Scientific Research Journal of India (SRJI) Vol - 2, Issue - 1, Year - 2013

Scientific Research Journal of India
(Multidisciplinary, Peer Reviewed, Open Access, Journal of science) ISSN: 2277-1700 Vol: 2, Issue: 1, Year: 2013
Office Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403 Website http://www.srji.info.ms URL Forwarded to http://sites.google.com/site/scientificrji Email editor.srji@gmail.com Contact +91-9320699167, 9305835734
Copyright 2013 Scientific Research Journal of India All rights reserved.
CONTENTS
Title Editorial Effect Of McConnell Taping on Pain, ROM & Grip Strength in Patients with Triangular
Author/s Dr. Krishna N. Sharma
Department
Page i
Dr. Shahid Mohd. Dar, Dr. R. Arunmozhi, Babloo Sharma Physiotherapy 1
Fibrocartilage Complex Injury
Evaluation of Knee Joint Effusion with Osteoarthritis by
Shanmuga Raju P., Suryanarayana Reddy V., Madurwar AU, Sridhar EB, Harsha Vardhan NS. Physiotherapy 10
Physiotherapy: A Pilot Study on Musculoskeletal Ultrasonography
Physical Therapy Management of Tuberculous Elbow Effect of Sensory Cueing on Gait and Balance during both On and Off Drug Phase of Sinha Siddharth, Bhatt Sunil Physiotherapy 26 Arthritis of the Amit Murli Patel Physiotherapy 16
Parkinsons Disease Congenital Talipes Equinovarus (CTEV) Analysis of Water Quality of Halena Block in Bharatpur Area
Mayank Pushkar
Physiotherapy
35
Sunil Kumar Tank, R. C. Chippa
Chemistry
42
ISSN: 2277-1700 Website: http://www.srji.info.ms URL Forwarded to: http://sites.google.com/site/scientificrji
iv
EDITORIAL
Greetings of the New Year!!! I am very pleased to present this issue of the Scientific Research Journal of India (SRJI). With this issue, we have entered in the 2nd year of our publication. This multidisciplinary and open access Journal of science published total 22 papers (13 papers in Physiotherapy, 1 paper in Surgery, 1 paper in Microbiology, 3 papers in Computer Technology, 1 paper in Chemical Engineering, 1 paper in Metallurgical Engineering, 1 paper in Agriculture, and 1 paper in Anthropology) last year. This year, we are hopeful to bring more researches in light. In the current issue we have covered two disciplines of science Physiotherapy, and Chemistry. Hopefully youll find these papers informative. Your comments and suggestions are very valuable for us.
Happy Reading.
Regards,
Dr. Krishna N. Sharma Editor in Chief
EFFECT OF MCCONNELL TAPING ON PAIN, ROM & GRIP STRENGTH IN PATIENTS WITH TRIANGULAR FIBROCARTILAGE COMPLEX INJURY
Dr. Shahid Mohd. Dar* MPT (Orthopaedic & Sports), Dr. R. Arunmozhi** MPT (Sports & Rehabilitation), Babloo Sharma*** MPT (Sports)
ABSTRACT STUDY OBJECTIVES: To find out the efficacy of McConnell Taping on Pain, Range of Motion and Grip strength in subjects with Triangular Fibrocartilage Complex (TFCC) injury. DESIGN: An Experimental Study. SETTING: All the Subjects were selected from various sports center from Dehradun and SAI Guwahati. Methods: A total of 28 subjects were recruited for the study on the basis of inclusion and exclusion criteria after signing the informed consent form. The subjects were divided into two Groups (A= Taping & B= Conventional Therapy). OUTCOME MEASURE: Grip Strength, Range of Motion for Wrist and Forearm & Numerical Pain Rating Scale. RESULTS: The result of the study shows that both McConnell Taping and Conventional Therapy are effective in improving the Range of Motion, Grip Strength and reducing the Pain level. Both groups showed significant improvement when comparison was made within the group. However, there is significant reduction in pain level between the groups for Group A (p=0.000). CONCLUSION: The present study demonstrates that both McConnell Taping and Conventional Treatment are effective in improving the Grip Strength, Range of Motion and reducing the Pain level in subjects with TFCC injury. However, it can be concluded that McConnell Taping is the better form of treatment in improving the Grip Strength, Range of Motion and reducing the Pain level in subjects with TFCC injury.
KEY WORDS: TFCC, Taping, Grip Strength, Range of Motion, Numerical Pain Rating Scale, Conventional Therapy.
INTRODUCTION The triangular fibrocartilage complex (TFCC) is a special structure at the ulno-carpal articulation.8 It is composed of semicircular biconcave
The problem that arises from soft tissue injury of this important structure is distal radio ulnar joint (DRUJ) instability. The DRUJ is a diarthroidal trochoid articulation, which is an incongruent articulation; only around 20% of its stability is produced by osseous articular contact. Soft-tissue structures of the TFCC play a critical role in intrinsic joint stability.7 Wrist injuries are often complex and their management will vary greatly; as such it is vital that the correct diagnosis is made. If we look specifically at the athletic population TFCC tears are more frequently seen in gymnastics, hockey,
fibrocartilage or articular disc called the TFC, the palmar and dorsal distal radioulnar ligaments, a meniscus homolog, ulnolunate and ulnotriquetral ligaments and the extensor carpi ulnaris tendon (ECU) subsheath.7,17 Functionally,
8
the
TFCC
extends the radio-carpal articulation, permitting pronation and supination. The TFCC is a
cartilaginous and ligamentous structure, important in the stabilization of the distal radial ulnar joint and in the absorption of load between the distal ulna and the volar carpus.7,17 The articular disc of the TFCC separates the ulna and the proximal carpal row, and carries about 20% of the axial load from wrist to forearm.17 Injuries to the TFCC occur with repetitive ulnar loading (e.g., bench press, racquet sports) or acute traumatic axial load with rotational stress (e.g., FOOSH).
17
racquet/batting sports, boxing, and pole vaulting. This is due to the repetitive high forces on the wrist that will often be in extension or ulnar deviation, or both (Parmelee-Peters & Eathorne, 2005).30 The most common mechanism of injury to the TFCC occurs with axial loading, ulnar deviation, and forced extremes of forearm rotation. Injury may also be associated with localized swelling, crepitus, grip weakness and sense of instability.7 The initial treatment for TFCC injury may include splinting, rest, anti-inflammatory
Most injuries to the TFCC have a
component of hyperextension of the wrist and rotational load. Injury to the TFCC is the most common cause of ulnar-sided wrist pain. Ulnarsided wrist pain made worse with ulnar deviation, wrist extension, or heavy use is the common complaint of an athlete who has a TFCC injury. TFCC injuries are more commonly seen in such sports as gymnastics, hockey, racquet sports, boxing, and pole vaulting.
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medications, cryotherapy, electrotherapy modalities and physiotherapy techniques like manual and exercise therapies.23 Biomechanical adjustments may be required to comprehensively manage the injury and reduce the incidence of recurrence.23 These include on court stroke analysis and if necessary, modifications to the athletes stroke mechanics, or their equipment, such as adjustments of the grip size,
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Scientific Research Journal of India Volume: 2, Issue: 1, Year: 2013
the over grip, the strings and string tension, the weight balance of the racket, or the grip placement (continental, eastern, semi-western, and western).23 Physiotherapists and Athletic Trainers often use athletic tape methods to support and prevent sport related injuries. Athletic tape is effective due to its reported ability to provide stability, maintain proper structural alignment, facilitate proprioception and also its neuromuscular effects. The aim of taping is to reduce healing time, to protect and support the wrist, and prevent future injury.23 In response to the limited effective taping options for wrist injuries involving the TFCC and/or ECU tendon, Kathleen Stroia and Kathy Martin applied the McConnell principles of unloading to the wrist.23 Stroia and Martin experimented with various tape applications and created a clinically effective tape technique, consisting of 1) an unload, 2) a block, and 3) a re-direction tape for players who sustained wrist injuries involving the TFCC and/or ECU tendon.23 This tape technique is effective for injuries involving both the TFCC and ECU as they are in close proximity to each other, and due to the co-morbid nature of ECU tenosynovitis and TFCC pathologies.23 This tennis-specific wrist taping technique protects and supports the injured
METHODS An experimental study design was conducted on total of 28 subjects who were recruited from various sports center in and around Dehradun and SAI Guwahati based on the inclusion and exclusion criteria. The subjects were divided into two groups after the informed consent was signed. Subjects with prediagnosed cases of TFCC injury were included in the study. Group A (Taping + Conventional Therapy, n=14) and Group B (Conventional Therapy, n=14). Pre intervention measurements of pain, range of motion and grip strength were taken out using Numerical Pain Rating Scale, Universal Goniometer and Hand Dynamometer. Both the groups were received intervention for total of 8 days with a rest period on the 4th day. Subjects were excluded from the participation if they present with any neurological deficit of the reference extremity, ay other reason of wrist and hand pain of the reference extremity, history of fracture or any other musculoskeletal surgery of wrist, pain or movement restriction more than 6 weeks and subjects with h/o TFCC injury less than 48 hours. Grip strength (pound)11,18, Range of Motion (degree)15 for Wrist and Forearm and Numerical Pain Rating Scale13,28 was taken as outcome measure before and after the total session of treatment. All the subjects were assessed for outcome on 1st day (before the intervention), 4th day and the final data was collected on 8th day. Protocol for Group A (Taping): Tennis Specific Unload, Block and Redirection Tape Technique were applied according to the principle of
structures; however it restricts only the desired motions (supination, ulnar deviation, and extension). The technique meets the desired goal of allowing a player to play with more support which improves function, while restricting extreme range of motion. It is designed to consider the anatomy and pathophysiology of the injury and the biomechanics of the two-handed backhand.23
McConnell taping. This tennis-specific wrist taping

3
technique
protects
and
supports
the
injured
structures; however it restricts only the desired motions (supination, ulnar deviation, and extension).23 The technique meets the desired goal of allowing a player to play with more support which improves function, while restricting extreme range of motion. It is designed to consider the anatomy and patho-physiology of the injury and the biomechanics of the two-handed backhand.23 1 subjects was dropout before the 4th day assessment.
Fig. 1.3: Tape with redirectional technique for supination
Fig. 1.4: Tape with supination end range block Fig. 1.1: Fixomull Stretch with Gutter
Protocol for Group B (Conventional Therapy): Conventional treatment of TFCC was given, which include rest to the part, Ultrasound Therapy and Home Exercise Program.23,2 The parameter for Ultrasound was Frequency: 3 MHz, Intensity: 1.4W/cm2, Time: 6 minutes, Mode: Continuous.6 2 subjects were dropout, 1 before the 4th day and other after the 4th day assessment. DATA ANALYSIS
Fig. 1.2: Tape with directional force
Data was analyzed by using SPSS software (version 16). Paired t-test was applied to compare the data within the groups whereas Independent t-
test was applied to compare the data between the groups. The p value was set at (0.05) with 95% confidence interval. RESULTS
Table 1.1: Comparison of Pre and Post Grip Strength score for Group A and B
MEAN PRE POST PRE SD t POST p
GROU PA
64.102
78.308
18.6662 9
24.674
Fig. 1.6: Comparison of Pre and Post Wrist Extension ROM for Group A and Group B
-6.697 .000
GROU PB
52.5
69.306
20.7864 4
24.55889
-7.824
.000
Table 1.3: Comparison of Pre and Post Pain Score for Group A and Group B
MEAN PRE GROUP A GROUP B 5.3077 5.8333 POST 0.6154 1.3333 PRE 0.63043 1.19342 SD t POST 0.50637 0.65134 26.836 12.539 .000 .000 p
Fig. 1.5: Comparison of Pre and Post Grip Strength score for Group A and B Fig. 1.7: Comparison of Pre and Post Pain Score for Group A and Group B
Table 1.2: Comparison of Pre and Post Wrist Extension ROM for Group A and Group B
MEAN PRE GROUP A GROUP B 67.692 POST 71.692 PRE 4.38529 SD t POST 2.35884 p
Table 1.4: Comparison of Grip Strength between Group A and Group B

MEAN SD GROUP A 18.66629 24.674 GROUP B 20.78644 24.55889 t p
-3.399
.005 GROUP A PRE POST 64.102 78.308 GROUP B 52.5 69.306
68.75
71.667
3.76889
3.25669
-2.244
.046
1.464 .913
.157 .371
Fig. 1.8: Comparison of Grip Strength between Group A and Group B Table 1.5: Comparison for Wrist Extension ROM between Group A and Group B
MEAN GROUP A PRE POS T 67.692 71.692 GROUP B 68.75 71.667 GROUP A 4.38529 2.35884 SD GROUP B 3.76889 3.25669 t p
Fig. 1.10: Comparison of NPRS between Group A and Group B
Results of the study showed that there is significant reduction in pain and improvement in grip strength
-.648 .023
.523 .982
and range of motion in both the groups after the intervention. However, Group A (Taping) showed more reduction in pain score when compared to Group B and this was found to be statistically significant p=.005 post intervention. Other variables also showed improvement but it was statistically non-significant. DISCUSSION Hand and wrist trauma accounts for 3-9% of all athletic injuries.12 An injury to the TFCC is very
Fig. 1.9: Comparison for Wrist Extension ROM between Group A and Group B
important as it is the most common cause of ulnar side wrist pain and limited wrist function in work or in sports.29 According to Kathleen Stroia et al., when
Table 1.6: Comparison of NPRS between Group A and Group B

MEAN GROUP A PRE 5.3077 GROUP B 5.8333 GROUP A 0.63043 SD GROUP B 1.19342 t p
the wrist is loaded into supination, ulnar deviation and extension, the TFCC, ECU tendon and sheath are loaded with significant stress. This is the typical position of the non-dominant wrist during the two-
-1.393
.177
handed backhand stroke, it also occurs during a forehand stroke.23
POST
0.6154
1.3333
0.50637
0.65134
-3.091
.005
The present study was done to find out the efficacy of Taping in terms of grip strength, range of motion and pain score in subjects with Triangular Fibrocartilage Complex Injury. The most probable reason for the reduction in pain after the application of tape could be due to reduction of strain on the injured structure in both the acute phase and also during the ongoing repair and rehabilitation phase. Supporting an injured joint with tape is widely believed to be helpful in reducing pain, preventing exacerbation of the injury and promoting tissue healing. This technique met the desired goal of allowing the players to play with full support and improved function as said by the Kathleen Stroia in his study.
23 4
neurophysiological model the tape may exert an effect on grip strength by primarily altering pain perception, either locally at the wrist by inhibiting nociceptors, facilitating large afferent fiber input into the spinal cord and/or possibly by stimulating endogenous processes of pain inhibition thereby increasing the grip strength and reducing the pain level as according to the Alireza Shamsoddini et al in his study.22 Limitations of the study are small sample size and different grades of the TFCC injury was not taken into consideration. So the further
recommendation for future studies need to be done with broader dimension, on the workers who are mainly involved with hand and wrist work, and its effectiveness can also be checked with other taping
Another possible effect of tape could be due to a direct mechanical effect on the TFCC, presumably by somehow improving the internal mechanics or by protecting the damage tissues from excess forces and as a result, decrease in pain and improving grip strength.26 Along with it, this method of taping technique also disperses the stress generated by the muscle during contraction which results in decreasing the pain level by reducing the painful inhibition. The possible mechanism behind the reduction in pain is due to its neurophysiologic effects on the nervous system, particularly the nociceptive system. In this
technique. CONCLUSION The present study demonstrates that both the technique is effective in improving the grip strength, range of motion and reducing the pain in subjects with TFCC injury. However, Taping technique used in this study proves to be effective in reducing the pain in subjects with TFCC injury. So, it can be concluded that Taping is the better choice of treatment in subjects with TFCC injury along with other therapeutic modalities.
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Norkin Cynthia C, White D. Joyce. Measurement Of Joint Motion- A Guide to Goniometry 3rd Edition. India: Jaypee Brothers Medical Publishers (P) Ltd; 2004.
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Palmer AK. Triangular Fibrocartilage Complex Lesion; A classification. Jour of Hand Surgery 1989;14(A):594-605.
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Peolsson A, Hedlund R, et al. Intra- and Inter- Tester Reliability and Reference Values For Hand Strength. J Rehab Med 2001;33:3641.
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Perkins R H, Davis D. Musculoskeletal Injuries in Tennis. Phys Med Rehabil Clin N Am 2006;17:609-631.
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Reid David C. Sports Injury Assessment & Rehabilitation. USA: Churchill Livingstone: 1992. Retting Arthur C. Athletic Injuries of the Wrist and Hand. Am J Sports Med 2004; 32: 262.
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Shamsoddini Alireza, Mohammad Taghi Hollisaz, et al. Initial effect of taping technique on wrist extension and grip strength and pain of Individuals with lateral epicondylitis. Iranian Rehabilitation Journal 2010;8(11).
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Stroia K, Baudo M, et al. Taping Techniques for TFCC and ECU injuries on the Sony Ericsson WTA Tour. Med Sci Tennis 2009;14(1):15-19.
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Tang JB, Ryu J, et al. The triangular fibrocartilage complex: an important component of the pulley for the ulnar wrist extensor. J Hand Surg Am 1998 Nov;23(6):986-91.
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Vezeridis Peter S, Yoshioka Hiroshi, et al. Ulnar-sided wrist pain. Part I: anatomy and physical examination. Skeletal Radiol 2010; 39:733-745.
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Vicenzino B, Brooksbank J, et al. Initial Effects of Elbow Taping on Pain-Free Grip Strength and Pressure Pain Threshold. J Orthop Sports Phys Ther 2003;33:400407.
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Wadsworth C T, Nielsen D H, et al. lnter-rater Reliability of Hand-Held Dynamometry: Effects of Rater Gender, Body Weight, and Grip Strength. J Orthop Sports Phys Ther 1992 August;16(2):74-81.
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Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. Journal of Clinical Nursing 2005;14;798-804.
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Yao-Tung Hou, Jui-Tien Shih, et al. Chronic triangular fibrocartilage complex tears with distal radioulna joint instability: A new method of triangular fibrocartilage complex reconstruction. Journal of Orthopaedic Surgery 2000;8(1):18.
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The Sports Physiotherapist Blog. Triangular Fibrocartilage Complex Tears: Evidence Based Assessment and Management. 2012 May 06.
CORRESPONDENCE
* Asst. Prof. Department of Physiotherapy, Dolphin (PG) Institute, Dehradun (UK) ** Associate Prof. Department of Physiotherapy, SBS PGI Biomedical and Research, Dehradun (UK) *** Student Researcher, Dolphin (PG) Institute, Dehradun (UK). Email: babloo83_sharma@yahoo.com
EVALUATION OF KNEE JOINT EFFUSION WITH OSTEOARTHRITIS BY PHYSIOTHERAPY: A PILOT STUDY ON MUSCULOSKELETAL ULTRASONOGRAPHY
Shanmuga Raju P. MPT*, Suryanarayana Reddy V. MS, Madurwar AU. MD, Sridhar EB. MD, Harsha Vardhan NS. MD
ABSTRACT AIM: The aim of study is to investigate the changes of knee joint effusion before and after osteoarthritis of knee, using by musculoskeletal Ultrasonograpy. DESIGN: Prospective, follow-up study. SETTING: Department of Physiotherapy, Chalmeda Anand Rao Institute of Medical sciences, Karimnagar. METHODS AND MATERIALS: 20 cases of unilateral knee osteoarthritis were assessed by PHILPS EnviSor CH D Ultrasonographic examination of knee effusion. Subjects were prospectively assigned to the follow-up treatment of Interferential stimulation and Non-thrust Manual exercise (including Knee, Hip and and Leg muscles. A 15 session treatment program, 30 minute per day was performed for KOA. OUTCOME MEASURES: Before and after intervention, we assessed knee joint effusion through ordinal scale. T test was used for comparison between pre and post treatment results in respectively. RESULTS: 12 cases (women 7, men 5) were identified and a total 20 subjects of knee OA. The mean score of effusion (2.75); T-value (2.20%) in the nonthrust manual exercise and interferential current. CONCLUSION: Significantly reduction in knee effusion in patients with knee osteoarthritis. KEYWORDS: Knee osteoarthritis, Musculoskeletal ultrasonography, Knee effusion, Interferential current,
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nonthrust manual exercise.
INTRODUCTION In 1743, Willams Hunter first described Osteoarthritis. Osteoarthrtis is a condition that primarily affect the articular cartilage, but involve the entire joint, including the subcondral bone, ligaments, capsule, synovial membrane and
Knee pain with independence walking. Aged between 40-75 years (Both female and male). PHILPS EnVisor C HD Musculoskeletal Ultrasonography. Ultrasonic Gel. L12- 3 MHZ probe/ Transducer. Universal Goniometry Interferential stimulation (IFS) modality. Nonthrust manual exercise Knee effusion Imaging Record Digital Camera.
periarticular muscles (Brandt.KD. et.al 2009). The basic aim of physiotherapy is to prevent disability, improve joint range of motion, reduce pain, stiffness, and improve muscular strength, fitness and Quality of life. The purpose of study is to investigate whether changes of knee joint effusion in patients with osteoarthritis before and after Physiotherapy treatment using musculoskeletal Ultrasonography. Musculoskeletal Ultrasonography is a noninvasive, lowcost, bedside procedure that may be used and to assess osteoarthrtic joints (Iagnocco.A. 2008). Ultrasound detects changes of intra articular knee effusion and inflammatory 1978 & arthritis RA.
Exclusion Criteria were A history of knee and Hip Replacement surgery Psoratric Arthritis Unable to walk without assistance Non-steroid anti-inflammatory Drugs. Corticosteroid injections Radicular pain below knee and A History of malignancy.
(Coopenberg.PL.et.al Et.al,1982).
Kanfman
The purpose of this study is to
investigate the changes of knee joint effusion before and after osteoarthritis of knee, using by
musculoskeletal ultrasonograpy Musculoskeletal Ultrasonography Imaging METHODS AND MATERIALS The study was conducted in the Department of Physiotherapy and association with Department of Radio- Diagnosis and Imaging, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar. The prospective, Follow-up study was done from first August 2008 to December 2009. PHILPS EnVisor CH D M2540 A Ultrasound System (L12-3 MHZ, Bothell, WA, USA 98041). Linear transducer was used to determine the presence of joint effusion (Meenagh.G. et.al 2006). Therefore a total 20 subjects with osteoarthritis of knee were investigated in this study.
Inclusion Criteria were as follows

11
power/Voltage 230 V. The pairs of rubber electrodes were placed over the trigger points of the knee joint. The intensity of the current was set a comfortable level as determined by subjects and ranged from 10 50 mA. The patient position was supine lying with comfortable support and 20 degree flexed knee. Figure: 1 Musculoskeletal Ultrasonography Non thrust manual exercise as repetitive passive movement of varying amplitudes and of low velocity, applied at different points through the range of motion, depending on the effect desired (Cameron. WM, 2006). The number of repetitions time 5-10 per session of program. Duration of treatment time KOA was 15 sessions. The patients recorded in a dairy their use of base, spectrum, intensity, treatment time of therapeutic modality and Figure: 2 Demonstration of long axis of transducer, to measure AP diameter of the supra patellar recess Examination of knee effusion was obtained by measuring the anterior posterior scan along the main axis of the bursa. The probe was placed just above the superior border of the patella with knee in 30 degree flexion. The AP diameter was scored (Grade) as 0/Absent, 1/mild < 5mm, 2/moderate (5-10mm), 3/severe (>10mm) (Kakati .P.et.al 2008). RESULTS TREATMENT PROTOCOL Initially, 20 subjects were enrolled in this study. Interferential current modality (LIFEMED V 744 04 04, Chennai, India). Alternating current frequency 50, 4000-4100HZ was used for this study. The treatment duration was applied to 20 minutes. The stimulation parameters of machines beat frequency 30HZ, sweep frequency 80 m second, wave 4 PV (6/6), Carbonized rubber electrodes, However, 8 patients did not undergo the evaluations due to lack of regularity and were automatically excluded; therefore, a total of 12 patients STATISTICAL ANALYSIS Before and after intervention, we assessed knee joint effusion through ordinal knee effusion scale. t test analysis was used for comparison between the pre and post treatment results in respectively. The value were expressed in mean, +_ standard deviation and median with statistical significance considered when P < 0.05. exercise.
participants in this study. All patients imaging were saved in consent forms before the evaluations.
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circulation, reducing spasm of muscles, pain, relaxation and changes in knee effusion. Kakati P.et.al (2008) observed that knee effusion and synovial thickening could be detected using ultrasonography in patients with Rheumatoid arthritis. Our study sample consisted of 12 cases OA Figure: 3 Sonographic view of Pre -evaluation of knee joint effusion in a patient with OA Knee. Knee followed -up Pre treatment and post treatment results showed Table 5 and 6. The results of this study demonstrated, the total knee effusion only was examined. Significantly
changes between 10-15 sessions of interferential stimulation and non thrust manual exercise.
However, in this study, pharmacological therapy, injections and replacement of surgery of knee/Hip Figure 4 Ultrasonographic view of Post evaluation for knee effusion results with OA Knee. The initial total knee effusion was not statistically different (P<.05), indicating that the initial effusion status of all participants in this study. Change of total effusion for KOA, the 2 LIMITATIONS OF THE STUDY There are few limitations in the study. Large sample size may give better were excluded. Following 15 sessions of
Interferential current and Nonthrust manual exercise, although reduction of the knee joint effusion was significant (12 Subjects of Knee OA).
measurements were taken in figure 4. After 15 sessions of treatment, decreased to effusion
approximately (t-2.20) of the observation. For analysis of the data showed that the decrease in knee effusion was significantly changed after 15 sessions of IFS/ Non-thrust manual knee exercise (T=37.77 and 20.2) respectively. DISCUSSION This is first controlled study to evaluate musculoskeletal ultrasonography detected changes in the effusion of knee with osteoarthritis of knee after interferential stimulation and non -thrust manual exercise. It is specifically used to increased arterial
13
understanding of reduction in knee effusion with osteoarthritis. This study was needed to explore the difference between musculoskeletal
ultrasonographic image and Hematological findings of effusion. Future studies are needed to evaluation of the cost effectiveness of using for
musculoskeletal
ultrasonography
assessing the condition progress compared with other techniques and the effect of the interferential stimulation and nonthrust manual exercise on control of knee effusion.
CONCLUSION Our study results shows that, Interferential
reduction in knee joint effusion with Osteoarthritis of knee. So, it is a low cost, short term relief, and promotion of health in senior citizens. Conflict of Interest: None
stimulation and Non-thrust manual exercise with musculoskeletal ultrasonography a significantly
References 1. Banwell,BF, Gall.V- Physical therapy management of Arthritis, Newyork, Churchill Livingstone , 1988; 77-106. 2. Braunwald, Fauci (2006)- Harrisons Principles of internal medicine, 15th ed, Vol:2, PP:1979-1987. 3. Chaveez, Lopez,MA, Naredo, F, Acebes cachafeiro, JC et.al Diagnostic accuracy of Physical examination of the knee in Rheumatoid Arthritis; Clinical and Ultrasonographic sytudy of jont effusion and Bakers Cyst, Rheumatol Clin, 2007; 3(3); 98-100. 4. F.Gogus, J.Kitchan, R, Collins, D.Kane: Reliability of physical Knee Examination for Effusion: Verification by Musculoskeletal Ultrasound, Annual ACR Meeting, san Francisco, 2008. 5. Guermazi Ali Imaging of Osteoarthritis, Radiological Clinic of North America, vol: 47; July 2009. 6. Hill CL, Gale DG, Chaisson, CL, et.al Knee effusions, popliteal cysts and synovial thickening; Association with knee pain in osteoarthritis, J Rheumatol 2001; 1330-1337. 7. Hatemi,G. Tascilar,K. Melikoglu, M, et.al Ultrasonographic and Physical Examination of the inflamed knee: Intra and Inter Rater Reliabiliy of the sonographers and Clinical Examiners, 20 Oct, 2009. 8. Jamt, Vedt.G. Dahm KT, Christie, A. et.al Physical Therapy Interventions for patients with Osteoarthrtis of the Knee: An overview of systemic Reviews, Phy The 2008, Vol. 88; PP 123-136. 9. Jan MH, Lai JS: The effect of Physiotherapy on Osteoarthrtic Knee of Females, J Formosan Med Assoc 1991; 90; 1008- 1013 (Medline). 10. Keen HI, Browa AK, Wakefield RJ, Conaghan, PG Update on Musculoskeletal Ultrsonography, J R Coll Physician Edin B; 2005; 35; 345-349. 11. Kellgren JH, Lawrence JS- Radiological Assessment of Osteoarthritis, ANN Rheum Dis 19576; 16; 494502. 12. Meenagyu G, Iagnocco E, Filppucci E, et.al Ultrasound imaging for the Rheumatologist IV, Ultrasonography of the knee, Clin Exp Rheumatol 2006; 24; 357-360. 13. Pratab K, Kushaljit SS, Manavijit SS, et.al Correlation between Ultrasonographic findings and the response to corticosteroid Injections in PesAnserinus Tendoino Bursitis syndrome in Knee Osteoarthritis patients, J Korean Med.Sci 2005; 20;109-12. 14. Robertson D-An introduction to Musculoskeletal Ultrasound, Sports Medicine 2007; July; 22-26.
14
15. Rubaltelli I, Fiocco U, Cozzi L, et.al- Prospective Sonographic and Arthroscopic Evaluation of proliferative knee joint synovitis.J Ultrsound Me 1994; 13; 855-862. 16. Smit j, Jonathan T, Finnoff DO- Clinical Reviwe; Current concepts Diagnostic and Interventional Muscculoskeletal Ultrsound Part 1 Fundamentals. 17. Scheel Ak, Matteson EL, et.al Clinical study: Reliability Exercise for the Polymyalgia Rheumatica Classification criteria study;: The oranjewound Ultrasound sub study, International journal of Rheumatology, vol 2009, article ID 738931, 5 Pages, Hindawi Publishing corporation. 18. Theodore P, Joel AB- Pain and Radiographic damage in Osteoarthritis 2009, BMJ, Vol 339; PP: 469. 19. Tuhimna N, David F., Jingbo N, et.al- Association between Radiographic features of knee Osteoarthrtis and Pain: results from two cohort studies 2009; BMJ, vol: 339; PP: 498-501. 20. Tsai LY, Jan MH, Tseng SC, et.al- Interrator and interrater reliability of the knee joint synovitis in patients with Knee Osteoarthritis: The use of Sonographic evaluation, Formoson journal of Physiotherapy 2003; 28; 19-26. 21. Van Holsbeeck MT and Intracaso JH- Musculoskeletal Ultrasound, 2nd ed Mosby, 1991 ISBN: 0815189753. 22. Wakamuke E, Kawooya M,et.al- Experience with Ultrasound of the knee joint at Mulago Hospital, Uganda , East cent, Afri.J. Surg, vol: 14; No: 2: July/August 2009.
ACKNOWLEDGMENT This research study was supported by Arihant Educational Society, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Andhra Pradesh, India. We would like to thank sri. C. Anand Rao, Ex.Minister of Law and Social worker, Sri.C.Lakshmi Narasimha Rao, BE, MBA Chairman, Dr.V. SurayaNarayana Reddy, MS, Director for grateful support of our study. We would like to acknowledge Prof. Dr. V. Aruna, MD, Dr.(Mrs.). Ezhilarasi Ravindran, MD, Prof. SA. Aasim,MD, Medical Superintendent CAIMS, Karimnagar, for useful discussions and support for preparing this study.
CORRESPONDING AUTHOR: * ShanmugaRaju P, Asst. Professor &I/C Head, Physiotherapy, Department of Physical Medicine & Rehabilitation, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar- 505001, Andhra Pradesh, INDIA. E-mail: shanmugampt@rediffmail.com
15
PHYSICAL THERAPY MANAGEMENT OF TUBERCULOUS ARTHRITIS OF THE ELBOW

Amit Murli Patel BPT, MPT-Orthopaedics*
ABSTRACT BACKGROUND AND PURPOSE: Tuberculous arthritis is not commonly seen by physical therapists in India. The purpose of this case report is to describe a case of tuberculous arthritis of the elbow. CASE
DESCRIPTION: The patient was a 35-year-old man referred for physical therapy evaluation and intervention for chronic elbow pain. After an evaluation and a trial of physical therapy, the patient was referred back to a primary care provider for additional tests to rule out systemic pathology. An open debridement of the synovium and a biopsy of the capitellum and radial head was positive for acid-fast bacilli, which was later identified as Mycobacterium tuberculosis. OUTCOMES: The patient was placed on a 4-drug antituberculosis regimen that resolved all patient complaints and restored full elbow function. DISCUSSION: Tuberculous arthritis has characteristic findings during examination and in diagnostic tests. Although tuberculous arthritis is uncommon, it should be considered when patients have chronic or vague musculoskeletal complaints. KEYWORDS: Tuberculous arthritis, Elbow arthritis, Knee effusion, Physical therapy managemet.
INTRODUCTION Tuberculous arthritis occurs in approximately 1% to 5% of all patients with TB. It can involve any
16
5
of the bones or joints of the body but is usually confined to one location, with 10% of tuberculous arthritis in the upper extremity6 and up to 8% in the
elbow.7 The sites most frequently affected are the spine, sacroiliac, hip, and knee.8 Because weightbearing joints are the most frequently involved, some authors5 suspect that trauma plays a role in the pathogenesis of bone and joint TB. Tuberculous arthritis is usually secondary to hematogenous dissemination of tubercle bacilli from a primary pulmonary lesion.
1,8
and
joint
deformities
may
develop.8
The
granulomatous process eventually imparts a boggy or doughy feeling to the joint and periarticular structures.9 Localized pain may precede other symptoms of inflammation or radiograph changes by weeks or even months.9 Other symptoms include joint stiffness, reduced range of motion, fever, night sweats, or weight loss.8,11 Because of the rarity of tubercular infections of joints and because the usual signs of inflammation (eg, erythema, heat) do not occur, diagnosis of tuberculous arthritis affecting peripheral joints is often delayed.8,11 When diagnosis is not timely, joint contractures and limited functional improvement after treatment are more likely to occur, especially if bone and articular cartilage are destroyed.12 Authors have reported diagnoses of olecranon bursitis,13,14 tennis elbow,15 and pyogenic arthritis, osteomyelitis, neopathic articular disease, and neoplasm before an eventual diagnosis of tuberculous arthritis. The purpose of this case report is to describe a case of tuberculous arthritis of the elbow. The patient described in this report had numerous previous diagnoses for chronic elbow pain and was ultimately referred for physical therapy evaluation and intervention.
Less commonly, it
can occur by spreading through the lymphatic system or into adjacent tissue. Joints can become infected by activation of dormant lymphatic or blood stream areas of morbidity.9 In the long bones, TB originates in the epiphysis in response to
8
mycobacteria and causes tubercle formation in the marrow, with secondary infection of the trabeculae.8 The joint synovium responds an to the
mycobacteria
by developing
inflammatory
reaction, followed by formation of granulation tissue. The pannus of granulation tissue formed then begins to erode and destroy cartilage and eventually bone, leading to demineralization. Because TB is not a pyogenic infection, proteolytic enzymes, which destroy peripheral cartilage, are not produced. The joint space, therefore, is preserved for a considerable time. If allowed to progress without treatment, however, abscesses may develop in the surrounding tissue.
5 5
Asaka et al10 described an abscess around the elbow joint and between the biceps brachii and brachioradialis muscles in a patient with tuberculous arthritis. In India, the most common early symptoms of tuberculous arthritis are insidious onset of local pain and swelling around the joint. In advanced cases, which occur primarily in countries where TB is more common and often is allowed to progress, sinuses
17
CASE DESCRIPTION Patient: The patient was a 35-year-old, Athlete, right-handdominant man who reported
experiencing intermittent sharp pain with insidious onset and swelling in his left elbow 10 months previously. He reported that his symptoms were aggravated with movements of the elbow and eased with rest. There was no known history of left elbow or arm injury. The patient did not report any recent
fever or weight loss, and he said that he was healthy except for the elbow pain. He stated that he had been an intravenous (IV) drug user for 5 years, during which he used his left arm for injections, but he said he had not used any IV drugs for 2 years prior to the physical therapist examination and evaluation. The patient was not working at the time of the examination His goal was to play Tennis pain-free. The patient had a 10-month history of evaluations for left elbow pain, swelling, and decreased range of motion. The patient had been diagnosed with lateral epicondylitis, degenerative joint disease, synovitis, and tenosynovitis by 3 different physicians at 3 different facilities, and he had been treated with nonsteroidal anti-inflammatory drugs. After 10 months, an orthopedic surgeon examined the patient. The physician referred the patient to the physical therapist for examination, evaluation, and Figure 1. Anteroposterior radiograph of elbow showing cyst-like structures (arrows).
intervention for chronic elbow pain and ordered electromyography (EMG) and nerve conduction studies (NCS). Three series of elbow radiographs were taken prior to the physical therapy evaluation. Each of the 3 series of elbow radiographs was taken at a different facility The first series, taken 10 months previously, showed no noticeable abnormalities. Two months later, a second series was negative for fracture, but there were cyst-like structures and mild exostotic bone formation in the region of the lateral epicondyle, and there was another cyst-like structure in the proximal shaft of the ulna (Fig. 1). The lateral view showed exostotic bone formation at the anterior distal humerus, which the radiologist stated may have been indicative of an old injury. The third radiographic series 4 months before the physical therapy evaluation revealed a posterior fat-pad sign, which the radiologist suggested may have been created by joint effusion or an occult fracture (Fig. 2). Normally, the posterior fat pad, which lies deep in the olecranon fossa, is not visible on the lateral view. It can be displaced out of the fossa by blood or synovial fluid within the joint, thus becoming visible.17 The radiologist who interpreted the third series recommended further evaluation if the patients complaints continued.
18
Figure 2. Lateral radiograph of elbow showing a posterior fat-pad sign (arrows)
Nerve conduction studies of motor and sensory components of the left median, ulnar, and radial nerves completed just prior to the physical therapy evaluation were within normal limits.
stopped. The wrist was cleared when overpressure was performed during active flexion and extension. Because both procedures failed to reproduce the patients elbow pain, the therapist considered the shoulder and wrist cleared as the source of his pathology. The therapist tested light touch sensation by moving the index fingers along the patients C4T2 dermatomes and upper-extremity nerve fields bilaterally. Sensation was recorded as intact and symmetrical. Muscle stretch reflexes were not tested. Manual muscle tests of the upper-extremity
Electromyograms of the middle deltoid, biceps brachii, brachioradialis, pronator teres, abductor pollicis brevis, and first dorsal interosseus muscles also were within normal limits. The patient had positive purified protein derivative (PPD) tests since the previous year. A standard posteroanterior chest radiograph for patients with a positive PPD test was normal. A normal chest radiograph shows no pleurisy with effusion. Pleurisy with effusion results when the pleural space is seeded with Mycobacterium tuberculosis.18
musculature were performed during the examination as described by Kendall and McCreary.19 The trapezius, middle deltoid, wrist flexor, dorsal and palmar interosseus, and extensor pollicis longus muscles were painless and rated normal bilaterally.
EXAMINATION The patient held his left elbow in a flexed position and apparently was guarding the elbow against his body. He had diffuse left elbow effusion, with the left elbow joint girth 1.5 cm greater than the right elbow joint girth measured at the elbow flexion crease. There was no ecchymosis at the time of examination, but wasting of the biceps and triceps muscles was noticeable. The patient had elbow active and passive range of motion of 30 to 110 degrees, with pain at both flexion and extension end ranges. Wrist range of motion was normal, but the patient did have a sharp pain at the lateral and medial condyles during end ranges of pronation and supination, respectively. The shoulder was cleared for pathology using overpressure during active flexion, abduction, and while the patient was reaching behind his back. The therapist performed overpressure by applying a force to the patients end range at the point where his active range of motion
19
19
The patient said that he was unable to hold the left biceps brachii, triceps brachii, and wrist extensor muscles in the test position against resistance because he said that it reproduced his pain. Because pain limited the patients effort during these muscle tests, grading was not done. Palpation revealed a mild increase in warmth around the left elbow compared with the right elbow. Palpation at the olecranon and both lateral and medial epicondyles caused a sharp pain that did not radiate. Palpation of the patients entire anterior forearm also reproduced his elbow pain.
EVALUATION A posterior fat-pad sign has been reported to be a possible sign of interarticular fracture or swelling.17 Due to local tenderness, swelling, and a documented fat-pad sign on this patients
radiographic report, the therapist chose to rule out systemic pathology or a fracture before initiating
aggressive
stretching
or
joint
immobilization
During the week 4 follow-up evaluation, the patient reported increased pain in the area of the medial and lateral epicondyles. Examination of elbow girth, active and passive ranges of motion, and palpation revealed no other changes. Based on the patients continued pain and swelling, the physician and Therapist agreed that a magnetic resonance image (MRI) could be informational. At the same time, the physician referred the patient back to the orthopedic surgeon for re-evaluation following the MRI. the Physical MRI therapy and was
intervention. The patient began a light physical therapy regimen of active range of motion exercises for 10 to 15 minutes 3 times a week on an upperbody cycle to maintain his present range of motion, followed by ice massage for 10 minutes. The patient was instructed to use ice bags for 10 to 15 minutes on his own throughout the day. He was also instructed to stop playing tennis. The therapist discussed the case ordered with a physician, who
subsequently
follow-up
radiographs, rule out an
including an oblique view to
discontinued
until
orthopedic
interarticular fracture as was originally advised in the most recent radiologists report.
evaluations were completed. The MRI showed a large joint effusion and increased marrow signal within the radial neck (Fig. 3).
RE-EVALUATION AND INTERVENTION The new radiographs showed a smaller posterior fat-pad sign but no fractures or evidence of other pathologies in osseous structures. Therefore, the patient continued his physical therapy program and was re-evaluated 2 weeks after the initial evaluation. During the week 2 follow-up, the patient reported that the pain had lessened and that his elbow was tender to palpation only at the olecranon. Both active and passive ranges of motion were unchanged, as was the elbow flexion crease girth. Resistive exercises were added because the patient expressed concern about the atrophy in his biceps and triceps muscles. Because he was reporting less elbow pain with palpation and range of motion end ranges, the therapist decided to allow the patient to perform seated biceps muscle curls and supine triceps muscle extension exercises in a pain-free range. The patient performed 3 sets of 10 repetitions, 3 times a week, in the clinic under the therapists supervision.
20
Figure 3. T2 weighted sagittal view of the elbow. Note the increased marrow signal within the radial neck (arrows). Signal intensity refers to the strength of the radiowave that a tissue emits following excitation. The strength of the radio wave determines the degree of brightness of the imaged structures. A bright (white) area in any image is said to demonstrate a
high signal intensity, and a dark (black) area demonstrates a decreased intensity.17 Hematopoietic marrow normally displays a low to intermediate signal intensity, whereas fluid displays a higher signal intensity on T2 weighted MRI.17 The radiologist suspected infection and recommended aspiration of synovial fluid and a biopsy. During the second orthopedic evaluation, 2 months after the MRI, the surgeon aspirated the elbow and ordered a bone scan. A culture of the aspirated fluid was negative for growth, but the bone scan image was consistent with possible septic arthritis and
patient had recovered normal elbow range of motion, and manual muscle tests of the biceps brachii, triceps brachii, and wrist extensor muscles were normal and painless.19 He said that he was working and playing Tennis without pain. The patient performed janitorial work, which consisted of Room cleaning, walls, and bathroom fixtures.
DISCUSSION Tuberculous arthritis usually occurs in an insidious manner, with pain and swelling of the affected joint. It is rare among people born in the India and is more often found in people born in other countries or those with a compromised immune
osteomyelitis. At the orthopedic follow-up 3 months later, the surgeon ordered an open debridement and biopsy based on the bone scan reports and performed an arthrotomy of the left elbow with open debridement of synovium and biopsy of the capitellum and radial head the next day. The culture was positive for acidfast bacilli, which was later identified as
system. The patient in this case report had chronic elbow pain and swelling without signs of infection. Lack of signs of infections is consistent with other cases of tuberculous arthritis described.15,16 He also reported a history of IV drug use, which, along with direct joint trauma, interarticular steroid injections, and systemic illness, has been found to be a predisposing factor for tuberculous arthritis.16 These factors and this patients history suggest an onset of TB that is consistent with reports of other patients who developed tuberculous arthritis. Joint effusion, such as that seen in this patient, often occurs with tuberculous arthritis and has been shown to affect muscles and nerves around the elbow.20,21 Chen and Eng20 noted compression of the posterior interosseous nerve at the region of the arcade of Frohse. Prem et al21 noted wasting of muscles around the upper limbs and shoulder girdle along with obliteration of bony landmarks due to swelling around an elbow infected with tuberculous arthritis. Yao and Sartoris1 also stated that weakness and muscle wasting could be present around
21
Mycobacteria tuberculosis. Following identification of TB, a physician specializing in infectious diseases evaluated the patient. The bacterium was sensitive to ethambutol, pyrazinamide, isoniazid, and rifampin, and the patient began a 4-drug anti-TB regimen for no less than 1 year.
OUTCOMES Four months after initiating the drug regimen, the patient reported that he was pain-free, and he was discharged from the orthopedic surgeons care. The therapist attended a weekly orthopedic clinic during which patient was evaluated by an orthopedic surgeon. At 12 months after the diagnosis of TB, the
involved joints. The patient in this case report did not have sensory deficits, but he did have noticeable wasting of his biceps and triceps muscles. Persistent effusion in the knee affects afferent activity of intracapsular receptors and can cause reflex
2224
appearance in the involved bone is not uncommon. The third set of radiographs revealed no abnormalities in bone or joint space, with the exception of a positive fat-pad sign. Greenspan17 reported that a positive fat-pad sign could be indicative of interarticular swelling or a fracture. The fourth set of radiographs eliminated the possibility of a fracture that had not been diagnosed, but they revealed a smaller fat-pad sign, which most likely appeared because of interarticular swelling. When radiographs are normal, an MRI may be beneficial by revealing early changes such as edema that are not visible on radiographs.27 The patients MRI identified the complex effusion in his elbow, but a biopsy that was needed for the definitive diagnosis. Biopsy is the most
6,9,13,15
inhibition of the quadriceps femoris muscle.
similar mechanism may have occurred in this patient, causing wasting of the biceps and triceps muscles due to capsular distention and intracapsular pressures. An alternative hypothesis might also attribute the muscle wasting to disuse secondary to pain during elbow motion. Radiographs can be powerful diagnostic tools, but they are not always beneficial during evaluation of a patient with tuberculous arthritis. Some authors have described normal chest radiographs in patients with tuberculous arthritis20,25 and old or active pulmonary disease evident in only 50% of chest radiographs in patients with tuberculous arthritis.
8,16
definitive
test
for
tuberculous arthritis.
Some authors have
reported that synovial fluid or tissue cultures establish a diagnosis in 90% of the cases of tuberculous arthritis.11 Material for the culture may be obtained from aspiration of joint fluid, but this may be inconclusive, as it was in this patients case. Laboratory tests such as sedimentation rate, granulocyte count, and lymphocyte count are not thought to be helpful.7 This patients prior tuberculin skin tests were positive, which is consistent with researchers findings for patients with tuberculous arthritis.6,10,20,25 However, as was described in cases involving a 66-year-old woman15 and a 76-year-old man16 with tuberculous arthritis of the elbow, a negative TB skin test does not exclude diagnosis of tuberculous arthritis. Repeated negative tuberculin tests, however, practically eliminate TB as a possible etiology.7 Before the advent of anti-TB
Elbow radiographs can also be negative, even when the disease is present.15 Unlike pyogenic organisms that produce rapid destruction of bone, TB has a gradual progression of symptoms.
26
It has been
reported to begin in the distal end of the humerus, olecranon, or synovium of the elbow joint.13,25 The first radiograph report of the patients elbow was normal. The second series of radiographs identified a cyst-like structure and mild exostotic bone formation that was not identified on the first and final radiographs. Munk and Lee26 contended that a normal appearance on imaging is the rule with TB infections because the underlying bone reacts (by forming cysts and producing sclerotic borders at the margins of the infected lesion) in an attempt to wall off the infectious process. Thus, a cyst-like
22
chemotherapy, the classic treatment in adults consisted of excision or arthrodesis of the elbow
joint.28 The disadvantage of arthrodesis was loss of motion, and the risk of excision was an unstable elbow.28 Anti-TB agents are effective in halting the destructive process and treating the infection. However, they cannot repair the anatomical defects that can occur in later stages. During these stages, fibrous tissue can result in ankylosis of the joint. Similarly, the untreated cases can evolve to bony ankylosis.16 The literature provides few specifics for the physical
29 8
patients elbow to being pain-free with full range of motion. Chen et al12 reported that a continuous passive movement (CPM) device improved
functional results after synovectomy and intraarticular debridement. Following surgery, the arc of movement was set at 30 to 90 degrees and then increased to a level that the patients were able to tolerate. Patients used the CPM device for 2 to 4 weeks until movement exceeded 120 degrees. The average flexion deformity in a group of 8 patients who used the CPM device was 24 degrees versus 34 degrees in a group of 8 patients who were treated with active and passive movement. Active and passive movement was not defined. The patient in this report responded well to antibiotics and regained full elbow function without immobilization or surgery. This improvement could have been due, in part, to the location of the disease in the joint. Vohra and Kang25 stated that prognosis is excellent in synovial and extra-articular lesions, whereas involvement of articular cartilage reduces the chances of maintaining good range of motion. In addition, this patients improvement could have been due to diagnosing tuberculous arthritis early and administering anti-TB treatment before severe destruction occurred. Chen et al12 noted that joints with severe intra- and extra-articular destruction usually become stiff with fibrosis and adhesions. Martini and Gottesman28 hypothesized that, unlike the lower-limb joints, the elbow is nonweight bearing and therefore more able to recover a normal, painless range of motion, as this patient was able to do.
therapist have
management
of
TB.
Investigators
reported using prolonged
immobilization for an average of 18 months. With the introduction of TB drugs, this is no longer necessary.
12 6,28
Some
authors
advocated
immobilizing the elbow for 1 to 2 months at 90 degrees to relieve pain and, in the event of fusion, to achieve a functional position. After removing the cast, rehabilitation proceeded daily for 3 to 6 months, with a back splint used between therapy sessions to prevent extension deformity and help the elbow flexors regain power.
6
No
specific
descriptions of the splint or interventions were reported. Surgery may be necessary in certain cases when the disease does not respond to drugs or to correct deformities or improve joint function. Vohra and Kang25 treated 6 cases of elbow TB, ranging from the disease being restricted to within the synovial membrane to extensive articular cartilage
8
involvement. Patients were treated with 3 to 6 weeks of immobilization after surgery followed by encouraging active movements and using night splints for 2 to 5 months. No other intervention specifics were given. Other authors
30
reported that CONCLUSION Patients with tuberculous arthritis are not often
23
using a hinged long arm brace for a month after surgically removing granulation tissue returned the
examined or treated by physical therapists in India due to the relative rarity of TB infections of joints. Because of its often slow progression,
physical therapist and other health care providers. Physical therapists and other health care providers can learn from this case to consider tuberculous arthritis in the differential diagnosis of unexplained musculoskeletal complaints, especially in patients with compromised immunity or from an area where TB is endemic.
tuberculous arthritis is a frequently misdiagnosed condition, which delays treatment and can lead deformities and functional deficits. This patients disease was identified as a result of diagnostic tests and communication between a
REFERENCES 1. Yao DC, Sartoris DJ. Musculoskeletal tuberculosis. Radiol Clin North Am. 1995;33:679689. 2. Centers for Disease Control and Prevention. Tuberculosis morbidityUnited States, 1997. MMWR Morb Mortal Wkly Rep. 1998;47: 253275. 3. Centers for Disease Control and Prevention. Progress toward the elimination of tuberculosisUnited States, 1998. MMWR Morb Mortal Wkly Rep. 1999;48:732736. 4. Zuber PL, McKenna MT, Binkin NJ, et al. Long-term risk of tuberculosis among foreign-born persons in the United States. JAMA. 2007;278:304 307. 5. Davidson PT, Horowitz I. Skeletal tuberculosis: a review with patient presentations and discussion. Am J Med. 1970;48:77 84. 6. Martini M, Benkeddache Y, Medjani Y, Gottesman H. Tuberculosis of the upper limb joints. Int Orthop. 2006;10:1723. 7. Martini M, Ouahes M. Bone and joint tuberculosis: a review of 652 cases. Orthopedics. 2005;11:861 866. 8. Wright T, Sundaram M, McDonald D. Radiologic case study: tuberculous osteomyelitis and arthritis. Orthopedics. 1996;19:699 702. 9. Rotrosen D. Infectious arthritis. In: Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrisons Principles of Internal Medicine. 12th ed. New York, NY: McGraw-Hill; 1991:544548. 10. Asaka T, Takizawa Y, Kariya T, et al. Tuberculous tenosynovitis in the elbow joint. Intern Med. 1996; 35:162165. 11. Naides SJ. Infectious arthritis: viral and less common agents. In: Schumacher HR, Klippel JH, Koopman WJ, et al, eds. Primer on the Rheumatic Diseases. 10th ed. Atlanta, Ga: Arthritis Foundation; 2003: 199 200. 12. Chen WS, Wang CJ, Eng HL. Tuberculous arthritis of the elbow. Int Orthop. 2007;21:367370. 13. Parkinson RW, Hodgson SP, Noble J. Tuberculosis of the elbow: a report of five cases. J Bone Joint Surg Br. 1990;72:523524. 14. Holder SF, Hopson CN, Vonkuster LC. Tuberculous arthritis of the elbow presenting as chronic bursitis
24
of the olecranon. J Bone Joint Surg Am. 1985;67:11271129. 15. Patel S, Collins DA, Bourke BE. Dont forget tuberculosis. Ann Rheum Dis. 1995;54:174 175. 16. George JC, Buckwalter KA, Braunstein EM. Case report 824: tuberculosis presenting as a soft tissue forearm mass in a patient with a negative tuberculin skin test. Skeletal Radiol. 2004;23:7981. 17. Greenspan A. Orthopedic Radiology: A Practical Approach. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 2007. 18. Daniel TM. Tuberculosis. In: Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrisons Principles of Internal Medicine. 12th ed. New York, NY: McGraw-Hill; 1991:637645. 19. Kendall FP, McCreary EK. Muscles: Testing and Function. 3rd ed. Baltimore, Md: William & Wilkins; 1983:18293. 20. Chen WS, Eng HL. Posterior interosseous neuropathy associated with tuberculous arthritis of the elbow joint: report of two cases. J Hand Surg [Am]. 1994;19:611 613. 21. Prem H, Babu NV, Chittaranjan BS, et al. Tuberculosis of the elbow: an unusual presentation. Tuber Lung Dis. 2004;75:157158. 22. Fahrer H, Rentsch HU, Gerber NJ, et al. Knee effusion and reflex inhibition of the quadriceps: a bar to effective retraining. J Bone Joint Surg Br. 2008;70:635 638. 23. Spencer JD, Hayes KC, Alexander IJ. Knee joint effusion and quadriceps reflex inhibition in man. Arch Phys Med Rehabil. 2004;65: 171177. 24. Stratford P. Electromyography of the quadriceps femoris muscles in subjects with normal knees and acutely effused knees. Phys Ther. 2002;62:279 283. 25. Vohra R, Kang HS. Tuberculosis of the elbow: a report of 10 cases. Acta Orthop Scand. 1995;66:5758. 26. Munk PL, Lee MJ. Musculoskeletal case 3: musculoskeletal tuberculosis. Can J Surg. 2009;42:120 121. 27. Gordon AC, Friedman L, White PG. Pictorial review: magnetic resonance imaging of the paediatric elbow. Clin Radiol. 1997;52: 582588. 28. Martini M, Gottesman H. Results of conservative treatment in tuberculosis of the elbow. Int Orthop. 1980;4:83 86. 29. Wilson JN. Tuberculosis of the elbow: a study of thirty-one cases. J Bone Joint Surg Br. 1953;35:551 560. 30. Yip KH, Lin J, Leung PC. Cystic tuberculosis of the bone mimicking osteogenic sarcoma. Tuber Lung Dis. 2006;77:566 568.
CORRESPONDING AUTHOR: * Amit Murli Patel BPT, MPT-Orthopaedics, Assistant Professor & Vice Principal, College Of Physiotherapy, Ahmedabad E-Mail : patelmpt@Yahoo.Com
25
EFFECT OF SENSORY CUEING ON GAIT AND BALANCE DURING BOTH ON AND OFF DRUG PHASE OF PARKINSONS DISEASE
Sinha Siddharth M.P.T. (Neurology)*, Bhatt Sunil M.P.T. (Neuro-science)**
ABSTRACT AIM: The effect of cueing has been well proved in PD but almost all of the studies are done in on drug phase of the disease. So in this study we tried to investigate the efficacy of a supervised cueing training in on drug as well as off drug phase of Parkinson patients. METHODOLOGY: Experimental study sample 8 individuals with idiopathic PD are selected on basis of inclusion criteria- Idiopathic Parkinsons , in stage 2-3 on hoer and yahr staging, excluded those MMSE < 24, any known Cardio respiratory complication that hinders the exercise program, any other known neurological condition ,any fracture or surgery of lower limb in last one year . Group A is OFF drug phase and group B ON drug phase. Both groups were assessed in both ON drug phase and OFF drug phase. Intervention consisted of a sensory cuing visual (floor markers) and auditory (beep) cues. The data analyzed within group and between groups for any improvements in both the phases. RESULTS AND CONCLUSION: cueing techniques is helpful in improving gait and balance in PD. But we suggest that treatment given in OFF drug phase is more beneficial. KEYWORDS: ON drug phase, OFF drug phase, PD, sensory cueing.
INTRODUCTION Parkinsons disease (PD) is one of the most
common neurological disorders in elderly people. Between the age of 55 and 85 years, 4.2% of all women and 6.1% of all men develop PD. The major
26
motor symptoms in PD are tremor, rigidity, bradykinesia, and postural instability, resulting in problems with gait, balance, transfers, and posture. These problems can lead to reduced mobility and decreased levels of physical activity, which in turn can cause increased dependency and social isolation and thereby reduce quality of life.19 it is therefore important to encourage patients to maintain their mobility and to stay active, for example, by referring them to physical training programs. These physical exercise programs include use of rhythmic cues. Cueing can be defined as using external temporal or spatial stimuli to facilitate movement (gait) initiation and continuation. Cueing can be defined as using external temporal or spatial stimuli to facilitate movement (gait) initiation and continuation.
19
limited. Although there is evidence to support the use of sensory cues to improve gait, balance and other impairments in PD but almost all of the literature available is using this technique in ON drug phase of disease i.e. when the PD patient is under the effect of antiparkinsons medicine. Secondary the definitive effect of sensory cueing in ON and OFF drug phase of the disease has not been compared.
BACKGROUND Sean Ledger, Rose Galvin et al. in their randomized controlled trial evaluated the effect of an individual auditory cueing device on freezing and gait speed in people with Parkinson's disease. In this study they used an Apple iPod-Shuffle and similar devices provide a cost effective and an innovative platform for integration of individual auditory cueing devices into clinical, social and home environments and are shown to have immediate effect on gait, with improvements in walking speed, stride length and freezing. Visual, auditory and somatosensory cueing devices have also been used in conjunction with walking aids, to improve gait in individuals with Parkinsons disease. Given the challenge that this clinical population may have with initiating motor movements during gait (i.e. freezing gait).37 The freezing phenomena are difficult to treat. Pharmacological treatment is usually disappointing. Rehabilitation in particular the efficacy of auditory and visual cues, is a new rehabilitation strategy based on treadmill training associated with auditory and visual cues. Giuseppe Frazzitta, MD, Roberto Maestri, MD et al. in their study investigated the effectiveness of a cueing with treadmill. One group of patient get treated with treadmill and other get
27
Unfortunately, evidence-based knowledge about effects of cueing in PD is limited. Best-evidence synthesis of 24 studies, up to 2002, showed only 1 high- quality study. Specifically focused on the effects of auditory rhythmical cueing. Studies claim positive effects of cueing on gait speed of patients with PD; however, it was unclear whether positive effects identified can be generalized to improved activities of daily living in patients own home setting and reduced frequency of falls in the community. In addition, the sustainability of a cueing training program remains uncertain.19 A recent review on cueing suggests that cueing can have an immediate and powerful effect on gait in PD. Vision-to facilitate locomotors activity was first described by Martin over 25 years ago. In a later study, Forsberg et a reported beneficial effects of visual guidance on gait movements in patients with Parkinson's disease. Unfortunately, evidencebased knowledge about effects of cueing in PD is
14 19
conventional treatment.15 Cueing strategies are thought to reroute the movement

9
Appropriate and precaution taken to avoid any fall. For subject both the groups were assessed in both ON and OFF drug phase. Group A (is ON drug patient) subject received training in ON drug phase. Group B (is OFF drug patient) subject received training in OFF drug phase. Each
through
nonautomatic
pathway,
removing it from the automatic basal ganglia pathway. Leland E. Dibble found that visual and auditory cueing technique in functional and
movement time task separately and results suggest that both technique get improve but visual cueing effects are not limited to gait tasks and auditory cuing results that cadence and stride length has been shown to consistently increase when auditory cues are present relative to when cues are not present.
1,7,13,23,36,37,38
participant received cueing training in the supervised situation with the help of a prototype cueing device. This cueing device provided 2 rhythmical cueing modalities: (a) an auditory modality (a beep), (b) a visual feedback Cueing training was delivered in the home setting. Participants were instructed to listen to the cueing when they are performing tasks. They were encouraged to listen to the rhythmical cue and to try to match their heel strike with the beat of the beep sound on the device and try to match heel strike with visual cue make on ground. The results were analyzed for within group and between the groups
Sensory cue enhanced gait training in mild to moderate PD patients. Treadmill with music has been proved to give additional benefits for improving gait related parameters.6
METHODOLOGY Subjects were selected through convenient sampling. After having the informed consent of 8 subjects and fulfillment of inclusion criteria
comparison.
systematic randomization was done and the subject were assigned to the particular group according to their sequence of approach i.e. 1st, 3ed, 5th, 7th in group A and 2ed, 4th, 6th, 8th in group B . Protocol All subjects underwent 20 minutes of each session including rest time (2 min), rest time to decrease the effect of fatigue, 1 session (Monday to Saturday) in a day for 2 weeks for 11 day , one day rest between the two subsequent weeks.
DESIGN AND PROCEDURE They were then randomly directed into 2 groups at baseline, all subject were assessed for gait (10 MWT), balance (BBS), and function (NQS).
28
RESULTS AND DISCUSSION Both of the groups showed clinically significant improvement in both on and off drug phases. Both phases have shown improvement in gait and balance parameters specially step length, speed, sit to stand, turning, time taken.
WITHIN THE GROUP Within the groups subject improved significantly in all the parameters namely gait, balance and function. Both of the groups showed clinically significant improvement in both on and off drug phases. Both phases have shown improvement in gait and balance parameters specially step length, speed, sit to stand, turning, time taken.
ON Drug Phase Group A patient initially did not have any difficulty to start the training as compared to Group B. The on phase of the disease in group A was improved i.e. these patients showed an increased step length, increased step per minute, reduced timing of sit to stand, during their on drug period. Also they had positive effects of cueing on gait and Graph of mean difference between Group A and Group B. gait related mobility. These patients had shown an improvement in their balance because of the challenges they faced during the gait training. Clinically and subjectively significant Subjectively also these patients reported that after intervention they were able to walk much more independently and safely and their day to day activities were much easier now. Some of the subjects in this group who complained of giddiness during initial assessment and training were now much better and their giddiness disappeared after the intervention. Also they had better endurance and their breathing abilities were improved; as reported by these subjects. These changes were evident in both ON drug and OFF drug periods of these subjects.
improvement in both ON and OFF drug phases, both phases have shown improvement in gait and balance parameters specially time taken for 10 meter, sitt to stand timing and speed.
Graph of mean difference between Group A and Group B significant variable.
OFF Drug Phase Group B patients initially had many difficulties in starting and performing the training sessions. As
29
training for these subjects was given in OFF drug phase, without the effect of medication they had difficulty in concentrating visual and auditory cueing simultaneously. Patient use to get puzzled between visual and auditory cues but after 2 days of training they learnt how to synchronies the visual and auditory cue to use them simultaneously. They had improved gait parameter like sit to stand, speed, time taken for 10 meter, step length after intervention. Neurophysiologically these improvements in both the groups can be attributed to the fact that sensory cueing training strengthens the neurons in cerebral cortex bypassing the damaged basal ganglia thereby cortex is independent of the damaged basal ganglia signals for performing the movements and functions.
14
synaptogenesis7,36,37,38,13,9 Cueing technique acts like a pacemaker and provides an external rhythm that is able to stabilize the defective internal rhythm of the basal ganglia. Increased activation of the lateral premotor cortex in PD patients during cueing lends support to this view (Hanakawa et al., 1999b).14
BETWEEN THE GROUPS Subjectively also group B patient reported better improvement compare with group A.
Subjectively, after intervention these subjects (group B) reported, that now if some time they have a delay in taking medicine timely or skip the drug dosage, still their symptoms did not worsen; infect they were better now compared to pre-intervention time. Also the fear of fall became less after the treatment, confidence level was increased. Because of training was given to them in the same phase (OFF drug). This context specific training helped them for better learning and hence more benefits. Carr and Sepherd.27 in their works have emphasized the importance of context specific training in rehabilitation. Plasticity is a general term describes the ability
Several authors have suggested that predictive external sensory cues, such as auditory rhythm, can provide the necessary trigger in Parkinson's disease to switch from one movement component in a movement sequence to the next and thus bypass defective internal pallidocortical projections,
25, 26
possibly via the lateral premotor cortex which receives sensory information in the context of externally guided movements.27, 32 However, the neurophysiologic basis for
to
show
modification.
Plasticity,
or
neural
auditory-motor interactions is not well understood. There is some evidence that rhythmic sound patterns can increase the excitability of spinal motor neurons via the reticulospinal pathway, thereby reducing the amount of time required for the muscles to respond to a given motor command.32 Recent work with animal models of PD indicate that rehabilitative training can stimulate a number of plasticity-related events in the brain, including neurotrophic factor expression and
30
modifiability, may be seen as a continuum from short-term changes in the efficiency or strength of synaptic connection to long term structural changes in the organization and number of connections among neurons.4, 33 Learning also can be seen as a continuum of short term to long term changes in the ability to produce skilled action. The gradual shift from short term to long term learning reflects a move along the continuum of neural modifiability, as increased
synaptic efficiency gradually gives way to structural changes, which are the underpinning of long term modification of behavior.
5
will improve their balance, gait and function in much more beneficial way and may reduce or alter their dependency on drugs; thereby providing them a complete rehabilitation. So rehabilitation given in
CONCLUSION Sensory cueing using visual and auditory cues is beneficial for Parkinsons disease. It improves their gait, balance and functional activity.
OFF drug phase may help to decrease or alter the drug usage by these patients and to provide an overall rehabilitation program to this population give the treatment in OFF drug phase because patient have more difficulty in OFF drug phase and context specific training, tasks specific training give better results.
Subjectively and objectively group B (subjects for whom training was given in off drug phase) showed significantly better results. We suggest that training given in OFF drug phase to Parkinsons patients
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use in 6-hydroxydopamine-treated rats: possible role of GDNF. J. Neurochem. 2003;85(2):299-305. 8. Cunnington R, Iansek R, Bradshaw JL, Phillips JG. Movement-related potentials in Parkinson's disease: presence and predictability of temporal and spatial cues.Brain 1995;118:935-50. 9. David A. Lehman, PhD, PT;1 Tonya Toole, PhD;2 Dan Lofald, PhD;3 Mark A. Hirsch, PhD4 Training with Verbal Instructional Cues Results in Near-term Improvement of Gait in People with Parkinson Disease, Journal of Neurological Physical Therapy Vol. 29 No. 1 2005 10. Ebersbach, G., Edler, D., Kaufhold, O., & Wissel, J. (2008). Whole body vibration versus conventional physiotherapy to improve balance and gait in Parkinson's disease. Archives of Physical Medicine and Rehabilitation, 89: 399403. 11. Farley BF and Koshland GF (2005a). Training BIG to move faster: The application of the speedamplitude relation as a rehabilitation strategy for people with Parkinsons disease. Exp Brain Res 167(3): 462- 467 (Epub Nov 11). Farley BF and Koshland GF (2005b). Efficacy of a large-
amplitude exercise approach for patients with Parkinsons disease- bradykinesia to balance. 9th International Congress of Parkinsons Disease and Movement Disorders, Abstract #466. 12. Folstein MF, Folstein SE, McHugh PR: Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. J Psychiatry Res 1975; 12:189-198. 13. Fisher BE, Petzinger GM, Nixon K, et al. Exercise induced behavioral recovery and neuroplasticity in the 1-methyl-4-phenyl 1,2,3,6-tetrahydropyridine-lesioned mouse basal ganglia. J Neurosci Res. 2004;77(3):378-390. 14. Gerald C McIntosh, Susan H Brown, Ruth R Rice, Michael H Thaut , Rhythmic auditory-motor facilitation of gait patterns in patients with Parkinson's disease Journal of Neurology, Neurosurgery, and Psychiatry 1997;62:22-26 15. Giuseppe Frazzitta, MD,1* Roberto Maestri, MD, Rehabilitation Treatment of Gait in Patients with Parkinsons Disease with Freezing: A Comparison Between Two Physical Therapy Protocols Using Visual and Auditory Cues with or Without Treadmill Training Movement Disorders Vol. 24, No. 8, 2009, pp. 11391143 _ 2009 Movement Disorder Society 16. Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell JL (April 2008). "The effectiveness of exercise interventions for people with Parkinson's disease: a systematic review and metaanalysis". Mov. Disord. 23 (5): 63140. doi:10.1002/mds.21922. PMID 18181210 17. Haas, C.T., Turbanski, S., Kessler, K., & Schmidtbleicher, D. (2006). The effects of random wholebody-vibration on motor symptoms in Parkinson's disease. NeuroRehabilitation, 21: 2936 18. Halsband U, Ito N, Tanji J, Freund HJ. The role of premotor cortex and the supplementary motor area
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in the temporal control of movement in man. Brain 1993;116:1017-43. 19. Inge Lim, PhD, Erwin van Wegen, PhD, Diana Jones, PhD, Lynn Rochester, PhD, Alice Nieuwboer, PhD, Anne-Marie Willems, PhD, Katherine Baker, PhD,Vicki Hetherington, MSc, and Gert Kwakkel, PhD Does Cueing Training Improve Physical Activity in Patients With Parkinsons Disease 20. Jeffrey M. Hausdorff, Justine Lowenthal,at all, Rhythmic auditory stimulation modulates gait variability in Parkinsons disease European Journal of Neuroscience, Vol. 26, pp. 23692375, 2007 21. King, L.K., Almeida, Q.J., & Ahonen, H. (2009). Short-term effects of vibration therapy on motor impairments in Parkinson's disease. Neuro Rehabilitation, 25: 297306 22. Janet H Carr, Roberta B. Shepherd, chepter- Background to the Development of the M.R.P. book- A Motor Relearning Programme For stroke , second edition reprint 1986, London Publisher-Aspen ,1986 23. Leland E Dibble at all, Sensory Cueing Improve Motor Performance and Reabilitaion in Person With Parkinsons disease. Vol 21 No 4 1997 24. Minna Hong, PT, PhD, and Gammon M. Earhart, PT, PhD, Effects of Medication on Turning Deficits in Individuals with Parkinsons Disease JNPT Volume 34, March 2010 25. McIntosh et al., 1997; Brotchie et al., 1991; Thaut, 2003; Jantzen et al., 2005; Zelaznik et al., 2005; Nagy et al., 2006. RAS may circumvent the pallidal- supplementary motor area pathway, possibly via the premotor cortex, and provide external cues to guide movement (Mushiake et al., 1991; Halsband et al., 1993; Hanakawa et al., 1999a; Elsinger et al., 2003) 26. Morris ME, Iansek R, Matyas TA, Summers JJ. Stride length regulation in Parkinsons disease. Normalization strategies and underlying mechanisms. Brain 1996;119:551568 27. Mushiake H, Inase M, Tanji J. Neuronal activity in the primate premotor, supplementary, and precentral motor cortex during visually guided and internally determined sequential movements. J Neurophysiol 199 1;66:705-18 28. Miyai, I., Fujimoto, Y., Yamamoto H., et al. 2002. Long-term effect of body weight-supported treadmill training in Parkinsons disease: a randomized controlled trial. Arch Phys Med Rehabil, 83(10):1370-1373. 29. Morris ME, Iansek R, Matyas TA, Summers JJ. The pathogenesis of gait hypokinesia in Parkinson's disease. Brain 1994;117:1169-81. 30. O'Sullivan & Schmitz 2007, pp. 873, 876 31. O'Sullivan & Schmitz 2007, p. 879
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32. Paltsev YI, Elner AM. Change in the functional state of the segmental apparatus of the spinal cord under the influence of sound stimuli and its role in voluntary movement. Biophysics 1967;12:1219-26 33. Reiko Kawagoe, Yoriko Takikawa and Okihide Hikosaka, Expectation of reward modulates cognitive signals in the basal ganglia 1998 Nature America Inc. http://neurosci.nature.com, nature neuroscience volume 1 no 5 september 1998 34. Rubinstein TC,GiladiN,Hausdorff JM. The power of cueing to circumvent dopamine deficits: a reviewof physical therapy treatment of gait disturbances in Parkinsons disease. Mov Disord. 2002; 17:1 148-1160. 35. Sean Ledger, Rose Galvin, Deirdre Lynch and Emma K Stokes , A randomised controlled trial evaluating the effect of an individual auditory cueing device on freezing and gait speed in people with Parkinson's disease , 11 December 2008 BMC Neurology 2008, 8:46 doi:10.1186/1471-2377-8-46 36. Tillerson JL, Cohen AD, Caudle WM, Zigmond MJ, Schallert T, Miller GW. Forced nonuse in unilateral parkinsonian rats exacerbates injury. J Neurosci. 2002;22(15):6790-6799. 37. Tillerson JL,Cohen AD,Philhower J,Miller GW,Zigmond MJ,Schallert T.Forced limb-use effects on the behavioral and neurochemical effects of 6-hydroxydopamine. J Neurosci. 2001;21(12):44274435. 38. Tillerson JL, Caudle WM, Reveron ME, Miller GW. Exercise induces behavioral recovery and attenuates neurochemical deficits in rodent models of Parkinsons disease. Neuroscience. 2003;119(3):899-911. 39. The National Collaborating Centre for Chronic Conditions, ed. (2006). "Other key
interventions". Parkinson's Disease. London: Royal College of Physicians. pp. 13546.ISBN 186016-283-5.
CORRESPONDING AUTHOR: * Department of Physiotherapy, Dolphin (P.G.) institute of bio medical and natural sciences, Dhradun , H.N.B. Garhwal University, Srinagar, Uttarakhand, India. Email: sidd2sinha@gmail.com ** Department of Physiotherapy, Dolphin (P.G.) institute of bio medical and natural sciences, Dhradun , H.N.B. Garhwal University, Srinagar, Uttarakhand, India.
34
CONGENITAL TALIPES EQUINOVARUS (CTEV)

Mayank Pushkar. BPT, MSAPT*
INTRODUCTION Congenital telipesequinovarus (CTEV) is a common congenital limb deformity involving one foot or both1. Congenital means a deformity that is present at birth, Telipes means simply the foot and ankle, and Equinovarus refers to position of the foot, which points downward and inward. CTEV is also known as Clubfoot. An estimated 30000 children born with CTEV every year in India2, although a rate of 1.24 or greater have been reported in UK. It is a common birth defect, occurring in about 1/1000 live births. Almost half of the cases of CTEV are bilateral. Male children are more affected than female children with a ratio of approximately 2:13. PATHOANATOMY The true clubfoot is characterized by different
35
deformities- Equinus, Varus, Adductus and cavus4. The equinus deformity is present at the ankle joint, TCN joint and forefoot. The varus component occurs primarily at TCN joint and the hind foot is rotated inward. The adductus deformity takes place at the talonavicular and the anterior subtalar joints. The cavus component involves forefoot plantar flexion, which contributes to the composite equinus.
Fig- 1- Showing CTEV in both the foot. AETIOLOGY Genetic factors play an important role in
inheritance of CTEV as a polygenic multifactorial trait5. Maternal Hyperthermia is also one of the causes for CTEV6, as maternal hyperthermia acts as adverse environmental factor in the sensitive period of intrauterine development. Mainly there are 3 broad categories responsible for CTEV deformity in newborn71. NEUROLOGICAL DAMAGE 2. MUSCULO-SKELETAL DEFORMITY 3. POSTURAL DEFORMITY 1.NEUROLOGICAL DAMAGE: Spina bifida overta with failure of development of the sacral part of the spinal cord but normal proximal development can results in an equinovarus deformity of the foot. 2. MUSCULO-SKELETAL DEFORMITY:
neural tube defect are some of the other causes of structural CTEV4. 2. POSTURAL CTEV: This type of CTEV is caused due to the compression in utero with the feet held in equionovarus position in final trimester. CLINICAL FEATURES OF CTEV Idiopathic clubfoot is characterized by a beanshaped foot prominence of the head of Talus, medial plantar cleft, deep posterior cleft, absence of normal creases over the insertion of tendon achilies, calcaneal tuberosity situated at a higher level and atrophy of calf muscle4. Three major components of deformities, those are, equinous, varus and adducts, are obvious on examination. Presence of other anomalies implies a non-idiopathic type of clubfoot. Hypertrophy of calf muscle is present and dorsiflexion and eversion are limited. Lateral malleolus is very prominent while the medial malleolus is buried in a depression because of the inversion at the subtalar joint. There is also exaggeration of longitudinal arch of the foot. ASSESSMENT OF CTEV
CTEV can results because of composite intrinsic pathology of muscle and the bone. There are varieties of other conditions which affectthe peripheral musculoskeletal tissues and cause an equinovarus deformity. 3. POSTURAL DEFORMITY: Some children born with equinovarus deformity of the feet, if they have been tightly packed in the utero with the feet fixed in an equinovarus position for some week prior to birth. TYPES OF CTEV
ANTENATAL DIAGNOSIS: The clubfoot can be diagnosed at 18-20 weeks of gestation with the advert of Ultrasound. Amniocentesis is made at < 20 weeks to check for the high incidence of associated genetic anomalies7,8. POSTNATAL DIAGNOSIS: The child as well as
1. STRUCTURAL CTEV: This type of CTEV is caused by genetic factors such as- a genetic defect with 3 copies of chromosome 18, which is known an Edward Syndrome. Compartment syndrome,
foot must be carefully assessed at birth. The early assessment of CTEV can be carried out by two methords9: 1. Photographic Assessment
36
Larsens syndrome, congenital heart defect and
2. Radiological Assessment 1.PHOTOGRAPHIC ASSESSMENT: Photograph of resting forefoot supination is recommended at birth. The focus of the camera is centred at the level of the ankle joint and an assistant holds the knee between finger and thumb and rotates the leg outward until the forefoot is superimposed upon the line of tibia. From the photograph it is then possible to measure an angle subtended by the forefoot on the line of the tibia (Fig. 2). Children with more than 90
0
CTEV is the correction of the deformity followed by maintenance of the in the corrected position. The management of CTEV can be conservative (Non-operative) method as well as operative depending on the severity of deformity and age of child. CONSERVATIVE TREATMENT The conservative method comprises of
manipulation with or without strapping or corrective plaster casts. The goal of physiotherapy management of CTEV consisted of short term and long term goals14. The short term goal is to correct the
of resting forefoot supination at birth were more resistant to surgical correction.
deformity so that ankle assumes plantigrade positioning by the time the child would be 3 months. The long term goal is to maintain the corrected ankle in the situ and follow up the maintained correction until the child start walking. MEANS OF PHYSIOTHERAPY
MANAGEMENT 1. Rhythmic and repeated gentle
manipulation10 Fig. 2- Showing the measurement of angle. 2.RADIOGRAPHIC ASSESSMENT: A standard lateral soft tissue radiograph of the lower leg can be used for the assessment of CTEV. But X-Rays are not routinely prescribed at birth as few bones in the foot are ossified4. Also there is not much of clinical use of radiographic assessment as it does not make any difference in management of CTEV. MANAGEMENT OF CTEV The main principle of the management of
37
2. Strapping and Plaster of Paris 3. Education and instruction to the mother and/ or parents10 1. RHYTHMIC AND REPEATED GENTLE MANIPULATION: To provide gentle manipulation, the PT placed the knee at 900 of flexion to prevent the damage to the lower end of tibia and fibular epiphysis and the ankle joint. To correct the adduction, the soft tissue of foot is passively stretched as- the forefoot is uncurled so that it moves away from epsilateral heel i.e. forefoot
abduction. To correct the inverted foot, the foot is turned such that the sole face outward i.e. eversion. Finally, to correct the equinus, the heel is cupped with the one hand from the front of the foot and an upward pressure is applied, which brings the ankle into dorsiflexion. The entire procedure is repeated 34 times in each foot. 2. STRAPPING AND PLASTER OF PARIS: This can be useful for fairly mild cases and should be started at birth. Strips of adhesive strapping are passed around the foot, up the side of legs, and over the top of the knee, to hold the foot in a corrected position. This is usually done weekly, followed by some manipulation by the physiotherapist. According to the International Clubfoot Study Group (2003), Kites, Ponsetis and Bensabels techniques have been approved as the standardized conservative regimes for the management of CTEV11. Kites Technique4: This technique was derived from the concept of three-point pressure. In this method, the manipulation can be started soon after birth. The forefoot is grasped and distracted while the other hand holds the heel. The counterpressure is applied over calcaneocuboid joint and the navicular is pushed laterally. The heel is everted as the foot is abducted. This is followed by application of slipper cast, which is extended to below the knee with the foot everted with gentle external rotation. Once the adduction and varus are corrected, then the foot is pushed into dorsiflexion to correct the equinous. The casts are changed every week. Following full correction, the foot are placed in a Denis Brown Bar. The average number of cast required for
38
correction by this technique is 20.4. Ponsetis Technique4: In Ponsetis technique, first 2 casts are applied with the supination of forefoot so as to bring into alignment with the hind foot12. The third cast is applied with the forefoot abducted and simultaneous counterpressure over the head of talus. In the fourth cast, the forefoot is further abducted. Before the application of fifth cast, the degree of dorsiflexion is assessed and if the dorsiflexion is not possible beyond neutral, then a Percutaneous AchiliesTenotomy is required, this is done under local anaesthesia. The casts are changed weekly intervals, before tenotomy, while the cast after the tenotomy is removed at the end of 3 weeks. After the removal of cast the patient is placed in modified Foot Abduction Orthosis (FAO). FAO is initially used 23 hrs.a day for 4 months and then subsequently for night-time for 3 years13. The average number of casts required with this technique is 5.4. French Technique4: This technique involves daily manipulation of the childs clubfoot by
Physiotherapist for 30 minutes,
followed by
stimulation of muscles (especially Peroneal muscle) around the foot and then adhesive strapping is applied. Daily treatment is required for
approximately 2 months and then reduced to 3 sessions per week for an additional six months. Tapping is continued until the patient is ambulatory. Once the child starts ambulation, then night-time splint is given for additional 2 to 3 years. 3. EDUCATION AND INSTRUCTION TO THE MOTHER: The mother should be assured and reassured that with her co-operation, consistency and
compliance to treatment, the deformity could be corrected. She should be taught how to mobilize the feet in the absence of strap10. She is advised to take care and observed every time when a fresh strapping or plaster is applied and also to prevent the plaster or strapping from being wet or soiled either by water or any other fluid. SURGICAL/ OPERATIVE MANAGEMENT The operative treatment is required once the conservative treatment fails or the chance of correction of deformity with conservative
prevent stiffness, which can be done with following physiotherapy interventions15. Movement of toe, hip and knee in the plaster cast only, by tickling or by holding child high in suspension. To improve strength and stability gradual active non-weight bearing and resisted foot and ankle exercises are given, followed by progression to weight-bearing exercises. To maintain the correction and avoid recurrence, Night splint are provided. Some of the splints used in the management of CTEV are-
management is very less. Different operative procedures are performed based on the age of child. At 9 months 3 years: A Postero-medial soft tissue release (PMR), which was introduced by Turco14 is performed and followed by Dennis Brown splint for 2 years. In this technique, the correction of the abnormal tarsal relationship is prevented by rigid pathological soft tissue contracture. At 3 years- 8 years: At this age, soft tissue release along with Wedge Osteotomy of cuboid bone, which is known as EVANS is performed. At 8- 12 years: At this age, the Wedge Osteotomy of calcaneum (Dwyers Operation) along with wedge osteotomy of tarsal bone is performed. Above 12 years: A triple arthrodesis of 3 joints of foot (i.e. subtalar, calcaneo-cuboid and talonavicular joint) is performed. POST-OPERATIVE MANAGEMENT The main objective of physiotherapy after surgical procedure is to keep the other joints mobile and
39
1. CTEV Splint 2. Dennis Brown Splint (Fig-4) 3. CTEV Shoes (Fig-5) Gait training with proper foot position is taught to the patient. Special CTEV shoes are given to the patients. The shoes got straight inner borer, which prevents forefoot adduction, outer shoe raise to prevent inversion and no heel to avoid equinus. An effective training is given to the mother or both parents for home care programme to maintain the correct position of the limb and how to give the exercise in correct way.
PHYSIOTHERAPY
Fig-3- CTEV Splint Fig-5- CTEV Shoes Splint
Fig-4- Dennis Brown
REFRENCES 1.Macnicol M. F.The management of Clubfoot: Issues for debate. J Bone Joint Surg[Br],2003;167-170. 2. Global clubfoot initiative. Last assessed on 15th May 2012 at: http://globalclubfoot.org/countries/india/ 3. Macnicol M. F. and Murray A. W. Changing Concepts in the management of congenital talipesequinovarus.Paedetrics and child health,2008; 272-277. 4. Anand, A. and Sala, D.A. Clubfoot: Etiology and treatment. Indian J Orthop,2008;42:22-28. 5. Lehman, W.B. The clubfoot. JB Lippincott: New York; 1996 6. Edwards, M.J. The experimental production of clubfoot in guinea pigs by maternal hyperthermia during gestation. J Pathol, 1971;103:49-53. 7. Katz K, Meizner I, Mashiach R, Soudry M. The contribution of prenatal sonographic diagnosis of clubfoot to preventive medicine.J Pediatr Orthop,1999;19:5-7 8. Roye, B.D., Hyman J., Roye, D.P. Jr. Congenital idiopathic talipesequinovarus. Pediatr Rev, 2004;25:124-30. 9. Porter, R. Club foot. The foot,1997;7: 181-193. 10.Ezeukwu, A.O. and Maduagwu, S.M. Physiotherapy management of an infant with bilateral congenital talipesequinovarus. African Health Science, 2011;11(3): 444-448.
40
11. Bensahel, H., Guillaume, A., Czukonyi, Z. andDesgrippes, Y. Results of physical therapy for idiopathic clubfoot: A long term8follow up study. J Pediatr Orthop,1990;10:189-92. 12. Ponseti IV, Campos J. Observations on pathogenesis and treatment of clubfoot. ClinOrthop, 1972;84:50-60. 13. Ponseti IV. Congenital clubfoot: Fundamentals of treatment. Oxford University Press: Oxford, England; 1996. 14. Turco VJ. Clubfoot. Churchill Livingstone: New York; 1981. 15. Goel RN. Goels Physiotherapy.Shubham Publication- Bhopal, Vol II, 2000.
CORRESPONDING AUTHOR: * Email: physio.mayank.pushkar@gmail.com
41
ANALYSIS OF WATER QUALITY OF HALENA BLOCK IN BHARATPUR AREA

Sunil Kumar Tank*, R. C. Chippa**
ABSTRACT Bharatpur is the well known place because of Keoladeo Ghana National Park due to which it is a world fame tourist place. The present study deals with the water quality of Halena block in Bharatpur area, which is assessed by examine various physico-chemical parameters of open wells, bore wells and hand pumps. The studies reveal that the water of most of the sampling area is hard and contaminated with higher concentration of total dissolved solids. KEYWORDS: Water pollution, Health problems, Bharatpur, Analytical techniques, Standard Data
INTRODUCTION Water is life. Without water, mans existence on the earth would be threatened and he would be driven close to extinction. All biological organisms depend on water to carry out complex biochemical processes which aid in the sustenance of life on
earth. Over 70 per cent of the earths surface materials consists of water and apart from the air man breathes, water is one of the most important elements to man. The quality of water is of great importance also for human lives as it is commonly consumed and used by households. In industry, it serves as a solvent, substrate or catalyst of chemical
42
reactions (Goncharuk 2012; Holt 2011; Van Leeuwen 2012; Petraccia et al. 2011). The physical, chemical and bacterial characteristics of ground water determine its usefulness for domestic, industrial, municipal and agricultural applications (CGWB, 2004 and Adhikary et al. 2010). The quality of water is more important compared to quantity in any water supply planning, especially for drinking purposes (CPHEEO 1998, Patnaik et al. 2002 and Tanriverdi et al. 2010).The
pollution also occurs when rain water runoff from urban and industrial area and from agricultural land and mining operations makes its way back to receiving waters (river, lake or ocean) and in to the ground. Bharatpur (Fig.1: Study Area), eastern
o o
gate of Rajasthan is situated between 26 22 to 27

o o
83 north latitude and 76 53 to 78 17 east longitude. Bharatpur is well known place because of Keoladeo Ghana National Park. Keoladeo National Park is the only the largest bird sanctuary in India. Ajan Bandh is the main water source to fill the various lakes, ponds of the park and villagers use this water for drinking purposes. In the present study several points of ground water sources such as open wells, bore wells and hand pumps have been selected to check the potability of water. MATERIAL METHOD Water quality is the physical, chemical and biological characteristics of water in relationship to a set of standards. Water quality is a very complex subject, in part because water is the complex medium intrinsically tied to the ecology of the earth. The physico chemical quality of drinking water was assessed during the month of January, 2011 by standard methods as suggested by APHA (1995) and compared with the values as guided by ICMR. The present research work is based on 15 ground water samples collected from open wells, bore wells and hand pumps in cleaned and screw capped polythene bottles. At the time of sampling, these bottles are thoroughly raised 23 times using the
43
accumulation of high levels of pollutants in water may cause adverse effects on humans and wildlife, such as cancer, reproductive disorders, damage to the nervous system and disruption of the immune system. Thus, it is an important requirement to interpret water quality status, identify significant parameters, and characterise the pollution sources as well as their quantitative contributions to water quality issues for conducting pollution management (Zhou et al. 2011). Water pollution means contamination of water by foreign matter such as micro-organisms, chemicals, industrial or other wastes, or sewage. Such matters deteriorate the quality of the water and renders it unfit for its intended uses. Water pollution is the introduction into fresh or ocean waters of chemical, physical, or biological material that degrades the quality of the water and affects the organisms living in it. Although some kinds of water pollution get occur through natural processes, it is mostly a result of human activities. The water we use is taken from lakes and rivers, and from underground [ground water]; and after we have used it and contaminated it most of it returns to these locations. Water
ground water to be sampled.
RESULTS AND DISCUSSION The physico-chemical parameters which were analysed in Post-monsoon season, January 2012 have been shown in Table-2. Colour: Fig . 1 The colour of a small water sample is caused by both dissolved and particulate material in water, These water samples are collected after pumping the water for 10 minutes (CPHEEO 1998, Chhabra 2008 and Shyam & Kalwania 2011). All the samples were properly labeled as and is measured in Hazen Units [HU]. Colour in water may be caused because of the presence of natural metallic ions (iron and manganese) humus, planktons etc. The presence of colour in water does not necessarily indicate that the water is not potable. Colour is not removed by typical water filters; however, slow sand filters can remove colour, and the use of coagulants may also succeed in trapping the colour causing compounds within the resulting precipitate. In the present study water is almost colourless. Odour: When minerals, metals and salts from soil etc. come in contact with water, they may change its taste and odour. Analyzed water samples are found odourless.
44
1,2,3,4,5,6,7,8,9 and 10 and a record was prepared which is indicated in Table 1.
Temperature: Use appropriate thermometer for calculating water temerature. Water temperature affects the ability of water to hold oxygen, the rate of photosynthesis by aquatic plants and the metabolic rates of aquatic organisms. Temperature of water samples is varied from 26.0 C to 27.2 C the variation of the water temperature having more effect directly or
o o
over falls and rapids; and as a waste product of photosynthesis. In general, rapidly moving water contains more dissolved oxygen than slow or stagnant water and colder water contains more dissolved oxygen than warmer water. In the studied water samples DO ranged from 4.6 to 7.8 mg/l. As DO level falls; undesirable odours, tastes and colours reduce the acceptability of water. The lowest DO value indicates not good healthy condition for the community (Jeena. B et al 2003). Total Alkalinity: Total alkalinity is calculate by Titration Method.
+
indirectly on all life processes. PH: Ph is measured by Ph meter. The balance of positive hydrogen ions (H ) and negative hydroxide ions (OH ) in water determines how acidic or basic the water is. In pure water, the concentration of positive hydrogen ions is in equilibrium with the concentration of negative hydroxide ions, and the pH measures exactly 7. pH is a term used to indicate the alkalinity or acidity of a substance as ranked on a scale from 1.0 to 14.0. In the present study area the pH value ranged from 7.70 to 8.76. A pH range from 7.0 to 8.5 is desirable concentration as per guided by ICMR. It is known that pH of water does not cause any severe health hazard. Water of study area is somewhat alkaline. Dissolved Oxygen (D.O.): DO can be determining by use of DO meter as well as measure by Winkler titration method.
-
Alkalinity is not a pollutant. It is a total measure of the substance in water that have acid-neutralizing ability. The main sources of natural alkalinity are rocks, which contain carbonate, bicarbonate, and hydroxide compounds, borates, silicates, and phosphates may also contribute to alkalinity.Total alkalinity is the total concentration of bases in water expressed as parts per million (ppm) or milligrams per liter (mg/l) of calcium carbonates (CaCO ). These bases are usually bicarbonates
3
(HCO ) and carbonates (CO2- ), and they act as a

3 3
buffer system that prevents drastic changes in pHs Water with high total alkalinity is not always hard, since the carbonates can be brought into the water in the form of sodium or potassium carbonate. The desirable limit of total alkalinity is 200 mg/l (ICMR). The value of study area is ranged from 161 to 202 mg/l. Alkalinity in itself is not harmful to human being, but in large quality, alkalinity imparts bitter taste to water. Total Hardness:
45
DO is the most important water quality parameter which shows the amount of oxygen present in water. It gets there by diffusion from the surrounding air, aeration of water that has jumbled
Complexometric titration using EDTA The total hardness is the sum of the hardness formers in a water (Ca, Mg, Ba and Sr ions) in mmol/l. Originally hardness was understood to be a measure of the capacity of water to precipitate soap. Soap is precipitated chiefly by the calcium and Mg
ions present. The maximum limit of hardness in drinking water is 600 mg/l (ICMR). Total hardness is measured in grains per gallon (gpg) or parts per million (ppm). If water contains less than 3.5 gpg, it is considered soft water. If it contains more than 7 gpg, it is considered hard water.
Hardness Description Soft Moderately hard Hard Very Hard > 300 Hardness range (mg/l as CaCO )
3
0-75 75-100 100-300
The total hardness value ranged in the studied area from 96 to 488 mg/l. So, the water of almost all sampling stations is hard. Calcium Hardness: Complexometric titration using EDTA hardness is sometimes confused with the terms water hardness and total hardness. Too little calcium hardness and the water are corrosive. Too much calcium hardness and the water are scale forming. The maximum permissible limit of calcium hardness is 200 mg/l (ICMR). The value of sampling stations ranged from 32.06 to 68.13 ppm. Thus sampling stations 5 and 12 have greater calcium hardness. Magnesium Hardness: Complexometric titration using EDTA Magnesium salts have a laxative and diuretic effect. The maximum permissible limit of magnesium hardness is 150 mg/l
46
A measure of the amount of calcium in water measured in ppm. High levels can cause scale buildup. Low levels can cause etching and equipment corrosion. Calcium
(ICMR). Mg hardness value in studied area ranged from 11.54 to 91.78 ppm. Chloride: Using silver nitrate titration method for calculate chloride in water. The maximum permissible concentration of
chloride is 1000 mg/l. (ICMR). So except some points the chloride contents of water samples are in limit. It varies from 53.76 to 406.07 ppm Sulphate: Ion chromatography is the only instrumental method for the direct determination of sulphate. Sulphate may be precipitated either with Ba2+ or 2aminoperimidinium salts. The precipitate may be
weighed for a direct determination of the sulphate as a gravimetric method. The maximum permissible limit of sulphate is 400 mg/l (ICMR). In the sampling areas the sulphate concentration ranged from 15.25 to 71.00 ppm. Waters with higher concentration of sulphate may cause intestinal disorders. Nitrate: Use spectrophotometer for calculating nitrate in water. Nitrate is a major ingredient of farm fertilizer and is necessary for crop production. Nitrate stimulates the growth of production. Nitrate stimulates the growth of plankton and waterweeds that provide food for fish.Maximum permissible limit of nitrate is 50 mg/l (ICMR). Nitrate in water supplies in concentration
-
fluoride can be determined by spectrophotometry or by ion-chromatography. Fluoride is more common in ground water than in surface water. The main sources of fluorine in ground water are different fluoride bearing rocks. The guideline value of fluoride is 1.5 mg/l in drinking water. In studied area, it ranged between 0.010 to 1.180ppm. Electrical Conductivity: Electrical conductivity estimates the amount of total dissolved salts (TDS), or the total amount of dissolved ions in the water. Its SI derived unit is the siemens per meter, (A S m Kg ) or more simply, Sm . It is the ratio of the current density to the electric field strength or, in more practical terms; is equivalent to the electrical conductance measured between opposite faces of a 1-meter cube of the material under test. Pure water is a poor conductor of electricity. Acids, bases and salts in water make it relatively good conductor of electricity. Electrical conductivity in studied area ranged between 7.5x102 to 2.1x103 mhos/cm. CONCLUSIONS The present results of water investigation show that the waters of study area are highly contaminated with total dissolved solids. Because of high concentration of TDS water loss its potability and high concentration of TDS also reduces the solubility of oxygen in water. Water of almost all study points are hard also because of this people of Bharatpur area are facing many problems like stomach diseases, gastric troubles etc. At some points nitrate level is also high than the permissible limit. It is recommended that water should be used
47
-1 2 3 -3 -1
over
100
mg/l.
causes
methamoglobinamia. Generally NO concentration is found in higher

3
concentration in rural areas because of runoff of nitrate rich fertilizers and animal manure into the water supply. The nitrate value ranged in
investigated area is between 17.06 to 93.2 ppm. Total Dissolved Solids (TDS): Use an appropriate TDS meter. Freshwater meters: 0-1990 ppm (parts per million). The term TDS describes all solids [usually mineral salts] that are dissolved in water. Desirable limit of TDS is 500 mg/l (ICMR). All the values obtained are much higher than the limit except points-1 and 2. It is an important parameter for imparts a peculiar taste to water and reduce its potability. Fluoride:
after boiling by the people of Bharatpur because after boiling the water, temporary hardness [carbonate hardness] can be removed and
concentration of total dissolved solids can also be decreased. Alum treatment is also a good option to make potable the water.
TABLE-1 Area, sourceof the sampling stations. Sample No. 1 2 3 4 5 6 7 8 9 10 Halena Halena bus stop Chhonkarwara Bus stand Aamoli Chote chhonkarwara Bijwari Khedli Mod Bachren Salempur Khurd Kamalpura Area Source Hand pump Hand Pump Bore Well Bore Well Hand Pump Bore Well Bore Well Hand Pump Hand Pump Hand Pump
TABLE-2 PARAM ETER pH EC 8.03 1.2x103 7.62 2.1x103 7.86 8.6x102 7.94 8.9x102 7.88 1.3x103 8.09 8.8x102 7.57 1.5x103 7.80 9.0x1 0 TDS 650 1170 497 485 690 485 760
2
S.1
S.2
S.3
S.4
S.5
S.6
S.7
S.8
S.9
S.10
7.24 1.9x1 0
3
8.25 7.5x1 02 404
493
1090
48
TH TA DO Ca+2 ppm Mg ppm Na + ppm

+2
248 168 5.7 56.91 30.57
464 183 7.6 64.93 87.10
152 185 7.8 44.89 11.54
148 191 5.7 32.06 19.61
212 175 5.9 49.70 25.38
96 174 6.1 32.87 14.04
312 161 5.5 67.33 41.53
208 176 4.6 55.31 20.19
488 202 4.6 68.13 91.78
192 188 5.6 48.90 20.18
90.39
176.87
50.57
83.26
138.69
94.99
110.86
51.29
118.2 2
89.72
Cl- ppm
149.99
406.07
53.76
87.93
197.85
81.95
262.13
69.69
340.1 4
84.03
SO42ppm NO3- ppm F- ppm
15.25
41.25
14.75
50.50
71.00
39.00
51.25
21.50
64.75
28.00
93.2 0.130
80.8 1.30
17.60 0.170
18.2 0.010
56.4 0.020
41.4 0.250
72.6 0.050
69.6 0.130
46.8 0.560
60.0 1.180
REFERENCES 1. APHA (American Public Health Association) (1995). American Water Works Association and Water Pollution Control Federation, Standard Methods of Examination of Water and Waste Water, 19 Edition, New York, USA. 2. Goncharuk, V. V. (2012). A new concept of supplying the population with a quality drinking water. Journal of Water Chemistry and Technology, 30, 129136. 3. Holt, M. S. (2011). Sources of chemical contaminants and routes into the freshwater environment. Food Chemistry and Toxicology, 38, S21S27. 4. Jena B, R. Sudarshana and S.B. Chaudhary ((2003)). Nat. Environ. Poll. Technol., 2(3), 329. 5. Kulshrestha S, S.S. Dhindsa and R.V. Singh (2002). Nat. Environ. Poll. Tech., 1(4), 453. 6. Petraccia, L., Liberati, G., Masciullo, S. G., Grassi, M., & Fraioli, A. (2011). Water, mineral waters and health. Clinical Nutrition, 25, 377385. 7. Van Leeuwen F. X. R. (2012). Safe drinking water: The toxicologists approach. Food Chemistry and Toxicology, 38, S51S58.
49
th
8. Zhou, F., Guo, H. C., Liu, Y. & Jiang, Y. M. 2011 Chemometrics data analysis of marine water quality and source identification in Southern Hong Kong. Marine Pollution Bulletin 54 (6), 745756. 9. Adhikary P. P., Chandrasekharan H., Chakraborty D. and Kamble K., 2010, Assessment Of groundwater pollution in West Delhi, India using geostatistical approach, Environmental Monitoring Assessment, 167, pp 599615. 10. Central Ground Water Board (CGWB), 2004, Annual report and other related reports on ground water quality, Central Ground Water Board, New Delhi. 11. Patnaik K. N., Satyanarayan S. V. and Poor R. S., 2002, Water pollution from major industries in Paradip area A case study. Indian Journal of Environmental Health,44(3), pp 203211. 12. Tanriverdi C., Alp A., Demirkran A. R. and Uckardes F., 2010, Assessment of surface water quality of the Ceyhan River basin, Turkey, Environmental Monitoring Assessment, 167, pp 175184.
CORRESPONDING AUTHOR: * Department of Chemistry, Suresh Gyan Vihar University Jaipur (Rajasthan). Email:
sunilkumar.179@rediffmail.com ** Associate Professor, Department of Chemistry, Suresh Gyan Vihar University Jaipur (Rajasthan)
50
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Author/s Dr. Krishna N. Sharma

Dr. Shahid Mohd. Dar, Dr. R. Arunmozhi, Babloo Sharma Physiotherapy 1

Fibrocartilage Complex Injury

Evaluation of Knee Joint Effusion with Osteoarthritis by

Physiotherapy: A Pilot Study on Musculoskeletal Ultrasonography

Sunil Kumar Tank, R. C. Chippa

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Dr. Krishna N. Sharma Editor in Chief

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Most injuries to the TFCC have a

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McConnell taping. This tennis-specific wrist taping

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Table 1.4: Comparison of Grip Strength between Group A and Group B

.005 GROUP A PRE POST 64.102 78.308 GROUP B 52.5 69.306

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Fig. 1.10: Comparison of NPRS between Group A and Group B

Table 1.6: Comparison of NPRS between Group A and Group B

handed backhand stroke, it also occurs during a forehand stroke.23

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nonthrust manual exercise.

The purpose of this study is to

Inclusion Criteria were as follows

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measurements were taken in figure 4. After 15 sessions of treatment, decreased to effusion

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CONCLUSION Our study results shows that, Interferential

stimulation and Non-thrust manual exercise with musculoskeletal ultrasonography a significantly

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PHYSICAL THERAPY MANAGEMENT OF TUBERCULOUS ARTHRITIS OF THE ELBOW

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Figure 2. Lateral radiograph of elbow showing a posterior fat-pad sign (arrows)

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radiographs, rule out an

including an oblique view to

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inhibition of the quadriceps femoris muscle.

Some authors have

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reported using prolonged

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INTRODUCTION Parkinsons disease (PD) is one of the most

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conventional treatment.15 Cueing strategies are thought to reroute the movement

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Graph of mean difference between Group A and Group B significant variable.

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