performance when performing a concrete task

involving meaningful interaction with an

object compared to an abstract task with no

object involved [12]. The movement was

faster in the concrete task than in the abstract

task [13]. Repetitive exercise may be as

critical to motor learning and it may drive

brain reorganization by what appears to be as

process of motor learning [14]. Time spent

completing the GRASP protocol was a

significant predictor of improvement in both

variables (CAHAI and B&BT) in both the

groups.

But, the supervised exercises is very

significant than unsupervised with CAHAI

and B&BT, and it is extremely significant in

grip strength. In the supervised group, during

intervention with the subjects, therapist used

the verbal cues and tactile cues to the subject

to complete the task in a proper way & in a

correct manner to avoid wrong synergy

pattern. And, therapists used sensory input,


38

verbal guidance and rewards to help the

patient to learn the task or to complete the

GRASP protocol.

Physical guidance are also used by the

therapist throughout the whole protocol/task to

demonstrate what is to be done and how to do

the task and it is given during the beginning,

middle and in finishing the task. All these

above factors help the supervised group to

improve the CAHAI.

In the supervised group, the therapist

used the extrinsic feedback. The extrinsic

feedback is provided to the subjects with

knowledge of result (KR) and knowledge of

performance (KP) by the therapist’s verbal

and tactile cuing during intervention

For example, to improve manual

dexterity, the therapist used extrinsic

feedback. Here, the goal is to pickup small

blocks from the peg board. KR is given in the

form of amount of time needed to complete

the task (whole peg board). KP is given

regarding information about the movement

patterns in the shoulder, elbow, wrist and

finger during grasping a block and during

releasing a block. So, with the help of

extrinsic feedback (KR and KP), the

supervised group had a statistically greater

improvement in manual dexterity of hand with

box and block test (B&BT).

When compared to the unsupervised

grip strength, the supervised grip strength is

extremely significant because, the subjects

practiced the grip strength exercises such as

Grip power, finger power, the twist and finger

strength in the GRASP Protocol with the help

of thera putty. During these thera putty

exercises, the subjects are complained about

the fatigueness and pain in the hands in both

groups

But in supervised group, proper resting

time and changing of exercises are advised.

But Modification of exercises are also done by

the therapist when the patient is not able to

perform the protocol and during these putty

exercises.

In unsupervised group, due to pain

and fatigue, subjects less used these theraputty

exercises compared to other exercises. Due to

poor adherence, (participating in less than half

required time), there is no therapist or family

member to explore the reasons behind the

problems and lack of solutions for the

problems.

The result of GRASP is better with the

involvement of therapist of caregiver or who

can assist with the exercises like track the

amount of exercise, motivation to the patient,

helping counting the repetitions; assist with

the positioning equipment like the target board

etc.

Researchers noted that the motor

cortex (M1) changes occurred (motor

learning) when (a) New or novel task were

used, (b) when movements were practiced

together, (c) when movements were frequently


39

repeated and (d) when movements were

important to the individual [15]. Our

intervention program (GRASP protocol),

meets the above same criteria which play a

important role in motor learning. The

supervised group, play a major role in motor

learning and neural plasticity.

Hence, the use of verbal and tactile

cues, proper sensory input, verbal guidance,

motivation, rewards and with proper feedback

by the therapist helps in process of motor

learning. Hence, this motor learning enhances

the neural plasticity of the brain.

CONCLUSION:

Task oriented program has been

proven one of effective methods of

management for stroke related disabilities.

The GRASP program is based on the concepts

of task oriented program which aims to treat

the motor problems on the neuro

biomechanical basis, and practicing on real

life activities. It is established well that real

life practice are more beneficial for motor

relearning. The present study aimed to assess

whether there is any significant difference in

the effectiveness of GRASP protocol between

supervised and non supervised program in arm

function. On the above discussed & tabulated

data and results after 6 weeks of intervention

program, it is concluded that both the

supervised and unsupervised GRASP

protocols shown greater improvement in arm

function. Further, supervised Grasp protocol

helps in better improvement in ADL

performance, manual dexterity and in grip

strength when compared to unsupervised

GRASP. Hence this study recommends that

supervised GRASP protocol for improving

arm functions in stroke subjects.

DEDICATION: To our beloved

‘Physiotherapy’ profession &God Almighty.

REFERENCES

[1]. Duncan PW, Samsa GP, Weinberger M, Goldstein L, Bonito A, Witter D,Enarson C, Matchar D. Health status of

individuals with mild strokes. Stroke. 1997; 28:740–745.

[2]. Dalal P, Bhattacharjee M, and Vairale J, Bhat P. UN millennium development goals: can we halt the stroke

epidemic in India? Ann Indian Acad Neurol 2007; 10: 130-6.


40

[3]. S Sunder, Text book of rehabilitation. 2nd edition, New Delhi, Jaypee publication, 2002, page 351.

[4]. Nakayama H, Jorgensen HS, Raaschou HO, Olson TS. Recovery of upper limb function in stroke patients: the

Copenhagen stroke study. Arch Phys Med Rehabil. 1994;75:394–398.

[5]. Dromerick AW, Lang CE, Birkenmeier R, Hahn MG, Sahrmann SA, Edwards DR. Relationship between upper-limb

functional limitations and self-reported disability 3 months after stroke. J Rehabil Res Develop.2006; 43:401–408.

[6]. Nichols-Larsen DS, Clark PC, Zeringue A, Greenspan A, Blanton S. Factors influencing stroke survivors’ quality of

life during subacute recovery. Stroke. 2005;36:1480–1484.

[7]. Taub E, Berman A. Movement and learning in the absence of sensory feedback. In: Freedman S, ed. The

neuropsychology of spatialy oriented behavior. Homewood: Dorsey Press; 1968, p. 173–192.

[8]. Taub E, Miller NE, Novack TA, Cook EW, 3rd, Fleming WC,Nepomuceno CS, et al. Technique to improve chronic

motor deficit after stroke. Arch Phys Med Rehabil 1993; 74: 347–354.

[9]. Jean-Marie Andre, Jean-Pierre Didier, and Jean Paysant. FUNCTIONAL MOTOR AMNESIA” IN STROKE (1904)

AND “LEARNED NON-USE PHENOMENON” (1966); J Rehabil Med 2004; 36: 138–140.

[10]. Barreca S,Wolf sl, Fasoli S,Bohannon R. Treatment interventions for the paretic upper limb of stroke survivors: A

critical review. Neurorehabil Neural Repair.2003Dec;17(4):220-6.

[11]. Schweighofer N, Choi Y,Winstein c. Task-oriented rehabilitation robotics. Am J Phys Med Rehbil. 2012 Nov;91(11

suppl 3):s270-9.

[12]. Vander weel,FR,et al (1991). Effect of task on movement control in cerebral plasy: Implications for assessment and

therapy. Dev Med child Neurol,33,419-426.

[13]. Van vliet p, Kerwin DG, Sheridan M et al.(1995). The influence of goals on the kinemetics of reaching following

stroke. Neurol Rep,19,11-16.

[14]. A sanuma H, Kellera(1991) Neuronal mechanisms of motor learning in mammals. Neuro report,2,217-224.

[15]. Byl N : The neural consequences of repetition, Neural Rep 24:60-70,2000.

CORRESPONDING AUTHOR:

*MPT (Neurology), MIAP, College of physiotherapy, SVIMS, Tirupati, India. Email :[email protected]

** MPT (Neuro), Ph.D., Assistant professor, college of physiotherapy, SVIMS, Tirupati.

*** MPT (CT), Ph.D., Professor, principal, college of physiotherapy, SVIMS.

41

EFFECTIVENESS OF CORE STRENGTHENING EXERCISES TO REDUCE

INCIDENCE OF SIDE STRAIN INJURY IN MEDIUM PACE BOWL ERS

Omkar P.Padhye*, Subin Solomen**, Pravin Aaroon***

ABSTRACT

BACKGROUND: Sports injuries are injuries that happen when playing sports or exercising. Some are from

accidents. A side strain refers to a tear of the internal oblique the external oblique, or the Transversalis fascia

at the point where they attach to the four bottom rib. In cricket prevalence of side strain injury in bowlers is

21% in bowlers 5% and overall 9% of total injury in cricket. Management of side strain takes lengthy

procedure so players may lose game so prevention is better than cure. Study done by Tymothy et al. stated

that muscle strengthening program can reduce incidence of injury Hence in this study we have discussed

about preseason core muscle strengthening can reduce the chances of incidence of side strain injury in

medium pace bowlers. OBJECTIVES: 1) To calculate the pre-season risk of side strain injury in medium

pace bowlers.2) To measure the effectiveness of core strengthening muscles to reduce incidence of side strain

injury.3) To calculate changes in plank score measurement in medium pace bowlers before and after

intervention.4) To assess severity of side strain injury using electrotherapeutic measurements. METHODS:

Longitudinal study.30 male medium pace bowlers from Goregaon sports club, Prabodhan sports club,

Payyade sports club selected for study. Pre and post plank score taken. Follow up done by phone call.

INTERVENTION: Core muscle strengthening exercise will be given to players for 6 weeks. On first visit

core strengthening exercise will be taught to all players, they will be observed for 6 weeks and follow up

taken. RESULTS: In the study group descriptive statistical analysis is used, statistically it was found that

there were significant increase in Prone hold test score(Plank test score) (pre intervention plank score

2.00±0.00) , ( post intervention plank score 2.93±0.64), P value(< .0001). Mean incidence were calculated by

new injury per 1000 hrs. of participation time there were 3% of wrist injuries,10% ankle, 3% groin,14%


42

hamstring 7% low back,3% shin splint, 13% shoulder,10% side strain and 37% no injuries.

INTERPRETATION & CONCLUSION: As compare to other common sports injuries like incidence of

Shoulder injury (33.33/1000hrs), incidence of Hamstring injury (33.33/1000hrs) incidence of side strain

injury (25.00/1000hrs) is less, so it proves that core muscle strengthening exercise is effective to reduce

incidence of side strain injury. Thus, Core muscle strengthening exercises can be given to medium pace

bowlers to reduce incidence of side strain injury.

KEYWORDS: Side strain, Prevalence of side strain injury, prone hold test, Sports injuries, Severity of side

strain.

INTRODUCTION

Almost half of all injuries to adult cricketers

occur during formal play. One third of cricket

injuries to children occur during school hours

reflecting the popularity of cricket as a school

sport, almost 20% of injuries occur during

training or practice.1, 2

To prevent injuries in cricket, the Australian

cricket board SPOT program advocates the

screening of young bowlers for risk factors,

including postural stature, physical

preparation, avoidance of over bowling, and

use of correct bowling techniques.2There are

various different physical demands involved

in different types of cricket, which has meant

the injury profile is slightly different between

five day test matches, 3 day matches, one day

matches, and twenty-20 matches. There are 5

common cricket injuries hamstring strain, low

back pain, side strain, shoulder pain, and

sprained ankle3. Side strain is fairly common

in cricket, where it typically occurs in

bowlers.4 Cricket injury surveillance research

in Australian first class cricket has reported

that side and abdominal strains account for the

second highest seasonal incidence and fourth

highest prevalence of all body areas5.

A side strain refers to a tear of the

internal oblique the external oblique,

or the Transversalis fascia at the point

where they attach to the four bottom

rib6. All side strain injuries to bowlers

described within the literature affect

the side opposite to the bowling arm,

with all but one injury affecting

internal oblique (IO) or external

oblique (EO)7. In cricket the bowlers

suffer the Side Strain7,8, on the non-

bowling arm side as a result of a

forcible contraction of the muscle on

that side while they are fully stretched

as the bowling arm is cocked for

bowling. It has been postulated that the

probable point of internal oblique

rupture in side strain injuries in cricket

bowlers is the sudden vigorous motion

from assumed maximum eccentric

contraction when the non-bowling arm

is fully flexed and then suddenly

extends or pulls through, allowing the


43

bowling shoulder to flex to bowl the

ball.

The fast bowling technique is

classified into four distinct styles:

(son)side-on, (sop)semi-open,

(fo)front-on or mixed, according to

their relationship between the planes of

the hips and shoulders, and shoulder

counter-rotation during the bowling

action8. Investigations of side strain in

cricket bowlers using MRI found that

the injury consistently occurred on the

non-bowling side and tended to affect

abdominal muscles internal oblique

muscle rather than the external oblique

muscle, this could suggest that the

asymmetrical muscular demands of the

repetitive bowling action creates

hypertrophy in the torque producing

muscles of trunk rotation and side

flexion.2

Side strain injury is very common in

cricket players and javelin throwers8,

in cricket prevalence of side strain

injury in bowlers is 21% in bowlers

5% and overall 9% of total injury in

cricket8. All side strain injuries

required some kind of treatment which

is aimed at pain relief and restore

mobility and strength9. Management of

side strain is ice application for twenty

minutes every two hours, application

of cohesive compression bandage to

help to limit bleeding in the tissue,

more active rehabilitation can be

started under the supervision of

physiotherapist, once the immediate

pain resolves. So if the strength of the

muscle is less then muscle is more

prone for strain injury10. Hence

strengthening exercises can be

incorporated to prevent sports injuries

like side strain injury. Core

strengthening exercises can be done on

an exercise mat using swiss ball and

resistance band which includes core

activation exercises, mat exercises,

simple exercise and the Pilates10.

Compare to other sports injuries side

strain injuries are not recurrent if

treated11.

Timothy et al did study to examine

whether players classified as “at risk”

participate in an intervention program

could reduce the incidence of adductor

muscle strain. The author concluded

that a preseason strengthening exercise

to adductor muscle group appears to be

an effective method for preventing

adductor strain in professional Ice

Hockey players, similarly it is not

known that whether a preseason core

strengthening exercises can reduce the

risk of incidence of side strain injury in

medium pace bowlers who are at

risk12.

Management of side strain takes

lengthy procedure so players may lose


44

game so prevention is better than

cure.9Hence, if the strength of muscle

is increased, it can increase

performance of the individual.12So

greater the performance more the

chance of winning the game and

increase in ranking level.

METHODOLOGY

Study design: Descriptive longitudinal study

Setting and Participants: 30 male medium

pace bowlers from prabodhan sports club,

payyade sports club, cricket clubs.Medium

pace bowlers with core muscle strength

average (i.e. Grade 2) on plank score, Age

group of 18 to 24, with bowling action front

on were included.Previous history of lateral

trunk pain or low back pain or side trunk

injuries, previous history of chest pain due to

cardio, respiratory disorders were excluded.

Intervention Procedure:

The plank test was described as follows. The

player lied in prone position on mat or couch.

Watch was being positioned on the ground

where the player and therapist can easily see

it. Player assumed the basic press up position

(elbow on the ground) and holded that

position for 60 seconds. Player lifted his right

arm off the ground and holded that position

for 15 seconds and take it return to the ground

after 15 seconds. Player lifted his left arm off

the ground and holded that position for 15

seconds and take it return to the ground after

15 seconds. Player lifted his right leg off the

ground and holded that position for 15

seconds and take it return to ground after 15

seconds. Player lifted his left leg off the

ground and holded that position for 15

seconds. Player lifted his left leg & right arm

off the ground and holded that position for 15

seconds and take it return to the ground after

15 seconds. Player lifted his right leg & left

arm off the ground and holded that position

for 15 seconds and take it return to basic up

position (elbows on the ground) and hold that

position for 30 second. Grading was done

according to scoring as mentioned in table

below.

Grades:

Time Grades Scores

Under 20 seconds Poor 1

21-45 seconds Average 2

46-70 seconds Good 3

71+seconds Excellent 4

Core muscle strengthening exercise22 was

given to players for 6 weeks. On first visit

core strengthening exercise was taught to all

players, they were observed for 6 weeks.

During exercise sessions, coaches or

physiotherapist were educated about side

strain injury, which includes concept of side

strain injury, its symptoms, diagnostic tests

and its management. After one season (20


45

matches) matches, number of incidence of

side strain injury was collected from coaches

or physiotherapist then severity of side strain

injury was assessed by Sonography or

Magnetic resonance imaging and was

confirmed by Orthopaedic. Data was collected

in form of number and percentage of

incidence of side strain injury after one

season.

OUTCOME MEASURES

• Number and percentage of incidence

of side strain injury among medium

pace bowlers after one season.

• Number and percentage of players who

are at risk of side strain injury

• Plank scores in all players before and

after one season.

DATA ANALYSIS

Data analysis was performed by SPSS

(version 17). Alpha value was set as 0.05.

Effectiveness of core strengthening exercise

was assessed by number and percentage of

incidence of side strain injury. Injury

incidence was calculated by new injury per

1000 hrs. of participation time. Wilcoxon

signed rank sum test was used to find out pre

post difference within the group for plank

score (ordinal scale) for assessing core muscle

strength.

RESULTS

Study Design: A study was undertaken to

measure effectiveness of core strengthening

muscle exercise to reduce incidence of side

strain injury.

Table 1: Descriptive statistics for demographic & outcome variables

46

Variables Range Minimum Maximum Mean Std. Deviation

Age 6.00 18.0 24.00 20.73 2.04

Height 19.0 165.00 184.00 171.68 4.66

Weight 34.00 59.00 93.00 70.03 7.22

BMI 14.30 19.90 34.20 23.79 2.64

Pre Plank Score 3.00 1.00 4.00 2.70 0.74

In the study group the range of age is 6,

minimum 18.00yrs. and maximum 24.00yrs.

with mean 20.73yrs and std. deviation of 2.04.

In the study group the range of height is 19

with minimum height 165cm and maximum

height 184cm with the mean of 171.68cm and

std. deviation of 4.66. In the study group range

of weight is 34.00 with minimum weight of

59.00kg and maximum weight of 93.00kg

with mean of 70.03kg and std. deviation 7.22.

In the study group the range of BMI is 14.30

with minimum BMI 19.90 and maximum BMI

34.20 with mean of 23.79 and std. deviation of

2.74 In the study group the range of Plank

score is 3 with minimum plank score as 1and

maximum as 4 with mean of 2.70 and std.

deviation 0.74.

Graph: Preseason risk of injury in

bowlers

This graph explains about preseason risk

medium pace bowlers. In the study group 88%

of medium pace bowlers are considered as at

risk of injury before season and 12% were

having no preseason risk of injury.

Graph : Side strain injury in 30 medium

pace bowlers


47

This graph explains about presence of side

strain injury in medium pace bowlers. In the

study group 90% of medium pace bowlers

have not shown side strain injury after one

season but 10% of medium pace bowlers have

shown side strain injury after one season(one

season = 20 matches).

Graph: Percentage of injuries in medium

pace bowlers

This graph explains about percentage of total

injuries in the study group it was 1( 3%) of

wrist injuries,3 (10%) ankle,1(3)%

groin,4(14%) hamstring,2( 7%) low

back,1(3%) shin splint, 4(13%)

shoulder,3(10%) side strain and11( 37%) no

injuries.

Table 2: Pre- post data within groups

Variable Pre post þ value

Plank score 2.00±0.00 2.93±0.64 < .0001

Data are mean ± SD in study Plank score is improved from pre mean score of 2.00with Sd. of 0.00

to post mean score 2.93 with Sd.of 0.64 and which was statistically significant.( p < 0.0001 ).

DISCUSSION

Objective of the present study was to calculate

the pre-season risk of side strain injury in

medium pace bowlers. Second objective was

to measure the effectiveness of core muscle

strengthening to reduce the incidence of side

strain injury. Third objective was to calculate

changes in plank score measurement in

medium pace bowlers before and after

intervention. & fourth objective was to assess

the severity of side strain injury using

electrotherapeutic measurements.


48

30 male medium pace bowlers were chosen

for present study. Demographic variables

included were age, weight, height, BMI. In the

present study players with age group 18-24

who were highly susceptible for side strain

injury was taken. This was in accordance with

study done by HaronObaid et al. Author did a

study on sonographic appearance of side strain

injury and author stated that there were nine

men, one woman who showed side strain

injury of mean age, 22 years; range, 16–30

years it concludes that this age group is highly

susceptible for side strain injury.

In the present study 21 right arm medium pace

bowlers and 9 Left arm medium pace bowlers

who fulfilled inclusion criteria and who were

having plank score Grade-2 (poor core muscle

strength) who were at risk of side strain injury

because of muscle weakness were chosen.

This was in accordance with study done by

HaronObaid et al. Author did a study on

sonographic appearance of side strain injury

and author stated that 8 bowlers have got

strain side injury out of which 7 were right

arm bowlers and one was left arm bowler, so it

concludes that incidence of side strain injury

was more to right arm bowlers than left arm.

In this study there were 88% out of 30

medium pace bowlers showed risk of injury.

This was in accordance with study done by R.

A. Stretch et al. Author stated that injuries

tend to occur during specific stages of the

season, with the many preseason matches and

the concentration of matches toward the end of

the season tending to result in an increase in

injuries at those times Fast bowlers are at the

greatest risk of injury for a variety of reasons,

including the demands that fast bowling places

on the musculoskeletal system, incorrect

technique, poor preparation and training, and

overuse.

In this study there were 3 side strain injury

(10%) observed after one season( 20 matches)

out of which one was left arm medium pace

bowler 33% and two were right arm medium

pace bowlers 67%. Number of games missed

by injured bowlers is 7, 6 & 5 respectively.


HaronObaid et al. Author stated in the study of

sonographic appearance of side strain injury

that 8 bowlers have got side strain injury out

of which 7 were right arm bowlers and one

was left arm bowler. So present study

concludes incidence of side strain injury were

more in right arm bowlers than left am

medium pace bowlers.

In the present study, 3 (10%) out of 30

medium pace bowlers have got side strain

injury after one season (20 matches), and 23

(90%) showed other injuries or no injury. As

bowlers perform high velocity combination of

sudden eccentric contraction when they bowl,

there are high chances of getting Side stain

injury. This was in accordance with study

done by Haronobaid et al. Author stated that

Side strain is thought to occur as a

consequence of a combination of sudden

eccentric contraction of the internal oblique


49

muscle that results in muscle tear. Also side

strain injury can occur due to Side due to

(plank score Grade-2) poor muscle strength

which is one of the causative factor for injury.


Timothy et al. Author stated in preseason risk

study that poor muscle strength may cause

stain of abductor muscles.

In the present study, there were 3% of wrist

injuries,10% ankle, 3% groin,14% hamstring,

7% low back,3% shin splint, 13%

shoulder,10% side strain and 37% no injuries.

This was in accordance with study published

by National Institute of Arthritis and

Musculoskeletal and Skin Diseases. NIAMS

updated that there are some most common

sports injuries are: Sprains and strains Knee

injuries swollen muscles Achilles tendon

injuries Pain along the shin bone Fractures

Dislocations.

In the present study, Plank test was used to

measure strength of core muscles. This was in

accordance with study done by Janine Gray

and Rene Naylor. Author have used plank test

for musculoskeletal assessment for to test

strength of core muscles. The test is used to

determine the relative strength of the global

stabilizers of the body namely the transverses

abdominus, internal and external obliques, and

scapula stabilizers. When compared with in

group it was found that there were significant

increase in plank score from a pre mean plank

score of 2.00 to post mean plank score 2.93

which was statistically significant.

Mean incidence was calculated by new injury

per 1000 hrs. of participation time.

Calculations were given by Foundation in

sports marketing. Out of 30 medium pace

bowlers there were 4 hamstring injury (33.33

mean incidence value) 1 wrist and forearm

injury (8.33 mean incidence), 3 side strain

injuries (25.00 incidence), 4 shoulder injuries

(33.33 mean incidence), 3 ankle injuries

(25.00 mean incidence), 1 groin injury (8.33

mean incidence), 2 low back injuries (16.66

mean incidence), and 1 shin injury (8.33

mean incidence). 11 players did not show any

injury after one season (20 matches).

Total numbers of hours played by 30 medium

pace bowlers were 3276 hours. Total numbers

of hours were calculated by the product of

number of matches played by individual

player and number of hours played by

individual. (e.g. 17 matches * 6 hours = 102

hours) and sum of all hours were calculated.

Total numbers of games played by 30 players

were 546and total games missed by 30 players

were 54. In the present study it was considered

one season = 20 matches so total number of

games played were calculated by product of

total number games played by 30 players and

20 matches (one season) and total number of

games missed by player were calculated by

subtracting total number of games missed by

30 players from the total number of games

played which was considered for 20 matches

i.e. one season.


50

In the present study, MRI technique is used to

measure severity of side strain injury. This

was in accordance with study done by

Kathleen shorter et al. Author stated that a

high percentage of type II or fast twitch fibers

may also be a predisposing factor to tearing.

MRI appears to be a sensitive test for

evaluating side strain injury, showing an

abnormality in all patients who had a clinical

suspicion of a muscular tear and also to assess

the severity of injury.

It is postulated that the mechanism of injury

for internal oblique muscle strain is sudden

eccentric contracture with rupture of muscle

fibers. Movements associated with medium

pace bowling, which is then subjected to

superimposed eccentric contraction, making it

vulnerable to rupture. Present study describes

an effective strategy for injury prevention, by

core muscle strengthening exercises program

before season in medium pace bowlers to

reduce incidence of side strain injury.

LIMITATIONS

� Inability to monitor player’s

compliance(daily exercise

performance) with the home exercise

program which might have influenced

the study.

� The study was done with small sample

size.

� Long term effects of the treatment

were not assessed.

� Involvement of side in terms of

dominance is not considered which

might have influenced the study.

� Lack of control group.

RECOMMENDATIONS

� Further studies can be done by

comparing core muscle strengthening

exercise with other pre-season

prevention protocols.

� Study can be done to see how much

incidence of side train injury is

reduced when compared to a preseason

when there is no intervention given

� Further studies can be done to find its

effectiveness in fast bowler, batsmen

& other sports like javelin throw

hockey, tennis, badminton etc.

CONCLUSION

Objective of present study was to calculate the

pre-season risk of side strain injury in medium

pace bowlers. Second objective was to

measure the effectiveness of core

strengthening muscles to reduce incidence of

side strain injury. Third objective was to

calculate changes in plank score measurement

in medium pace bowlers before and after

intervention. & fourth objective was to assess

severity of side strain injury using

electrotherapeutic measurements. As there was

a significant improvement in pre and post

plank score (prone hold test) with in group.

And significant improvement in core muscle


51

strength. Incidence of side strain injury as

compare to other common cricket injuries

were less. Hence null hypothesis was rejected.

The study concludes as “Core muscle

strengthening exercises are effective in

reducing the incidence of side stain injury in

medium pace bowlers”. Thus, Core muscle

strengthening exercises can be given to

medium pace bowlers to reduce incidence of

side strain injury.

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• Email: [email protected]

53

A COMPARATIVE STUDY OF STANDING BALANCEPERFORMANCE

BETWEEN OA KNEE PATIENTS COMPARED WITH NORMAL AGE

MATCHED CONTROLS

Alagappan Thiyagarajan.T MPT (Sports)*, DY, PGDFWM; Prem Karthik .GS MPT (Ortho)

ABSTRACT

OBJECTIVE: To find out the standing balance performance among osteoarthritis of knee patients compared

with normal age matched controls STUDY DESIGN: Descriptive study. SAMPLING TECHNIQUE: Non

Probability convenient sampling. SETTING: Department of physiotherapy, Pallava Hospital, Chennai.

SUBJECT: 20 osteoarthritis patients and 20 normal were taken for this study. METHOD: To assess the

balance performance functional research test were administered to both osteoarthritis patients and control

groups. RESULTS: Functional reach test score value, which is higher for control group compared with

osteoarthritis patients. CONCLUSION: The results suggests that osteoarthritis of knee patients having

significant loss of (proprioception) balance performance compared with normal age matched controls

INTRODUCTION

Osteoarthritis is a heterogeneous

condition for which the prevalence, risk

factors, clinical manifestation, and prognosis

vary according to the joints affected. It most

commonly affects knee, hips, hand and spinal

apophyseal joints. It is characterized by the

focal areas of damage to the cartilage surfaces

of the synovial joints and is associated with

remodelling of the underlying bone and mild

synovitis1.

Osteoarthritis is one of the most


54

prevalent musculoskeletal complaints

worldwide. It is a major cause of

impairment and disabling among the

elderly. Individual with osteoarthritis of

knee suffer progressive loss of function,

displaying increasing dependency in

walking, stair climbing and other lower

extremity tasks2.

Balance is a complex function

involving numerous neuromuscular

mechanisms. Control of balance is dependent

upon sensory input from the vestibular, visual,

and somatosensory systems. Central

processing of this information results in

coordinated neuromuscular response that

ensures the center of mass remains within the

base of the support in situation when balance

is disturbed3.

Effective control of balance thus

relives not only on account sensory input but

also on timely response of strong muscles.

Balance is an integral component of activities

of daily living. Balance impairments are

associated with an increased risk of falls and

poorer mobility in the elderly population3.

Most of our clinical practice while

treating osteoarthritis patients we use to

concentrated to relieve pain and swelling and

increase the muscle power and so on. But

nobody concentrated4,5,6,7on balance

performance. The recent literatures are

suggests that osteoarthritis patients having

significance loss of proprioception that leads

to imbalance. So, this study helps to find out

balance performance among osteoarthritis of

knee patients compared with normal age

matched controls

OSTEOARTHRITIS AN OVERVIEW

CAUSES OF OSTEOARTHRITIS

� Over weight in the main cause � Harmful stress upon the knee

CLINICAL FEATURES

� Pain � Muscle spasm � Stiffness � Loss of movement � Muscle wasting and weakness � Joint enlargement � Deformity � Crepitus � Loss of function

DURING ACTIVE INFLAMMATION

� Heat. � Redness. � Swelling. � Pain.

PAIN The onset is of low intensity and can be

described as three types.

1. Pain on weight bearing, severe aching,

due to stress on the synovial

membrane and later due to the bone

surfaces, which are rich in nerve

endings, coming into contact.

2. During and after exercise there is pain

described as being around the joint.

3. AT night especially after a very active

day there is severe aching.

NATURE OF PAIN

1. Aching is dominant, at first

fleeting and then becoming more

constant.


55

2. Referred pain is described as

passing down a limb distally from

the affected joint.

3. Sharp stabbing pain is associated

with a loose body becoming

impacted in the joint.

MUSCLE SPASM This occurs over one

aspect of the joint and is initially protective

but where it remains beyond the acute episode

it must be treated to prevent contractures.

STIFFNESS This is present after rest and

takes a little time to wear off with movement.

It may be due to loss of joint lubrication,

chronic oedema in the periarticular structures

or swelling of the articular cartilage.

LOSS OF JOINT MOVEMENTThis is

different from stiffness because it does not

wear off. It may be permanent where there is

articular cartilage destruction but will respond

to physiotherapy where it is due to muscle

spasm or soft-tissue contracture.

MUSCLE WASTING AND WEAKNESS

Muscle become weak often on the aspect of

the joint which is opposite to contracures.

(E.g. his extensors).

JOINT ENLARGEMENT Chronic oedema

of the synovial membrane and capsule

together with muscle wasting makes the joint

appear large.

DEFORMITY Each joint tends to adopt a

characteristic deformity.

CREPITUS The flaked cartilage and

eburnated bone ends grate with a

characteristic sound on movement.

LOSS OF FUNCTION Pain, muscle,

weakness, giving way lead to inability to use

the limb normally and can be severely

disabling.

CLINICAL FEATURES RELATING TO

KNEE JOINT Pain is described as round and

through the joint. And may be referred up the

anterior aspect of the tight or down to the

ankle. Muscle spasm may be present in the

hamstring muscles. Deformity from prolonged

hamstring spasm is flexion and there is

deformation of the tibia with valgus

deformity. The joint is enlarged and there is

quadriceps atrophy especially vastus medialis.

There is a limp due to pain and a tendency for

the joint to give way especially during

stepping down.

PATHOLOGY This will be considered in

relation to each joint structure as follows:

1. Articular Cartilage 2. Bone 3. Synovial membrane 4. Capsule 5. Ligaments 6. Muscles

1. ARTICULAR CARTILAGE Erosion

occurs, often central and frequently in the

weight- bearing areas. Cartilage is usually the

first structure to be affected. Fibrillation which

cause softening, splitting and fragmentation of

the cartilage occurs in both weight bearing and

non – weight bearing areas.


56

Collagen fibres split and there is

disorganization of the proteoglycan- collagen

relationship such that water is attracted into

the cartilage which causes further softening

and flaking flakes of cartilage break off and

may be impacted between the join surfaces

causing locking and inflammation.

Proliferation occurs at the periphery of the

cartilage.

2. BONEEburnation – the bone

surfaces become hard and polished as there is

loss of protection from the cartilage

Cystic cavities form in the subcondalar

bone because eburnated bone is brittle and

microfractures occur allowing the passage of

synovial fluid into the bone tissue. There can

also be venour congestion in the subchondral

bone.

Osteophytes form of the margin of

articular surfaces where they may project in to

the joint or into the capsule and ligaments.

Bone of the weight – bearing joints alters in

shape- the femoral head becomes flat and

mushroom shaped. The tibial condyles

become flattened.

3. SYNOVIAL MEMBRANE This

undergoes hypertrophy and becomes

oedematour. Later there is fibrour

degeneration. Reduction of synovial fluid

secretion results in loss of nutrition and

lubrication of the articular cartilage.

4. LIGAMENTS This undergo the same

changes as the capsule and according to the

aspect of the joint become contracted or

elongated.

5. CAPSULE This undergoes fibrous

degeneration and there are low grade chronic

inflammatory changes.

6. MUSCLE These undergo atrophy which

may be related to disuse because pain limits

movement and function. Without adequate

exercise the muscles may undergo fibrous

atrophy.

METHODOLOGY

STUDY DESIGN - The design of the study is

Descriptive study.

SETTING - Department of Physiotherapy,

A.C.S General Hospital, Chennai

SAMPLE - 20 osteoarthritis Patients20

control Subjects

SAMPLING TECHNIQUES - Non

probability convenient sampling

INCLUSION CRITERIA

� Age between (45-65years)

� Patient Body mass index (BMI) value

between (25-30) Kg/m2

� The patient who has diagnosed

osteoarthritis of knee from orthopedic

department of A.C.S. General

Hospital, Chennai.

EXCLUSION CRITERIA

� H/o injuries and multiple falls

� Uncorrected visual impairments


57

� H/o stroke and cerebellar disorder

� H/o hospitalization in last two months

EQUIPMENTS AND MATERIALS

� Inch tape

� Weight machine

� Wooden Scale

METHOD:

The functional reach test is developed as a

quick screen for balance problems in older

adults. For performing this test subject’s stand

with feet shoulder distance apart and with the

arm raised to 90°flexion without moving their

feet, subjects reach as for forward as they can,

while still maintaining their balance. The

distance reached is measured and compared to

age-related norms3.

Twenty osteoarthritis knee patients and

twenty normal subjects were participated in

this study. To assess the balance performance

the functional reach test is administered to

both the groups. Before applying the test, the

procedure was clearly explained to the patient.

To perform the functional reach test

subjects stand with feet shoulder distance

apart and with the arm raised to 900 flexion

without moving their feet, subjects reach as

for forward as they can, while still

maintaining their balance. The measuring

scale is placed on the wall.

SAMPLE

The sample consists of 20 Osteoarthritis,

patients and 20 control subjects.

Functional Reach Test By Patient


58

Functional Reach Test By Patient

TABLE -1

FUNCTIONAL REACH SCORES OF

MALE SUBJECTS (45-65 YRS)

OA KNEE CONTROL

11.2 16.3

10.5 15.6

9.5 15.2

10.4 16

11 17

8.9 14.8

9.3 15.6

10.6 16.8

8.5 16.5

9.2 16.7

TABLE 2 (MALES)

BETWEEN GROUP ANALYSIS USING

PAIRED T-TEST FOR MALES

OA KNEE

CONTROL

SIGNIFICANT

Mean

9.91

Mean 16.05

(p <0.001)

SD 0.9409 S.D 0.7337

RESULTS:

Table 2 shows the value of mean and S.D

functional reach test score between OA knee

patients and control subjects. For OA patients

mean value is 9.91 and standard deviation


59

(S.D) 0.9409. For control subjects mean value

16.05 and S.D 0.7337. In order to find out the

level of significance. I used paired T- test. The

results shows that level of significance p value

<0.001.

BAR DIAGRAM

0

5

10

15

20

BETWEEN GROUP ANALYSIS USING PAIRED T-TEST FOR MALES

OA (MALE) CONTROL(MALE)

TABLE 3

FUNCTIONAL REACH SCORES OF FEMALE SUBJECTS (45-65YRS)

OA KNEE CONTROL

9.3 14.6

8.5 13.3

9.4 12.6

10.5 14.5


60

8.9 13.3

9.2 14

10.1 14.2

9.5 12.5

8.5 13.9

10.2 14.5

FUNCTIONAL REACH TEST SCORES OF FEMALES(45 TO 65 YRS)

0

2

4

6

8

10

12

14

16

SUBJECTS

FR

T S

CO

RES

OA CONTROL

TABLE 4 (FEMALES)

BETWEEN GROUP ANALYSIS OF FEMALE USING PAIRED T-TES T

RESULTS:

Table 4 shows the value of mean and standard

deviation of functional reach test score

between OA patients and control subjects. For

OA KNEE

CONTROL

SIGNIFICANT

Mean

9.4

Mean

13.74

(p <0.005)

SD 0.688 S.D 0.7763


61

OA patients mean value 9.4 and SD 0.688. For

control subjects mean value 13.74 and SD

0.7763. In order to find out the level of

significance I used paired t-test. The results

shows that the level of significance p-value <

0.005.

BAR DIAGRAM

0

5

10

15

BETWEEN GROUP ANALYSIS OF FEMALE USING PAIRED T-TEST

OA KNEE CONTROL

DISCUSSION

The aim of this study is to identify the

standing balance performance between OA

knee patients and age matched normal

controls.

Table -1 Shows that value of functional reach

test score for male. The value of functional

reach score which is high for control subjects

compared with AO patients.

Table 2 shows the value of mean and S.D

functional reach test score between OA knee

patients and control subjects. For OA patients

mean value is 9.91 and standard deviation

(S.D) 0.9409. For control subjects mean value

16.05 and S.D 0.7337. In order to find out the

level of significance. I used paired T- test. The

results shows that level of significance p value

<0.001.

Table – 3 Shows that the value of functional

reach test score for female. The value of

functional reach test score which is high for

control subjects compared with OA patients.

Table 4 shows the value of mean and standard

deviation of functional reach test score

between OA patients and control subjects. for

OA patients mean value 9.4 and SD 0.688. For

control subjects mean value 13.74 and SD

0.7763. In order to find out the level of

significance I used paired t-test. The results


62

shows that the level of significance p-value <

0.005.

KORALEWICZ 12et-all 2000 concludes knee

proprioception in middle aged and elderly

persons with advanced knee arthritis are

reduced in comparison with that in middle

aged and elderly persons without arthritis.

HASSON11et-all 2001 June concluded

compared with age sex mateched controls,

subjects with symptomatic knee osteoarthritis

have quadriceps weakness reduced knee

proprioception and increased postural way.

PAI Y.C.6et-all 2005 concludes

proprioception declines with age and is further

impaired in elderly patients with knee

osteoarthritis poor proprioception may

contribute to functional impairment in

osteoarthritis.

Based on the results it is suggests that OA

knee patients having significant loss of

(Proprioception) balance performance

compared with normal controls. While

comparing the functional reach test score

value between male and female, male

obtaining more value than female. It suggests

that female having more risk of imbalance

than man.

CONCLUSION

To conclude from the results of this study

osteoarthritis knee patients having significant

loss of (Proprioception) balance performance

compared with normal age match controls.

RECOMMENDATION

This study can be carried out large sample

size. This study can be carried out different

BM.

REFRENCES

1. Tidy’s physiotherapy 4th Edition Page No. 107-109 Author – TIDYS and THOMSON.

2. Orthopaedics and Traumatology – 6th Edition Author - NATARAJAN

3. Motor control theory and practical applications Page No.208-209 Author – ANNE SHUMWAY, MARJORIE

WOOILACOTT

4. Effects of kinaesthesia and balance exercises in knee osteoarthritis – 2005 Dec., DIRACOGLU .D, AYDIN. R

5. Effects of age and osteoarthritis on knee proprioception 12th Dec., 2005 PAI.Y.C

6. Impaired proprioception and osteoarthritis 1997 May – SHARMA .L, PAI.Y.C

7. Is knee joint proprioception worse in the arthritic knee versus the unaffected knee in unilateral knee

osteoarthritis 1997 August- HOLT KAMP .K, RYMER WZ

8. Relationship of knee joint proprioception to pain and disability in individuals with knee osteoarthritis 2000-

KIM.L, BENNELL, RANA.S.

9. Static postural sway, proprioception and maximal voluntary quadriceps contraction in patterns with knee

osteoarthritis and normal control subjects, January 2001, HASSAN B.S. , MOCKETT.S

10. Effect of pain reduction on postural sway. Proprioception and quadriceps strength in subjects with knee

osteoarthritis 2002 May- HASSAN B.S., DOHERTHY. S.A.


63

11. Influence of elastic bandage on knee pain. Proprioception and postural sway in subjects with knee osteoarthritis

2002- B. HASSAN, S. MOCKETT

12. Comparison of proprioception in arthritic and age matched normal knees 2000- KORALEWICZ L.M. ENGH.

G.A.

13. The incidence and neutral history of knee osteoarthritis in the elderly- 1995, OCT., FILSON D.T. , ZHANQ.Y

14. Incidence and progression of osteoarthritis in women with unilateral knee disease in the general population the

effect of obesity Sept., 1994- D.V. DOYLE, D.J. HART

15. Incidence and risk factor for radiographic knee osteoarthritis in middle aged women 22 May 2001- KIM.D.

DEBORAH, J. HART.

16. The influence of pathology pain balance and self-efficacy on function in women with osteoarthritis of the knee

Sept., 2004 – A.L. HARRISON.

17. Strategies for enhancing proprioception and neuromuscular control of the knee 2002 Sep., - WILLIAMS AND

WILKINS.


* Department of physiotherapy Pallava hospitals


64

THE EFFECTS OF BIT VERSUS MCIMT ON FUNCTIONAL

PERFORMANCE OF UPPER EXTREMITY IN CHRONIC HEMIPARES IS

Dr. Bhatri Pratim Dowarah, MPT(Neurology)*

ABSTRACT

Aim of the study was to evaluate the effectiveness of Bilateral Isokinematic training versus Modified

Constraint Induced Movement therapy in improving the functional performance of the upper extremity in

chronic hemiparetic subjects. METHOD: In mCIMT group, training was administered intensively for 2

hours per day for 6 days per week for 12 weeks with restraining of the unaffected upper extremity in sling

and splint. In BIT group, 2 hour session containing 5 exercise each with minimum 5 trails of every task and

maximum the patient can perform with BIT. SUBJECTS: The population of 30 patients was included in the

study which was divided by random allocation into two groups. The features of each group was as

mentioned under 15 minutes of therapy was spent on stretching and weight bearing exercises for

normalization of muscle tone of the affected limb as needed in both the group. RESULTS: Subjects in

mCIMT group Confirmed that they were largely using their affected limb for ADL following intervention

with significant changes in MAL and ARAT score suggesting increased use of the affected limb, whereas

subjects in the BIT group showed nominal MAL and ARAT changes and reported the pattern of use similar

to those that they reported before intervention.

KEY WORDS: Modified CIMT, BIT, MAL scale, ARAT scale

65

INTRODUCTION

Many stroke survivors experience

impairments such as hemiparesis, spasticity,

sensory/perceptual disorders, hemianopia,

dysphasia or cognitive impairments 8. Most

patients regain their walking ability, but

between 30 and 60% are no longer able to

use their more affected hand after 3-6 months 4,7,19. Only 11% to 18% of those sustaining a

severe post stroke upper extremity paresis

achieve full upper extremity function 7. The

inability to reach, to grasp and to manipulate

objects limits activities and causes particular

difficulties to perform daily personal care.

Perceived loss of arm function has been

reported as a major problem in approximately

65% of patients with stroke Thus, there is a

strong need to develop effective arm-hand

treatment methods in stroke rehabilitation 4.

Constraint-induced movement therapy

(CIMT), also known as forced use movement

therapy, is a therapeutic approach to

rehabilitation of movement after stroke. The

principal therapy involves constraining

movements of the less-affected arm with a

sling for 90% of waking hours for the

duration of therapy, while intensively

training use of the more-affected arm. 3

Chronic lack of use of the upper extremity

induced in monkey by unilateral sectioning

of the dorsal cervical and upper thoracic

spinal nerve roots could be reversed several

months to years later with a physical restraint

applied to the contralateral unaffected arm 21.

Most patients who survive a stroke

experience persistent impairment of arm

movement 10,11 . It has been suggested that

constraint- induced movement therapy or less

intensive variants of constraint-induced

movement therapy (i.e. modified) may be

used to overcome the learned non-use

phenomenon and improve functional

performance of the affected arm of stroke

patients in the acute, subacute and chronic

phases 13,17,18,25.

Bilateral Isokinematic Training (BIT) is used

for upper limb rehabilitation in stroke

patients and is based on the theory that

therapy for stroke patients needs to be

directed at the central nervous system

because it is the brain that is damaged by a

stroke, not the muscles. Quite simply, BIT

trains the stroke patient to use both hands in

the same way, simultaneously but separately

(“bilateral” = both sides, “iso” = equal/same,

“kinematic” = same movement of both upper

limbs simultaneously) 23.

Need and Significance of the study:

Functional recovery of the paretic upper

extremity post stroke continues to be one of

the greatest challenges faced by rehabilitation

professionals. Although most patients regain

walking ability, 30%–66% of stroke

survivors fail to regain functional use of their

arm and hand 10.

The incorporation of bimanual movements

into upper limb rehabilitation protocols, also


66

it is considered that the BIT approach is in

direct contrast to constraint- induced therapy

as long as the implementation of the

technique is considered 6.

Hypothesis

Experimental Hypothesis: There may be

significant difference in the effectiveness

between Modified Constraint Induced

Movement therapy and Bilateral

Isokinematic Training in improving

functional performance of upper extremity in

chronic hemiparesis.

Null Hypothesis: There may not be any

significant difference in the effectiveness

between Modified constraint Induced

Movement therapy and Bilateral

Isokinematic Training in improving

functional performance of upper extremity in

chronic hemiparesis.

Materials & Methodology:

For the present comparative study a pre test

and post test design was used. Population

included chronic hemiparetic subjects.

Subjects were assigned to two groups, Group

A for mCIMT with 15 subjects and Group B

for BIT with 15 subjects with equal

probability

In mCIMT group, training was administered

intensively for 2 hours per day for 6 days per

week for 12 weeks with restraining of the

unaffected upper extremity in sling and

splint.

15 minutes of therapy was be spent on

normalization of muscle tone of the affected

limb as needed by stretching and weight

bearing exercises, patient’s unaffected hand

and wrist was restrain with sling and splint

every week days for 6 hours identified as a

time of frequent arm use. 6

In BIT group, 2 hour session(training period

matching to mCIMT group in duration)

containing 5 exercise each with minimum 5

trails of every task and maximum the patient

can perform with BIT (spatiotemporally

identical movement performed bilaterally but

with each limb independently).

Taub and Colleagues et al showed that

chronic lack of use of the upper extremity

induced in monkey by unilateral sectioning

of the dorsal cervical and upper thoracic

spinal nerve roots could be reversed several

months to years later with a physical restraint

applied to the contralateral unaffected arm 2,21,22.

Wolf and Colleagues et al conducted studies

on chronically hemiparetic stroke and

traumatic brain injury patients which

involved forced use, that is, restraint of the

less affected arm with sling for 2 weeks

while requiring the more affected arm to

conduct routine daily living activities found


67

that speed of the task execution improved for

most functional task for up to a year

following intervention 20.

CIMT and mCIMT involve restraint of the

unaffected limb for an extended period and

repeated task-specific training of the affected

limb. Numerous studies in stroke patients

have shown that CIMT/mCIMT can enhance

performance of the affected UE during

unilateral and bimanual functional tasks (e.g.,

flipping a light switch, putting on socks)

assessed, for example, using the Motor

Activity Log (MAL). During the unilateral

task mCIMT produce a greater increase in

the amount of preplanned control of reaching

movement than did TR 6.

In recent years the development of new

rehabilitation therapies has demonstrated that

significant progressions in movement ability

are achievable in chronic stroke patients

many months or even years after the initial

event 6,9.

Motor Activity Log scale is a structured

interview during which subjects used a six

point scale to rate how much and how well

they use their hemiparetic limb to perform

common functional activities 22.

It appears to captureboth how well and how

much patients use their more-impairedarm to

accomplish ADL, and, therefore, might

simply be namedthe Arm Use scale 14.

Action Research Arm Test (ARAT) is the

valid and consistent scale for measuring

recovery of arm-hand function in stroke

patient. ARAT may reflect not only arm

function but also upper extremity motor

impairmrnt that represents the exteriorization

of neurophysiological state due to

cerebrovascular diseases.

The score of ARAT may also represent the

degree of upper extremity impairment.

Inter-rater and retest reliability have been

shown to be high (ICC > 0.98) in studies

involving patients with stroke 25

Concurrent validity has been confirmed by

comparison with the upper limb component

of the Fugl- Meyer Assessment and the

Motor Assessment Scale (MAS) 12,25.

Study settings

All the patients were referred by consultant

neurologist from the above mentioned

hospitals and clinics.

Research Design:

It was a comparative study design, a

sample of 30 subjects were included in the


68

study with a pretest and post test study

design. The subjects were selected by

convenient sampling method based on an

initial baseline assessment and diagnosis of

their condition as per neurologist.

Inclusion Criteria :

• Hemiparesis

• Age 45-75 years 19.

• Duration more than 1 year and less

than 2 years

• Patient who can perform some active

finger and wrist extension 6,11.

• Patient on MMSE( Mini Mental Scale

Examination) more than 23/30 .

• Spasticity grading less than or equal

to 2/5 on modified Ashworth Scale .

• Both gender to be included

• Both dominant and nondominant

hemisphere lesion involvement patient

will be equally included

• Considerable nonuse of the more

affected limb (Amount of Use<2.5 on

Motor activity log scale 20.

• Patients consent for participation.

Exclusion Criteria

• Patient who has any orthopaedic

condition like post fracture stiffness or

contractures of wrist and fingers.

• Patient with any congenital deformity of

upper extremity like heterotrophic

ossification.

• Patients with any other neurological

disability like any head trauma, dementia,

learning disorder, schizophrenia, major

depression before the stroke, epilepsy

brain tumor .

• Patients with visual impairment.

• Patient who had stroke more than once in

the ipsilateral hemisphere or stroke in the

contralateral hemisphere on imaging

studies.

Population:

The population of 30 patients was included in

the study which was divided by random

allocation into two groups. The features of

each group was as mentioned under

Sample Design:

30 subjects with chronic hemiparesis

duration between 1-2 years and age group

between 40-60 years were taken. The

definition of 'chronic' for the purposes of this

study was defined as onset of stroke at least

one year prior to the commencement of the

treatment phase of this study 13,20,26.

Time and Duration of the study:

Duration of the study was 6 months & Data

were collected within the period of 3 months.

Protocol:


69

The subjects underwent the standardized

assessment technique based on an initial

baseline assessment which also included

patient’s cognitive assessment by MMSE

scale and assessment of the tone of the upper

limb by Modified Ashworth Scale and

diagnosis of their condition as per

neurologist.

In mCIMT group, training was administered

intensively for 2 hours per day for 6 days per

week for 12 weeks with restraining of the

unaffected upper extremity with sling and

splint. In mCIMT, we concentrated on use of

the affected limb during functional task

chosen by patients and the treating therapist.

It consisted of shaping which involved

1. Selecting functional tasks tailored to

address the motor deficits of the affected

hand.

2. Increasing the task difficulty in small steps

when performance was improved.

15 minutes of therapy was spent on


limb as needed by stretching and weight

bearing exercises, patient’s unaffected hand

and wrist was placed in restrain every week

days for 6 hours identified as time of

frequent arm use 6.

In BIT group, 2 hour session(training period

matching to mCIMT group in duration)

containing 5 exercise each with minimum 5

trails of every task and maximum the patient

can perform with BIT (spatiotemporally

identical movement performed bilaterally but

with each limb independently).

Procedure:

15 minutes of therapy was spent on

stretching and weight bearing exercises for


limb as needed in both the group.

All the 15 patients of Group A were

given restraint using sling and splint on the

unaffected extremity for 6 hours identified as

a time of frequent arm use. Training had

taken place during regularly scheduled

physical therapy session, and all other routine

interdisciplinary stroke rehabilitation was as

usual. Group program was given to the

patients (with 3-4 patients in a group), for 2

hours per day 6 Patients were seated on the

chair with harness tied around the trunk to

prevent the trunk rotation and forward

flexion (only if required) and a table in front

of the patient 2cm below the elbow the level

or standing with support provided by the

assistant as necessary6.

Training in Group B had also taken place

during regularly scheduled physical therapy

session, and all other routine interdisciplinary

stroke rehabilitation was as usual. All 15

patients were seated on the chair with harness

tied around the trunk to prevent the trunk

rotation and forward flexion(only if required)

and a table in front of the patient 2cm below

the elbow the level or standing with support


70

provided by the assistant as necessary.

Exercise in BIT included activities with both

hands doing same task separately, but at the

same time and same speed.

Analysis and Interpretation

The data obtained using ARAT, MAL(AOU)

scale of this study are ordinal and not interval

or ratio. Since this does not adequately fulfill

the conditions for parametric tests; non-

parametric test is applied here. The result

shows a significant improvement in both the

group getting both mCIMT and BIT.

Within group analysis

Table: Group analysis within Group A and

Group B of ARAT scale

Within group analysis

MAL (AOU)

0

0.5

1

1.5

2

2.5

3

3.5

4

Day 0 Day 45 Day 90

Table: Group analysis within Group A and Group B of MAL(AOU) scale

RESULT

The present study was undertaken to

determine the effect of the mCIMT and BIT

on the functional performance of the upper

extremity of hemiparetic stroke patient.

Data collected through the study showed more

improvement in the hand function and

Outcome

measures

Day 0

Mean

± SD

Day

45

Mean

± SD

Day

90

Mean

± SD

Repetitive

measures

Z P

ARAT

Group

A

30.60

± 8.34

37.73

± 7.76

42.47

± 8.14

-2.90

.000

Group

B

27.67

± 7.32

31.07

± 7.22

33.20

± 6.12

-3.86

.000

Outcome

measures

Day 0

Mean

± SD

Day

45

Mea

n ±

SD

Day

90

Mea

n ±

SD

Repetitive

measures

Z P

MAL

(AOU)

Group

A

1.47±.

516

2.40

±.54

1

3.37

±.51

6

-2.90

.000

Group

B

1.27±.

594

1.73

±.56

3

2.40

±.47

1

-3.86

.000

ARAT

05

1015202530354045

Day 0 Day 45 Day 90


71

functional activities in patients with

hemiparesis in the group A. Thus, it can be

concluded that mCIMT is more beneficial in

improving hand function for hemiparetic

patients post stroke. There results showed that

patients treated with mCIMT had their

functional performance of affected upper

extremity improved significantly more

DISSCUSSION

It has been recorded from the study that use of

mCIMT and BIT produces significant

improvement in functional performance of the

upper extremity in patients with hemiparesis

due to stroke.

A positive effect was found on the subjective

Amount of Use of the affected arm in ADL

(measured by the MAL(AOU) scale)

especially in the patients with the learned non-

use.

LIMITATIONS

The study is done on an immediate basis i.e.

the MAL scale was measured immediately on

the use of mCIMT and BIT and no follow up

was done. The lack of follow up has the

drawback that sustained of this improvement

and further progression value is not revealed.

It is known that right sided hemiparesis

usually have some perceptual disorder also

which is not considered in the study, but

nevertheless can affect the outcome.

CONCLUSION

The present study showed a lasting effect of

forced use therapy on the functional

performance of the affected arm, as measured

by the ARA test in comparison to the Bilateral

Isokinematic training.

A positive effect was found on the subjective

Amount of Use of the affected arm in ADL

(measured by the MAL(AOU) scale)

especially in the patients with the learned non-

use.

REFERENCES

1. Anna Tuke, Constraint Induced Movement Therapy: A Narrative Review; Physiotherapy 94 (2008) 105-114

2. Anne Shumway, M.H. Woollacott, Motor Control Theory and Practical Application, Page 521-523.

3. Atena, Clinical policy BulletinNo.0665

4. Brogardh C and Sjölund BH (2006). Constraint induced movement therapy in patients with stroke: a pilot study

on effects of small group training and of extended mitt use. Clin Rehabil (20) 218-227.

5. Ching-Lin Hsieh, I-Ping Hsueh, Fu-Mei Chiang, Po-HsinIN Lin: Interrater reliability and validity of the ARAT in

stroke patients. Age and aging 1998; 27: 107-113.

6. Ching yi Wu, Keh Chung Lin, We-hsein Hong, Hsieh-ching Chen and I-hsuen Chen et al. Constraint Induced

movement therapy on movement Kinematics and daily function in patient with stroke: Neurorehabilitation and

neural repair 2(5);2007- Pg 460-465

7. Darcy Umpherd, Neurological Rehabilitation,Fourth Edition; page 797-798.


72

8. Gresham GE, Duncan PW and Stason WB (1995). Post-stroke rehabilitation; Clinical practise guidline. Vol. 16

AHCPR.

9. Gwyn Lewis N, Wiston D Byblow, Neurophysiological and behaviour adaptations to a bilateral training

intervention following stroke. Clin rehab 2004;18,48.

10. Janet Carr, Roberta Shephard; Neurological Rehabilitation- Optimizing motor performance 143-144.

11. K-C Lin, Effects of modified constraint-induced movement therapy on reach-to-grasp movements and functional

performance after chronic stroke: a randomized controlled study; Clinical Rehabilitation 2007; 21: 1075–1086

12. Michelle McDonnell Action Research Arm Test; Australian Journal of Physiotherapy,2008, Vol.54

13. Miltner W, Bander H, Sommer M,et al. Effects of Constraint induced movement therapy on patient with chronic

motor deficits ater stroke : A replication stroke. 1999; 30; 586-592

14. Mudie MH and Matyas T.A. (1996) Upper extremity retraining following stroke: Effects of bilateral practice.

Journal of Neurologic Rehabilitation 10(3): 167-184.

15. Nadir Bharucha,Epidemiology of stroke in India; Neurol.J.Southeast Asia 1998,3:5-8

16. Nakayama H, Jorgensen HS, Raaschou HO and Olsen TS (1994). Recovery of upper extremity function in stroke

patients: the Copenhagen strokestudy. Arch Phys Med Rehabil (75) 394-398.

17. Page SJ, Sisto S, Johnston MV, et al. Modified CIMT after subacute stroke: a preliminary study. Neurorehabil

neural repair 2002; 16: 290-295.

18. Page Stefen J, Levin Peter, Modified CIMT in chronic stroke: result of a single blinded randomized controlled

trial: Phy Therapy 2008; 88: 333-340.

19. Physical Rehabilitation, Edition 5, Susan B O’Sullivan. Thomas J Schmitz, 2007, page 706.

20. Taub E, Miller NE, Novack TA et al. Technique to improve motor deficits after stroke. Arch Phy Med. Rehab.

1993; 74: 347-59

21. Taub E. Some anatomical observation following chronic dorsal rhizotomy in monkeys Neuroscience 1980;

5:389-401.

22. Taub E. Technique to improve chronic motor deficit after stroke. Arch Phys Med rehaib 1993; 74: 347-354.

23. The Star Sunday May 15, 2005 Using your hands in a BIT

24. Uswatte G, Taub E, Morris D, Vignolo M, Mc Culloch K : Reliability and Validity of Upper Extremity motor

activity log-14 for measuring real – world arm use. Stroke 2005; 36 : 2493-6’’

25. Van Der Lee JH, Wagenaar RC, Lankhorsst GJ, et al. Forced use of upper extremity in chronic stroke patients.

Stroke. 1999; 30: 2369-2375.

26. Wolf St, Lecrew DE, Barton LA, Jann BB. Forced use of hemiplegic upper extremities to reverse the effect of

learned nonuse among chronic stroke and head injured patients. Exp neurol 1989b; 104(2):


* PhD Scholar, Srimanta Sankardeva University of Health Sciences, Guwahati, Assam


73

RARE PRESENTATION OF TYPE 1 DIABETES MELLITUS AS DI ABETIC

KETOACIDOSIS COMPLICATING INTO ACUTE PANCREATITIS: A

CASE REPORT

Srinivas Madoori, Kapil C, Mangath Bhukya, Sandeep Chilumoju

ABSTRACT

Patients diagnosed to have Type 1 Diabetes Mellitus (T1DM) initially present with diabetic ketoacidosis

(DKA) in 10-15% cases. Acute Pancreatitis (AP) as a complication is rare. AP is more likely associated

with severe episode of DKA with marked acidosis and hypertriglycerdemia. We report a case of a 12 year

old female child brought to the Emergency Department with features of DKA with severe

hypertriglycerdemia and AP with no previous history of T1DM. Case was managed successfully with insulin

therapy and adequate hydration.

KEYWORDS: Type 1 Diabetes Mellitus, diabetic ketoacidosis, hypertriglyceridemia, acute pancreatitis.

INTRODUCTION

Acute pancreatitis coexisting with diabetic

ketoacidosis (DKA) as a cause or result has

been reported previously (1-4). During severe

episodes of DKA, insulin deficiency increases

free fatty acid (FFA) and amino acids release

from adipose tissue and muscle respectively

and increased counter regulatory hormones

cause increased gluconeogenesis and

glycogenolysis in the liver(5,6). Elevated FFA

taken up by the liver leads to increased

production of very low density lipoprotein


74

(VLDL) cholesterol, which causes

hypertriglyceridemia (7-9).

Hypertriglyceridemia is an uncommon cause

of acute pancreatitis accounting for 1 to 4% of

cases, especially when the serum triglycerides

(TG) levels exceed 1000 mg/dl. These

transiently elevated levels of serum

triglycerides cause acute pancreatitis (10).

Diabetic ketoacidosis is known to mask the

clinical features of acute pancreatitis, with

acute pancreatitis reported in 10 to 15% of

patients (9). We report a case of Type 1

Diabetes mellitus first presenting with diabetic

ketoacidosis and acute pancreatitis as a

complication.

CASE REPORT

A 12 year old girl was brought to the

emergency department with complaints of

fever, pain abdomen for 1 day. Fever was high

grade, intermittent, without chills and rigors.

Pain was in the epigastric region, squeezing

type, non-radiating, not associated with

vomiting and loose motions. Her development

is appropriate for age. She was immunized

according to national immunization schedule.

She did not attain menarche till date. There

were no similar complaints in the family.

On admission child was determined to be 129

cms height (<3rd percentile, WHO growth

charts), 20 kgs weight (<3rd percentile, WHO

growth charts) with body mass index 20 with

sexual maturity score 1. Child was drowsy

with kussumaul acidotic breathing,

Respiratory rate 44/min, pulse rate 126/min,

blood pressure 100/60 mm Hg and

temperature was 1010 F. On physical

examination she had sunken eyes, dry tongue

and decreased skin turger without evidence of

xanthoma, xanthelesma and eruptive

xanthomas. On abdomen examination, soft

tender epigastrium with normal bowel sounds

without any mass or skin discoloration. Lungs

with equal air entry on both sides without any

adventitious sounds. Pupils were equal in size

and reacting to light on both sides without any

focal neurological deficit. Blood sample

collected for the laboratory workup had milky

white appearance (Figure:1).

Figure: Lipaemic sample

Initial laboratory findings are hemoglobin

16.5 gm/dl, total leukocyte count 16000 cells /

cumm, random blood sugar 398 mg/dl,

Urinary ketone bodies 8 mmol/dl, total

cholesterol 775 mg/dl, triglycerides 3000

mg/dl, LDL 148 mg/dl, HDL 27 mg/dl, serum

sodium 141 meq/L, potassium 4.1 meq/L,


75

chloride 121 meq/L, Arterial blood gas (PH

6.985,pco2- 10.3 mm hg,Hco3-2.5 meq/liter

and Sao2 98.4 %)), total serum proteins 5.3

gm/dL, serum albumin 3gm/dl, total serum

bilirubin 0.8 mg/dl, alkalinephosphatase levels

60 IU/L, blood urea nitrogen 33mg/dL, serum

creatinine 0.8 mg/dl, ,HBA1C levels are

10%,C-peptide(premeal) 0.3 ng/ml

(normal – 1.1–

4.4ng/ml,T32.015ng/ml,T4125.16ng/ml,TSH2

.08microlit/ml.

With a provisional diagnosis of T1DM with

DKA and hypertriglyceridemia with AP child

was given adequate hydration and started on

intravenous soluble insulin.On the 2nd day of

hospitalization, her sensorium improved,

respiratory rate came down to 22/min, random

blood glucose was within normal limits, her

epigastric pain persisted. Clinically there was

tenderness, suspecting acute pancreatitis

serum amylase and lipase levels were

estimated and CT imaging of abdomen was

done. Laboratory analysis of serum amylase

and lipase levels were elevated (Table 1).

CT abdomen showed bulky pancreas which

confirmed acute pancreatitis.

Table 1.Laboratory findings

Parameters Initial Day3 Day4 Day8 Day9

Total cholesterol (TC) 775 644 -------- ------- 260

Triglycerides (TG) 3000 1800 ------- ------ 160

High density lipoproteins (HDL)

27 29 --------- ------- 40

Lowdensity lipoproteins (LDL)

148 255 172

Very low density lipo proteins

600 360 30

Blood glucose 398 301 246 180 178

Urinary ketone 8 mmol 4 mmol nil ----- -----

K+ 4.1 3.2 3.9 4.2 4.3

Na+ 141 136 134 138 142

Cl- 121 111 96 105 109

HCO3- 2.5 3.1 16 ---- ----

PH 6.985 7.1 7.35 ------ ----


76

Serum amylase 482 ----- ------- ------ 69

Serum lipase 750 ------ ------- ----- 250

Blood urea nitrogen 19 ---- 25 ----- ----

Serum creatinine 0.6 ------ 0.9 ---- ----

On 3rd day of hospitalization TG levels were

decreased to 1800 mg/dl (Table1) epigatric

pain had diminished; patient commenced oral

intake and multiple subcutaneous insulin. On

4th day of hospitalization, all her symptoms

completely subsided. On 9th day of

hospitalization, repeat laboratory workup

showed normal serum levels of triglycerides

blood glucose, serum amylase and lipase

(Table1). The child was discharged on 12th

day of hospitalization.

She was followed for two months for every 20

days with lipid profile, blood sugar levels and

clinical examination. No similar episodes were

noted and she maintained her blood glucose

levels within normal limits with approximately

1U/Kg of insulin per day.

DISCUSSION

In DKA, the deficiency of insulin activates

lipolysis in adipose tissue releasing increased

FFA, which accelerates formation of VLDL in

the liver. In addition, reduced activity of

lipoprotein lipase in peripheral tissue

decreases removal of VLDL from the plasma,

resulting in hypertriglyceridemia. Moderate

hypertriglyceridemia is common during

episodes of DKA(10). However, severe

hypertriglyceridemia, which is defined as a

TG level >2,000 mg/dL, is rare. Although

morbidity is <1%, clinicians should be aware

that devastating consequences such as acute

pancreatitis or lipidemia retinalis are possible

(11).

In severe hypertriglyceridemia, there is an

increased risk of developing acute pancreatitis.

The mechanism is related to high plasma

chylomicrons or TGs, which are hydrolyzed

by lipase in the pancreatic capillaries and

subsequently trigger FFA(12) release that, in

turn, causes activation of trypsinogen and

commences pancreatic capillary damage by

free radical damage(13,14). The common

clinical scenario of hypertriglyceridemia-

induced acute pancreatitis involves poorly-

controlled diabetes mellitus. In the two case

reports by Sunil et al (15), Suk Jae Hahn et

al(16), there was previous history of diabetes in

cases presenting with diabetic ketoacidosis

with hypertriglyceridemia and acute

pancreatitis. In our case report, the case

presenting with diabetic ketoacidosis with

hypertriglyceridemia and acute pancreatitis

did not have previous history of diabetes

mellitus. Moderate hyperlipidemia (usually

<400 mg/dL) can be observed secondary to


77

acute pancreatitis and should not be confused

with the marked hypertriglyceridemia that

causes acute pancreatitis(17) as in the present

case.

Serum levels of triglycerides 3000 mg/dl in

present case report in a 12 yr old child causing

acute pancreatitis is less as compared with the

case report by Suk Jae Hahn et al(16) where

triglyceride levels of 15240 mg/dl were seen

in a 20 yr old female and more compared to

serum levels of trigycerides of 1020 mg/dl of

case report by Sunil et al(15). This shows

increase in serum triglycerides level in

diabetic ketoacidosis corelates with age.

Nonspecific elevations of amylase and lipase

without clinical evidence of pancreatitis have

been reported in 24.7-79.0% of DKA cases (18).

At least in those patients with continuous

abdominal pain, it is prudent to seek further

laboratory evaluation or a CT scan of the

abdomen. In case reports by(1-4),diagnosis of

acute pancreatitis was based solely in clinical

features and associated elevations in serum

pancreatic enzymes without any confirmatory

imaging findings .In present case there was

confirmatory CT findings in addition to

clinical features and elevated serum pancreatic

enzymes. In our case CT abdomen showing

bulky pancreas indicative of acute pancreatitis.

CONCLUSION

Diabetic ketoacidosis can be the first

presentation of Type 1 diabetes mellitus. In

every case of type 1 diabetes mellitus

presenting as DKA, particularly if the

epigastric pain is not subsiding and vomiting

continue, acute pancreatitis should be

suspected. In case of acute pancreatitis with

hypertriglyceredemia line of management is

conservatively with insulin and hydration

therapy.

REFERENCES

1. Tully GT, Lowenthal JJ. The diabetic coma of acute pancreatitis. Ann InternMed 1958; 48: 310 –9.

2. Hughes PD. Diabetic acidosis with acute pancreatitis. Br J Surg. 1961; 49: 90–1.

3. Davidson AJ. Diabetic coma without ketoacidosis in a patient with acutepancreatitis. Br Med J 1964; 1: 356.

4. Maclean D, Murinson J, Griffiths PD. Acute pancreatitis and diabeticketoacidosis in accidental hypothermia,

and hypothermic myxoedema. Br MedJ 1973; 4: 757– 61.

5. Exton JH. Mechanisms of hormonal regulation of hepatic glucose metabolism.Diabetes Metab Rev 1987; 3:

163-83

6. Fortson MR, Freedman SN, Webster PD 3rd. Clinical assessment of hyperlipidemic

Pancreatitis. Am J Gastroenterol 1995; 90: 2134-9.

7. Chiasson JL, Aris-Jilwan N, Belanger R, Bertrand S, Beauregard H, Ekoe JM, Fournier H, Havrankova 1.

Kitabchi AE, Nyenwe EA. Hyperglycemic crises in diabetes mellitus: diabeticJ. Diagnosis and treatment of

diabetic ketoacidosisand the hyperglycemic hyperosmolar state. CMAJ 2003; 168:859-66.

8. Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, MaloneJI, Wall BM. Hyperglycemic

crises in diabetes. Diabetes Care 2004; 27Suppl 1: S94-102


78

9. Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis & acutepancreatitis: observations in

100 consecutive episodes of DKA. Am J Gastroenterol 2000; 95:2795 – 800.

10. Fulop M, Eder H. Severe hypertriglyceridemia in diabetic ketosis. Am JMed Sci 1990; 300: 361-5.

11. Fulop M, Eder HA. Plasma triglycerides and cholesterol in diabetic ketosis.Arch Intern Med 1989; 149:

1997-2002.

12. Havel RJ. Pathogenesis, differentiation and management of hypertriglyceridemia.Adv Intern Med 1969; 15:

117-54.

13. Havel RJ. Approach to the patient with hyperlipidemia. Med Clin NorthAm 1982; 66: 319-33.

14. Tsuang W, Navaneethan U, Ruiz L, Palascak JB, Gelrud A. Hypertriglyceridemicpancreatitis: presentation

and management. Am J Gastroenterol2009; 104: 984-91.

15. Acute Pancreatitis in Association with Diabetic Ketoacidosis in a Newly Diagnosed Type 1 Diabetes Mellitus

Patient; Case Based Review.International Journal of Clinical Cases and Investigations 2012. Volume 4 (Issue

1), 54:60, 1st April, 2012.

16. Severe Hypertriglyceridemia in Diabetic Ketoacidosis Accompanied by Acute Pancreatitis: Case Report DOI:

10.3346/jkms.2010.25.9.1375 • J Korean Med Sci 2010; 25: 1375-1378.

17. Nair S, Yadav D, Pitchumoni CS. Association of diabetic ketoacidosis and acute pancreatitis: observations in

100 consecutive episodes of DKA. Am J Gastroenterol 2000; 95: 2795- 800.

18. Yadav D, Nair S, Norkus EP, Pitchumoni CS. Nonspecific hyperamylasemiaand hyperlipasemia in diabetic

ketoacidosis: incidence and correlationwith biochemical abnormalities. Am J Gastroenterol 2000; 95: 3123-

8.


Srinivas Madoori, MD (Pediatrics)Professor of Pediatrics, Department of Pediatrics, Chelmeda Anand Rao

Institute of Medical Sciences,Bommakol, Karimnagar - 505001 Andra Pradesh, India.Mobile: 91

9866535700, Email: [email protected]


79

CASE REPORT VERY LARGE SUPPURATIVE PERICARDIAL EFFU SION

CAUSED BY GROUP “A” Β – HEMOLYTIC STREPTOCOCCUS: IN THE

ANTIBIOTIC ERA.

Dr. J. Rajendra Kumar*, Dr. Mamta B. Kumbhare**, D r. P. Shanmuga Raju***, Dr. M.

Manjusha****, Dr. M. Sumanth*****, Dr.Ch. Rachna*** ***

ABSTRACT

Suppurative or Purulent bacterial pericarditis is a rare disease. In most cases; pericardial

infection does not produce a purulent effusion. Viral infection, which together with “idiopathic”

pericarditis account for 90% of pericarditis cases 1, rarely produces purulent pericardial effusion

and is typically self limited. In contrast, bacterial infections of the pericardium are relatively

uncommon but are much more likely to produce purulent effusion and to proceed to cardiac

tamponade and pericardial constriction. We report a 17 –year-old male patient who presented

with fever with progressive dyspnea. Large pericardial effusion with cardiac tamponade was

detected by the transthoracic-two-dimensional echocardiography.

KEYWORDS: Purulent Pericarditis, Cardiac tamponade, Streptococcus viridans , group A

streptococcus pericarditis.

80

INTRODUCTION

Purulent (or Suppurative) pericarditis is

defined as an infection of the pericardial space

that produces pus that is found on gross

examination of the pericardial sac, on tissue

microscopy and characteristic appearance on

transthoracic two-dimensional

echocardiography. It is usually a severe acute

illness with high mortality, especially if

diagnosis and treatment both are delayed.

Pericarditis is more common in adults than

children, and of the infectious causes of

pericarditis, bacterial pericarditis is seen in a

minority of cases 2. Several bacterial agents

have been reported to cause purulent

pericarditis. These include Staphylococcus

aureus, Streptococcus pneumoniae,

Haemophilus influenzae, and anaerobic

bacteria .The clinical course of purulent

pericarditis is usually fulminant, manifesting

with shock syndrome due to cardiovascular

collapse and /or septic phenomena leading to

catastrophic outcome. However, it can also be

insidious. Here, we describe a febrile male

patient presenting with purulent pericarditis

caused by Group A β-hemolytic

Streptococcus, leading to very large

pericardial effusion, which was successfully

treated by an emergency pericadiocentesis and

adequate antibiotic treatment.

Case report:

A 17 year- old-male patient was referred to

our department (Department of medicine,

Chalmeda Anand Rao Institue of Medical

Sciences Karimnagar, A.P.), for evaluation of

fever and progressive dyspnea. His illness

begun 2 weeks before with daily fever, and

cough with expectoration. Fever was

associated with chills. Expectoration was

yellow in color, non foul smelling and not

blood tinged. He consulted a private

practitioner and has taken antibiotic (I/V,

Cefotaxime 1 gm X 8 hourly), antipyretic

(Oral Paracetamol) for 6 days, but his

symptoms did not subside. He also had history

of progressive dyspnea, fatigue and

substernal chest discomfort, 8 days prior to

admission .Chest discomfort was described as

“my heart is floating in my chest”. There was

no history of sore throat in the weeks

preceding his presentation, dysphagia,

hiccups, dysphonia and no evidence of

sinusitis, septic arthritis and meningitis. On

physical examination patient was, thin built,

moderately nourished and conscious (Figure

no. 9). Vital signs included a body temperature

of 36.8 0 C, heart rate of 125beats per minute,

respiratory rate 22 per minute and blood

pressure of 90/60 mmHg in supine position ,

and the arterial oxygen saturation was 91%

which was measured by non invasive

monitoring technique ( pulse oximetry) on

room air . Pulsus paradoxus was present. His

Jugular venous pressure was elevated (6cm

above the sternal angle).Precordium was quite.

His heart sounds were distant but regular, with

no significant murmur. Trachea was central in

position. Chest percussion note were impaired

in right basal, right infra mammary, right


81

lower axillary and right infra scapular region.

Lung auscultation revealed bilateral basal

crackles and tubular bronchial breathing in

right lower lobe of lung. Ewart’s sign was

present (dull percussion note over left

subscapular area.) The reminder of physical

and systemic examination was unremarkable.

His laboratory studies revealed a white –

blood-cell count of 22,000/µL, with

64%segmented cells , 21% bands, 14%

lymphocyte, 12.8g/dL hemoglobin and a

platelet count of 310,000/µL. Erythrocyte

sedimentation rate was 36mm/hr.The C-

reactive protein level was 12.6mg/L.His liver

function and kidney function test were with in

normal limit. His prothrombin time was 12sec;

international normalized ratio 1.1; partial

thromboplastin time 32sec ; CPK-MB

3.2ng/ml and Troponin- T was

32ng/ml.Twelve lead surface

electrocardiogram revealed sinus tachycardia

with rate of 125 beats per minute, T wave

inversion in V5, V6 chest leads, and diffuse

low voltage QRS complex (Figure no. 4).

Chest radiograph showed cardiomegaly

(water-bottle-shaped – heart) and radio opaque

shadow in right lobe of lung due to pneumonic

consolidation (Figure no. 1 &2). An

emergency trans-thoracic-2 dimensional

echocardiography revealed very large

pericardial effusion (3.1.cm posterior, 2.90cm

lateral, 3.00cm apical, 2.50cm around right

ventricle, 2.40cm around right atrium,1.10cm

around great arteries origin), thickened

pericardium ( 1.15cm parietal pericardium and

1.10cm visceral pericardium) and early

diastolic collapse of free walls of the right

atrium and right ventricle but without

evidence of oscillating vegetation or valve

regurgitation ,consistent with cardiac

tamponade ( Figure no.5 and 6). Consistency

of pericardial fluid appeared thickened on an

echocardiography examination.(Figure no. 6).

Left atrial collapse was absent (Figure no. 5 &

6).An emergency subxiphoid percutaneous

pericardiocentesis was performed and around

800 ml of purulent pericardial fluid was

drained form pericardial cavity. Initial few

milliliters of pericardial fluid was slightly

blood tinged but after that it was yellow in

color. A pigtail catheter was placed in the

pericardial sac for continuous drainage (Figure

no. 2 & 9). Immediate (Primary) irrigation of

pericardial cavity was done with the use of

streptokinase (STK) fibrinolytic agent in dose

of 250,000 IU, dissolve in 20 ml of normal

saline and catheter was clamped for 4 hours.

Intrapericardial instillation of STK was

continued for 7 days in dose of 250,000IU, at

12 hour interval and catheter was clamped for

4 hours after irrigation of pericardial cavity.

Laboratory analysis of the pericardial fluid

showed 384,000 nucleated cells/µL, with 76%

segmented cells, 15%bands, 12%

lymphocytes and 4% monocytes,340 red blood

cells/µL, lactate dehydrogenase of 3700 U/L,

triglycerides of 24mg/dl, glucose of

15mg/dl,protein of 5.2gm/dl, , and negative

activity of adenosine deaminase. The acid-fast

stain was negative. A Gram stain of the


82

pericardial fluid revealed Gram-Positive cocci

in chains and within 12 hours, routine

bacterial cultures grew Group A β-hemolytic

streptococcus. The organism was susceptible

to Penicillin, Clindamycin,

Erythomycin,Ceftriaxone,Tetracycline and

Vancomycin. Intravenous antibiotic treatment

was started according to pericardial fluid

culture and sensitivity report. In our case we

started intravenous, 3 million U of Penicillin

G every fourth hourly and 1 gram Ceftriaxone

at twelve hour interval. A subsequent culture

of pericardial fluid was negative for bacteria,

mycobacterium and fungi. All culture reports,

including blood culture, sputum culture, and

urine culture, showed no bacterial growth.

Further laboratory studies including thyroid

function test, a polymerase chain reaction for

tuberculosis bacilli in pericardial fluid,

autoimmune disease test and tumor marker

were within normal limits. Percutaneous

pigtail catheter aspiration was done at 6 hours

interval and continued until the volume of

effusion decreased to less than 25 ml per day.

We also repeated Trans –thoracic-2

dimensional echocardiography and X-ray

chest PA view, at regular interval which

revealed gradual decrease in pericardial

effusion, no evidence of adhesion or loculated

pericardial effusion (Figure no. 7 & 8) and

pneumonic consolidation disappeared in right

lower lobe of lung (Figure no. 3). Intravenous

antibiotics Penicillin G antibiotic and

Ceftriaxone were continued for total 4 weeks

and the patient recovered well after 4 weeks.

At the time of discharge his trans-thoracic-2

dimensional echocardiography was repeated

which revealed minimal pericardial effusion

and normal biventricular function. We advised

regular follow up at time of discharge and

during 12 months follow up patient had

recovered uneventfully (Figure no. 8).

Discussion:

Purulent pericarditis is a rare entity in highly

developed antibiotic era. In most cases,

pericardial infection does not produce a

purulent effusion. It generally presents with

acute cardiovascular decompensation and a

sepsis-like appearance. Cardiac tamponade is

a medical emergency, which should be

diagnosed carefully and treated thoroughly.

Common causes of cardiac tamponade include

inflammation, infection, immunological

disorder, neoplasm, myxedema, renal

insufficiency, pregnancy, aortic or cardiac

rupture, trauma to the chest, nephrotic

syndrome, hepatic cirrhosis and chronic heart

failure 4. Bacterial purulent pericarditis is not

typically a primary infection but is almost

exclusively a complication from an underlying

infection. In our case the predisposing factor

was pneumonic consolidation of right lob of

lung. In the pre-antibiotic era, patients most

frequently developed bacterial pericarditis due

to pneumonia with empyema, and most

common organism was Streptococcus

pneumoniae 7.In the antibiotic –era the

common organism is Staphylococcus aureus 6.

Recent studies have noted a trend towards


83

involvement of more diverse microbes, and

anaerobes have been reported as a common

cause of purulent pericarditis 8. A

retrospective study found primary anaerobic

infection in 40% of cases and mixed infection

(aerobic / anaerobic) in 13%; however, there

were no clinical or diagnostic differences

between these types of infection 8. The current

etiologies of bacterial purulent pericarditis

include seeding from circulating bacteremia,

contiguous intrathoracic source (Empyema,

Pneumonia), penetrating trauma, surgical

wounds (sternal osteomyelitis), intracardiac

source, and esophageal rupture with fistula

formation, retropharyngeal abscess, and

hepatic/sub diaphragmatic abscess9 .(Table

no.3). The recognized risk factors for bacterial

pericarditis include advance age, diabetes

mellitus, untreated infection (eg. Pneumonia

,Empyema ),extensive burns, an

immunosuppressed state, cardiac surgery,

thoracic trauma and a preexisting aseptic

pericardial effusion (renal failure, congestive

cardiac failure) 5,6,7. Our patient had only one

recognized risk factor ( Pneumonia of right

lobe of lung) out of all of these risk factors

.Comorbidities associated with bacterial

pericarditis include renal failure, AIDS,

immunosuppression (due to chemotherapy or

intrinsic disease), alcoholism, diabetes,

preexisting pericardial effusion and indwelling

venous access, particularly if the patient is

receiving total parenteral nutrition 5,6,79.

Bacterial pericarditis typically presents with

fever at regular intervals and chills, substernal

chest pain (often with dyspnea), tachypnea,

cough, generalized weakness and tachycardia

out of proportion to fever. Our patient had

these entire clinical features. Classic

symptoms of pericarditis, including substernal

chest pain and pericardial friction rub; occur in

only 50% of patients1-3. Tachycardia is often

due to the febrile response, but it may be an

effort to compensate for decreased cardiac

output from reduced ventricular filling due to

cardiac tamponade. In our patient febrile

response and cardiac tamponade both are

cause of tachycardia .Features of the

underlying infection also may be present, such

as cough with purulent sputum and findings of

lung consolidation if pneumonia is the source

(like in our patient) or skin findings of

injection drug use and a cardiac murmur if

bacterial endocarditis is the source. Our

patient did not have any cardiac murmur,

features of infective endocarditis and skin

finding of injection drug use 10. Arsura et al 11

found purulent pericarditis conformed by

pericardial fluid analysis or at autopsy in 13%

of patients admitted in intensive care unit with

a diagnosis of sepsis. Thus, it is important to

maintain a high index of suspicion for

pericardial involvement in patients with a

septic presentation (Fever and hypotension).

The presence of Cardiomegaly on chest

radiograph and elevated ST segments on

electrocardiography suggest pericarditis and

raise the possibility of pericardial effusion,

which can be confirmed by echocardiography

(Table no. 1 & 4). If untreated this condition


84

has a mortality rate up to 100%. Early

diagnosis, along with combination therapy

using systemic antibiotics and surgical

drainage, has reduced the mortality rate to <

10% in some reports and between 10 % to 20

% in others 12, 13. . Thus effective management

of purulent pericarditis requires a combined

medical and surgical approach. It is important

to use a regimen that includes an

antistaphylococcal agent until information

about the causative organism is available. No

guidelines exist regarding the duration of

antibiotic therapy; however, most patients in

the literature have been treated successfully

with 2 to 4 weeks of intravenous antibiotic

therapy. The antibiotic regimens most often

reported in the literature have used β –lactum

agents such as penicillin and ampicillin, either

alone or in combination with an

aminoglycoside. Although pericardiocentesis

is a crucial life saving intervention, complete

drainage of the pericardial collection using a

definitive surgical procedure is important in

preventing further complications such as

constrictive pericarditis. Several methods of

surgical drainage have been reported 13. (Table

no. 5). There are no definitive data on the

appropriate dose of these fibrinolytic agents

like STK and Urokinase in purulent

pericarditis. Fibrinolytic agent (STK) should

be dissolve in 20 ml of normal saline, to

ensure adequate diffusion into pericardial

space. Fibrinolytic agents must be retained in

the pericardial space by clamping the drain for

2 to 4 hours. Intra - pericardial infusion of

thrombolytic agents enhances the complete

drainage of pericardial fluid by dissolving its

fibrinous components and therefore

minimizing the risk of constrictive

pericarditis. Complications of fibrinolytic

agent’s infusion in to the pericardial cavity are

allergy, major hemorrhage, and cardiac

tamponade. Our patient did not develop any

complication of STK infusion. Most patients

with bacterial purulent pericarditis respond

well with subxiphoid tube drainage except

H.influenzae, because of its tendency to cause

thick, loculated pus (that is described as

“scrambled eggs” and very difficult to

drainage with catheter and likely to require

partial pericardiectomy) and constrictive

pericarditis 12- 13. Our patient very well

responded to subxiphoid Percutaneous, pigtail

catheter drainage, intra-pericardial STK

infusion and intra venous antibiotic. There is a

paucity of reported cases of purulent

pericarditis caused by GAS. This organism

has, however, been implicated in a self –

resolving, nonprogressive syndrome of

streptococcal tonsillitis associated with acute

nonrheumatic myopericarditis without

effusion. Dissemination of bacteria to the

pericardium can occur either from a

contiguous focus in the lung or by

hematogenous spread. Manifestations of GAS

disease can be classified into the following:

(1) Invasive (2) Noninvasive (3)

Nonsuppurative. Invasive diseases include,

among others, bacteremia, pneumonia, septic

arthritis, necrotizing fasciitis, puerperal sepsis


85

and streptococcal toxic shock syndrome 14.It is

possible that the antibiotic era has seen very

few cases of GAS-purulent pericarditis due to

widespread use of antibiotics for common

infection such as tonsillitis and pharyngitis.

During the past 10 to 15 years, severe invasive

infections caused by GAS have been reported

with increase frequency 15. Pericarditis should

be suspected in the context of acute respiratory

decompensation, shock and a sepsis –like

presentation, especially when supported by

findings of distant heart sounds and an

enlarged cardiac silhouette (Table no.2).

Although this case provides an example of a

disease that remains extremely rare, it does

occur periodically, and the clinician must

maintain a high index of suspicion for this

particular organism in the setting of purulent

pericarditis.

Conclusion:

Purulent pericarditis is typically an acute and

often catastrophic illness. Both early detection

and effective management of purulent

pericarditis require much effort and skill to

achieve correct diagnosis. Therefore,

clinicians should be very alert to the type of

disease setting. Diagnostic pericardiocentesis

should be performed early, followed by a

percutaneously placed catheter via a

subxiphoid route along with appropriate

antibiotic treatment Evacuation of the

pericardial fluid is essential to minimize the

risk of subsequent development of constrictive

pericarditis. We conclude that an

Echocardiography plays a major role in the

diagnosis of purulent pericardial effusion,

detection of severity (Grading) of pericardial

effusion, detection of complications (pre and

post operative), response to medical and

surgical treatment, future treatment plan,

assessment of ventricular function, oscillating

vegetations and valvular regurgitation.

Percutaneous catheter drainage of pericardial

fluid is an easy, safe and effective technique

and should be considered as first choice of

treatment in purulent pericarditis.

REFERENCES

1. Lange RA, Hills LD. Clinical practice. Acute pericarditis [Published erratum appears in N Engl J Med

2005;352:1163]. N. Engl Med 2004; 351:2195-202.

2. Gould K, Barnett JA, Sanford JP. Purulent pericarditis in the antibiotic era. Arch Intern Med 1974;

134:923-927.

3. Trougton RW, Asher CR, Klein AL. Pericarditis. Lancet 2004; 363:717-727.

4. Spodiac DH. Acute cardiac temponade. N Engl J Med 2003;349:648-690.

5. Spodick DH. Acute pericarditis current concepts and practice. JAMA 2003;289:1150-1153.

6. Rubin RH, Moellering RC Jr. Clinical microbiologic and therapeutic aspects of purulent pericarditis.

American Journal of Medicine 1975; 59:68-78.


86

7. Klacsmann PG, Bulkley BH, Hutchins GM. The changed spectrum of purulent pericarditis: an 86 year

autopsy experience in 200 patients.. Am J of Med. 1977; 63:666-673.

8. Brook I, Frazier EH. Microbiology of acute purulent pericarditis. A 12 - year experience in a military

hospital. Arch Intern Med. 1996; 156:1857-60.

9. Little WC, Freeman GL. Pericardial disease [published erratum appears in Circulation 2007; 115:e406].

Circulation 2006; 113; 1622-1632.

10. Pankuweit S, Ristic AD, Seferovic PM, Maisch B. Bacterial pericarditis diagnosis and management. Am J

cardiovasc Drugs 2005;5:103-12.

11. Arsura EL, Kilgore WB, Strategos E. Purulent pericarditis misdiagnosed as a septic shock. South Med J

1999;92:285-8.

12. Roodpeyma S, Sadeghian N. Acute pericarditis in childhood: a 10-year experience. Pediatr Cardiol

2000;21:363 – 367.

13. Cakir O. Gurkan F, Balci AE, Eren N, Dikici B. purulent pericarditis in childhood: ten years of experience.

J.Pediatr Surg 2002;37:1404-1408.

14. Stevens DL. Invasive groups A streptococcus infections. Clin infect Dis 1992; 14:2-11.

15. Davies HD, McGeer A, Schwartz B, Green K, Cann D, Simor AE, Low DE. Invasive group A streptococcal

infection in Ontario, Canada. Ontario Group A streptococcal study group. N Engl J med 1996:335:547-

554.

Figure - 1. X-Ray chest PA view, before

pericardiocentesis, shows, cardiomegaly (water-bottle-

shaped) and radio-opaque shadow in right lower lobe

(consolidation of lower lobe of right lung).

Figure-2. X-Ray chest PA view, after

pericardiocentesis, shows, cardiomegaly, and radio-

opaque shadow in right lower lobe and a pigtail

catheter in pericardial sac for continuous drainage.


87

Figure-3. Normal X-Ray chest PA view in our

patient after 45 days of treatment.

Figure -4. Twelve leads surface electrocardiogram

shows, sinus tachycardia, diffuse low voltage QRS

complex and T –wave inversion in V6 andV6 chest

lead.

Figure -5. Trans-Thoracic 2 –Dimensional

Echocardiography (TTE) – before pericardiocentesis;

in Subcostal- four- chamber view , shows an echo-

free space surrounding the entire heart (Large or

massive pericardial effusion ), swinging heart in

pericardial fluid and thickened pericardium.

Figure -6. TTE – before pericardiocentesis; in Apical

4 chamber view, shows an echo-free space

surrounding the entire heart (Large pericardial

effusion), swinging heart in purulent pericardial fluid,

consistency of fluid appeared thick and thickened

pericardium.

Figure -7. TTE – 5 days after of an emergency

pericardiocentesis, shows mild pericardial effusion

(Right diastolic and Left systolic frame in apical 4

chamber view)


88

Figure -8. TTE - One year after treatment, shows no

pericardial effusion, normal thickness of pericardium

and no complication (like - Pericardial constriction).

[Right frame - Parasternal long axis in diastolic and

Left frame - parasternal short axis view in diastole].

Figure -9. Photograph of our patient shows,

thin built, moderately nourished and a pigtail

catheter (right side, blue in color).

Table 1. Electrocardiography findings in pericarditis

Stage ST – Segment T- Waves PR- Segment

I Elevated Upright Depressed or Isoelectric

II Early Isoelectric Upright Isoelectric or depressed

II Late Isoelectric Low to flat to inverted Isoelectric or depressed

III Isoelectric Inverted Isoelectric

IV Isoelectric Upright Isoelectric

Table 2. Different type of paradoxus in large (massive) pericardial or cardiac tamponade.

1. Arterial Paradoxus

( Pulsus Paradoxus)

A drop in systolic blood pressure > 10 mmHg, during

inspiration, whereas diastolic blood pressure remains

unchanged.

2. Venous Paradoxus An inspiratory increase in Jugular venous pressure

(Kussmaul’s sign). Prominent “x”descent and absent or

diminished diastolic “y” descent.


89

3. Radiological paradoxus Cardiomegaly seen in X-ray chest PA view due to pericardial

effusion but actually the heart size is normal.

Table 3. Classification of purulent pericarditis according to source of infecting organism.

1. Infection by contiguous spread from a pleura, mediastinum or pulmonary focus.

2. Infection by contiguous spread of intracardiac infection.

3. Infection following systemic bacteremia.

4. Infection with contiguous spread from a postoperative infection.

5. Infection following a sub diaphragmatic Suppurative infection.

Table 4. Grading of pericardial effusion by Trans- Thoracic - 2 – Dimensional

Echocardiography.

Small An Echo-free space <10 mm in diastole.

Moderate An Echo-free space between 10 to 20 mm in diastole

Large An Echo-free space ≥ 20 mm in diastole

Very Large

An Echo-free space >20 mm in diastole and compression of the heart.

Table 5. Different surgical modalities for pericardial effusion evacuation or drainage.

1. Subxiphoid Percutaneous catheter.

2. Subxiphoid tube drainage.

3. Subxiphoid tube drainage or Percutaneous catheter and fibrinolysis.


90

4. Pericardial window and pleural drain.

5. Partial pericardiectomy with pericardial tube drainage.

6. Anterior interphrenic pericardiectomy.

7. Total pericardiectomy.


*Associate Professor,

**Senior Specialist Anesthesia, Dhanvanthari Hospital, NTPC, RSTPS, Jyothi Nagar District Karimnagar

(AP) India – 505 215 )

***Assistant Professor , Department of Physical Medicine and Rehabilitation, CAIMS, Bommakal,

Karimnagar (A.P.) India – 505 001)

****PG student, Department of Medicine, CAIMS, Bommakal, Karimnagar (A.P.) India – 505 001)

*****PG student, Department of Medicine, CAIMS, Bommakal, Karimnagar (A.P.) India – 505 001)

******PG student, Department of Medicine, CAIMS, Bommakal, Karimnagar (A.P.) India – 505 001)


91

TECHNICAL SOFTWARE PROJECT MANAGER VS NON TECHNICAL

SOFTWARE PROJECT MANAGER

Zunera Jalil*, Nazia Tabbasum**

ABSTRACT

In software industry many projects exceed from budget and time and acquire low customer satisfaction due

to managerial problems. These managerial and technical problems lead to the shipment of an unsuccessful

project, setting the reputation of the whole software organization on stake. Such failures not only damage

the economical condition of the software market, they also create an air of uncertainty to win future

projects. Keeping in view the managerial and technical problems being faced by the Pakistani software

industry at present, we thought of conducting a survey on project manager’s soft and hard skills. In this

paper we highlight those technical and non-technical skills that need further consideration or improvement.

In addition to this, it is to give the software houses an overall picture of those practices that are common in

our software industry and help them move towards the ideal direction so that they could effectively improve

their skills.

KEYWORDS: Software project management; project manager; technical skills; non technical skills

I. INTRODUCTION

In the 1970s and early 1980s, achieving

effective software project management

became recognized as a significant issue.


Projects were often delivered late and over

budget and didn’t meet requirements and

expectations. As we approached the 1980s

and our knowledge and sophistication with

software development grew, the number of

complex systems began to increase

dramatically, and the problems associated

with ineffective project management became

more acute. Collectively, these initiatives

embodied a four-pronged technical and

management attack: standardize the process,

standardize the product, standardize the

support environment, and professionalize the

workforce [1]. Many organization and

companies arrange project management

training for their employees, but did not get

the desired results. According to the Standish

Group CHAOS report, 2009 [2] as illustrate

in Figure 1.1-1:

� 32% completed on time, within budget

and fully functional.

� 44% exceed budget and schedule.

� 24% failed or canceled.

Figure 0-1: Standish Group Chaos Report

2009 [3]

Project manager can improve/enhance his/her

abilities through training to contribute

technically, but it is unlikely to improve their

management skills. Some basic terminology

is define as

PROJECT MANAGEMENT

Managementin all organizational and

business activities is the act of getting people

together to accomplish required goals and

objectives using available resources

efficiently and effectively. Management is

composing of planning, organizing, staffing,

leading or directing and controlling an

organization. Project management requires a

deep knowledge of human behavior and the

ability to skillfully apply right interpersonal

skills.

TECHNICAL SOFTWARE PROJECT

MANAGERS

Technical skills are also called hard

skills, considered a science and processes,

tools and techniques to plan and execute

projects on time and on budget. Technical

experts create project schedule, identify risks

and conflicting issues, control changes, track

the budget and schedule [4, 5].Some project

managers prefer to have little technical

knowledge about the projects to manage and

leave the technical management to other

junior managers, such as programming

managers or network managers. Some have

detailed technical skills of computer

languages, software, and networks. On larger


complex projects, such as systems integration

projects or multiple-year projects, there are

normally too many multifaceted technologies

for the project manager to handle. Project

manager is eventually responsible for the

entire management of the project, technical

or otherwise, require solutions to the

technical issues that will occur [6,7].

A technical software project manager

should know how to apply project

management tools, techniques,

methodologies and process. For example, he

should know how to prepare requirements

specification document, construct a network

diagram, and work breakdown structure.

Without these skills, software project

manager cannot coordinate and facilitate the

creation of a high-quality project plan and

maintain control during project execution.

NON-TECHNICAL SOFTWARE

PROJECT MANAGERS

Soft skills can be termed as “how we use

it”. Non-technical skills are soft skills that are

normally neglected during software project

management. Soft skills are an art which

concerned with managing and working with

people, ensuring customer satisfaction. These

skills also help in creating conducive

environment for the project team exceeding

stakeholder expectations, improve cost

performance and high quality product [8, 9,

10]. With reference from various studies,

following soft skills are considered essential:

teambuilding; leadership style; responsibility;

self directed learning; ethical and

professional moral; planning; negotiation;

oral and written communication;

interpersonal ability to apply knowledge in

the workspace; creativity and capacity to

learn new skills; critical thinking and

problem solving ability [1-12].

Software project manager should have

technical skills but not necessity as: “Many

IT project managers lose control of a project

because their technical leads provided

erroneous information, such as unrealistic

estimates, flawed reasons for falling behind

schedule, requests for unnecessary software,

etc. This is because the project manager does

not have the experience to know the

difference” [13]. Normally software projects

fail not because of lack of adequate

technology but because the “soft science”

portions of the project have not been

addressed adequately. Responsibilities of

project managers are to develop and

implement management strategies and

communication plans of their respective

stakeholders and are also responsible for co-

coordinating the scope of work packages and

applicable terms and conditions [14].

Outsourcing is another successful way to

build new software quickly and

inexpensively. However, when companies

outsource solely, they fail due to

misunderstanding, inadequate


communication and time zone. Software

development in outsourcing requiring right

mix of hard skills, such as software

programming, architecture designing, and

engineering, and soft skills, such as

communication, collaboration, and project

management. For more complex projects

software project managers require a mix of

programming skills, technical proficiency,

cultural compatibility and communications

Unfortunately in most of the software

organizations; management and project

management disciplines are considered

redundant, futile and most importantly not

the main focus of work. Like traditional

mindsets, many believe that the best way to

get work completed is through technical

skills mainly. People, employees and team

members or team heads within the projects

consider technical work as the central focal

point of the project and therefore pay no

attention to project management. Due to

these reasons, an improvement in the

technical and non-technical skills is

essentially required for the overall

improvement and organizational

sustainability, maturity and development.

The objective of this research is to help the

software organizations in Pakistan analyze

the technical vs. non-technical skills of

project managers and evaluate them with

respect to the ideal project management

practices as defined by the Project

Management Institute (PMI), the leading

project management association. This also

helps software project managers to

understand how they can perform better in

project management area by considering the

soft skills of their working. This paper

identifies and analyzes problem that help us

understand the barriers to management of

project management area within the

organizations. The survey conducted on the

basis of the above

Since the field of software project

management is new to Pakistani software

industry, we are interested in assessing the

abilities of the software project managers

working in different software companies;

analyze their qualification, experience, skills,

and success rate of their software projects.

The survey will be intended to determine

project manager’s abilities by investigating

the following:

� Technical skills to measure project

managers’ ability of implementing

basic project management tools and

techniques throughout a project life

cycle.

� Skills such as teamwork, leadership

and communication to manage real-

world problems.

A survey of 59 software project managers

was conducted from all over Pakistan. For

this research, survey is conducted focusing

mainly on level of project manager (PM)

skills and also include the problems which

have been involved in software project


implementation. It has been found that there

are more or less twenty five software project

managers in Pakistan who have management

skills very strong. It is made sure that all

organizations and software project managers

are approached for their response. And for

this purpose questionnaires have been

designed which are then floated via web,

emails, face to face interviews and personal

contacts. The methodology and process

adopted for conducting this research is

further elaborated in this chapter.

A. SURVEY FORM

The survey form was made to get the

following information about software project

managers:

� Technical PM Education

• Post Graduate Degree(Comp.

Science/Software Engineering/IT)

• Graduate Degree (Comp.

Science/Software Engineering/IT)

• Basic Education (Diploma in

(Comp. Science/Software

Engineering/IT)

� Non-Technical PM Education

• Post Graduate

Degree(Management/Others)

• Graduate Degree

(Management/Others)

• Basic Education (Diploma in

(Management/Other)

• Others

� Project Management Training level

• Certifications

• Training courses

� Technical Skills

• Experience in Software

development

• Experience in Project Management

• Strong understanding of domain

• Planning and control

� Non technical Skills

• Communication skills

• Team building skills

• Conflict resolution skills

• Planning and Control skills

• Leadership skills

• Problem solving skills

• Management skills

• Time management skills

� Experience

• Number of years in project

management

• Number of years in other disciplines

B. OBSERVATIONS AND ANALYSIS


Technical PMs: Focus on Technical and Time management skills

The results show us that about half of

the technical project managers having

moderate technical skills (follow standard

method, experience and domain knowledge).

In addition to this, 40-50% percent non-

technical project managers have socio-

cultural skills such as leadership and problem

solving.

Non-technical PMs focus on Team

development, communication, leadership and

management skills. Most of project managers

are fortunately able to meet the deadlines,

probably because of putting in extra hours,

making the resources sit late till night in the

offices and in some cases, making the

weekends on (time management: 82% ).

Therefore, we conclude that the project

managers of our software industry put too

much stress on the team members regarding

the completion of work in little time

allocated to the project activities. This could

be because of pressure from the client end,

but the project managers should devise

methods to avoid making their team members

work in a crunch mode.

FREQUENCY OF RESPONSES

ACCORDING TO COMPANY SIZE

As can be seen in the graph below that the

only type of enterprise that has minimal

responses is Micro-Enterprise. Therefore, it

is evident from the fact that the sample of

this survey mainly contains the Small,


Medium and Large Enterprises.

Figure 0-2: Percentage responses according to company size

Our statistics have confirmed that Companies

involved in offshore development are higher

in rate than the rest of the companies.

In hybrid development, project managers

always motivate, consult with team members

before taking any decision and timely

decision and we observe in relation to

team involvement and motivation are about

53 percent in in-house development. 50-60%

of the technical software project managers

sometime follows standard method and has

domain knowledge. Many project managers

cannot handle resources and appropriate

decision.

Figure 3: Responses according to Type of Business

In off-shore development, non-technical PM

seem to realize the importance of effective

communication skills and because of this,

58% non-technical PM motivate team


members to complete the work assigned to

them. In In-house development, most of the

project managers almost focus to define clear

goal, monitor the performance and motivate

their team to promote cooperation. The

analysis confirmed that following soft/hard

categories are at the High, Medium and Low

severity levels according to Company Types.

In the world of software technology,

experience is a particularly powerful and

effective teacher. Statistics have confirmed

that majority of the PM population in this

survey is of the software practitioners having

experience more than two years and less than

6 years.

The results show that 90 of the project

managers we targeted in our survey had some

prior software development experience.

Having some software development

experience indeed is an added quality of a

successful project manager who can well

understand and comprehend the technicalities

of the project. But the emphasis should be on

managing projects without getting too much

involved in the technical details of the project

and taking into consideration the business

aspect of the project as describe by PMI [17-

18].

Statistics have confirmed that majority of

the PM population in this survey is of the

software practitioners having certification

almost fifty percent of total population. In the

world of software technology, certification is

a particularly effective trainer. From our

survey, we observed that the project

managers in the market fall in the following

range of PM experience:

� 54 percent Non-Technical PM’s on the

average have PMP Certification.

� 42 percent Non-Technical PM’s on the

average have No Certification.

� The rest have 4 percent CMMI

Certification

� 33 percent Technical PM’s on the

average have PMP Certification.

� 56 percent Technical PM’s on the

average have No Certification.

� The rest have 11 percent CMMI

Certification


Figure 4: Percentage responses according to Respondent’s Certification

CONCLUSION

In this thesis, the level of software

project manager (PM) skills is conducted, by

gathering inputs from Pakistan software

industry. There are a total of 45 software

project managers who have participated in

this research. It has revealed more of the soft

skills were missing in past articles. The

survey has a significant importance among

past studies related to soft and hard skills

because of (i) technical vs. non-technical

skills are specific to Project Management

Body of Knowledge(PMBOK), (ii) Survey is

conducted on Pakistan Software Industry

which has its own uniqueness in a way that it

is a Industry of an under-developed country

and having a different culture in terms of

both political instability and economic

situation, and (iii) It has revealed that

software industry currently has more less-

experienced project managers than the

experienced ones.

The complexity of recent software

systems also causes difficulties for software

project managers. The potential challenge is

the ever-changing requirement of customers

as users learn and mature with time and the

difficulties in incorporating multiple,

diversified and contradictory vision and

views. We can reduce technical and

management risks with proper practices.

Some of the experience software project

managers when interviewed on the

enhancement and improvement strategies for

technical and non-technical skills, responded

that these soft skills must be promote and

tackle with the professionalism and training

on the importance of leadership, they also

mentioned that top management should now

forget about the past experiences and should

have the courage to meet the challenges of

coping up with the standardization of their

software, if they want to be recognized as a

reliable software industry in the world. They

have also stated that new opportunities must

now be created for the true professions in the

Industry by giving them job security and

seeking new ideas to improve or evolve their

processes as this could be the only way to

introduce CMMI in their organizations and

pacing it up to the ultimate capability level

just like some of the top-notch companies


have already done in recent years of Pakistan.

FUTURE WORK

From our observation, it can be concluded

that the software industry currently has more

less-experienced project managers than the

experienced ones. Emphasis should lie on

making the more experienced project

managers help the inexperienced ones by

giving them valuable guidance and direction

so that they could turn out to be good project

managers as well. Furthermore, educational

programs in the institutes could also prove to

be helpful in producing good project

managers by equipping them with the desired

soft and hard skill sets so that they can stand

out to be better project managers and help the

software industry using their managerial

skills. The training of project managers

should focus on those identified skills

required to deal with the “Typical Problems”

encountered.

REFERENCE

1. A Guide to the Project Management Body of Knowledge (PMBOK Guide), Fourth Edition ed.: Project

Management Institute, 2008.

2. "The Standish Group’s CHAOS Report 2009," CHAOS University, http://www.standishgroup.com/chaos

2009.

3. S. El-Sabaa, "The skills and career path of an effective project manager," International journal of project

management, vol. 19, no. 1, pp. 1-7, 2001.

4. J.R. Müller and R.Turner, "Communication and Co-operation on Projects Between the Project Owner As

Principal and the ProjectManager as Agent," European Management Journal, vol. 22, no. 3, pp. 327–336,

June 2004.

5. D.H. Stevenson and J.A. Starkweather, "PM critical competency index: IT execs prefer soft skills,"

International Journal of Project Management, vol. 28, no. 7, pp. 663–671, 2010.

6. T.A. Carbone and S. Gholston, "Project Manager Skill Development: A Survey of Programs and

Practitioners," Engineering Management Journal, vol. 6, no. 3, September 2004.

7. J.M. Conrad and Y. Sireli, "Learning Project Management Skills in Senior Design Courses," in Frontiers in

Education, 2005. FIE '05. Proceedings 35th Annual Conference, 2005, p. F4D.

8. E. Hemmatnia. (2005) A Project Manager:Specialist in Management or Specialist in a Topic Area?

[Online].http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.84.7106&rep=rep1&type=pdf.

9. J. R. Turner and R. Muller , "The project manager's leadership style as a success factor on projects: A

literature review," Project management journal, vol. 36, no. 1, pp. 49-61, 2005.

A. Aitken and L. Crawford, "Coping with stress: Dispositional coping strategies of project managers,"

International Journal of Project Management, vol. 30, no. 7, pp. 1-4, 2007.

10. V.Vadlamuri. (2007, March) How techie does a project manager need to be, to be successful in 21st century”.

[Online]. Http://blogs.ittoolbox.com/pm/vadlamuri/archives/howtechie-does-a-project-manager-need-to-be-

to-be-successfulin-21st-century-1499


11. Z. Jalil and A. A. Shahid, "Is Non Technical Person A Better Software Project Manager?," in 2008

International Conference on Computer Science and Software Engineering, vol. 2, 2008, pp. 1-5.

12. S.A. Slaughter and T. Mukhopadhyay N. Langer, "Project Managers' Skills and Project Success in IT

Outsourcing," in ICIS 2008 Proceedings, 2008, p. 147.

13. S. Gillard, "Soft skills and technical expertise of effective project managers," Issues In Informing Science and

Information Technology, vol. 6, 2009.

14. S. Milladi. (2007) What it Takes to be a Better Project Manager – Going Beyond Project Management.

[Online]. http://www.pmworldtoday.net/

15. D. G. Morales, L. M. de Antonio, and J. LR. Garcia, "Teaching “Soft” Skills in Software Engineering," in

Global Engineering Education Conference (EDUCON), 2011, pp. 630 - 637.

16. M. Pinkowska, B. Lent, and S. Keretho, "Process Based Identification of Software Project Manager Soft

Skills," in Computer Science and Software Engineering (JCSSE), 2011 Eighth International Joint Conference

on, 2011, pp. 343 - 348.

17. S. Dillon, H. Taylor, and G. Rodriguez-Jolly. (2010) The identification of IT project manager competencies: a

grounded theory approach. [Online]. http://www.pacis-net.org/file/2011/PACIS2011-044.pdf


*Department of Computer Science, International Islamic University, Islamabad, Pakistan.

**Department of Computer Science, International Islamic University, Islamabad, Pakistan.

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