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

Volume: 1 No: 4 Year: 2012 ISSN 2277-1700
Scientific Research Journal of India
SRJI
an open access journal
Scientific Research Journal of India (SRJI)

Dr. L. Sharma Campus, Muhammadabad Gohana Mau, U.P., India. Pin- 276403 | Cont: +91-9320699167, 8822485959, 9305835734 Email: editor.srji@gmail.com | Web: http//www.srji.co.cc
Vol.1 No.4 2012
About Us: Scientific Research Journal of India (SRJI) is the official organ of Dr. L. Sharma Medical Care and Educational Development Society. It was founded by Dr. Krishna N. Sharma. It is funded by the Dr. L. Sharma Medical Care and Educational Development Society. It is a Multidisciplinary, Peer Reviewed, Open Access Journal of science. The intended audiences of this journal are the professionals and students. The scope of journal is broad to cover the recent inventions/discoveries in structural and functional principles of scientific research. The Journal publishes sele selected original research articles, reviews, short communication and book reviews in the fields of Botany, Zoology, Medical Sciences, Agricultural Sciences, Environmental Sciences, Natural Sciences, Anthropology and any other branch of related sciences. Frequency: The issues will be regularly published quarterly. Special Issue: Special issue based on specific themes may be published at the suggestion of the executive committee of Dr. L. Sharma Medical Care and Educational Development Society and the members of editorial of SRJI. Disclaimer:

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Vol.1 No.4 2012
Index
Dr. Krishna N. Sharma Bijender Sindhu, Dr.Manoj Sharma, Dr.Raj K Biraynia Dharam Pani Pandey, Dr. Uday Shankar Sharma, Dr. Ram Babu
Editorial
Comparison of Clinic and Home Based Exercise Programs after Total Knee Arthroplasty: A Pilot Study
Electrical Muscle Stimulation (EMS) Improve Functional Independence in Critically Ill Patients
19
A Comparative Study on Supervised Clinical Exercise versus Home Based Exercise in Primary Unilateral Total Knee Arthroplasty
Bijender Sindhu, Dr.Manoj Sharma, Dr.Raj K Biraynia
Physiotherapy
27
Comparison of the Effect of Isometric Exercise of Upper Limb on Vitals between Young Males and Females
Pranjal Parmar
37
Paraplegia with Sacral Pressure ulcer treated by Ultrasound therapy- A Single Case Report
Shanmuga Raju P., Ramalingam P. Anil Degaonkar, Nikhil Bhamare, Mandar Tilak Akshay Vijay Dongarwar
50
Arterio-Enteric Fistula: A Case Report
Surgery
57
All-Oxide Solar Cells: The Way of the Future
Chemical Engineering
63
Vol.1 No.4 2012
Editorial
Dear Readers, I am very pleased to present the fourth issue of the Scientific Research Journal of India (SRJI) as the next Editor in Chief. This multidisciplinary and open access Journal of science is the official organ of Dr. L. Sharma Medical Care and Educational Development Society. The previous issues had covered three disciplines of science Physiotherapy, Agriculture, Anthropology and Computer science. In this current issue we are covering two new branches of science- Surgery, and Chemical Engineering. I would like to mention that this journal is intended to publish selected original research articles, reviews, short communications and book reviews etc. in the various fields of science like Botany, Zoology, Medical Sciences, Agricultural Sciences, Environmental Sciences, Natural Sciences, Anthropology and any other branch of related sciences and well be more than happy to recognize any of your works in these field too. Your comments and suggestions are very valuable for us.
Happy Reading.
Regards,
Dr. Krishna N. Sharma Editor in Chief
Vol.1 No.4 2012
Comparison of Clinic and Home Based Exercise Programs after Total Knee Arthroplasty: A Pilot Study
Bijender Sindhu PhD, PT*, Dr.Manoj Sharma, MBBS, MS(Ortho)**, Dr.Raj K Biraynia, MBBS,
D.Ortho***
Abstract: Sixteen patients (mean age, 68+-8 years) having primary total knee arthroplasty were assigned randomly to two rehabilitation programs: (1) clinicbased rehabilitation provided by outpatient physical therapists; or (2) homebased rehabilitation monitored by periodic telephone calls from a physical therapist. Both rehabilitation programs emphasized a common home exercise program. Before surgery, and at discharge and follow up after surgery, no statistically significant differences were observed between the clinic and the home-based groups on any of the following measures: (1) total score on the Knee Society clinical rating scale; (2) total score on the ILOA level of assistance (3) total score on the Goniometry; (4) total score of VAScale. After primary total knee arthroplasty, patients who completed a home exercise program (home-based rehabilitation) performed similarly to patients who completed regular outpatient clinic sessions in addition to the home exercises (clinic-based rehabilitation). Additional studies need to determine which patients are likely to benefit most from clinic-based rehabilitation programs.
Key Words: Total Knee Arthroplasty, Home Based Exercise Program, Clinic Based Exercise Program
INTRODUCTION The aim of the arthroplasty is to resurface the tibiofemoral joint to allow better articulation and to reciprocate normal kinematics of the knee (Palmer & Cross,2004) Another aim of surgeons is to correct valgus deformity through the release of lateral structures (Elson & Brenkel, approach 2006). is the The most common
support
and
motivation.
Home-based
programs, however, typically do not require the patient to attend outpatient clinic sessions or require attendance at a minimum number of outpatient sessions, and provide fewer opportunities for monitoring or program modification.
Although usually developed by and taught to patients by physical therapists, homebased exercises typically are completed independently by the patient at home. The populations examined in those studies have tended to be younger individuals who otherwise were healthy, and with an interest in returning to work or sporting activities or both. The efficacy of clinicand home-based rehabilitation programs is particularly important with respect to elderly patients. Owing to the older age of patients who have total knee arthroplasty, the likelihood of complicating medical conditions, the serious implications of postoperative complications in this
medial
parapatellar
approach. This has been shown to give better radiological results, but more pain in the short term than the minimally invasive mid-vastus approach (Chen,
2006). Soft tissue and bony alignment can be ensured using the Tensor/ Balancer system (Winemaker, 2002). The Tensor/ Balancer system is important as
malalignment can lead to failure of the operation (Winemaker,2002) Prostheses consist of a femoral and tibial component. The femoral or tibial component can be cemented, hybrid (one component
cemented and the other uncemented) or uncemented (Zavadak et al., 1995). The type of prosthesis used depends on the surgeons protocol.This question is
population,and the medicolegal climate, surgeons may be hesitant to prescribe non clinically based rehabilitation programs after hospital discharge. An often used alternative to mandatory outpatient
important because of time and cost differences between these service delivery settings. Clinic-based programs typically are provided by outpatient physical
physical therapy has been having all patients complete a limited number of clinic visits. Another alternative may be a home-based program, monitored via
therapy clinics, and facilitate monitoring the patients progress, modifying
individual programs, and providing patient
periodic telephone calls. Monthly phone
Vol.1 No.4 2012 calls by therapist
Scientific Research Journal of India individuals were
or major neurologic conditions were excluded. Randomization to Groups At the time of primary total knee arthroplasty, 32 patients were assigned randomly to two rehabilitation programs (1) clinic-based rehabilitation provided by outpatient physical therapy clinics; or (2) home-based rehabilitation, monitored by a physical therapist via periodic telephone calls.
associated with increased function in patients with osteoarthritis. Although
caution must be exercised in generalizing the findings of their study, home exercise programs developed and monitored by physical therapists via periodic phone calls may provide an alternative to mandatory clinic-based programs and to requiring a defined number of clinic visits, and a means to provide some monitoring of patients during the early rehabilitation phase.
Inpatient and Home Exercise. Familiarization Period
Objective of the Study: The purpose of the current study was to compare two rehabilitation programs after total knee arthroplasty: (1) clinic-based rehabilitation delivered in outpatient
All Objectivereceived standard inpatient patients of the Study: physical therapy twice daily, for 20 minutes on each occasion. Inpatient physical therapy also included instruction in a series of home exercises to be completed daily after discharge, regardless of the patients group assignment.
physical therapy clinics; and (2) homebased rehabilitation monitored by a
physical therapist via periodic telephone calls, on disease-specific, joint-specific, and functional outcome measures.
Ambulatory status on the surgical side was weight bearing as tolerated on discharge after surgery, at which time the patient progressed to walking with walker.
MATERIAL AND METHODS Inclusion and Exclusion Criteria Patients were selected using the following criteria: patients having primary unilateral total knee arthroplasty as a result of osteoarthritis, both male and female who had a primary unilateral TKA, age 50-85. Able to give independent informed
Discharge criteria included the ability to transfer independently, ambulate more than 30 m using walker/crutches, and ascend and descend at least five steps. Medication given at discharge was pain killer, nutritions and antibiotics. Common Home Exercises (for both groups)
consent. Patients with rheumatoid arthritis http://www.srji.co.cc
The common home exercise program was that developed for routine total knee arthroplasty rehabilitation at the authors institution, and consisted of basic (Stage 1) and more advanced (Stage 2) ROM and strengthening exercises. Each patient
Group A physical therapist familiar with the common home exercises telephoned each patient in the home-based group at least two times ask whether the patient was having any problems with the exercises, to remind them of the
received Stages 1 and 2 booklets, which included written and pictorial descriptions of each exercise and educational
importance of completing the exercises, and to provide advice on wound care, scar treatment, and pain control. During each telephone call, which lasted approximately 10 minutes, the patient was asked when and how often he or she wished to be telephoned in the future. Patients also were provided with a contact telephone number to call if additional questions arose.
information on using ice, controlling swelling, walking, and ROM. They were instructed to complete the common home exercises three times daily until their 8week follow up, at which time they were advised to continue the home exercises at least once daily, indefinitely. Home-Based
Variable Continuous variables: mean (standard deviation) Age (years) Height (cm) Mass (kg) Disease duration (years) Discrete variables: frequency and percent of group (percent) Genderfemale Left replacement Contralateral knee involvement Contralateral hip involvement Ipsilateral hip involvement
Clinic-Based (n=16) 65.2 (6.9)* 160.2 (9.6) 86.4 (15.6) 9.8 (6.4)
HomeBased(n=16) 64.6 (7.8) 162.3 (11.1) 85.5 (15.9) 9.2 (7.3)
9 (56.25%) 6 (37.5%) 8 (50%) 3 (18.75%) 1 (6.25%)
5 (31.25%) 3 (18.75%) 6 (37.50%) 1 (6.25%) 0 (0%)
Table 1. Patient Baseline Characteristics for the Clinic- and Home-Based Groups
Clinic-Based Group
In addition to the common home exercises, patients in the clinic-based group were
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11
required to attend outpatient physical therapy after discharge to 8 weeks after surgery, for as many as three sessions per week, for approximately 1 hour per session. Outpatient physical therapists were provided with copies of the Stages 1 and 2 exercise booklets, and were asked to use these exercises as the basic component of their rehabilitation program. However, they were not advised that the patient was participating in a study comparing two rehabilitation programs. Therapists were permitted to modify or add exercises, use therapeutic modalities (such as ice, heat, and ultrasound), joint mobilizations, or other measures as they deemed
Fig 1. The study time-sequence flow chart is shown. Patients in both rehabilitation groups completed the common home exercises daily between Weeks 2 to 8. Assessments and Measurements In conjunction with routine orthopaedic clinic evaluations pre surgically, and at discharge, 8 weeks after surgery, patients completed a series of questionnaires and functional tests that required
approximately 1 hour. Throughout the study, these tests were conducted by two experienced testers who were blinded as to the patients group assignment, and gave the test results directly to the study coordinator. The following tests were completed: (1) total score on the Knee Society clinical rating scale; (2) total score on the ILOA level of assistance (3) total score on the Gonioetry; (4) total score of VAScale. From a position of maximum extension, the patient slid the heel of the
appropriate. Patients in the clinic-based group were requested to complete the common home exercises at home only twice on days that they attended clinic sessions.
Eligibility Randomization Clinic Based Rehabilitation Home Based Rehabilitation
test leg toward the buttocks to a position of maximum knee flexion. The knee angle was measured using a goniometer and scored as the average of three repetitions. Non directional, t tests, and tests of the significance of the difference between two percentages were used to compare the clinic- and home-based groups on pre
OPD 2 session /week at 1 hour
Total Knee Arthroplasty Inpatient Physical Therapy Common Home Exercise Hospital Discharge at 5-7 days Atleast 1 telephonic call by therapist Stage 2 4 week follow up Instruction common home exrecise OPD 3 session /week at 1 hour
Atleast 1 telephonic call by therapist Stage 3 8 week follow up Instruction common home exrecise
surgical descriptive measures, and to compare the patients who were lost to, or dropped out of the study with those who remained in the study, on baseline http://www.srji.co.cc
measures. Four-way analysis of variance (ANOVA) were used to examine the following four criterion variables(1) total score on the Knee Society clinical rating scale; (2) total score on the ILOA level of assistance (3) total score on the Gonioetry; (4) total score of VAScale. After a significant F-ratio, the Newman-Keuls technique was used to compare selected means. Any patients who were removed from their assigned group by the surgeons for reasons related to the surgically treated knee or medical conditions not related to the surgically treated knee, or who withdrew consent to participate, were encouraged to continue with the home exercises and any other therapies
three times of measurement (before surgery, and discharge and 6 weeks after surgery). In view of the number of statistical tests computed and to minimize the likelihood of Type 1 or alpha error, the 0.01 level was used to denote statistical significance throughout analyses.
RESULT Before surgery, no significant differences were observed between the clinic- and the home based groups on the demographic variables shown in Table 1, or on any of the nine criterion measures (p>0.01). No statistically significant differences were observed between the patients lost and those who remained in the study (Table 2), or between the patients lost to the two groups on the baseline scores for any of the four criterion measures, or for age, height, and weight (p>0.01). Length of stay in the hospital for the patients who completed the study in their assigned group was 5.1+-1.5 and 5.2+-1.7 days for the homeand clinic-based groups,
prescribed, and to continue coming for regular follow ups and testing. To take into account that some patients were removed or otherwise lost from their group, but did continue to be tested at their regular follow ups, two types of analyses were completed: (1) a per protocol analysis, which included all patients who completed the study in their assigned group; and (2) an intent to treat analysis, in which all patients were analyzed as having remained in their assigned group, regardless of whether they had completed the study in that group. Analysis of variance tests were confined to patients who had full data sets for the
respectively. On ANOVA tests, the per protocol and the intent to treat analyses produced identical results for all nine criterion measures; no treatment, surgeon, or prosthesis-related effects were observed (p>0.01), and only the main effect for time (averaged over treatment, surgeon) was significant (p<0.01) (Figs 2, 3).
Subsequent analysis of the main effect for
Vol.1 No.4 2012
13
time indicated that the scores before surgery, at discharge after surgery, and 6 weeks after surgery differed significantly from one another (p<0.01); with one minor exception. Pain before surgery, measured via Visual analog score, was significantly greater than that at discharge
and 8 weeks after surgery (p<0.01), whereas there was no statistically
significant difference (p>0.01) between the pain scores at discharge and 8 weeks, on the per protocol and the intent to treat analyses.
Patient Losses Patients lost during the inpatient period (before hospital discharge) Medical issues related to the surgically treated knee Withdrawal of consent by the patient Other medical issues Totals Patients lost after hospital discharge (Weeks 252 after surgery) Medical issues related to the surgically treated knee Withdrawal of consent by the patient Other medical issues Total losses
Clinic (n=16)
Based
Home (n=16)
Based
2 1 2 5
1 2 1 4
0 0 1 1
1 0 1 2
Table 2. Number of Patients Lost From Each Group and Reason for Loss
DISCUSSION After primary total knee arthroplasty, patients who completed performed completed home-based similarly to
support available through clinic-based rehabilitation was not advantageous for the population studied. These findings were not confounded by any interactions with surgeon, type of prosthesis or time since surgery. The current results extend those of previous studies of meniscectomy 5,7,10 and anterior cruciate ligament reconstruction1,3,4,11 populations, and corroborate a previous retrospective study using a total knee arthroplasty sample. Patients who were lost to their assigned group were not included in the per protocol analysis, but did raise concerns
rehabilitation patients who
clinic-based
rehabilitation during the first 4 weeks after surgery. That all four criterion measures in the current study produced similar results for the per protocol and the intent-to-treat analyses suggests that these findings apply across a spectrum of disease-specific, joint-specific, and functional variables. Overall, the additional patient monitoring, adjustment of program, and motivational
that the group comparisons may have been affected (Table 2). Comparisons within and between groups indicated no
Knee Society Knee Score

80 70 60 50 40 30 20 10 0 PRE POST
differences between patients lost and those remaining. In addition, when patients who had been lost to their assigned group, but continued being tested at their normal follow-ups and had complete data sets, were returned to their assigned group for the intent to treat analysis, results were the same as for the per protocol analysis. For r these reasons, patient losses were not considered to have significantly affected the overall results of the current study.
HOME CLINIC
Visual analog Score

25 20 15 10 5 0
HOME CLINIC
Fig 2 AC. Total scores for the (A) Range of Motion Knee Flexion (B) ILOA level of assistance (C) KSKS knee society knee score nee Range of Motion (Knee Flexion)
100 80 60 40 20 0 PRE POST
HOME CLINIC
PRE
POST
Between discharge and 8 weeks four weeks, more patients were removed from the home-based group than from the clinic clinicbased group for reasons related to failure r of the surgically treated knee to progress (Table 2). These patients then had more intensive outpatient physical therapy than that provided by the clinic-based program. based Four patients in the clinic clinic-based group were advised by their surgeon to continue eir clinic-based rehabilitation after Week 12. Although both groups of patients tended
ILOA Level of Assistance

35 30 25 20 15 10 5 0 PRE POST
to have poorer baseline scores on the majority of objective measures, their

HOME CLINIC
scores were not consistently low across the same measures and tended to b within be 1 standard deviation of the group mean. The combination of poorer scores plus
Vol.1 No.4 2012
15
subjective factors such as the patients attitudes, motivation, pain tolerance, and home environment were considered in making the decision to remove these patients from their assigned group or to continue clinic-based rehabilitation.
enabled some monitoring of the patients medical status. The major component of the current study was the common home exercise program, taught to all patients during their
hospitalization after surgery and at their 8 week follow up. Outpatient clinicians used this program as the basis for their treatments, and determined the number and frequency of treatments, which
Additional studies are needed to document psychosocial and demographic variables to help identify patients who might derive greatest benefit from clinic-based
rehabilitation programs. The telephone calls to patients in the home based group were completed by an experienced physical therapist who had been introduced to all of the patients during their inpatient period. The
averaged 15+-20 sessions; whereas the home-based group was monitored by periodic telephone calls from a physical therapist, which averaged 3+-1 calls during the first 8 weeks after hospital discharge. At hospital discharge, patients in the home-based group indicated when they wished to be telephoned, and again did so during each telephone call. Pilot study had indicated that virtually all patients having primary total knee
telephone calls focused on the home exercises and did not introduce any new exercises or provide unique treatment guidance beyond that available from similarly experienced therapists. Two patients with potential major
arthroplasty had previous experience with home exercise programs and that the majority preferred to determine the
problem ,such as unresolved swelling, infection, and deep vein thrombosis, were identified via the telephone calls and were referred to the patients physician or surgeon for treatment. Whether delayed treatment of these conditions would have resulted in major complications is unclear. All of these patients completed the 8 week study in their assigned group. As a result, the telephone calls received by the homebased group provided a form of minimally supervised rehabilitation, which also
contact schedule themselves. In addition to the phone calls, the followups at 4 and 8 weeks after surgery included review of the home exercises. That no patients in the home-based group requested additional telephone calls after 4weeks and only three patients in the clinic-based group phoned to ask
questions about the home exercises, suggests all patients felt competent in http://www.srji.co.cc
doing their home exercises. Although passive ROM was examined by the surgeons at each follow up, active ROM was used to compare groups, to minimize the extent to which pain tolerance and motivation may have affected ROM. Compliance with the home exercises was considered high, with only two patients in the home-based group and one patient in the clinic-based group considered to have been noncompliant at discharge and 4 after surgery (where compliance was defined as completion of the home exercises at least 90% of the time, as per exercise compliance log was booklets). discussed Exercise with the
CONCLUSION The current study compared two
rehabilitation programs, where the basic component of each program was a series of common exercises to be completed independently by all patients at home. Because these exercises were developed by and taught to the patients by physical therapists, the current study might be viewed as having compared two means of providing physical therapy services; that is, physical therapy monitored by telephone calls (home-based) and physical therapy monitored in person by outpatient physical therapists (clinic-based). The current study did not compare physical therapy versus no physical therapy. There is no
patients before surgery and at each follow up thereafter. The sample studied was limited to elderly patients who agreed to be assigned randomly to one of the two rehabilitation programs. Approximately 10% of eligible patients refused to participate for this reason. The extent to which a home exercise program would be effective for patients with a more
significant difference in the data of study but there is statistical difference in both group. So this pilot studies shows that the group of clinic based rehabilitation after total knee arthroplasty having more better prognosis than home based exercise group ie. range of motion and functional ability and pain.
complicated history, more limited ROM, or less motivation, needs to be determined.
REFERENCES: 1. Beard DJ, Dodd CAF: Home or supervised rehabilitation following anterior cruciate A ligament randomized 2. 2Bellamy N, Buchanan WW, controlled trial. J Orthop Sports Phys Ther 27:134143, 1998.
reconstruction:
Goldsmith CH, Campbell J, Stitt
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LW: Validation study of WOMAC: A health status instrument for measuring patient clinically important to in 7. Jokl P, Stull PA, Lynch JK, Vaughan V: Independent home exercise versus supervised following knee surgery: A
relevant
outcomes therapy
antirheumatic
drug
rehabilitation arthroscopic prospective
patients with osteoarthritis of hip or knee. J Rheumatol 15:1833 1840, 1988.
randomized
trial.
Arthroscopy 5:298305, 1989.
3. De Carlo MS, Sell KE: The effects of the number and frequency of physical therapy treatments on selected outcomes of treatment in patients with anterior cruciate
8. Mahomed NN, Koo See Lin MJ, Levesque L, Lan S, Bogoch ER: Determinants and outcomes of inpatient versus home-based
rehabilitation following elective hip and knee replacement. J
ligament reconstruction. J Orthop Sports Phys Ther 26:332339, 1997.
Rheumatol 27:17531758,2000.
9. Rene J, Weinberge M, Mazzuca 4. Fischer DA, Tewes DP, Boyd JL, et al: Home based rehabilitation for anterior cruciate Clin ligament Orthop SA, Brandt KD, Katz BP:
Reduction of joint pain in patients with knee osteoarthritis who have received monthly telephone calls from lay personnel and whose medical treatment regimens have
reconstruction.
347:194199, 1998.
5. Forster DP, Frost CEB: Costeffectiveness physiotherapy of after outpatient medial
remained stable. Arthritis Rheum 35:511515, 1992.
menisectomy. BMJ 284:485487, 1982.
10. Seymour N: The effectiveness of physiotherapy after medial
menisectomy. Br J Surg 56:518 6. Insall JN, Dorr L, Scott RD, Scott WN: Rationale of the Knee 11. Treacy SH, Baron OA, Brunet ME, Barrack RL: Assessing the need http://www.srji.co.cc 520, 1969.
Society clinical rating system. Clin Orthop 248:1314, 1989.
for
extensive
supervised following
12. Ware JE, Sherbourne CD: The Medical Outcomes Study Short Form (SF-36). Med Care 3:473, 1992. Clinical Orthopaedics 234 Kramer et al and Related Research
rehabilitation
arthroscopic reconstruction. Am J Orthop 26:2529, 1997.
ACKNOWLEDGMENT: The authors thank Dharam Pandey (MPT-neuro), Deepa Dabas (MSc-psycho) for assistance throughout the study.
CORRESPONDENCE:
*Bijender Sindhu PhD,PT Research Student**Dr.Manoj Sharma, MBBS, MS(ortho)***Dr.Raj k Biraynia, MBBS, D.ortho *School of Physical Therapy, Faculty of Medical Science, Singhania University**Department of orthopedic surgery, Jaipur Golden Hospital *** Department of orthopedic surgery, Sarvodaya Multispeciality Hospital. This study was not funded through a grant from the any organization.
Vol.1 No.4 2012
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Electrical Muscle Stimulation (EMS) Improve Functional Independence in Critically Ill Patients
Dharam Pani Pandey PT*, Dr. Uday Shankar Sharma**,Dr. Ram Babu***
Abstract: Objective. This study was designed to investigate the effects of electrical muscle stimulation (EMS) on strength of muscle groups stimulated and improvement in functional independence in critically ill patients .Methods. 134 subjects were recruited among the patient admitted in multidisciplinary intensive care units and randomly divided in to control and EMS group. Patients unable to understand or speak English and or Hindi due to language barrier or cognitive impairment prior to admission, unable to transfer from bed to chair at baseline prior to hospital admission, Patient with known history of primary systemic neuromuscular disease were excluded from study. Results. EMS group patients achieved higher MRC scores than controls in knee extensors and ankle dorsiflexors. Independence level was higher in EMS group Conclusions. EMS application constitutes a promising means of muscle strength preservation and early mobilization which can directly reflects the gain in functional independence post ICU discharge in critically ill patients.
Key words: Electrical muscle stimulation, muscle strength, CIPNM, CIM, functional independence
INTRODUCTION Weakness that is hospitalization for
acquired critical
during is
critically ill patients13 and are associated with increased morbidity and mortality.4,5 Critical illness polyneuromyopathy
illness
increasingly recognized as common and important clinical problem. Weakness acquired in the intensive care unit (ICU) and related acquired neuromuscular
(CIPNM) is an acquired neuromuscular disorder observed in survivors of acute critical illness. It is characterized by profound muscle weakness and
dysfunction occur in a large percentage of
diminished
or
absent
deep
tendon
The
objective
of
this
study is
to
reflexes1 and is associated with delayed weaning from mechanical ventilation2 suggesting a possible relation between limb and respiratory neuromuscular
investigate stimulation
whether (EMS)
electrical will
muscle improve
functional independence in critically ill patients.
involvement. In addition, the syndrome is associated with prolonged hospitalization and increased mortality.3 The diagnosis of CIPNM requires a reliable bedside muscle eliable strength examination and depends on patient's cooperation and maximal effort.4 Several risk factors have been identified including systemic inflammatory response and sepsis5, medications and
7
such
as
corticosteroids6 control8, bacteremia9
neuromuscular immobility4, Gram-negative Our experimental Hypothesis was that EMS would beneficially affect muscle functional status and will improve
blocking agents , inadequate glycemic protracted hypoalbuminemia9, and
severity
of
organ
dysfunction.10 Thus, looking for the potentially reversible risk factors and subsequent adjustment of therapy are so far advocated as preventive measures to decrease the risk of CIPNM. A very few of studies available suggesting the treatment and prevention of critical illness myopathy these includes intensive insulin therapy, optimal gycemic control and minimized use of neuromuscular uromuscular blocking agents, high dose and prolong use of corticosteroids.
functional independence in critically ill patients.
MATERIAL AND METHODS Subjects: The 134 subjects were recruited among the patient admitted in multidisciplinary n intensive care units during the study period. Exclusion criteria: Unable to understand or speak English and or Hindi due to language barrier or
OBJECTIVE OF THE STUDY
cognitive impairment prior to admission, unable to independently transfer from bed
Vol.1 No.4 2012
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to chair at baseline prior to hospital admission (based on detail history taken from caregivers. Patient with known history of primary systemic
EMS was implemented on knee extensors, tibialis anterior and Patients of both received lower daily
extremities.
sessions. After skin cleaning, rectangular electrodes (90 50 mm) were placed on motor point of targeted muscle. The stimulator (Unistim, HMS medical system) delivered biphasic, symmetric impulses of 50 Hz, 100 sec pulse duration, 12 seconds at intensities able to cause visible contractions. The duration of the session was 30 minutes each muscle group. EMS sessions were continued until ICU
neuromuscular disease, vascular events, organ transplant, intracranial process that is associated with localizing weakness, transferred from another ICU after >2 consecutive ventilation, days of mechanical of lower
amputation
extremities, any limitation of life support, pregnancy, age under 18 years, obesity, technical obstacles that did not allow the implementation of EMS such as bone fractures, skin lesions and, end-stage malignancy were excluded from our study Design of study: The study employed a randomized single blind controlled experimental study design consisting of two group experimental group and control group, Subjects were randomly assigned ether to experimental group or to control group everyday the ICU patient admission register were observed and with in 24 hour the assessment were done , each time when a patient met the criteria for inclusion a random number were picked up between 1 to 10 using sealed envelope method if it were an odd number than the subject were assigned to experimental group similarly if it even number were obtained the subjects were assigned to control group. Intervention:
discharge, both group were getting routine physiotherapy included the passive
movements, active assisted movements and chest physiotherapy. Outcome Measures: Primary Outcome Measures were the score of barthel index, it is reliable and valid outcome measure used to assess functional independence. Secondary Outcome Measures were lower extremity strength, at ICU discharge, of 2 bilateral muscle groups which were stimulated measured by MMT using a
composite Medical Research Council (MRC) score.
DATA ANALYSIS AND RESULTS All continuous variables were presented by mean. The statistical significance of P value was set at 0.05. One-way repeated measures analysis of variance (ANOVA) http://www.srji.co.cc
was made to compare MRC Grading and barthel index score between-group. Two group. hundred and thirty-eight patients were eight admitted to our multidisciplinary ICU during the eight-month study period and month 104 patients fulfilled the exclusion criteria or stayed in the ICU less than 48 hours. The study population consisted of 134 patients of which of these patients, 70 hese were randomly assigned to the EMS group and 64 to the control group. 6 patients from EMS group and 1 patient from control died or were discharged from the ICU before the second measurement. MRC muscle grading score of muscle group being stimulated were for left knee extensors were control group mean 3.49 and EMS group mean 3.91 (p = 0.0187), right knee extensors control group mean 3.69 and EMS group mean 3.87 0.0387). left ankle dorsiflexors (p = control Graph 2: Showing the mean and significance level of two group of left and right ankle dorsiflexors. Graph 1: Showing the mean and significance level of two group of left and right knee extensor.
group mean 3.78 and EMS group m mean 3.91 (p = 0.04), right ankle dorsiflexors were observed as follows mean control group mean 3.37 and EMS group mean 3.3.46 (p = 0.0587) found. Barthel index score of control group was (mean) 68.6 and EMS group (mean) 71.9 and found significant between groups (p = een 0.010). DISCUSSION The main finding of our randomized controlled study is that EMS of lower extremities seems to preserve the muscle Graph 3: Showing the mean and significance level functional independence level as assessed on barthel index.
Vol.1 No.4 2012
23
strength of critically ill patients as assessed with MRC muscle strength grading system. EMS of lower extremities applied to critically ill patients upon admission is associated with a lesser degree of muscle strength loss of these patients as assessed with MRC muscle strength grading system. barthel index score were higher in EMS group and the patient of EMS group were more
specific health status.18 Recently, an study identified an acute systemic effect exerted by EMS on peripheral microcirculation of critically ill patients.19 Specifically, after performing a 45-minute session of EMS on the lower extremities, an improvement in the microcirculation of the thenar muscle as assessed by near infrared spectroscopy technique was observed. EMS, as a possible substitute to aerobic and resistance exercise training in severe CHF and COPD patients, has been shown to improve muscle performance, aerobic exercise capacity, and disease-specific health status.9-11
independent. Electrical stimulation has been used to increase strength and endurance in
partially and fully paralyzed muscle. It has been used for peroneal nerve stimulation10,
11
the restoration of shoulder movement12, CONCLUSIONS EMS exercise induces beneficial effects in muscle strength of ICU patients. These effects mainly concern muscle groups directly stimulated, but there is also evidence of effects in muscle groups not stimulated. EMS application constitutes a promising means of muscle strength preservation and early mobilization which can directly reflects the gain in functional independence post ICU discharge in critically ill patients. Clinical relevance & limitation EMS is an alternative method of exercise causing minimal discomfort to patients who are not able to perform any form of physical exercise, as is often the case in critically ill patients. It is a limitation of http://www.srji.co.cc prosthesis.14
recovery of tendonesis grip13, and in the use of an upper arm
Electrical muscle stimulation (EMS) has been used as an alternative to active exercise in patients with chronic heart failure (CHF)15 and chronic obstructive pulmonary disease (COPD).16, 17 Many of these patients, even those who are clinically unstable, experience severe
dyspnea on exertion, which can prohibit the regular application of conventional exercise training, considered necessary for an integrated therapeutic approach. In a recent systematic review, EMS
implementation in most of the selected controlled significant clinical trials in produced muscle
improvements
strength, exercise capacity and disease-
this study that it did not evaluated the follow up stage and upper extremities function. Further studies are needed to explore the possible role of EMS as a tool for preserving the muscle strength and gain in functional independence post ICU
discharge
with
longer
follow
up
evaluation, the muscle properties and preventing CIPNM in critically ill patients and to define which patients would benefit most from this intervention.
REFERENCES: 1. De Jonghe B, JP, Sharshar Authier T, FJ, 4. Garnacho-Montero J, MadrazoOsuna J, Garcia-Garmendia JL, Ortiz- Leyba C, Jimenez-Jimenez FJ, Barrero-Almodovar A, et al. Critical risk illness factors polyneuropathy: and clinical
Lefaucheur
Durand-Zaleski I, Boussarsar M, et al; Groupe de Reflexion et dEtude des Neuromyopathies en
Reanimation. Paresis acquired in the intensive care unit: a
consequences: a cohort study in septic patients. Intensive Care Med 2001;27(8): 12881296.
prospective
multicenter
study.
JAMA 2002;288(22):28592867.
2. De Letter MA, Schmitz PI, Visser LH, Verheul FA, Schellens RL, Op de Coul DA, van der Meche FG. Risk factors for the
5. Spitzer AR, Giancarlo T, Maher L, Awerbuch G, Bowles causes A. of
Neuromuscular
prolonged ventilator dependency. Muscle Nerve 1992;15(6):682686.
development of polyneuropathy and myopathy in critically ill patients. Crit Care Med
6. Rudis MI, Guslits BJ, Peterson EL, Hathaway SJ, Angus E, Beis S,
2001;29(12):22812286. 3. Coakley JH, Nagendran K,
Zarowitz BJ. Economic impact of prolonged complicating motor weakness
Yarwood GD, Honavar M, Hinds CJ. Patterns of neurophysiological abnormality in prolonged critical illness. Intensive Care Med
neuromuscular
blockade in the intensive care unit. Crit Care Med 1996;24(10):1749 1756.
1998;24(8):801807.
Vol.1 No.4 2012
25
7. Latronico N, Peli E, Botteri M. Critical illness myopathy and
Anesthesiology 2004;101(3):583 590.
neuropathy. Curr Opin Crit Care 2005;11(2):126132. 12. MacFarlane IA, Rosenthal FD. Severe 8. Bednarik J, Lukas Z, Vondracek P. Critical illness polyneuromyopathy: the electrophysiological 13. Witt NJ, Zochodne DW, Bolton CF, GrandMaison F, Wells G, Young GB, Sibbald WJ. Peripheral nerve function 9. Van den Berghe G, Wouters P, Weekers F, Verwaest C, multiple organ in sepsis and Chest myopathy after status Lancet
asthmaticus
(letter).
1977;2(8038):615.
components of a complex entity. Intensive Care Med
2003;29(9):15051514.
failure.
1991;99(1):176184.
Bruyninckx F, Schetz M, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345(19):13591367. 14. Knox AJ, Mascie-Taylor BH,
Muers MF. Acute hydrocortisone myopathy in acute severe asthma. Thorax 1986;41(5):411412.
10. Tennila A, Salmi T, Pettila V, Roine RO, Varpula T, Takkunen O. Early signs of critical illness polyneuropathy in ICU patients with response Intensive systemic syndrome Care inflammatory or sepsis. Med 15. Hund E, Genzwurker H, Bohrer H, Jakob H, Thiele R, Hacke W. Predominant involvement of motor fibres in patients with critical illness polyneuropathy. Br J
2000;26(9):13601363.
Anaesth 1997;78(3):274278.
11. Rabuel C, Renaud E, Brealey D, Ratajczak P, Damy T, Alves A, et al. Human of septic myopathy:
16. Thiele RI, Jakob H, Hund E, Tantzky S, Keller S, Kamler M, et al. Sepsis and catecholamine
induction
cyclooxygenase,
support are the major risk factors for critical illness polyneuropathy after open heart surgery. Thorac http://www.srji.co.cc
heme oxygenase and activation of the ubiquitin proteolytic pathway.
Cardiovasc Surg 2000;48(3):145 150. 17. Garnacho-MonteroJ, Amaya-Villar R, Garcia-Garmendia JL,MadrazoOsuna J, Ortiz-Leyba C. Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and the length of stay
in septic patients. Crit Care Med 2005;33(2):349354.
18. Bolton
CF.
Sepsis
and
the
systemic inflammatory response syndrome: neuromuscular
manifestations. Crit Care Med 1996;24(8): 14081416.
ACKNOWLEDGMENT: We would like also to acknowledge the support of all intensive care unit staff, consultants and all the patients caregivers.
CORRESPONDENCE:
*Department Of Physiotherapy & Rehabilitation,BLK Super Speciality Hospital, Pusa Road, New Delhi, India. **Sr. Consultant Neurologist, Department of Neurology, Jaipur Golden Hospital,2 institutional area, sector 3, Rohini, New Delhi, India. ***Sr. Consultant Physician, Department of Internal, Medicine, Jaipur Golden Hospital,2 institutional area, sector 3, Rohini, New Delhi, India.
Vol.1 No.4 2012
27
A Comparative Study on Supervised Clinical Exercise versus Home Based Exercise in Primary Unilateral Total Knee Arthroplasty
Bijender Sindhu PhD, PT*, Dr.Manoj Sharma, MBBS, MS(Ortho)**, Dr.Raj K Biraynia, MBBS,
D.Ortho***
Abstract: Objective. This study was designed to investigate the effects of supervised clinical exercise and home Based Exercise in patient with unilateral total knee arthroplasty in sub acute phase (after 5-6 weeks of discharge). To assess the effect on function ability of patient after primary unilateral total knee arthroplasty. To assess the effect on knee integrity (it include pain, ROM, knee stability)of patient after primary unilateral total knee arthroplasty. Methods. 130 subjects were recruited from OPD physiotherapy among the patient discharge from hospital and randomly divided into supervised clinic exercise and home based exercise. Socio demographic and clinical data, pain, range of movement (ROM) and function of TKA patients were collected on day of discharge (ie day 5 to 8 post operation). A self designed data capture sheet, the goniometer, VAS (Visual Analogue Scale) and ILOA (Iowa Level of Assistance) KSKS (kne society knee score)were used to measure data. Criteria for recruitment is patient having primary unilateral total knee replacement, having a functional hip on operated side, both male and female and age between 50 to 80 years. Able to follow simple verbal commands. Patient excluded from study who are suffering from Rheumatoid Arthritis, revision TKA, bilateral knee arthroplasty. Results. The results indicate that there is significant difference between experimental group (supervised clinical exercise) and Control group (home based exercise). For knee integrity measured using the Knee Society Knee Score (p=0.017)and function measured using the ILOA Scale (p= 0.018) and goniometry (p=>0.05). The average age was 64 years in male and 66 years in females . There were 41% males and 59% females. There is statistical difference between pain, range of motion, Knee integrity, Knee functional outcomes of groups that receive post-
discharge outpatient physiotherapy as compared to those who do not attend physiotherapy. Conclusions. After primary total knee arthroplasty, patients who completed a home based exercise program (control group) performed similarly to patients who completed regular outpatient clinic sessions in addition to the home exercises (supervised clinic exercise ie. experimental group). Additional studies need to determine which patients are likely to benefit most from clinic-based rehabilitation programs. The overall aim of this study was to establish the early post operative status of Total knee arthroplasty patient.
Key words: Supervised clinical exercise, Home based exercise, KSKS (knee society knee score), ILOA (ILOA level of assistance)
INTRODUCTION Osteoarthritis is a leading cause of pain and disability affecting joints (Marchet al 1999). Progressive loss of the articular cartilage can result in joints that are painful and inflamed. The joint becomes stiffer and there is less stability in the joint (Parmet et al 2003). These factors affect the function of the joint which ultimately impacts on patients functional ability and their quality of life (March et al 1999). Total knee arthroplasty has been found to be effective in the management of pain (Palmer & Cross, 2004), functional status and quality of life in people suffering from OA, rheumatoid arthritis (RA) and related conditions (Zavadak et al., 1995). Physiotherapists contractures aim et to al., prevent 2006)
aims to minimize the complications following total knee replacements and to rehabilitate the patient to full functional recovery. Techniques such as cryotherapy, strengthening and stretching exercises are used (Zavadak et al 1995). Physiotherapy in hospital also includes functional
techniques such as bed mobility, transfers, ambulation and stair climbing. An
assumption can be made that if there is a relationship between knee integrity and function, physiotherapists may decide to only work on improving function, or only work on improving knee knee of integrity motion,
(improving
range
reducing swelling, reducing pain and improving muscle strength). Time could then be better utilized on one aspect of rehabilitation. Early discharge can sometimes result in transfer to an inpatient facility. A study by Bozic et al. (2006), states that clinical,
(Lenssen
decrease pain and swelling and improve knee and functional mobility in
preparation for discharge (Oldmeadow et al.,2002. Post operative physiotherapy
Vol.1 No.4 2012
Scientific Research Journal of India operation who gave
29 informed
demographic and socioeconomic factors all affect the decision to discharge a patient to an inpatient rehabilitation centre. Objective of the Study: To assess the effect on knee integrity (it include pain, ROM and knee stability) and knee function ability. To establish
constant).Able to follow simple verbal commands
Exclusion criteria: Any additional trauma to the lower limb, inability to participate in the assessment from a physical and cognitive point of view such as dementia, confusion etc. Inability of the patient to walk prior to the TKA(with suffering or from without aid). Patient Arthritis. in the
pain,ROM of the operated knee and functional level of TKA patients. To establish socio-demographic factors and clinical data of TKA patients on first follow up. To establish the relationship amongst supervised clinical exercise as well as home based exercise and
Rheumatoid to participate
Unwillingness
assessments Revision TKA, Bilateral knee arthroplasty. Inability of the patients to walk prior to the total knee replacement (with or without the aid of an assistive device).
postoperative functional status of TKA patients. To study this procedure can be clinically implemented.
MATERIAL AND METHODS Subjects: 130 subjects were recruited from OPD physiotherapy among the patient discharge from hospital and Design of study: The study employed a randomized single blind controlled experimental study design consisting of two group experimental group and control group, Subjects were randomly assigned either to experimental Inclusion criteria: Patient having primary unilateral total knee replacement having a functional hip on operated side .Both male and female who had a primary unilateral TKA able to give independent informed consent Patient between the age of 50 to 80 years of age, presented to the first follow-up session. (This was around six to eight weeks post http://www.srji.co.cc group or to control group everyday in physiotherapy OPD before discharge , each time when a patient met the criteria for inclusion a random number were picked up between 1 to 10 using sealed envelope method if it were an odd number than the subject were assigned to
randomly divided into supervised clinic exercise and home based exercise.
experimental group.
Intervention Supervised clinical exercise: These are exercise which are perfomed by patient under the observation of a qualified physiotherapist. Postoperative
assistive devices and appliance, walking pattern, safety & precaution, dos and donts.
Outcome Measures: ILOA : The patients functional ability was assessed using the Iowa Level of Assistance (ILOA) Scale, which was first described by Shields et al (1995). It was shown to be reliable and valid.The best overall result the patient is able to achieve with this scale is zero. This indicates that the patient was able to perform all five tasks independently without the use of any assistive device. The worst overall score that could be achieved is fifty which indicates that the patient was unable to perform the tasks due to medical and safety reasons and the assistive device used for standing or mobilizing was a walking frame. KSKS: This rating system was developed in 1989 by the American Knee Society to provide an evaluation form for knee integrity (Insall et al, 1989). The knee assessment has three parameters which measure pain, stability and range of motion. The knee is given a score out of a hundred. A well-aligned knee with no pain, negligible instability and range of motion of 125 degrees scores a hundred points Goniometry: It is a measuring tool used to assess the range of motion of a joint. It can be used as an initial assessment and it
rehabilitation usually consists of passive and active knee mobilisation, quadriceps strengthening and functional activities (Lenssen et al., 2006). Hip and knee flexion; hip and knee extension in neutral; hip abduction; hip adduction to neutral; ankle dorsi- and plantar flexion, static
quadriceps contraction and inner range quadriceps contraction over a rolled up towel. The physiotherapist performs antiinflammatory modalities on the patient which include ultrasound, interferential therapy, pulsed short wave diathermy, transcutaneous electrical nerve stimulation (TENS), laser, acutouch and heat or cryotherapy. Myofascial release,
continuous passive mobilisation exercises, stretching, strengthening exercises, gait re-training, massage, patient education and an exercise programme are also prescribed. Home based exercise: Home based exercise group performed the exercise which are explained and demonstrated by physiotherapist in OPD at the time of discharge to the patient for home, which included quadriceps, isometric knee exercises of for
range
motion,
strengthening exercise, effective use of
Vol.1 No.4 2012
31
evaluate the patients progress (Rothstein et al 1983). Rothstein et al (1983) assessed goniometric reliability and which
TKA patients, Knee integrity and Sociodemographic factors and clinical data of TKA patients, The relationship between identified factors and postoperative
goniometer size was the most reliable in a clinical setting.
functional status of TKA patients in relevance of level of assistance (ILOA) in
DATA ANALYSIS AND RESULTS All continuous variables were presented by mean. The statistical significance of P value was set at 0.05. One-way repeated measures analysis of variance (ANOVA) was made to compare ILOA score, KSKS score, Goniometry range between-groups. 130 subjects were recruited from OPD physiotherapy among the patient
control group mean (home based exercise) is11.94 and experimental group
(supervised clinical exercise) 10.01 (p= 0.018), KSKS in control group mean (home based exercise) is74.72 and
experimental group (supervised clinical exercise) 76.78 (p=0.017), goniometry in control group mean (home based exercise) is 88.06 and experimental exercise) group 95.52
(supervised
clinical
discharge from hospital and randomly divided into supervised clinic exercise and
(p=>0.05) found.
ROM Knee Flexion

ROM )in degtree) 150. 100. 50. 0. pre Home Super 30.46 28.86 post 88.06 95.52
home based exercise. 19 patients not fulfilled the inclusion criteria and four patients due to prolonged hospital stay for medical reasons, two patients for medical conditions, two patient consented to the socio demographic and clinical
questionnaire, but not to the goniometry and Iowa Level of Assistance (ILOA) testing, and therefore had to be excluded. One patient refused to be tested two patient had been discharged before the
Graph 1: Showing the mean and significance level of range of motion of two group of supervised and home based exercise.
40. 30. Level of assistence 20. 10. 0. pre Home Super 33.9 32.9 post 11.94 10.1
ILOA
researcher had been able to collect data (morning of day three). The following results are presented: Range of movement (ROM) of the operated knee and functional level of
Graph 2: Showing the mean and significance level of IOLA(level of assistance) of two group of supervised and home based exercise.
been shown to reduce pain in patients at intervals of 24-hours, 48-hours, 72- hours and at one to eight weeks post operation (Hubbard and Denegar 2004; Jensen et al
Knee integrity & function
100. 50. 0.
KSKS
1985; Jarit et al 2003). 2: Range of motion: People normally require knee flexion of 45 to 105 during
pre Home Super 18.16 18.52
post 74.72 76.78
various activities of daily living. To demonstrate a normal gait pattern, 65 of flexion is required. To ascend and descend stairs, 90 of flexion is needed and to go from sitting to standing, 105 of flexion is required (Miner et al 2003). From the results of the range of movement shows that experimental group (mean=95.52) and control group (mean=88.06), one can assume that 51% of the patients (twenty six patients) would not be able to go from sitting to standing as they only had knee flexion of 80. However, from our sample of 50-patients, 24-patients (49%) who had 90-100 of knee flexion were able to go from sitting to standing independently without any assistance or assistive devices. Patients with less than 95 of knee flexion had worse Goniometry scores (p<.0001). Only patients with a very stiff knee will have function that is really affected by ROM. Their study identified 95 of knee flexion as a clinically meaningful cut-off point above which ROM does not limit a patients normal activities after TKR. However the long-term effects of this limitation of ROM could be detrimental to
Graph 3: Showing the mean and significance level of KSKS (knee society knee score) of two group of supervised and home based exercise. DISCUSSION KSKS: 1. Pain: Fifty percent of the patients had virtually no pain at six weeks post operation. The other fifty percent had pain that ranged from occasional to severe pain Two patients (4%) had severe pain. This indicates that the patients pain is not being managed well at home after discharge. They are perhaps not given physiotherapy modalities which are
healing in reducing pain. Cryotherapy and simultaneous exercise is more effective in reducing pain than icing alone. Icing and compression also helps to reduce pain in patients post surgery. Transcutaneous Electrical Nerve Stimulation (TENS)
causes a reduction of pain in 93% of patients who undergo surgery and the TENS group of patients consumed less pain medication. Interferential therapy has
Vol.1 No.4 2012
33
the normal joints, because of the patients over compensation when performing
this range of motion, the patient should manage functionally. Patients also
activities of daily living. 3. Knee Stability and alignment: The majority of the patients had normal stability and alignment. This indicates that the total score of the Knee Society Knee Score in this sample is not really affected by the components of stability and alignment, but mainly by pain and ROM. Malalignment of the prosthesis could result in stiffness which although
compensate when performing activities by using the other leg or their arms to assist with transfers. The quality of is the not
movement
being
performed
important to the patient, what is of importance is completing the movement by any means possible. The long term effect of poor ROM and poor quality of movement is that the normal joints take excess strain and over a prolonged period, there is an increased risk of developing pain and discomfort in the normal joints due to osteoarthritis. ILOA Score: Most of the patients were able to go from lying to sitting, sitting to standing and walking 4.57 meters independently, with minimal assistance. The patients scored very well in these three categories. This indicates that the ILOA Scale is not a sensitive enough functional measuring tool when used at six weeks post operation. It measures basic functional ability, not higher function. It was developed to determine whether patients who had had total hip and knee replacements were ready to be discharged from hospital (Shield et al 1995). It is the role of physiotherapists in the hospital to ensure that patients are able to perform basic transfers so that they will be independent at home, after they are discharged from http://www.srji.co.cc
uncommon is a disabling problem (Jerosh and Aldawoudy 2007). Treatment of malalignment could include manipulation or revision arthroplasty (Bong and Di Cesare 2004),which has been shown to be successful in terms of post-operative function(Miner et al 2003). 4. Knee Flexion contracture and extension lag: A percentage of the patients in this study had some degree of a flexion contracture and some degree of an extension lag at six weeks post operation. This could indicate that attaining full knee extension and flexion is not that important when it comes to functional activities such as going from sitting to standing, walking and stair climbing, as these same patients performed well when assessed using the ILOA Scale. Functional range of motion is between 45 and 105 (Miner et al 2003). As long as the extension lag and the flexion contracture do not interfere with
hospital. Five patient did not use an assistive device to perform the five functional tasks. She did however require nearby supervision for the walking, stairs and the speed test. Two patients used a walking frame at six weeks after the operation. Only one patient was unable to climb the stairs even with maximal assistance
therapist with knowledge of their acute postoperative rehabilitation status and appropriate that will
programme
influence their prognosis. integrity which was measured using the Knee Society Knee Score and function as measured using the ILOA Scale, six to eight weeks post surgery on total knee replacement. Research Recommendations: A functional tool should be developed that
CONCLUSIONS The goal of a TKA is to provide the patient with a stable and painless knee with sufficient ROM to perform ADLs (Gandhi et al., 2006). As many studies only focused on the long-term status of TKA patients (Aarons et al., 1996), this study examined the short-term status. The value of this is to furnish patients and the
assesses
the
attainment
of
higher
functional milestones, as well as the quality of the movement. If a more sensitive functional assessment tool was used, one that looked at higher functional levels, a more accurate functional
evaluation of the knee replacement could be determined.
REFERENCES: 1. De Jonghe B, Sharshar T, polyneuropathy and myopathy in
Lefaucheur JP, Authier FJ, DurandZaleski I, Boussarsar M, et al; Groupe de Reflexion et en dEtude des
critically ill patients. Crit Care Med 2001;29(12):22812286.
Neuromyopathies
Reanimation.
3.
Coakley
JH,
Nagendran
K,
Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA 2002;288(22):28592867.
Yarwood GD, Honavar M, Hinds CJ. Patterns abnormality illness. of in neurophysiological prolonged Care critical Med
Intensive
2. de Letter MA, Schmitz PI, Visser LH, Verheul FA, Schellens RL, Op de Coul DA, van der Meche FG. Risk factors for the development of
1998;24(8):801807.
4. Garnacho-Montero J, MadrazoOsuna J, Garcia-Garmendia JL, Ortiz-
Vol.1 No.4 2012 Leyba C,
Scientific Research Journal of India FJ,
35
Jimenez-Jimenez
9. Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345(19):13591367.
Barrero-Almodovar A, et al. Critical illness polyneuropathy: risk factors and clinical consequences: a cohort study in septic patients. Intensive Care Med 2001;27(8): 12881296.
10. Tennila A, Salmi T, Pettila V, 5. Spitzer AR, Giancarlo T, Maher L, Awerbuch G, Bowles A. Roine RO, Varpula T, Takkunen O. Early signs of critical illness
Neuromuscular causes of prolonged ventilator dependency. Muscle Nerve 1992;15(6):682686.
polyneuropathy in ICU patients with systemic inflammatory response
syndrome or sepsis. Intensive Care Med 2000;26(9):13601363.
6. Rudis MI, Guslits BJ, Peterson EL, Hathaway SJ, Angus E, Beis S, Zarowitz BJ. Economic impact of prolonged complicating neuromuscular blockade in the motor weakness 11. Rabuel C, Renaud E, Brealey D, Ratajczak P, Damy T, Alves A, et al. Human septic myopathy: induction of cyclooxygenase, heme oxygenase and activation of the ubiquitin proteolytic pathway. 2004;101(3):583590. Anesthesiology
intensive care unit. Crit Care Med 1996;24(10):17491756.
7. Latronico N, Peli E, Botteri M. Critical illness myopathy and
12. MacFarlane IA, Rosenthal FD. Severe myopathy after status Lancet
neuropathy. Curr Opin Crit Care 2005;11(2):126132.
asthmaticus
(letter).
1977;2(8038):615.
8. Bednarik J, Lukas Z, Vondracek P. Critical illness polyneuromyopathy: the electrophysiological components of a complex entity. Intensive Care Med 2003;29(9):15051514.
13. Witt NJ, Zochodne DW, Bolton CF, GrandMaison F, Wells G, Young GB, Sibbald WJ. Peripheral nerve function in sepsis and multiple organ failure. Chest 1991;99(1):176184.
14. Knox AJ, Mascie-Taylor BH, Muers MF. Acute hydrocortisone
17. Garnacho-MonteroJ, Amaya-Villar R, Garcia-Garmendia JL,Madrazo-
myopathy in acute severe asthma. Thorax 1986;41(5):411412.
Osuna J, Ortiz-Leyba C. Effect of critical illness polyneuropathy on the withdrawal from mechanical
15. Hund E, Genzwurker H, Bohrer H, Jakob H, Thiele R, Hacke W.
ventilation and the length of stay in septic patients. Crit Care Med
Predominant involvement of motor fibres in patients with critical illness polyneuropathy. Br J Anaesth
2005;33(2):349354. 18. Bolton CF. Sepsis and the
systemic syndrome:
inflammatory
response
1997;78(3):274278.
neuromuscular Crit Care Med
manifestations. 16. Thiele RI, Jakob H, Hund E, Tantzky S, Keller S, Kamler M, et al. Sepsis and catecholamine support are the major risk factors for critical illness polyneuropathy after open heart surgery. Thorac Cardiovasc Surg
1996;24(8): 14081416.
19. Latronico N, Fenzi F, Recupero D, Guarneri B, Tomelleri G, Tonin P, et al. Critical illness myopathy and neuropathy. Lancet 1996;
2000;48(3):145150.
347(9015):15791582.
ACKNOWLEDGMENT: The authors thank Dharam Pandey (MPT-neuro), Deepa Dabas (MSc-psycho) for assistance throughout the study.
CORRESPONDENCE:
*Bijender Sindhu PhD,PT Research Student**Dr.Manoj Sharma, MBBS, MS(ortho)***Dr.Raj k Biraynia, MBBS, D.ortho *School of Physical Therapy, Faculty of Medical Science, Singhania University**Department of orthopedic surgery, Jaipur Golden Hospital *** Department of orthopedic surgery, Sarvodaya Multispeciality Hospital. This study was not funded through a grant from the any organization.
Vol.1 No.4 2012
37
Comparison of the Effect of Isometric Exercise of Upper Limb on Vitals between Young Males and Females
Pranjal Parmar. BPT*
Abstract: Background and objective: studies on gender difference in cardiovascular responses to isometric exercises have been numerous and confliction the objective of this study was to determine if cardiovascular response to upper extremities isometric exercises differ between apparently healthy male and female subjects. Method: 60 young adults age between 18 to 22 years were included in study. These consisted of 30 males and 30 females. The baseline cardiovascular parameters (HR, SBP, DBP & MAP) were recorded. After two sets of three isometric upper limbs for 3 minutes these parameters recorded at the end of exercise and after recovery. Results:An increase in HR ,SBP , DBP&MAP was seen in both groups after exercise .the result showed group B had more increase in HR,SBP,DBP and MAP as compared to group A and significant rise in MAP &SBP in group B. Conclusion: Isometric exercise of upper limb can lead to increase in SBP, DBP, MAP &HR among apparently healthy males & females. It is more proannounced in males as compared to females. SBP &MAP increased in both but more in males as compared to females.
Keywords: Isometric Exercises, Cardiovascular Measures
INTRODUCTION Exercise, a common physiological stress, can elicit cardiovascular abnormalities not present at rest and can be used to determine the adequacy of cardiac function.1 The isometric contractions are
seen in various exercises like pushing or lifting heavy load where net displacement of load is not, but the rising tension can be felt in contracting muscles.3 It imposes greater pressure than volume load on left http://www.srji.co.cc
ventricle in relation to the body ability to supply oxygen.4 The metabolic demands of the exercising muscles increases, depending upon intensity of exercises and are met with various changes in circulatory and respiratory system.13 The effect of isometric exercises on vitals in between males and females may vary with substantial anatomical, physiological and morphological differences that exist between men and women which may affect their exercise capacity and influence magnitude of response to exercise.5 The average isometric strength estimate is generally 30% greater in men than in women in different muscle group. Gender difference in cardiovascular response to static exercise is believed to be due to differences in sympathetic
During exercise it is mainly adrenaline that produces changes in the heartbeat. Adrenaline is a hormone which causes the heart rate to quicker. 2. Breathing quickens and deepens: You breathe quicker so as to get more oxygen into the lungs. An efficient heart can then transport this to the working muscles. Training can be of great benefit to the Respiratory System. The capacity of the lungs is increased, which allows more oxygen to be taken in per breath. 3. Temperature rises: When we exercise, our muscles are working and they generate heat, so our body temperature rises. Body temperature is regulated by heat radiating from the skin and water evaporating by sweating. When we shiver, our muscles are working to produce heat in order to raise our body temperature. 4. Start to sweat: As we have just seen, some of our energy is turned into heat. The body will tolerate a small rise in temperature, but very soon we begin to sweat. If the conditions are hot, we sweat more and produce less urine. We also lose salt as well as body heat and water. We have to replace the salt so that the body stays the same, otherwise we will get cramp. 5. Muscles begin to ache: As we now know, in order to work, muscles need energy. Energy comes from
parasympathetic or adrenal interactions at cardiac level. The larger the muscle group that is involved in isometric tension the greater the cardiovascular response.6 Response To Exercise:7 When you exercise or take part in a strenuous sport you will notice several changes taking place in your body: a. Your heart beats stronger and faster b. Your breathing quickens and deepens c. Your body temperature increases d. You start to sweat e. Your muscles begin to ache 1. Heart beats stronger and faster:
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food, which is mainly converted to glucose. To work more efficiently muscles also need plenty of oxygen. Glucose and oxygen are brought to the muscles in the blood. Wastes such as carbon dioxide are carried away in the blood. This process of getting energy is called respiration. Glucose + Oxygen = Energy + CO2 + Water When muscles do extra work more Glucose and Oxygen are needed, so more blood must flow to the muscles.
Vitals response to exercise has been used as major criteria in exercise prescription for both patient and healthy population. Thus for prescribing isometric exercise, repetitions and frequency it would be helpful and prevent the adverse effect on vitals. The study would also be helpful in prescribing exercises for those with cardiovascular compromise. It would help to determine the safety limits of the exercise.
Eventually it becomes impossible to get enough oxygen to the muscles, so they use a different method of getting energy. Glucose is still used, but now there is a waste product called lactic acid, which makes muscle ache, & muscles.
OBJECTIVES: 1. To analyze if there is any change in vitals as a result of isometric exercises of upper limb 2. To compare the response of upper limb isometric exercises in young male and female.
Acute
Cardiovascular
Response
to METHODOLOGY Research Design: An quasi-Experimental (comparative) study. Sample Size: 60 normal individuals. Sample Population: 60 young adults between 18 to 22 yrs. Group A: 30 normal individuals (females) Group B: 30 normal individuals(males) Type of Sampling: Convenient sampling with random assignment. Duration of Study: one month. Study Set Up:
Exercise: As exercise intensity increases, heart rate, stroke volume, and cardiac output increase to get more blood to the tissues. More blood forced out of the heart during exercise allows for more oxygen and nutrients to get to the muscles and for waste to be removed more quickly. Blood flow distribution changes from rest to exercise as blood is redirected to the muscles and systems that need it.
Physiotherapy OPD of a tertiary care hospital.
CLINCAL SIGNIFICANCE
Inclusion Criteria:
No previous history of known cardiovascular condition. Normal values of vitals at rest. No neurological defecit in upper limb. Sex both male and female. Willingnessof patient.
intervention
was
explained
to
the
individuals and their written consent was taken from them. 60 individuals were assigned into two groups, group A and group B, 30 patients in each group. Procedure details of group A and group B: Pre-measures: Heart rate and blood pressure was measured using an electronic sphygmomanometer in standing position. Reading was noted. Individual position: standing position. Therapist position: on the individual side in stride standing position. Procedure: Participants in upstanding position performed 3 upper extremities isometric exercises i.e. 2 sets of each exercise for each 30 second each thus total duration of exercise for 3 minutes. 1. The exercise are pushing against the wall with outstretched arms and were instructed to exert maximal tension on wall.8 2. Hands clasped together and brought to manubrosternal level to chest while shoulders are 60 70 degree abducted and participants were instructed to maximally generate tension by pressing opposite was hands against each other.8 3. Both palms on wall with participants standing ahead arms extended and were
Exclusion Criteria: Fracture of upper limb bones. Cervical fracture. Neurogenic deficit. Congenital anomalies. Previous exercise training Any disability limiting to upper limb exercise. Psychiatric patients. Non-willing patients. vertebrae or scapula
Outcome Measures: Heart rate of patient at rest, immediately post exercise and 3 minutes after exercise Blood pressure i.e. systolic and diastolic blood pressure at rest, immediately postexercise and 3 minutes after exercise. Mean arterial pressure
calculated from the above data.
PROCEDURE 60 individuals were selected according to the inclusion and exclusion criteria. The need of the study and treatment
asked to push the wall without coming behind and keeping elbow straight.8 Participants were instructed to avoid valsalva maneuver by not holding breath
Vol.1 No.4 2012
41
Thereafter participants were asked to rest for 10 minutes before leaving. Postmeasures: Heart rate and blood pressure was measured immediately after exercise and 3 minutes after exercise. All patients s were comfortable after the treatment session.
MEAN AGE OF POPULATION

20.25 20.2 20.15 20.1 MEAN AGE OF POPULATION
DATA ANALYSIS AND RESULT The data collected was entered in excel sheet and statistical analysis was done using SPSS software. Heart rate and blood pressure are objective data hence can be considered for statistical analysis. This isan interval data hence pre and post parmeters was statistically analysed using paired t-test, and difference in paramate test, paramaters Post exercise -5.46072 -10.1411 10.1411 1.64e-05 3.14e 3.14e-09 Rest Recovery
The above graph shows mean age of group A and group B.
Group A (females) Group B (males)
Table 2 Rest Post exercise 117.8 123.28 123.6 134.58
Recovery 120.45 128.95
Value Group A Group B
Table 3 P value
Significance Difference is significant. Difference is significant.
Value -10.0176 P 2.19e-11 value between two groups was statistically analysed using unpaired t- test. -
-1.6912 3.47e 3.47e10 -1.3678 3.17e 3.17e12 Table 4
Table No.1 Mean age (yrs)of study group )of Group A B Number 30 30 Age (yrs) 20.23 20.16 Table 2 shows mean of systolic blood pressure at rest in group A is 117.8 and group B IS 123.6 ,post exercise in group A is 123.28 and group B is 134.58 and recovery in group A is 120.45and group B is 128.95.
Table 3 shows p value by paired t test in group A and group B and difference is statically significant. Table 4 shows p value by unpaired t test in group A and group B at rest, post exercise and recovery and difference is statically significant.
0.3SYSTOLIC BLOOD PRESSURE - RECOVERY 0.25 0.2 0.15 Female 0.1 Male 0.05 0 108101214161820222426283032 1 1 1 1 1 1 1 1 1 1 1 1 128
The above graph shows distribution of

150 100 50 0 REST POST EXERCISE RECOVERY
SYSTOLIC BLOOD PRESSURE
systolic blood pressure in males and females at rest, post exercise and recovery. Diastolic Blood Pressure Table 5 Rest Post exercise 75.6 84.25 80 96.50 Recovery 80.20 83.60
The graph shows mean of males and females of systolic blood pressure at rest , post exercise and recovery. . 0.2 SYSTOLIC BLOOD PRESSURE - REST
0.15 0.1 0.05 0 102106110114118122126130 Female Male
Group A (Females) Group B (Males)
Group A Group B
0.15SYSTOLIC BLOOD PRESSURE - POST EXERCISE 0.1 Female 0.05 Male 0 108112116120124128132136140
Value P value
Table 6 P value Significance 3.95e- Difference is 15 significant. -1.236 3.21e- Difference is 08 significant. Table 7 Rest Post Recovery exercise -5.78263 -14.6703 -4.4098 14.6703 1.1e-06 3.14e-09 1.58e-07 09 Value -1.345
Table 5 shows mean of diastolic blood pressure at rest in group A is 75.6 and group B is 80, at post exercise in group A is 84.25 and in group B is 96.50 and at recovery in group A is 80.20 and group B is 83.60.
Vol.1 No.4 2012
43
Table 6 shows p value by paired t test in group A and group B and difference is statistically significant. Table 7 shows p value by unpaired t test at rest, post exercise and recovery in group A and group B and difference is statistically significant
The above graph shows distribution of diastollic blood pressure between males and females at rest, post exercise and recovery.
Mean Arterial Pressure Table 8 Rest Post exercise 89.66 97.26 94.53 109.19 Recovery 93.61 98.71
DIASTOLIC BLOOD PRESSURE

120 100 80 60 40 20 0
FEMALES
Group A (Females) Group B (Males)
MALES
Group A Group B
Table 9 P value 5.78e10 -1.784 4.08e12 Table 10 Value -1.327 Rest Post exercise -9.57881 1.91e-11
Significance Difference is significant Difference is significant. Recovery -7.17096 2.06e-09
The above graph shows mean of males and females of diastolic blood pressure at rest, post exercise and recovery. Value P value
-7.001 1.16e09
0.2 0.1 0
DIASTOLIC BLOOD PRESSURE - REST

Female Male 68 70 72 74 76 78 80 82 84 86 88
Table 8 shows mean of mean arterial pressure at rest in group A is 89.66 and in group B is 94.53,at post exercise in group A is 97.26and in group B is 109.19 and at recovery in group A is 93.61 and group B
0.2 0.1 0
DIASTOLIC BLOOD PRESSURE - POST EXERCISE
is 98.71. Table 9 shows p value by paired t test in group A and group B difference is statistically significant.
Female Male 74767880828486889092949698 00 1 102
0.2 DIASTOLIC BLOOD PRESSURE - RECOVERY 0.1 0 70 72 74 76 78 80 82 84 86 88 90 92 Female Male
Table 10 shows p value by unpaired t test at rest, post exercise and recovery in group A and group and difference is statistically significant.
The above graph shows distribution of

MEAN ARTERIAL PRESSURE
120 100 80 60 40 20 0
mean arterial pressure between males and females at rest, post exercise and recovery.
Heart Rate
FEMALES MALES
Group A (Females) Group B (Males) The above graph shows mean of mean arterial pressure at rest, post exercise and recovery between group A and group B. Group B
MEAN ARTERIAL PRESSURE -REST 0.2
0.15 0.1 0.05 0 80 90 100 Female Male
Table 11 Rest Post exercise 72.6 80.40 74.4 82.95
Recovery 76.40 78.65
Table 12 Group A Value 0.00615 P value Significance 0.015E- Difference 04 is significant 0.00322 0.14E- Difference 05 is significant Table 13 Rest Post Recovery exercise 0.00123 0.00808 0.00055 0.012e0.080e- 0.055e-06 06 05
Value P value
Table 11 shows mean of heart rate at rest

0.1 MEAN ARTERIAL PRESSURE - POST EXERCISE 0.05 0 86 90 94 9800104108112116 88 92 96 1 102106110114118 0.2 MEAN ARTERIAL PRESSURE - RECOVERY 0.15 0.1 0.05 0 82 84 86 88 90 92 94 96 98 100102104106 Female Male Female Male
in group A is 72.6 and in group B is 74.4, at post exercise in group A is 80.40 and in group B is 82.95 and at recovery in group A is 76.40 and in group B is 78.65. Table 12 shows p value by paired t test in group A and group B and difference is statistically significant. Table 13 shows p value by unpaired t test at rest, post exercise and recovery in group A and group B and difference is statistically significant.
Vol.1 No.4 2012 Heart Rate

100 80 60 40 20 0
45
The above graph shows distribution of heart rate between males and females at rest, post exercise and recovery.
FEMALES MALES
DISCUSSION The study investigated the gender
difference in cardiovascular response to The above graph shows mean of heart rate in males and females at rest, post exercise and recovery. upper extremities isometric exercise
among apparently young healthy subjects. 60 participants were included in the study. They were divided into two groups, group
0.2 0.15 0.1 0.05 0 65
HEART RATE - REST
A and group B. Group A included female gender and group B included male gender.
Female Male
BP, HR and MAP were taken as outcome measure. These measures were taken pior, immediately after test and 3 minutes after
70
75
80
study. The data collected was statistically analysed. The result showed group B had more increase in HR,SBP ,DBP AND
0.15 0.1
HEART RATE - RECOVERY
MAP as compared to group A and there was significant rise in MAP and SBP in
Female
group B. The average isometric strength estimate is generally about thirty percent greater in men than in women in different
0.05 0 68 78 88
Male
muscle groups . Upon initiating isometric tension, increases in heart rate, systolic
0.15 0.1
HEART RATE - POST EXERCISE
blood
pressure,
and
diastolic
blood
pressure occur. Mitchell and associates

Female 0.05 0 72 82 92 Male
and
Seals
et
al
suggested
that
cardiovascular responses to isometric exercise are greater when larger muscle groups are involved. While heart rate responses to sustained submaximal static contractions tend not to be significantly http://www.srji.co.cc
different before, during, or after exercise, blood pressure responses to this exercise are significantly elevated before, during, and after exercise Gender differences in cardiovascular responses to static exercise are believed to be due to differences in sympathetic-parasympathetic or adrenal interactions at the cardiac level. The finding of this study revealed that there was no significant gender difference in vitals of participants at baseline which was statistically significant. The data collected reveals that post exercise heart rate, systolic blood pressure ,diastolic blood pressure and mean arterial pressure were higher than pre exercise values and was statistically significant in both groups ie group A and group B. When values of recovery i.e. 3 minutes after exercise when compared it was almost same in both groups but when compared to values at rest it was much greater than recovery values. The result between the two was calculated using unpaired t test. Therefore upper extremities isometric exercise had
These result indicate that more blood is pumped by left ventricle into aorta in response to upper extremities isometric exercise among males than females; while myocardial oxygen uptake & measure of oxygen consumption of heart muscles of female participants in response to upper extremities isometric exercises is higher than that of males. The tissues working hard during exercise and also after the completion of exercise require more oxygen than normal to pay off this oxygen debt incurred during the exercise. These results in increase in blood supply to active muscles to supply this extra amount of blood. At rest, muscles receive approximately 20% of total blood flow but during exercise blood flow to muscles increase to 80 -85% . Generally ,longer the duration of exercise greater the role the cardiovascular system plays in metabolism and performance during exercise bout.eg an 1T00 meter walk (little or no cardiovascular
involvement) versus a marathon(maximal involvement).9 It has reported that release of adrenaline and lactic acid into the blood result increase in a heart rate. The isometric exercises does not increase the oxygen demand to the extend raised by isotonic exercise thus DBP does not rise much in isometric exercise The isometric exercise results in pressure overload on
significant effect on heart rate, systolic blood pressure, diastolic blood pressure and mean arterial blood blood pressure. When values of group A and group B at post exercise were compared it was seen that male participants (group B) had higher post exercise MAP and SBP had level than females (group A) (p<0.05)
Vol.1 No.4 2012 heart. The myocardial
Scientific Research Journal of India oxygen extremities isometric
47 exercise in
consumption (mvo2) also increase due to exercise . Higher ventricular contraction is evoked among males leading to increase in systolic blood pressure. This indicates that the males have higher myocardial oxygen demand during
normotensive subjects. By Cembada and Gender differences in cardiovascular response to isometric in seated and supine positions by Don Melrose. The proposed mechanisms attempting to explain gender differences in cardiovascular responses to isometric exercise have been numerous and conflicting. Sanchez et al. found differences in adrenergic patterns between genders in response to isometric exercise and support the study. Ettinger and associates demonstrated attenuated
isometric exercise predisposing them to greater risk of ischemia if developing cardiovascular risk, factor compromising the coronary blood flow.10 It has been seen males have higher plasma levels of all three catecholoamines out of which plasma levels of epinephrine are higher as compared to females .this results in increase in MAP immediately at of exercise. The findings supports the results of previous investigators than upon initiation isometric tension increase heart rate, systolic blood pressure and diastolic blood pressure occur.12 The result of
increases in blood pressure and muscle sympathetic nerve activity compared with men. In data also derived from static exercise as well as temperature and psychological stressors, Jones et al found that gender did not influence sympathetic neural reactivity to stressors such as isometric handgrip exercise Changes in posture often experienced during exercise or sporting activities have also been shown to elicit various
investigations have been reported at best inconsistent and do not follow definite pattern.12 However during the recovery period the vitals were decreased as compared to immediately post exercise in both genders. However the vitals were not the same as they were at rest prior to commmencent of exercise. The result of study is supported by the articles Gender difference to in upper
circulatory adaptations. Sagiv et al. and Borst et al. both noted changes in cardiovascular regulation as a result of postural changes. Relatively fewer studies have investigated the cardiovascular
adaptations to exercise performed when posture does not change during the time course of the positions. A further study can be made:
cardiovascular
response
Comparison of vitals for larger muscles groups to smaller muscles group in upper limb isometric exercises.
pressure ,diastolic blood pressure ,mean arterial pressure and heart rate among apparently healthly males and females. 2. This was more preannounced in males than females .Systolic blood pressure (SBP) and Mean arterial pressure (MAP) increased in both but more males as compared to females
Comparison of vitals in isometric exercise for upper limb versus lower limb.
The result can be used as It can be used for prescription of exercise in those with
LIMITATION 1. The participants in study were young and elderly or middle aged participants were not included in these study. 2. All the subjects who were included in the study were students. 3. The participants nutritional status or
cardiovascular crompromise and elderly patients. It can be used to determine the safety regimen. limits during exercise
CONCLUSION The above study gives following
BMI were not considered while selection. 4. The occupation or lifestyle of
conclusion: 1. Isometric exercises of upper limb can lead to increase in systolic blood
participants was not considered. 5. The muscle mass or bulk of upper limb was not considered.
REFERENCES: 1. Journal of Exercise Physiology Online. Volume 8, number 5, august 2005. 2. Therapeutic Exercise, Carolyn 5. Effect of exercise .stending
lenderg 2004 6. Gender cardiovascular difference response in to
Kisner & Lynn Allen Collby.Pg No 168,5th Edition 3. Sports Fitness Advisor, Fleck
isometric exercise.gatzke 2005 7. Circulation, amercian heart
association,2007pg no 3 &4 8. Clinical Orthopaedic
st&kramerwj(2004). 4. Husketh Mount, pg no 92-96,lord street,merseyside, england.
rehabilitation ,2nd editions brent brotzman,pg no 138-142
Vol.1 No.4 2012 9. Cardiovascular system
Scientific Research Journal of India and isometric exercise
49 of upper
exercise physiology,aulter &amer suleman 10. International journal of biomedical reserach,srinath galag & ravipati sarath volume 2,november 2011 11. Gender cardiovascular difference response in to
limbs,howden et clf 2006. 12. Gender cardiovascular difference response in to
isometric exercise,gatzke 13. The essential guide to building muscles by phil daviee.
CORRESPONDENCE:
* Consultant Physiotherapist, Bhagwan Mahaveer Medical Centre, M.G. Road, Goregaon (W), Mumbai. Email: pranjalparmar38@yahoo.in
Paraplegia with Sacral Pressure ulcer treated by Ultrasound therapy- A Single Case Report
Shanmuga Raju P. MPT *, Ramalingam P. MS, FICA, MAMS
Abstract: Pressure ulcers are important and common complications after paraplegia. The use of therapeutic ultrasound as an adjunct to wound healing has gained interest in recent years. An twenty five year old male reported with a two months history of a grade two, non healing, sacral pressure ulcer. Ultrasound therapy (UST) is simple, safe, without side effects, bedside procedure, inexpensive with positive wound healing results for difficult to treat non healing pressure sore. I hope that this article will encourage other wound care specialists to engage in further research in this area.
Key Words: Paraplegia, Sacral pressure ulcer; Continuous mode of ultrasound therapy; wound healing.
INTRODUCTION Pressure Ulcer, also called as Decubitus ulcers, was first seriously studied by Jean- Martin Charcot, a clinician in the 19th Century (1-3). Pressure ulcer is a serious health issue, very painful, a significant physiological challenge, can shorten the life of patient, an emotional and financial burden to the patient. Pressure sore are important and common complications after paraplegia. An
time (9). Pressure ulcer are treated by using wound dressings, relieving pressure on the wound, Water beds/ Alpha bed by treating concurrent conditions which may delay healing and by the use of physical therapy such as electrical stimulation, laser therapy and ultrasound (1). Ultrasound is now the most frequently used electrophysical agent worldwide, used at least daily for patient treatment by the majority of physiotherapists (4-5).The aim of this study to investigate the effect of ultrasound (US) therapy in sacral
estimated 50 80% of individuals suffering from spinal cord injury develop pressure ulcer at least once in their life
Vol.1 No.4 2012
51
pressure ulcer with paraplegia. Limited clinical research is available and no consensus exists regarding the efficacy of ultrasound for treating pressure ulcer, particularly full thickness pressure ulcers.
department of physical medicine and rehabilitation OPD, CAIMS, Karimnagar on February 26th, 2011. On physical examination, he is bed ridden and was unable to sit without support in the chair, had sustained the sacral pressure
CASE REPORT A twenty five year old man presented with a two months history of a grade two, non healing sacral pressure ulcer. He was a former. He had history of fall from height. His past medical history, complete
ulcer. He has bedsore of 6.2 X 4.0 cm, the depth ranging from 10mm, grade II sacrum ulcer with necrotic slough
according to European pressure ulcer Advisory classification panel (EPUAP) wound His
system
(Figure.1).
paralysis of both lower limbs, loss of sensation, urinary and bladder
albumin count 2.4 g/dL, haemoglobin 11.0 g/dL, temperature was 38 degree Celsius. There was no evidence of osteomyelitis. He was put on conservative treatment, consisting of water bed mattress, bed postioning, regular pressure relief, daily saline water dressing and appropriate antibiotics.
incontinence, loss of mobility and sacral pressure ulcer for past one month. His medical problems included spinal cord injury and severe depression. He had become unable to walk since two months and was carried either in bed or in his wheelchair. He was diagnosed as a case of D11, and D12 wedge compression of spine with traumatic paraplegia (American spinal cord injury association impairment score: A- no motor or sensory function in the sacral segments) and sacral pressure ulcer. Five month back, he underwent placement of spinal fixation rods and plates from D11 to L1 level. A thoraco Lumbar-sacral corset was fabricated for him. Routine hematology and
OUTCOMES EVALUATED Wound measurements and digital
photographs of wound beds were obtained weekly. Wound dimension monitored and depth measurements were obtained using a sterile, cotton-tip applicator and ruler (Steven JK et al, 2007). Wound surface area was determined using Bates-Jenes wound assessment tool.
biochemistry investigations were within normal limits. He received antibiotics and vitamin supplements. He was referred to
ULTRASOUND INTERVENTION
THERAPY
On February 2011, Continuous mode of ultrasound therapy (Electroson 709,
Pulse duration: 2 ms Duty factor: 0.2 Spatial temporal average radiating surface area: 5.2 cm2 Duration of treatment: 10 minutes per session for sacral pressure ulcer
Chennai) treatment was performed in sacral pressure ulcer region. are The applied:
following
protocols
ultrasound machine with frequency of 3 MHz and spatial average intensity 0.8 w/cm2 sound head, in conjunction with a coupling media of aquasonic ultrasound transmission gel was used. Ultrasound was applied to the outer surface, and edge of sacral ulcer region (Fig. 2). Before the treatment of CUS therapy, we splashed each wound by oxygen spray. Sacrum ulcer was cleaned using 2% hydrogen peroxide. The standard normal saline (Nacl) dressing was done. Ultrasound treatment time was 10 minutes per session 6 days a week, for six weeks. At the end of third week there was marked
Duration of treatment: 6 weeks
RESULT The indolent pressure ulcer, apart from routine therapy, continuous mode
ultrasound therapy enhanced the healing of pressure ulcer in six weeks.
improvement in pressure ulcer i.e size, floor and wound margin reduced. There was no pus discharge after treatment (Fig. 3). A healthy granulation tissue was noted (Fig. 4). The patient made good progress and wound was completely healed within 42 days (Fig. 5). Fig: 1 On assessment, the sacral pressure ulcer presented as non- healing grade II pressure ulcer measuring 6.2 x 4.0 cm with erythema.
Table:
Parameter
of
Ultrasound
therapy treatment (McDiarmid etal, 1985) Ultrasound frequency: 3 MHz Spatial average temporal peak intensity: 0.8 W/cm2
Vol.1 No.4 2012
53
Fig: 2 the full thickness of sacral ulcer was treated with continuous mode ultrasound therapy (CUST)
Fig: 5 After six week of treatment, picture showing that sacral pressure ulcer are completely healed. DISCUSSION The purpose of the study was to assess the effect of ultrasound therapy in healing of sacrum pressure ulcer in patients with paraplegia. Infected sores heal more
slowly than clean sores while no effect of ultrasound clean sores were observed ultrasound therapy appeared to improve Fig: 3 three weeks after the treatment of CUST the rate of healing of infected sores. It is non thermal effect produced by ultrasound that are most significant in the stimulation of tissue repair (Dyson, 1976). Paul et al (1960) ultrasound was effective in
relieving congestion, cleansing necrotic areas and promoting healing with healthy, non-adherent skin approaching normal thickness. Cyclic vibration effect of ultrasound might induced a form of micro massage which by reducing edema, might Fig: 4 Fifth weeks after CUST, the wound size are decreased for sacral ulcer facilitate repair, their requires further investigations. It is also stimulate protein synthesis infact ultrasound initiates two http://www.srji.co.cc
processess which results in release of energy tissue: Surface cavitation (creation and dissipation of tiny bubbles in the tissues) and acoustic microstreaming that is movement of fluids along acoustic boundaries, such as cell membrane. This biophysical effect that are non-thermal alternations in cellular protein synthesis and release, blood flow and vascular permeability, angiogenesis, and collagen content and alignment by various workers it as quoted as follows: 1. General protein and collagen synthesis by fibroplasts (Harvey etal, 1975, Webster etal. 1980). 2. Fibroplast mobility (Miller etal, 1978). 3. Fibroblast ultrastructure (Dyson and Pond, 1970). 4. Permeability (Harvey of fibroblast 1975). 5.
cm2, Duration of treatment 10 minute per/session, Duration of frequency 6 weeks) pressure ulcer healed in time without side effects. Our case study showed that continuous mode of
ultrasound therapy treatment enhances healing of sacral pressure ulcer. This case study confirmed that continuous UST has a positive effect on pressure ulcer with paraplegia (Fig.5). No complications were observed with application of the
continuous ultrasound. Further studies are needed to evaluate the efficacy of ultrasound therapy in pressure ulcers in spinal cord injury in a large number of patients.
membrane
etal,
CONCLUSION Continuous mode of ultrasound therapy was effective in the treatment of patient with grade II pressure ulcer in young paraplegic patient. Ultrasound therapy treatment of pressure ulcer is less
Lysosomal fragilty (Tayor and Pond, 1972). 6. Tensile strength and elasticity of scar tissue (Dyson et al, 1979). 7. Modification of contraction in skin
wounds (Dyson et al, 1981). With this parameters of ultrasound
expensive, more comfortable and can enhance wound healing process without side effects and complication.
treatment (frequency 3 MHz, Intensity 0.8 W/cm2, Pulse duration 2 ms, Duty cycle 0.2, effective radiating surface area 5.2
REFERENCES: 1. Sella EJ, Barrette C. Staging of charcot neuro arthropathy along the medial column of the foot in the diabetic patient. J. Foot Ankle Surg. 1999, 38; 34-40. 2. Levine JM. Historical perspective on pressure ulcers: The decubitus ominosus of Jean- Martin Charcot.
Vol.1 No.4 2012
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J Am. Geriatr. Soci, 2005, 53; 1248- 1251.
8. Callam MJ, Dale Jj, Harpel DR, etal. A controlled trial weekly ultrasound therapy in chronic leg
3. Levine JM. Historical perspective: The neuropathic theory of skin ulceration. J. Am.Geriatr.Soci,
ulceration, Lancet. 1987; ii; 204206.
1992; 40, 1281.
9. Saad A, Williams A. Effect of therapeutic ultrasound the system on the
4. Goh AC, Chock B, Wong WP et al. Therapeutic ultrasound rate of usage, knowledge of use, and opinions on dosimetry. Physiother Singapore 1999; 2: 69-83.
activity phagocyte
of
mononuclear in vivo.
Ultrasound Med Biol, 1986; 12; 145-150.
10. Steven JK, David AL, Andrea JB, 5. Chipchase LS, Trinkle D. Jenny LM, Julie AB, Karen LA. Expedited wound healing with Non-contact, ultrasound Low therapy in frequency chronic
Therapeutic Ultrasound: Clinician usage and perception of efficacy. HongKong Physio Ther J. 2003; 21: 5-13.
wounds: A retrospective analysis. Adv. Skin and wound care, 2008,
6. Ali
Akbari
S,
Flemming Wollina
K, U. for The
vol: 21 (9); 416-23.
Cullum
NA,
Therapeutic pressure
Ultrasound (2009).
11. Arthro PJ, Thyme B, Warring (2002). A Calibration study of the ultrasound unit, Phys Ther, 82; 257-263. 12. Ankrom MA, Benneh RG, Sprigle
ulcers,
Cohrane collaboration, John wiley and Son ltd, p:1-18.
7. Paul BJ, Lafratta CW, Dawson AR etal. Use of ultrasound in the treatment of pressure sores in patients with spinal injury. Arch phys Med Rehabil, 1960; 41; 438440.
S, et al. Pressure related deep tissue injury under intact skin and the current pressure ulcer staging systems. Adv. Skin Wound care, 2005; 18 (1); 35-45.
13. McDiarmid T, Burns PN, Lewith GT, Machin D. Ultrasound and the treatment of pressure sores,
16. TerRiet Knipschild randomized
G, P
Kessels (1996). trial
AG, A of
clinical
Physiotherapy, 1985; 71; 66-70.
ultrasound in the treatment of pressure sores. Phys Ther 76;
14. Dyson M. Role of ultrasound in wound healing. In: Mcculloch JM. Kloth LC, Feeder JA, eds. Wound Healing. Alteratives in
1301-1311.
17. Whatson GW, Milani JC, Dean LS. Pressure sore profile: cost and management, ASIA, Abstracts
Management, 2nd ed, Philadelphia Pa: FA Davis co; 1995; 319-345.
Digest, 1987; 115-119.
15. Sari
AA
etal.
Therapeutic
18. Houghton
PE,
Kincaid
CB,
ultrasound for pressure ulcers. Cochrane Database of systemic reviews. 2009 (4).
Campell KE, et al. Photographic assessment of the appearance of chronic pressure and leg ulcers. Ostomy / Wound Management. 2000; 46(4); 20-30.
ACKNOWLEDGMENT: I thank the men who participated in this trial. I would also like to thank chairman Sri. C. Lakshmi Narasimha Rao, Prof. V. Suryanarayana Reddy, Director, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar for his support and encouragement of this study.
CORRESPONDENCE:
*Asst. Professor & I/C Head, Department of Physical Medicine and Rehabilitation Chalmeda Anand Rao Institute of Medical Sciences Karimnagar -505001, Andhra Pradesh, INDIA. Mobile: 08790544270, Fax: 08782285318. E-mail: shanmugampt@rediffmail.com
Vol.1 No.4 2012
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Arterio-Enteric Fistula: A Case Report

Anil Degaonkar*, Nikhil Bhamare**, Mandar Tilak***
Abstract: Gastro-intestinal (GI) bleeding may originate anywhere from oral cavity to anus from the innocuous one like peptic ulcers to capricious lesion like ca colon.Classically if the cause of bleeding is somewhere below the ligament of Treitz, the stools are maroon or bright red in colour and it is described as lower GI bleeding or hematochezia. Arterioenteric fistula signifies a rare but important cause of massive lower GI bleeding .The vexing problem lies in proper and timely diagnosis of this condition.A keen clinical acumen and proper use of tests lead to accurate diagnosis and prompt treatment and can be lifesaving for the patient by treating significant ongoing bloodloss. We wish to report such a case of an arterio-enteric fistula between artery of broad ligament of uterus and terminal ileum diagnosed and successfully treated at our institute .
Keywords: Arterioenteric fistula, massive GI bleed, rare cause
INTRODUCTION Arterioenteric fistula is a anomalous communication between artery &
anemia. She had undergone exploration for ectopic pregnancy 1 month back at a private hospital..On 8th post operative day she had complained of three episodes of per rectal bleeding which was associated with giddiness and profound weakness. Her sigmoidoscopy had been done and no
gastrointestinal tract. It is a rare cause of massive lower GI bleeding with the dreaded aortoenteric fistula leading to massive and many times fatal GI bleed.
CASE REPORT A 28 yr lady presented with complains of recurrent per rectal bleeding and severe
abnormality was detected.Patient had been transfused, stabilised and subsequently discharged .She whad been stable for the http://www.srji.co.cc
next 20 days and now presented with above complains of recurrent per rectal bleeding and severe anemia. Patient was ere investigated. Hematological investigations showed low haemoglobin hb-5 gm% with 5 reticulocytosis. Platelets were adequate and bleeding and clotting time was normal. Serum Beta hCG was elevated .Upper GI scopy showed no abnormality. significant On O
exploratory
laparotomy
after
proper
resuscitation of the patient was taken. On exploratory laparotomy there was evidence of f adherent ileum to the
posterior aspect of the broad lig. of uterus (site at which the gestational sac of previous ectopic was present.) Ileum was separated from adhesion site. Erosion of ileum wall with bleeder at site of adhesion to broad ligament was found. ad The site of adhesion on the broad ligament showed necrosis.
colonoscopy
only
finding
observed was presence of blood clots near caecum. USG was suggestive of
heterogeneous mass in right adnexa with left ovarian cyst. CT confirmed the ultrasound findings. Pt was transfused with 3 pints of PCV. Her condition improved and she remained ition stable for next 8 days .On 9th day she developed three episodes of massive per rectal bleed and went into hypovolemic shock. Her pulse rate was 146/min, BP 90/60 mm of hg. Patient was pale and dehydrated. She did not have any an Fig.1: Involved Ileal Segment Thus this was a case of arterioenteric fistula between the adherent ileum and a branch of the ovarian artery supplying the broad ligament. All bowel adhesions were ll separated. The bleeder as ligated
hematemesis and ryles tube aspirate was clear. Due to absence of hematemesis and pain in epigastrium upper GI bleeding was less likely. Also patient had a history of abdominal arterioenteric exploration. fistula was Thus an
hysterectomy was done. Adherent and eroded segment of ileum was resected. Intra-operative operative enteroscopy both
suspected.
antegrade and retrograde was done in the ileum to rule out any othe site of GI bleed. Ileo-ileal anastomosis was done. ileal Postoperatively the patient was monitored in surgical intensive care unit. Patient
Advanced investigation modalities like tion angiography and technicium99 labelled rbc scan was unavailable at our institute. Hence a decision for emergency
Vol.1 No.4 2012
Scientific Research Journal of India tuberculosis, inflammatory non drug steroidal enteropathy
59 antianti and
received 3 blood transfusions. Patients general condition improved steadily and patient was discharged on 14th post operative day. tion Gross observation of resected specimen of ileum and uterus with broad ligament as well as histopathological analysis
enteric fever are the major causes of lower GI bleeding in India.2,3 Small bowel sources and other colonic pathologies like small bowel diverticular disease,
inflammatory bowel diseases, neoplasia of small and large bowel, angiodysplasia, aorto-enteric enteric fistula, ischaemic and
suggested a arterio-enteric fistul between enteric the ileum and the broad ligament of the uterus.
radiation colitis are uncommon causes but pose a challenge to the clinician in making correct preoperative diagnosis.3,4 It is imperative to localize the source of bleeding preoperatively for successful treatment. Only rarely does laparotomy need to be performed in emergency without knowledge of the site s of hemorrhage.5 The diagnostic work work-up should be done as soon as the resuscitation is over and the general condition stabilizes. The first step is nasogastric aspiration and upper gastrointestinal endoscopy
Fig.2. & 3: Resected specimen of uterus esected (gross)
(esophago-gastroduodenoscopy) to rule gastroduodenoscopy) out upper GI hemorrhage since peptic er ulcer bleeding may be the cause of
DISCUSSION The causes of lower GI bleeding shows a geographical variation, wit colonic
hematochezia and malena. Proctoscopy and sigmoidoscopy (rigid or flexible) are relatively simple procedures to exclude hemorrhage reflection below such as the bleeding peritoneal internal
diverticulitis and vascular ectasia of colon are the most common causes in the West.1 Idiopathic ulcerative colitis, acute colitis, colonic polyps, solitary rectal ulcer, colonic carcinoma, ileal and colonic
hemorrhoids, rectal polyps and growths. orrhoids, Colonoscopy, visceral angiography and abdominal scintigraphy with 99m Tc labeled RBCs are three useful tests for http://www.srji.co.cc
localization.5 Colonoscopy may be most useful if the bleeding has stopped or at least slowed substantially. Selective visceral angiography is very useful if the patient is having active bleeding to locate exact site of bleeding. Abdominal scintigraphy with 99m Tc labeled RBC infusion is helpful in delineating the site of bleeding when bleeding is intermittent and at a rate below that which is detectable by angiography. In case the above facilities are not at hand, a combination of sigmoidoscopy and air contrast barium enema may be tried if patients general condition permits.6 We have searched the literature on the subject and have come across some pathological conditions leading to fistula formation between aorta and the intestine.7,8 Abdominal aortic aneurysm and infective aortitis may lead to primary aorto-enteric fistula but in most of the cases the bleeding occurs due to erosion of aortic vascular prosthesis through the wall of distal duodenam due to prolonged contact between prosthetic graft and a fixed segment of intestine (secondary aortoenteric fistula). Bleeding may occur due to dehiscence of the anastomosis with bleeding into the bowel lumen from the edges of the eroded intestine.7 The intestine may take blood supply from the anterior abdominal wall due to
adhesion formation as seen sometimes as a sequele of mesenteric venous thrombosis, malignancies and fungal infection. A case has been reported where mucomycosal invasion took place into the iliac artery causing severe haemorrhage, in a case of non Hodgkins lymphoma receiving chemotherapy.8 In this case, the cause of arterio-enteric fistula formation was due to continued trophoblastic activity of
incompletely removed gestational sac & as the syncytiotrophoblast has invading property.9 It has eroded the ileum & fistula is formed between uterine artery of broad ligament & terminal ileum.
Monitoring of trophoblastic activity can be done by estimation of serum beta HCG levels.10 In the above case report we have presented a case of arterio-enteric fistula between ileum and broad ligament of the uterus. This is a very rare pathology and has seldom been reported. We hypothesize that the ectopic pregnancy and exploratory laparotomy for the same probably created a inflamed and eroded surface on the broad ligament where ileum adhered. The ileal wall was further eroded .The inflammatory process exposed a artery on the broad ligament and this adhered to the ileum cresting the arterioenteric fistula.
Vol.1 No.4 2012 REFERENCES:
61
1. DeMarkles MP, Murphy JR. Acute lower gastrointestinal bleeding.
Invest
Clin
2002
Mar-Apr;
52(2):119-24.
Med Clin North Am 1993 Sep; 77(5):1085-100. 6. Mark HB, Robert B, Mark B. Merk 2. Goenka MK, Kochhar R, Mehata SK. Spectrum of lower an Manual Diagnosis and
Therapy. Seventeenth Edition Sec 3, Ch-22. Gastrointestinal
gastrointestinal
hemorrhage:
Bleeding.
endoscopic study of 166 patients. Indian J Gastroenterology 1993 Oct; 12(4):129-31. 7. Kahhlke V, Brossmanm J, Klomp HJ. Lethal hemorrhage caused by aortoenteric 3. Anand AC, Patnaik PK, Bhalla VP, Choudhary, et al. Massive lower intestinal bleeding a decade of experience. Trop Gastroenterol 8. Mir N, Edmonson R, Yeghen T, Rashid 4. Miller LS, Barbarvech C, H. Gastrointestinal complicated by endovascular fistula stent following implant.
Cardiovasc Intervent. Radiol 2002 May-Jun:25(3):205-7.
2001 Jul-Sep;22(3):131-4.
mucormycosis
Friedman LS. Less frequent causes of lower gastrointestinal bleeding. Gastroenterol Clin North Am
arterio-enteric fistula in a patient with non-Hodgkins lymphoma. Clin Lab Haematology 2000
1994 Mar;23(1):21-52.
Feb;22(1):441-4.
5. Gracia Osogobio S, Remes Troche JM, et al. Surgical treatment of lower digestive tract hemorrhage Experience at the Institute
9. Datta;
textbook
of
gynaecology;6th 2;page no.23
edtn;chapter
Nacional de ciencias Medicas Y Nutricion Salvador Zubiran.Rev
10. Datta;
textbook
of
gynaecology;6th 15;page no.186.
edtn;chapter
CORRESPONDENCE:
*Assistant Professor Surgery, Dr. Shankarrao Chavan Govt Medical College, Nanded, Maharashtra; **Resident 3rd yr General Surgery, Dr. Shankarrao Chavan Govt Medical College, Nanded, Maharashtra; ***Assistant Professor Surgery, Dr. Shankarrao Chavan Govt Medical College, Nanded, Maharashtra. E-mail id: i.mandar@hotmail.com Mob no: 09975033726
Vol.1 No.4 2012
63
All-Oxide Solar Cells: The Way of the Future

Akshay Vijay Dongarwar*
Abstract: We as a world are looking at our globe depleting of its natural resources. The quantity of coal presently available can lead us through for twenty more years at maximum considering the growing demand for high quality coal and natural resources and to suffice the growing population and bettering lifestyle. Again, on one side we have cut throat technological advancement in the silicon valley and the mobile world and on other, we have fairly advanced technologies for bringing in better, faster, more efficient and cheaper solutions to the environmental concerns. The question is basically inspired from this ever daunting situation. Cant we have a cheap and highly effective solar energy treatment plant which can actually reach poor countries and help them get over their energy crisis without undergoing high-end processing in posh labs like is done for silicon cells? Even in one of the fastest growing economies of world, India, silicon processing is not done by any industry commercially to make solar cells. All the pre-processed cells are imported and further distributed because of the complexity in the process. Also, being cheap and easily available, it must have a huge life like silicon cells have. So, it should possess the best of silicon while eliminating the negatives. Can we find an alternative to conventional solar cells that can reach out to everyone?
Keywords: All Oxide Solar Cell
THE QUESTION We as a world are looking at our globe depleting of its natural resources. The quantity of coal presently available can lead us through for twenty more years at maximum considering the growing
demand for high quality coal and natural resources and to suffice the growing population and bettering lifestyle. Again, on one side we have cut throat
technological advancement in the silicon
valley and the mobile world and on other, we have fairly advanced technologies for bringing in better, faster, more efficient and cheaper solutions to the
polish of cavity from atmospheric reaction. Such cavity behaves as metal-metal junction solar cell (termed M-M cavity solar cell). But using nanowires and nanotubes increases the functionality further as diffraction light rays occurs. Again, using metal oxide makes further sense as they are chemically under thermodynamic
environmental concerns. The question is basically inspired from this ever daunting situation. Cant we have a cheap and highly effective solar energy treatment plant which can actually reach poor countries and help them get over their energy crisis without undergoing high-end processing in posh labs like is done for silicon cells? Even in one of the fastest growing economies of world, India, silicon
equilibrium. Another approach is used which is of titanium dioxide for photosensitization.
RESEARCH The main challenge with producing a solar cell with whole new materials is the availability of photo sensitive materials and their production. I had prepared a project for the prestigious KVPY
processing is not done by any industry commercially to make solar cells. All the pre-processed cells are imported and further distributed because of the
complexity in the process. Also, being cheap and easily available, it must have a huge life like silicon cells have. So, it should possess the best of silicon while eliminating the negatives. Can we find an alternative to conventional solar cells that can reach out to everyone?
scholarship, where I tried to theoretically explain the use of metal-metal junction cavity cell for emitting electrons. The same research is used here, but with some changes to make it further effective and to eliminate short-comings. Here, I present an all-oxide solar cell fabricated from vertically oriented zinc oxide nanowires
HYPOTHESIS A cavity of metal m2 (W2) with thin polish of metal m1 (W1, W1<W2) on inner surface, with a pin hole is kept at the focus of the solar concentrator coinciding the pinhole and focus. Pinhole is covered with transparent glass to protect inner
and
cuprous
oxide
nanoparticles.
It
consists of vertically oriented n-type zinc oxide nanowires, surrounded by a film constructed from p-type cuprous oxide nanoparticles. The idea behind using metal oxides is to eliminate the effects of atmosphere. Oxides being benign, are safe
Vol.1 No.4 2012
65
from environmental contamination. The use of cuprous oxide as solar cells is a very well studied since last 20 years. Adding another metal-oxide film seemed difficult at first as the oxides are already in stable states and to make use of metalmetal junction films, we had to change the physical properties to excite them. But, with the knowledge of photo-electricity (diffusion) that I had acquired in the recent months made me think a step further and the idea of using nanowires and nano-particles that respond better to incident light seemed possible. In the second part, I used titanium dioxide, another successful oxide to take in the solar light and convert them into
5 mM solution of zinc acetate dihydrate in absolute ethanol was prepared. Two drops of this solution were placed onto an indium tin oxide (ITO) coated glass substrate (Thin Film Devices, ~40-50 /square). The substrate was then rinsed with absolute ethanol and blown dry with nitrogen. The dropcasting, rinsing and drying was repeated four times per substrate. The substrates were then
annealed in air at 350C for 30 minutes, converting the Zn(OAc)2 into ZnO, and then cooled to room temperature. This process was then repeated a second time to ensure a conformal layer of ZnO. The nanowires were then grown by placing the seeded substrate in an aqueous solution containing 25 mM zinc nitrate hexahydrate, 25 and 5 mM mM
electricity (Research done by Dr. M. Graetzel ). The cell was not taken as it was. I just used pure titanium dioxide dust here as polyphyrine derivatives. I did not use dyes as is done in Graetzel cell but instead let the oxide in white colour. Its property of reflecting back visible range light was later used and sorted out with design. Being from an engineering
hexamethylenetetraamine,
polyethyleneimine at 90C. The substrate was suspended upside-down to prevent any larger ZnO aggregates from
accumulating on the surface. Typical growth times ranged from 30-60 minutes, yielding wires that averaged from 4001000 nm in length and 30-50 nm in diameter. After the growth, the nanowire arrays were rinsed thoroughly with
background, I designed a model, that could make use of both these oxide films efficiently and expected to get a desired output of >12% efficiency.
deionized water, then annealed at 400C for 30 minutes to remove any residual
EXPERIMENT Zn oxide film preparation:
organics on the nano wire surface.
air. After 12 hours, the burgundy solution turned into deep green, indicating the oxidation of the copper nanoparticles into Cu2O. The Cu2O nanoparticles underwent further cleaning by repeated precipitation with ethanol. Finally, the nanoparticles were dispersed in toluene for dropcasting onto the ZnO nanowire arrays. The processing required no posh research labs and could be done without much efforts. The titanium oxide film is prepared the usual Graetzel cell way. Except, we do not use dye. The main motto was to simplify the The Cu2O nanoparticles (NPs) were prepared as follows: A solution of copper (I) acetate (0.5 g), trioctylamine (15 mL) and oleic acid (Alfa Aesar, 99%, 4 mL) was flushed with nitrogen, then rapidly heated to 180C under nitrogen flow. The solution was maintained at this temperature for 1 hour, then was quickly increased to 270C and held for one additional hour, ultimately producing a burgundy colloidal solution, which are metallic copper nanoparticles. The solution was cooled to room DATA The complete experiment was done by using the available technologies at process. Dying induces lot of
complexity and we want the process to remain easy.
disposal. Instead of using the paraboloid sun-tracking reflector concentrator, a fine beam of SODIUM VAPOUR LAMP was used to create a similar effect. The metalmetal oxide junction solar cell and the titanium oxide cell were tested over a long period of time to get accurate readings. The cuprous oxide-zinc oxide junction cells were studied first as they formed the key research. A fine layer of the junction nanoparticles was taken and placed in a small glass box. The glass was designed in such a way that it didnt let the incident
temperature, at which point absolute ethanol was added to precipitate the nanoparticles. The supernatant was
removed and the nanoparticles were redispersed in hexane and then exposed to
Vol.1 No.4 2012
67
light get out and caused multiple internal reflections, thereby reproducing the effect as we see in the model. The input currents and output currents were first measured for a silicon solar cell of known efficiency. It gave the total losses caused due to atmosphere and other resistances in the wire. Considering the same,the silicon solar cell was replaced by the meta-metal junction cell. Calculating the output currents for same input current given t sodium vapour lamp and subtracting the effects of losses previously calculated, the efficiency was calculated to be The details of the experiment are given as follows There were mainly 2 methods employed to double check the results 1) V-A meter, where voltage of input was noted and then the output current. Thus the power of cell was measured. 2) A solar cell's energy conversion efficiency (eff), is the percentage of incident light energy that actually ends up as electric power. This is calculated at the maximum power point, Pm, divided by the input light irradiance (E, in W/m2) under standard test conditions (STC) and thesurface area of the solar cell (Ac in m2). eff=P/EA Similar procedure was carried out for Titanium dioxide cell. The net efficiency was found out as 12.2374% Now, we observe that the efficiency of the proposed cells with the given design comes out to be quite more than that of the silicon cells. Thus, one coupling the cells, the efficiency will increase further. http://www.srji.co.cc Max power point 1.0243 Light irradiance 1000w/m^2 Area is 12*8 cm^2 or 0.0096 m^2 Efficiency= 10.6697 1 2 3 10.2 10.3 10.2 Max power point 1.146 w Light irradiance 1000 w/m^2 Area is 12*8cm^2 or 0.0096 m^2 Efficiency=11.9374 OBSERVATION The observations of the experiment that I performed are listed below For the Metal-metal oxide junction cell: Sr No 1 2 3 Voltage (V) 11.5 10.6 11.4 Output Current (mA) 100 99 100
For the titanium dioxide cell Sr No Voltage (V) Output current (mA) 100 100 99
Here, an interesting trend observed is that the maximum power point doesn't change much for a considerable change of input voltage in case of metal-metal oxide junction cells. The reason is unknown.
importing silicon cells was never cheap. Hence, here, with technologically
advanced institutes in the nation like IITs and NITs the implementation and
bettering the scope of the idea can be done. A major issue was designing.
CONCLUSION Thus, as the results showcase, using some of the most common oxides and some simple primary treatment processes
How could we make most of the sunlight. The answer came with the paraboloid concentrator.
How could we use it at all times during the day? The secret lied with the solar tracking device which had become pretty common.
coupled with engineering ideas, we were able to increase the efficiency of solar energy harnessing devices by an
outstanding ~6-7% (results show 4.3% but that is under lab conditions). Thus, the basic idea of trying to use the metal oxides arising from a simple urge to use environmentally inert materials turns out to be a revolutionary alternative for the conventional silicon solar cells. The trait that make the idea highly successful is that the processing is very easy and can be done on a commercial level with some material engineering guidance. Also, it turns out to be a relief for countries like India and other developing countries as
How would we place the cells to get output from both? The design came to me by instincts. After a host of designs, the most suitable and easy to construct was used.
Titanium di-oxide reflects back the visible light. I offered a solution in the design.
At some places, the solar energy is directly used for heating purposes. Thus a band filter can be employed to filter out the harmful ultraviolet and infra-red light.
CORRESPONDENCE:
*29, Nelco Housing Society, Near Nagarjuna Trust Hospital, Khamla-Nagpur-440025. Contact- +91 9175017645, Email-id: adongarwar@gmail.com
Vol.1 No.4 2012
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Call for Papers Scientific Research Journal of India (SRJI) globally welcomes research scholars & scientists from different fields of science like Botany, Zoology, Medical Sciences, Agricultural Sciences, Environmental Sciences, Natural Sciences, Anthropology etc to contribute their researches in this Open Access Publication. ::For full detail kindly visit:: http://www.srji.co.cc

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

Scientific Research Journal of India

Scientific Research Journal of India (SRJI)

Vol.1 No.4 2012

Scientific Research Journal of India

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Vol.1 No.4 2012

Scientific Research Journal of India

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

Arterio-Enteric Fistula: A Case Report

All-Oxide Solar Cells: The Way of the Future

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Vol.1 No.4 2012

Scientific Research Journal of India

Dr. Krishna N. Sharma Editor in Chief

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therapy clinics, and facilitate monitoring the patients progress, modifying

individual programs, and providing patient

periodic telephone calls. Monthly phone

Vol.1 No.4 2012 calls by therapist

Scientific Research Journal of India individuals were

associated with increased function in patients with osteoarthritis. Although

Inpatient and Home Exercise. Familiarization Period

physical therapy clinics; and (2) homebased rehabilitation monitored by a

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

HomeBased(n=16) 64.6 (7.8) 162.3 (11.1) 85.5 (15.9) 9.2 (7.3)

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

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

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Scientific Research Journal of India

Subsequent analysis of the main effect for

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Scientific Research Journal of India

and 8 weeks after surgery (p<0.01), whereas there was no statistically

rehabilitation patients who

Knee Society Knee Score

Visual analog Score

ILOA Level of Assistance

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

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Scientific Research Journal of India

CONCLUSION The current study compared two

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

Goldsmith CH, Campbell J, Stitt

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Scientific Research Journal of India

rehabilitation arthroscopic prospective

patients with osteoarthritis of hip or knee. J Rheumatol 15:1833 1840, 1988.

Arthroscopy 5:298305, 1989.

rehabilitation following elective hip and knee replacement. J

ligament reconstruction. J Orthop Sports Phys Ther 26:332339, 1997.

5. Forster DP, Frost CEB: Costeffectiveness physiotherapy of after outpatient medial

remained stable. Arthritis Rheum 35:511515, 1992.

menisectomy. BMJ 284:485487, 1982.

10. Seymour N: The effectiveness of physiotherapy after medial

Society clinical rating system. Clin Orthop 248:1314, 1989.

arthroscopic reconstruction. Am J Orthop 26:2529, 1997.

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INTRODUCTION Weakness that is hospitalization for

dysfunction occur in a large percentage of

functional independence in critically ill patients.