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

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

ISSN: 2277-1700

Vol: 2, Issue: 1, Year: 2013

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CONTENTS

Title Author/s Department Page

Editorial Dr. Krishna N. Sharma i

Effect Of McConnell Taping on

Pain, ROM & Grip Strength in

Patients with Triangular

Fibrocartilage Complex Injury

Dr. Shahid Mohd. Dar,

Dr. R. Arunmozhi,

Babloo Sharma

Physiotherapy 1

Evaluation of Knee Joint Effusion

with Osteoarthritis by

Physiotherapy: A Pilot Study on

Musculoskeletal Ultrasonography

Shanmuga Raju P.,

Suryanarayana Reddy V.,

Madurwar AU,

Sridhar EB,

Harsha Vardhan NS.

Physiotherapy 10

Physical Therapy Management of

Tuberculous Arthritis of the

Elbow

Amit Murli Patel Physiotherapy 16

Effect of Sensory Cueing on Gait

and Balance during both “On”

and “Off” Drug Phase of

Parkinson’s Disease

Sinha Siddharth,

Bhatt Sunil Physiotherapy 26

Congenital Talipes Equinovarus

(CTEV) Mayank Pushkar Physiotherapy 35

Analysis of Water Quality of

Halena Block in Bharatpur Area

Sunil Kumar Tank,

R. C. Chippa Chemistry 42

ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji

iv

i

EDITORIAL

Greetings of the New Year!!! I am very pleased to present this issue of the Scientific Research Journal of

India (SRJI). With this issue, we have entered in the 2nd year of our publication.

This multidisciplinary and open access Journal of science published total 22 papers (13 papers in

Physiotherapy, 1 paper in Surgery, 1 paper in Microbiology, 3 papers in Computer Technology, 1 paper in

Chemical Engineering, 1 paper in Metallurgical Engineering, 1 paper in Agriculture, and 1 paper in

Anthropology) last year. This year, we are hopeful to bring more researches in light.

In the current issue we have covered two disciplines of science Physiotherapy, and Chemistry. Hopefully

you’ll find these papers informative.

Your comments and suggestions are very valuable for us.

Happy Reading.

Regards,

Dr. Krishna N. Sharma

Editor in Chief

1

EFFECT OF MCCONNELL TAPING ON PAIN, ROM & GRIP STRE NGTH IN

PATIENTS WITH TRIANGULAR FIBROCARTILAGE COMPLEX INJ URY

Dr. Shahid Mohd. Dar* MPT (Orthopaedic & Sports), Dr. R. Arunmozhi** MPT (Sports &

Rehabilitation), Babloo Sharma*** MPT (Sports)

ABSTRACT

STUDY OBJECTIVES: To find out the efficacy of McConnell Taping on Pain, Range of Motion and Grip

strength in subjects with Triangular Fibrocartilage Complex (TFCC) injury. DESIGN: An Experimental Study.

SETTING: All the Subjects were selected from various sports center from Dehradun and SAI Guwahati.

Methods: A total of 28 subjects were recruited for the study on the basis of inclusion and exclusion criteria after

signing the informed consent form. The subjects were divided into two Groups (A= Taping & B= Conventional

Therapy). OUTCOME MEASURE: Grip Strength, Range of Motion for Wrist and Forearm & Numerical Pain

Rating Scale. RESULTS: The result of the study shows that both McConnell Taping and Conventional Therapy

are effective in improving the Range of Motion, Grip Strength and reducing the Pain level. Both groups showed

significant improvement when comparison was made within the group. However, there is significant reduction in

pain level between the groups for Group A (p=0.000). CONCLUSION: The present study demonstrates that both

McConnell Taping and Conventional Treatment are effective in improving the Grip Strength, Range of Motion

and reducing the Pain level in subjects with TFCC injury. However, it can be concluded that McConnell Taping

is the better form of treatment in improving the Grip Strength, Range of Motion and reducing the Pain level in

subjects with TFCC injury.


2

KEY WORDS: TFCC, Taping, Grip Strength, Range of Motion, Numerical Pain Rating Scale, Conventional

Therapy.

INTRODUCTION

The triangular fibrocartilage complex (TFCC)

is a special structure at the ulno-carpal articulation.8

It is composed of semicircular biconcave

fibrocartilage or articular disc called the TFC, the

palmar and dorsal distal radioulnar ligaments, a

meniscus homolog, ulnolunate and ulnotriquetral

ligaments and the extensor carpi ulnaris tendon

(ECU) subsheath.7,17 Functionally, the TFCC

extends the radio-carpal articulation, permitting

pronation and supination.8 The TFCC is a

cartilaginous and ligamentous structure, important in

the stabilization of the distal radial ulnar joint and in

the absorption of load between the distal ulna and

the volar carpus.7,17 The articular disc of the TFCC

separates the ulna and the proximal carpal row, and

carries about 20% of the axial load from wrist to

forearm.17

Injuries to the TFCC occur with repetitive ulnar

loading (e.g., bench press, racquet sports) or acute

traumatic axial load with rotational stress (e.g.,

FOOSH).17 Most injuries to the TFCC have a

component of hyperextension of the wrist and

rotational load. Injury to the TFCC is the most

common cause of ulnar-sided wrist pain.7 Ulnar-

sided wrist pain made worse with ulnar deviation,

wrist extension, or heavy use is the common

complaint of an athlete who has a TFCC injury.

TFCC injuries are more commonly seen in such

sports as gymnastics, hockey, racquet sports, boxing,

and pole vaulting.17

The problem that arises from soft tissue

injury of this important structure is distal radio ulnar

joint (DRUJ) instability. The DRUJ is a diarthroidal

trochoid articulation, which is an incongruent

articulation; only around 20% of its stability is

produced by osseous articular contact. Soft-tissue

structures of the TFCC play a critical role in intrinsic

joint stability.7

Wrist injuries are often complex and their

management will vary greatly; as such it is vital that

the correct diagnosis is made. If we look specifically

at the athletic population TFCC tears are more

frequently seen in gymnastics, hockey,

racquet/batting sports, boxing, and pole vaulting.

This is due to the repetitive high forces on the wrist

that will often be in extension or ulnar deviation, or

both (Parmelee-Peters & Eathorne, 2005).30 The

most common mechanism of injury to the TFCC

occurs with axial loading, ulnar deviation, and

forced extremes of forearm rotation. Injury may also

be associated with localized swelling, crepitus, grip

weakness and sense of instability.7

The initial treatment for TFCC injury may

include splinting, rest, anti-inflammatory

medications, cryotherapy, electrotherapy modalities

and physiotherapy techniques like manual and

exercise therapies.23 Biomechanical adjustments may

be required to comprehensively manage the injury

and reduce the incidence of recurrence.23 These

include on court stroke analysis and if necessary,

modifications to the athlete’s stroke mechanics, or

their equipment, such as adjustments of the grip size,

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

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the over grip, the strings and string tension, the

weight balance of the racket, or the grip placement

(continental, eastern, semi-western, and western).23

Physiotherapists and Athletic Trainers often

use athletic tape methods to support and prevent

sport related injuries. Athletic tape is effective due to

its reported ability to provide stability, maintain

proper structural alignment, facilitate proprioception

and also its neuromuscular effects. The aim of taping

is to reduce healing time, to protect and support the

wrist, and prevent future injury.23

In response to the limited effective taping

options for wrist injuries involving the TFCC and/or

ECU tendon, Kathleen Stroia and Kathy Martin

applied the McConnell principles of “unloading” to

the wrist.23 Stroia and Martin experimented with

various tape applications and created a clinically

effective tape technique, consisting of 1) an unload,

2) a block, and 3) a re-direction tape for players who

sustained wrist injuries involving the TFCC and/or

ECU tendon.23 This tape technique is effective for

injuries involving both the TFCC and ECU as they

are in close proximity to each other, and due to the

co-morbid nature of ECU tenosynovitis and TFCC

pathologies.23 This tennis-specific wrist taping

technique protects and supports the injured

structures; however it restricts only the desired

motions (supination, ulnar deviation, and extension).

The technique meets the desired goal of allowing a

player to play with more support which improves

function, while restricting extreme range of motion.

It is designed to consider the anatomy and patho-

physiology of the injury and the biomechanics of the

two-handed backhand.23

METHODS

An experimental study design was conducted

on total of 28 subjects who were recruited from

various sports center in and around Dehradun and

SAI Guwahati based on the inclusion and exclusion

criteria. The subjects were divided into two groups

after the informed consent was signed. Subjects with

prediagnosed cases of TFCC injury were included in

the study. Group A (Taping + Conventional

Therapy, n=14) and Group B (Conventional

Therapy, n=14). Pre intervention measurements of

pain, range of motion and grip strength were taken

out using Numerical Pain Rating Scale, Universal

Goniometer and Hand Dynamometer. Both the

groups were received intervention for total of 8 days

with a rest period on the 4th day. Subjects were

excluded from the participation if they present with

any neurological deficit of the reference extremity,

ay other reason of wrist and hand pain of the

reference extremity, history of fracture or any other

musculoskeletal surgery of wrist, pain or movement

restriction more than 6 weeks and subjects with h/o

TFCC injury less than 48 hours.

Grip strength (pound)11,18, Range of Motion

(degree)15 for Wrist and Forearm and Numerical

Pain Rating Scale13,28 was taken as outcome measure

before and after the total session of treatment. All

the subjects were assessed for outcome on 1st day

(before the intervention), 4th day and the final data

was collected on 8th day.

Protocol for Group A (Taping): Tennis Specific

Unload, Block and Redirection Tape Technique

were applied according to the principle of

McConnell taping. This tennis-specific wrist taping


4

technique protects and supports the injured

structures; however it restricts only the desired

motions (supination, ulnar deviation, and

extension).23 The technique meets the desired goal of

allowing a player to play with more support which

improves function, while restricting extreme range

of motion. It is designed to consider the anatomy

and patho-physiology of the injury and the

biomechanics of the two-handed backhand.23

1 subjects was dropout before the 4th day

assessment.

Fig. 1.1: Fixomull Stretch with Gutter

Fig. 1.2: Tape with directional force

Fig. 1.3: Tape with redirectional technique for

supination

Fig. 1.4: Tape with supination end range block

Protocol for Group B (Conventional Therapy):

Conventional treatment of TFCC was given, which

include rest to the part, Ultrasound Therapy and

Home Exercise Program.23,2 The parameter for

Ultrasound was Frequency: 3 MHz, Intensity:

1.4W/cm2, Time: 6 minutes, Mode: Continuous.6

2 subjects were dropout, 1 before the 4th day

and other after the 4th day assessment.

DATA ANALYSIS

Data was analyzed by using SPSS software

(version 16). Paired t-test was applied to compare

the data within the groups whereas Independent t-


5

test was applied to compare the data between the

groups. The p value was set at (≤0.05) with 95%

confidence interval.

RESULTS

Table 1.1: Comparison of Pre and Post Grip Strength score for Group A and B

MEAN SD

t p PRE POST PRE POST

GROUP A 64.102 78.308 18.6662

9 24.674 -6.697 .000

GROUP B 52.5 69.306 20.7864

4 24.55889 -7.824 .000

Fig. 1.5: Comparison of Pre and Post Grip Strength score for Group A and B

Table 1.2: Comparison of Pre and Post Wrist Extension ROM for Group A and Group B

MEAN SD

t p

PRE POST PRE POST

GROUP

A 67.692 71.692 4.38529 2.35884 -3.399 .005

GROUP

B 68.75 71.667 3.76889 3.25669 -2.244 .046

Fig. 1.6: Comparison of Pre and Post Wrist Extension ROM for Group A and Group B

Table 1.3: Comparison of Pre and Post Pain Score for Group A and Group B

MEAN SD

t p

PRE POST PRE POST

GROUP

A 5.3077 0.6154 0.63043 0.50637

26.836 .000

GROUP

B 5.8333 1.3333 1.19342 0.65134

12.539 .000

Fig. 1.7: Comparison of Pre and Post Pain Score for Group A and Group B

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

MEAN SD

t p GROUP

A

GROUP

B

GROUP

A

GROUP

B

PRE 64.102 52.5 18.66629 20.78644 1.464 .157

POST 78.308 69.306 24.674 24.55889 .913 .371


6

Fig. 1.8: Comparison of Grip Strength between Group A and Group B

Table 1.5: Comparison for Wrist Extension ROM between Group A and Group B

MEAN SD

t p GROUP

A

GROUP

B

GROUP

A

GROUP

B

PRE 67.692 68.75 4.38529 3.76889 -.648 .523

POS

T 71.692 71.667 2.35884 3.25669

.023 .982

Fig. 1.9: Comparison for Wrist Extension ROM between Group A and Group B

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

MEAN SD

t p GROUP

A

GROUP

B

GROUP

A

GROUP

B

PRE 5.3077 5.8333 0.63043 1.19342 -1.393 .177

POST 0.6154 1.3333 0.50637 0.65134 -3.091 .005

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

Results of the study showed that there is significant

reduction in pain and improvement in grip strength

and range of motion in both the groups after the

intervention. However, Group A (Taping) showed

more reduction in pain score when compared to

Group B and this was found to be statistically

significant p=.005 post intervention. Other variables

also showed improvement but it was statistically

non-significant.

DISCUSSION

Hand and wrist trauma accounts for 3-9% of all

athletic injuries.12 An injury to the TFCC is very

important as it is the most common cause of ulnar

side wrist pain and limited wrist function in work or

in sports.29 According to Kathleen Stroia et al., when

the wrist is loaded into supination, ulnar deviation

and extension, the TFCC, ECU tendon and sheath

are loaded with significant stress. This is the typical

position of the non-dominant wrist during the two-

handed backhand stroke, it also occurs during a

forehand stroke.23


7

The present study was done to find out the

efficacy of Taping in terms of grip strength, range of

motion and pain score in subjects with Triangular

Fibrocartilage Complex Injury.

The most probable reason for the reduction in

pain after the application of tape could be due to

reduction of strain on the injured structure in both

the acute phase and also during the ongoing repair

and rehabilitation phase. Supporting an injured joint

with tape is widely believed to be helpful in

reducing pain, preventing exacerbation of the injury

and promoting tissue healing.4 This technique met

the desired goal of allowing the players to play with

full support and improved function as said by the

Kathleen Stroia in his study.23

Another possible effect of tape could be due to

a direct mechanical effect on the TFCC, presumably

by somehow improving the internal mechanics or by

protecting the damage tissues from excess forces and

as a result, decrease in pain and improving grip

strength.26

Along with it, this method of taping technique

also disperses the stress generated by the muscle

during contraction which results in decreasing the

pain level by reducing the painful inhibition. The

possible mechanism behind the reduction in pain is

due to its neurophysiologic effects on the nervous

system, particularly the nociceptive system. In this

neurophysiological model the tape may exert an

effect on grip strength by primarily altering pain

perception, either locally at the wrist by inhibiting

nociceptors, facilitating large afferent fiber input

into the spinal cord and/or possibly by stimulating

endogenous processes of pain inhibition thereby

increasing the grip strength and reducing the pain

level as according to the Alireza Shamsoddini et al

in his study.22

Limitations of the study are small sample size

and different grades of the TFCC injury was not

taken into consideration. So the further

recommendation for future studies need to be done

with broader dimension, on the workers who are

mainly involved with hand and wrist work, and its

effectiveness can also be checked with other taping

technique.

CONCLUSION

The present study demonstrates that both the

technique is effective in improving the grip strength,

range of motion and reducing the pain in subjects

with TFCC injury. However, Taping technique used

in this study proves to be effective in reducing the

pain in subjects with TFCC injury. So, it can be

concluded that Taping is the better choice of

treatment in subjects with TFCC injury along with

other therapeutic modalities.

REFERENCES

1. Adams BD, Holley KA. Strains in the articular disk of the triangular fibrocartilage complex: a

biomechanical study. J Hand Surg Am. 1993 Sep;18(5):919-25.

2. Brukner P, Khan K. Clinical Sports Medicine 3rd Edition. India: Tata McGraw-Hill; 2008.


8

3. Busconi B, Stevenson J H. Sports Medicine Consult. USA: Lippincott Williams and Wilkins,

Wolters Kluwer; 2009.

4. Constantinou M, Brown M. Therapeutic Taping For Musculoskeletal Conditions. Australia:

Churchill Livingstone; 2010.

5. Cornwall R. The Painful wrist in Pediatric Athlete. J Pediatr Orthop 2010 March;30(2).

6. David O. Draper. Ultrasound and Joint Mobilizations for Achieving Normal Wrist Range of

Motion After Injury or Surgery: A Case Series. Journal of Athletic Training 2010;45(5):486–491

7. Dr. Wai L H. Management of triangular fibrocartilage complex injury, a cause of ulnar wrist pain.

HKMA CME Bulletin 2011 May.

8. Gerbino Peter G. Wrist Disorders In The Young Athlete. Operative Techniques in Sports Medicine

1998 October;6(4):197-205.

9. Hyde T E, Gengenbach M S. Conservative Management Of Sports Injuries 2nd Edition. United

Kingdom: Jones & Bartlett; 2007.

10. Joshi S. S, Joshi S. D, et al. Triangular Fibrocartilage Complex (TFCC) of Wrist: Some

Anatomico-clinical Correlations. J Anat Soc India 2007;56(2):8-13.

11. Mathiowetz V, Kashman N, et al. Grip and Pinch Strength: Normative Data for Adults. Arch Phys

Med Rehabil 1985;66:69-72.

12. Maffulli N, Lango U G, et al. Sports Injuries: a review of outcomes. British Medical Bulletin

2010; 1–34.

13. Moore J, Ali D. Rehab Measures: Numeric Pain Rating Scale. Rehabilitation Measures Database;

12/15/2010.

14. Nakamura T, Yabe Y, et al. Functional anatomy of the triangular fibrocartilage complex. J Hand

Surg Br. 1996 Oct;21(5):581-6.

15. Norkin Cynthia C, White D. Joyce. Measurement Of Joint Motion- A Guide to Goniometry 3rd

Edition. India: Jaypee Brothers Medical Publishers (P) Ltd; 2004.

16. Palmer AK. Triangular Fibrocartilage Complex Lesion; A classification. Jour of Hand Surgery

1989;14(A):594-605.

17. Parmeelee-Peters K, Eathorne Scott W. The Wrist: Common Injuries and Management. Primary

Care: Clinics In Office Practice 2005;32:35–70.

18. Peolsson A, Hedlund R, et al. Intra- and Inter- Tester Reliability and Reference Values For Hand

Strength. J Rehab Med 2001;33:36–41.

19. Perkins R H, Davis D. Musculoskeletal Injuries in Tennis. Phys Med Rehabil Clin N Am

2006;17:609-631.

20. Reid David C. Sports Injury Assessment & Rehabilitation. USA: Churchill Livingstone: 1992.

21. Retting Arthur C. Athletic Injuries of the Wrist and Hand. Am J Sports Med 2004; 32: 262.


9

22. Shamsoddini Alireza, Mohammad Taghi Hollisaz, et al. Initial effect of taping technique on wrist

extension and grip strength and pain of Individuals with lateral epicondylitis. Iranian

Rehabilitation Journal 2010;8(11).

23. Stroia K, Baudo M, et al. Taping Techniques for TFCC and ECU injuries on the Sony Ericsson

WTA Tour. Med Sci Tennis 2009;14(1):15-19.

24. Tang JB, Ryu J, et al. The triangular fibrocartilage complex: an important component of the pulley

for the ulnar wrist extensor. J Hand Surg Am 1998 Nov;23(6):986-91.

25. Vezeridis Peter S, Yoshioka Hiroshi, et al. Ulnar-sided wrist pain. Part I: anatomy and physical

examination. Skeletal Radiol 2010; 39:733-745.

26. Vicenzino B, Brooksbank J, et al. Initial Effects of Elbow Taping on Pain-Free Grip Strength and

Pressure Pain Threshold. J Orthop Sports Phys Ther 2003;33:400–407.

27. Wadsworth C T, Nielsen D H, et al. lnter-rater Reliability of Hand-Held Dynamometry: Effects of

Rater Gender, Body Weight, and Grip Strength. J Orthop Sports Phys Ther 1992

August;16(2):74-81.

28. Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. Journal of

Clinical Nursing 2005;14;798-804.

29. Yao-Tung Hou, Jui-Tien Shih, et al. Chronic triangular fibrocartilage complex tears with distal

radioulna joint instability: A new method of triangular fibrocartilage complex reconstruction.

Journal of Orthopaedic Surgery 2000;8(1):1–8.

30. The Sports Physiotherapist Blog. Triangular Fibrocartilage Complex Tears: Evidence Based

Assessment and Management. 2012 May 06.

CORRESPONDENCE

* Asst. Prof. Department of Physiotherapy, Dolphin (PG) Institute, Dehradun (UK)

** Associate Prof. Department of Physiotherapy, SBS PGI Biomedical and Research, Dehradun (UK)

*** Student Researcher, Dolphin (PG) Institute, Dehradun (UK). Email: [email protected]

10

EVALUATION OF KNEE JOINT EFFUSION WITH OSTEOARTHRIT IS BY

PHYSIOTHERAPY: A PILOT STUDY ON MUSCULOSKELETAL

ULTRASONOGRAPHY

Shanmuga Raju P. MPT*, Suryanarayana Reddy V. MS, Madurwar AU. MD, Sridhar EB. MD,

Harsha Vardhan NS. MD

ABSTRACT

AIM: The aim of study is to investigate the changes of knee joint effusion before and after osteoarthritis of knee,

using by musculoskeletal Ultrasonograpy. DESIGN: Prospective, follow-up study. SETTING: Department of

Physiotherapy, Chalmeda Anand Rao Institute of Medical sciences, Karimnagar. METHODS AND

MATERIALS: 20 cases of unilateral knee osteoarthritis were assessed by PHILPS EnviSor CH D

Ultrasonographic examination of knee effusion. Subjects were prospectively assigned to the follow-up treatment

of Interferential stimulation and Non-thrust Manual exercise (including Knee, Hip and and Leg muscles. A 15

session treatment program, 30 minute per day was performed for KOA. OUTCOME MEASURES: Before and

after intervention, we assessed knee joint effusion through ordinal scale. T –test was used for comparison between

pre and post treatment results in respectively. RESULTS: 12 cases (women 7, men 5) were identified and a total

20 subjects of knee OA. The mean score of effusion (2.75); T-value (2.20%) in the nonthrust manual exercise and

interferential current. CONCLUSION: Significantly reduction in knee effusion in patients with knee

osteoarthritis.

KEYWORDS: Knee osteoarthritis, Musculoskeletal ultrasonography, Knee effusion, Interferential current,


11

nonthrust manual exercise.

INTRODUCTION

In 1743, Willams Hunter first described

Osteoarthritis. Osteoarthrtis is a condition that

primarily affect the articular cartilage, but involve

the entire joint, including the subcondral bone,

ligaments, capsule, synovial membrane and

periarticular muscles (Brandt.KD. et.al 2009). The

basic aim of physiotherapy is to prevent disability,

improve joint range of motion, reduce pain, stiffness,

and improve muscular strength, fitness and Quality

of life. The purpose of study is to investigate

whether changes of knee joint effusion in patients

with osteoarthritis before and after Physiotherapy

treatment using musculoskeletal Ultrasonography.

Musculoskeletal Ultrasonography is a non-

invasive, lowcost, bedside procedure that may be

used and to assess osteoarthrtic joints (Iagnocco.A.

2008). Ultrasound detects changes of intra articular

knee effusion and inflammatory arthritis

(Coopenberg.PL.et.al 1978 & Kanfman RA.

Et.al,1982). The purpose of this study is to

investigate the changes of knee joint effusion before

and after osteoarthritis of knee, using by

musculoskeletal ultrasonograpy

METHODS AND MATERIALS

The study was conducted in the Department of

Physiotherapy and association with Department of

Radio- Diagnosis and Imaging, Chalmeda Anand

Rao Institute of Medical Sciences, Karimnagar. The

prospective, Follow-up study was done from first

August 2008 to December 2009.

Inclusion Criteria were as follows

• Knee pain with independence walking.

• Aged between 40-75 years (Both female and

male).

• PHILPS EnVisor C HD Musculoskeletal

Ultrasonography.

• Ultrasonic Gel.

• L12- 3 MHZ probe/ Transducer.

• Universal Goniometry

• Interferential stimulation (IFS) modality.

• Nonthrust manual exercise

• Knee effusion Imaging Record

• Digital Camera.

Exclusion Criteria were

• A history of knee and Hip Replacement

surgery

• Psoratric Arthritis

• Unable to walk without assistance

• Non-steroid anti-inflammatory Drugs.

• Corticosteroid injections

• Radicular pain below knee and

• A History of malignancy.

Musculoskeletal Ultrasonography Imaging

PHILPS EnVisor CH D M2540 A Ultrasound

System (L12-3 MHZ, Bothell, WA, USA 98041).

Linear transducer was used to determine the

presence of joint effusion (Meenagh.G. et.al 2006).

Therefore a total 20 subjects with osteoarthritis of

knee were investigated in this study.


12

Figure: 1 Musculoskeletal Ultrasonography

Figure: 2 Demonstration of long axis of

transducer, to measure AP diameter of the supra

patellar recess

Examination of knee effusion was obtained by

measuring the anterior posterior scan along the main

axis of the bursa. The probe was placed just above

the superior border of the patella with knee in 30

degree flexion. The AP diameter was scored (Grade)

as 0/Absent, 1/mild < 5mm, 2/moderate (5-10mm),

3/severe (>10mm) (Kakati .P.et.al 2008).

TREATMENT PROTOCOL

Interferential current modality (LIFEMED V

744 04 04, Chennai, India). Alternating current

frequency 50, 4000-4100HZ was used for this study.

The treatment duration was applied to 20 minutes.

The stimulation parameters of machines beat

frequency 30HZ, sweep frequency 80 m second,

wave 4 PV (6/6), Carbonized rubber electrodes,

power/Voltage 230 V. The pairs of rubber electrodes

were placed over the trigger points of the knee joint.

The intensity of the current was set a comfortable

level as determined by subjects and ranged from 10

– 50 mA. The patient position was supine lying with

comfortable support and 20 degree flexed knee.

Non thrust manual exercise as repetitive passive

movement of varying amplitudes and of low

velocity, applied at different points through the

range of motion, depending on the effect desired

(Cameron. WM, 2006). The number of repetitions

time 5-10 per session of program. Duration of

treatment time KOA was 15 sessions. The patients

recorded in a dairy their use of base, spectrum,

intensity, treatment time of therapeutic modality and

exercise.

STATISTICAL ANALYSIS

Before and after intervention, we assessed knee

joint effusion through ordinal knee effusion scale. t –

test analysis was used for comparison between the

pre and post treatment results in respectively. The

value were expressed in mean, +_ standard deviation

and median with statistical significance considered

when P < 0.05.

RESULTS

Initially, 20 subjects were enrolled in this study.

However, 8 patients did not undergo the evaluations

due to lack of regularity and were automatically

excluded; therefore, a total of 12 patients

participants in this study. All patients imaging were

saved in consent forms before the evaluations.


13

Figure: 3 Sonographic view of Pre -evaluation of

knee joint effusion in a patient with OA Knee.

Figure 4 Ultrasonographic view of Post evaluation

for knee effusion results with OA Knee.

The initial total knee effusion was not

statistically different (P<.05), indicating that the

initial effusion status of all participants in this study.

Change of total effusion for KOA, the 2

measurements were taken in figure 4. After 15

sessions of treatment, decreased to effusion

approximately (t-2.20) of the observation.

For analysis of the data showed that the

decrease in knee effusion was significantly changed

after 15 sessions of IFS/ Non-thrust manual knee

exercise (T=37.77 and 20.2) respectively.

DISCUSSION

This is first controlled study to evaluate

musculoskeletal ultrasonography detected changes in

the effusion of knee with osteoarthritis of knee after

interferential stimulation and non -thrust manual

exercise. It is specifically used to increased arterial

circulation, reducing spasm of muscles, pain,

relaxation and changes in knee effusion.

Kakati P.et.al (2008) observed that knee

effusion and synovial thickening could be detected

using ultrasonography in patients with Rheumatoid

arthritis. Our study sample consisted of 12 cases OA

Knee followed -up Pre treatment and post treatment

results showed Table 5 and 6.

The results of this study demonstrated, the total

knee effusion only was examined. Significantly

changes between 10-15 sessions of interferential

stimulation and non thrust manual exercise.

However, in this study, pharmacological therapy,

injections and replacement of surgery of knee/Hip

were excluded. Following 15 sessions of

Interferential current and Nonthrust manual exercise,

although reduction of the knee joint effusion was

significant (12 Subjects of Knee OA).

LIMITATIONS OF THE STUDY

There are few limitations in the study.

• Large sample size may give better

understanding of reduction in knee effusion

with osteoarthritis.

• This study was needed to explore the

difference between musculoskeletal

ultrasonographic image and Hematological

findings of effusion.

• Future studies are needed to evaluation of

the cost effectiveness of using

musculoskeletal ultrasonography for

assessing the condition progress compared

with other techniques and the effect of the

interferential stimulation and nonthrust

manual exercise on control of knee effusion.


14

CONCLUSION

Our study results shows that, Interferential

stimulation and Non-thrust manual exercise with

musculoskeletal ultrasonography a significantly

reduction in knee joint effusion with Osteoarthritis

of knee. So, it is a low cost, short term relief, and

promotion of health in senior citizens.

Conflict of Interest: None

References

1. Banwell,BF, Gall.V- Physical therapy management of Arthritis, Newyork, Churchill Livingstone , 1988;

77-106.

2. Braunwald, Fauci (2006)- Harrison’s Principles of internal medicine, 15th ed, Vol:2, PP:1979-1987.

3. Chaveez, Lopez,MA, Naredo, F, Acebes cachafeiro, JC et.al – Diagnostic accuracy of Physical

examination of the knee in Rheumatoid Arthritis; Clinical and Ultrasonographic sytudy of jont effusion

and Baker’s Cyst, Rheumatol Clin, 2007; 3(3); 98-100.

4. F.Gogus, J.Kitchan, R, Collins, D.Kane: Reliability of physical Knee Examination for Effusion:

Verification by Musculoskeletal Ultrasound, Annual ACR Meeting, san Francisco, 2008.

5. Guermazi Ali – Imaging of Osteoarthritis, Radiological Clinic of North America, vol: 47; July 2009.

6. Hill CL, Gale DG, Chaisson, CL, et.al – Knee effusions, popliteal cysts and synovial thickening;

Association with knee pain in osteoarthritis, J Rheumatol 2001; 1330-1337.

7. Hatemi,G. Tascilar,K. Melikoglu, M, et.al – Ultrasonographic and Physical Examination of the inflamed

knee: Intra and Inter Rater Reliabiliy of the sonographers and Clinical Examiners, 20 Oct, 2009.

8. Jamt, Vedt.G. Dahm KT, Christie, A. et.al – Physical Therapy Interventions for patients with

Osteoarthrtis of the Knee: An overview of systemic Reviews, Phy The 2008, Vol. 88; PP 123-136.

9. Jan MH, Lai JS: The effect of Physiotherapy on Osteoarthrtic Knee of Females, J Formosan Med Assoc

1991; 90; 1008- 1013 (Medline).

10. Keen HI, Browa AK, Wakefield RJ, Conaghan, PG – Update on Musculoskeletal Ultrsonography, J R

Coll Physician Edin B; 2005; 35; 345-349.

11. Kellgren JH, Lawrence JS- Radiological Assessment of Osteoarthritis, ANN Rheum Dis 19576; 16; 494-

502.

12. Meenagyu G, Iagnocco E, Filppucci E, et.al – Ultrasound imaging for the Rheumatologist IV,

Ultrasonography of the knee, Clin Exp Rheumatol 2006; 24; 357-360.

13. Pratab K, Kushaljit SS, Manavijit SS, et.al – Correlation between Ultrasonographic findings and the

response to corticosteroid Injections in PesAnserinus Tendoino Bursitis syndrome in Knee Osteoarthritis

patients, J Korean Med.Sci 2005; 20;109-12.

14. Robertson D-An introduction to Musculoskeletal Ultrasound, Sports Medicine 2007; July; 22-26.


15

15. Rubaltelli I, Fiocco U, Cozzi L, et.al- Prospective Sonographic and Arthroscopic Evaluation of

proliferative knee joint synovitis.J Ultrsound Me 1994; 13; 855-862.

16. Smit j, Jonathan T, Finnoff DO- Clinical Reviwe; Current concepts Diagnostic and Interventional

Muscculoskeletal Ultrsound Part 1 Fundamentals.

17. Scheel Ak, Matteson EL, et.al – Clinical study: Reliability Exercise for the Polymyalgia Rheumatica

Classification criteria study;: The oranjewound Ultrasound sub study, International journal of

Rheumatology, vol 2009, article ID 738931, 5 Pages, Hindawi Publishing corporation.

18. Theodore P, Joel AB- Pain and Radiographic damage in Osteoarthritis 2009, BMJ, Vol 339; PP: 469.

19. Tuhimna N, David F., Jingbo N, et.al- Association between Radiographic features of knee Osteoarthrtis

and Pain: results from two cohort studies 2009; BMJ, vol: 339; PP: 498-501.

20. Tsai LY, Jan MH, Tseng SC, et.al- Interrator and interrater reliability of the knee joint synovitis in

patients with Knee Osteoarthritis: The use of Sonographic evaluation, Formoson journal of Physiotherapy

2003; 28; 19-26.

21. Van Holsbeeck MT and Intracaso JH- Musculoskeletal Ultrasound, 2nd ed Mosby, 1991 ISBN:

0815189753.

22. Wakamuke E, Kawooya M,et.al- Experience with Ultrasound of the knee joint at Mulago Hospital,

Uganda , East cent, Afri.J. Surg, vol: 14; No: 2: July/August 2009.

ACKNOWLEDGMENT

This research study was supported by Arihant Educational Society, Chalmeda Anand Rao Institute of Medical

Sciences, Karimnagar, Andhra Pradesh, India. We would like to thank sri. C. Anand Rao, Ex.Minister of Law and

Social worker, Sri.C.Lakshmi Narasimha Rao, BE, MBA Chairman, Dr.V. SurayaNarayana Reddy, MS, Director

for grateful support of our study. We would like to acknowledge Prof. Dr. V. Aruna, MD, Dr.(Mrs.). Ezhilarasi

Ravindran, MD, Prof. SA. Aasim,MD, Medical Superintendent CAIMS, Karimnagar, for useful discussions and

support for preparing this study.

CORRESPONDING AUTHOR:

* ShanmugaRaju P, Asst. Professor &I/C Head, Physiotherapy, Department of Physical Medicine &

Rehabilitation, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar- 505001, Andhra Pradesh,

INDIA. E-mail: [email protected]

16

PHYSICAL THERAPY MANAGEMENT OF TUBERCULOUS ARTHRITI S OF

THE ELBOW

Amit Murli Patel BPT, MPT-Orthopaedics*

ABSTRACT

BACKGROUND AND PURPOSE: Tuberculous arthritis is not commonly seen by physical therapists in India.

The purpose of this case report is to describe a case of tuberculous arthritis of the elbow. CASE

DESCRIPTION: The patient was a 35-year-old man referred for physical therapy evaluation and intervention

for chronic elbow pain. After an evaluation and a trial of physical therapy, the patient was referred back to a

primary care provider for additional tests to rule out systemic pathology. An open debridement of the synovium

and a biopsy of the capitellum and radial head was positive for acid-fast bacilli, which was later identified as

Mycobacterium tuberculosis. OUTCOMES: The patient was placed on a 4-drug antituberculosis regimen that

resolved all patient complaints and restored full elbow function. DISCUSSION: Tuberculous arthritis has

characteristic findings during examination and in diagnostic tests. Although tuberculous arthritis is uncommon, it

should be considered when patients have chronic or vague musculoskeletal complaints.

KEYWORDS: Tuberculous arthritis, Elbow arthritis, Knee effusion, Physical therapy managemet.

INTRODUCTION

Tuberculous arthritis occurs in approximately

1% to 5% of all patients with TB.5 It can involve any

of the bones or joints of the body but is usually

confined to one location, with 10% of tuberculous

arthritis in the upper extremity6 and up to 8% in the


17

elbow.7 The sites most frequently affected are the

spine, sacroiliac, hip, and knee.8 Because weight-

bearing joints are the most frequently involved,

some authors5 suspect that trauma plays a role in the

pathogenesis of bone and joint TB.

Tuberculous arthritis is usually secondary to

hematogenous dissemination of tubercle bacilli from

a primary pulmonary lesion.1,8 Less commonly, it

can occur by spreading through the lymphatic

system or into adjacent tissue.8 Joints can become

infected by activation of dormant lymphatic or blood

stream areas of morbidity.9 In the long bones, TB

originates in the epiphysis in response to

mycobacteria and causes tubercle formation in the

marrow, with secondary infection of the trabeculae.8

The joint synovium responds to the

mycobacteria by developing an inflammatory

reaction, followed by formation of granulation

tissue. The pannus of granulation tissue formed then

begins to erode and destroy cartilage and eventually

bone, leading to demineralization.5 Because TB is

not a pyogenic infection, proteolytic enzymes, which

destroy peripheral cartilage, are not produced. The

joint space, therefore, is preserved for a considerable

time. If allowed to progress without treatment,

however, abscesses may develop in the surrounding

tissue.5

Asaka et al10 described an abscess around the

elbow joint and between the biceps brachii and

brachioradialis muscles in a patient with tuberculous

arthritis.

In India, the most common early symptoms of

tuberculous arthritis are insidious onset of local pain

and swelling around the joint. In advanced cases,

which occur primarily in countries where TB is more

common and often is allowed to progress, sinuses

and joint deformities may develop.8 The

granulomatous process eventually imparts a “boggy”

or “doughy” feeling to the joint and periarticular

structures.9 Localized pain may precede other

symptoms of inflammation or radiograph changes by

weeks or even months.9 Other symptoms include

joint stiffness, reduced range of motion, fever, night

sweats, or weight loss.8,11 Because of the rarity of

tubercular infections of joints and because the usual

signs of inflammation (eg, erythema, heat) do not

occur, diagnosis of tuberculous arthritis affecting

peripheral joints is often delayed.8,11 When diagnosis

is not timely, joint contractures and limited

functional improvement after treatment are more

likely to occur, especially if bone and articular

cartilage are destroyed.12 Authors have reported

diagnoses of olecranon bursitis,13,14 tennis elbow,15

and pyogenic arthritis, osteomyelitis, neopathic

articular disease, and neoplasm before an eventual

diagnosis of tuberculous arthritis.

The purpose of this case report is to describe a

case of tuberculous arthritis of the elbow. The

patient described in this report had numerous

previous diagnoses for chronic elbow pain and was

ultimately referred for physical therapy evaluation

and intervention.

CASE DESCRIPTION

Patient: The patient was a 35-year-old, Athlete,

right-hand–dominant man who reported

experiencing intermittent sharp pain with insidious

onset and swelling in his left elbow 10 months

previously. He reported that his symptoms were

aggravated with movements of the elbow and eased

with rest. There was no known history of left elbow

or arm injury. The patient did not report any recent


18

fever or weight loss, and he said that he was healthy

except for the elbow pain. He stated that he had been

an intravenous (IV) drug user for 5 years, during

which he used his left arm for injections, but he said

he had not used any IV drugs for 2 years prior to the

physical therapist examination and evaluation. The

patient was not working at the time of the

examination His goal was to play Tennis pain-free.

The patient had a 10-month history of evaluations

for left elbow pain, swelling, and decreased range of

motion. The patient had been diagnosed with lateral

epicondylitis, degenerative joint disease, synovitis,

and tenosynovitis by 3 different physicians at 3

different facilities, and he had been treated with

nonsteroidal anti-inflammatory drugs. After 10

months, an orthopedic surgeon examined the patient.

The physician referred the patient to the physical

therapist for examination, evaluation, and

intervention for chronic elbow pain and ordered

electromyography (EMG) and nerve conduction

studies (NCS).

Three series of elbow radiographs were taken

prior to the physical therapy evaluation. Each of the

3 series of elbow radiographs was taken at a

different facility

The first series, taken 10 months previously,

showed no noticeable abnormalities. Two months

later, a second series was negative for fracture, but

there were cyst-like structures and mild exostotic

bone formation in the region of the lateral

epicondyle, and there was another cyst-like structure

in the proximal shaft of the ulna (Fig. 1). The lateral

view showed exostotic bone formation at the

anterior distal humerus, which the radiologist stated

may have been indicative of an old injury.

Figure 1. Anteroposterior radiograph of elbow showing cyst-like structures (arrows).

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

The third radiographic series 4 months before

the physical therapy evaluation revealed a posterior

fat-pad sign, which the radiologist suggested may

have been created by joint effusion or an occult

fracture (Fig. 2). Normally, the posterior fat pad,

which lies deep in the olecranon fossa, is not visible

on the lateral view. It can be displaced out of the

fossa by blood or synovial fluid within the joint, thus

becoming visible.17 The radiologist who interpreted

the third series recommended further evaluation if

the patient’s complaints continued.


19

Nerve conduction studies of motor and sensory

components of the left median, ulnar, and radial

nerves completed just prior to the physical therapy

evaluation were within normal limits.

Electromyograms of the middle deltoid, biceps

brachii, brachioradialis, pronator teres, abductor

pollicis brevis, and first dorsal interosseus muscles

also were within normal limits. The patient had

positive purified protein derivative (PPD) tests since

the previous year. A standard posteroanterior chest

radiograph for patients with a positive PPD test was

normal. A normal chest radiograph shows no

pleurisy with effusion.

Pleurisy with effusion results when the pleural

space is seeded with Mycobacterium tuberculosis.18

EXAMINATION

The patient held his left elbow in a flexed

position and apparently was guarding the elbow

against his body. He had diffuse left elbow effusion,

with the left elbow joint girth 1.5 cm greater than the

right elbow joint girth measured at the elbow flexion

crease. There was no ecchymosis at the time of

examination, but wasting of the biceps and triceps

muscles was noticeable. The patient had elbow

active and passive range of motion of 30 to 110

degrees, with pain at both flexion and extension end

ranges. Wrist range of motion was normal, but the

patient did have a sharp pain at the lateral and

medial condyles during end ranges of pronation and

supination, respectively.19 The shoulder was cleared

for pathology using overpressure during active

flexion, abduction, and while the patient was

reaching behind his back. The therapist performed

overpressure by applying a force to the patient’s end

range at the point where his active range of motion

stopped. The wrist was cleared when overpressure

was performed during active flexion and extension.

Because both procedures failed to reproduce the

patient’s elbow pain, the therapist considered the

shoulder and wrist cleared as the source of his

pathology. The therapist tested light touch sensation

by moving the index fingers along the patient’s C4-

T2 dermatomes and upper-extremity nerve fields

bilaterally. Sensation was recorded as intact and

symmetrical. Muscle stretch reflexes were not tested.

Manual muscle tests of the upper-extremity

musculature were performed during the examination

as described by Kendall and McCreary.19 The

trapezius, middle deltoid, wrist flexor, dorsal and

palmar interosseus, and extensor pollicis longus

muscles were painless and rated normal bilaterally.

The patient said that he was unable to hold the left

biceps brachii, triceps brachii, and wrist extensor

muscles in the test position against resistance

because he said that it reproduced his pain. Because

pain limited the patient’s effort during these muscle

tests, grading was not done.

Palpation revealed a mild increase in warmth

around the left elbow compared with the right

elbow. Palpation at the olecranon and both lateral

and medial epicondyles caused a sharp pain that did

not radiate. Palpation of the patient’s entire anterior

forearm also reproduced his elbow pain.

EVALUATION

A posterior fat-pad sign has been reported to be

a possible sign of interarticular fracture or

swelling.17 Due to local tenderness, swelling, and a

documented fat-pad sign on this patient’s

radiographic report, the therapist chose to rule out

systemic pathology or a fracture before initiating


20

aggressive stretching or joint immobilization

intervention. The patient began a light physical

therapy regimen of active range of motion exercises

for 10 to 15 minutes 3 times a week on an upper-

body cycle to maintain his present range of motion,

followed by ice massage for 10 minutes. The patient

was instructed to use ice bags for 10 to 15 minutes

on his own throughout the day. He was also

instructed to stop playing tennis. The therapist

discussed the case with a physician, who

subsequently ordered follow-up radiographs,

including an oblique view to rule out an

interarticular fracture as was originally advised in

the most recent radiologist’s report.

RE-EVALUATION AND INTERVENTION

The new radiographs showed a smaller

posterior fat-pad sign but no fractures or evidence of

other pathologies in osseous structures. Therefore,

the patient continued his physical therapy program

and was re-evaluated 2 weeks after the initial

evaluation. During the week 2 follow-up, the patient

reported that the pain had lessened and that his

elbow was tender to palpation only at the olecranon.

Both active and passive ranges of motion were

unchanged, as was the elbow flexion crease girth.

Resistive exercises were added because the patient

expressed concern about the atrophy in his biceps

and triceps muscles. Because he was reporting less

elbow pain with palpation and range of motion end

ranges, the therapist decided to allow the patient to

perform seated biceps muscle curls and supine

triceps muscle extension exercises in a pain-free

range. The patient performed 3 sets of 10 repetitions,

3 times a week, in the clinic under the therapist’s

supervision.

During the week 4 follow-up evaluation, the

patient reported increased pain in the area of the

medial and lateral epicondyles. Examination of

elbow girth, active and passive ranges of motion,

and palpation revealed no other changes. Based on

the patient’s continued pain and swelling, the

physician and Therapist agreed that a magnetic

resonance image (MRI) could be informational. At

the same time, the physician referred the patient

back to the orthopedic surgeon for re-evaluation

following the MRI. Physical therapy was

discontinued until the MRI and orthopedic

evaluations were completed. The MRI showed a

large joint effusion and increased marrow signal

within the radial neck (Fig. 3).

Figure 3. T2 weighted sagittal view of the elbow. Note the increased marrow signal within the

radial neck (arrows).

Signal intensity refers to the strength of the

radiowave that a tissue emits following excitation.

The strength of the radio wave determines the degree

of brightness of the imaged structures. A bright

(white) area in any image is said to demonstrate a


21

high signal intensity, and a dark (black) area

demonstrates a decreased intensity.17 Hematopoietic

marrow normally displays a low to intermediate

signal intensity, whereas fluid displays a higher

signal intensity on T2 weighted MRI.17 The

radiologist suspected infection and recommended

aspiration of synovial fluid and a biopsy. During the

second orthopedic evaluation, 2 months after the

MRI, the surgeon aspirated the elbow and ordered a

bone scan. A culture of the aspirated fluid was

negative for growth, but the bone scan image was

consistent with possible septic arthritis and

osteomyelitis.

At the orthopedic follow-up 3 months later, the

surgeon ordered an open debridement and biopsy

based on the bone scan reports and performed an

arthrotomy of the left elbow with open debridement

of synovium and biopsy of the capitellum and radial

head the next day. The culture was positive for acid-

fast bacilli, which was later identified as

Mycobacteria tuberculosis. Following identification

of TB, a physician specializing in infectious diseases

evaluated the patient. The bacterium was sensitive to

ethambutol, pyrazinamide, isoniazid, and rifampin,

and the patient began a 4-drug anti-TB regimen for

no less than 1 year.

OUTCOMES

Four months after initiating the drug regimen,

the patient reported that he was pain-free, and he

was discharged from the orthopedic surgeon’s care.

The therapist attended a weekly orthopedic clinic

during which patient was evaluated by an orthopedic

surgeon.

At 12 months after the diagnosis of TB, the

patient had recovered normal elbow range of motion,

and manual muscle tests of the biceps brachii,

triceps brachii, and wrist extensor muscles were

normal and painless.19 He said that he was working

and playing Tennis without pain. The patient

performed janitorial work, which consisted of Room

cleaning, walls, and bathroom fixtures.

DISCUSSION

Tuberculous arthritis usually occurs in an

insidious manner, with pain and swelling of the

affected joint. It is rare among people born in the

India and is more often found in people born in other

countries or those with a compromised immune

system. The patient in this case report had chronic

elbow pain and swelling without signs of infection.

Lack of signs of infections is consistent with other

cases of tuberculous arthritis described.15,16 He also

reported a history of IV drug use, which, along with

direct joint trauma, interarticular steroid injections,

and systemic illness, has been found to be a

predisposing factor for tuberculous arthritis.16 These

factors and this patient’s history suggest an onset of

TB that is consistent with reports of other patients

who developed tuberculous arthritis.

Joint effusion, such as that seen in this patient,

often occurs with tuberculous arthritis and has been

shown to affect muscles and nerves around the

elbow.20,21 Chen and Eng20 noted compression of the

posterior interosseous nerve at the region of the

arcade of Frohse. Prem et al21 noted wasting of

muscles around the upper limbs and shoulder girdle

along with obliteration of bony landmarks due to

swelling around an elbow infected with tuberculous

arthritis. Yao and Sartoris1 also stated that weakness

and muscle wasting could be present around


22

involved joints. The patient in this case report did

not have sensory deficits, but he did have noticeable

wasting of his biceps and triceps muscles. Persistent

effusion in the knee affects afferent activity of

intracapsular receptors and can cause reflex

inhibition of the quadriceps femoris muscle.22–24 A

similar mechanism may have occurred in this

patient, causing wasting of the biceps and triceps

muscles due to capsular distention and intracapsular

pressures. An alternative hypothesis might also

attribute the muscle wasting to disuse secondary to

pain during elbow motion.

Radiographs can be powerful diagnostic tools,

but they are not always beneficial during evaluation

of a patient with tuberculous arthritis. Some authors

have described normal chest radiographs in patients

with tuberculous arthritis20,25 and old or active

pulmonary disease evident in only 50% of chest

radiographs in patients with tuberculous arthritis.8,16

Elbow radiographs can also be negative, even when

the disease is present.15 Unlike pyogenic organisms

that produce rapid destruction of bone, TB has a

gradual progression of symptoms.26 It has been

reported to begin in the distal end of the humerus,

olecranon, or synovium of the elbow joint.13,25 The

first radiograph report of the patient’s elbow was

normal.

The second series of radiographs identified a

cyst-like structure and mild exostotic bone formation

that was not identified on the first and final

radiographs. Munk and Lee26 contended that a

normal appearance on imaging is the rule with TB

infections because the underlying bone reacts (by

forming cysts and producing sclerotic borders at the

margins of the infected lesion) in an attempt to wall

off the infectious process. Thus, a cyst-like

appearance in the involved bone is not uncommon.

The third set of radiographs revealed no

abnormalities in bone or joint space, with the

exception of a positive fat-pad sign. Greenspan17

reported that a positive fat-pad sign could be

indicative of interarticular swelling or a fracture. The

fourth set of radiographs eliminated the possibility

of a fracture that had not been diagnosed, but they

revealed a smaller fat-pad sign, which most likely

appeared because of interarticular swelling. When

radiographs are normal, an MRI may be beneficial

by revealing early changes such as edema that are

not visible on radiographs.27 The patient’s MRI

identified the complex effusion in his elbow, but a

biopsy that was needed for the definitive diagnosis.

Biopsy is the most definitive test for

tuberculous arthritis. 6,9,13,15 Some authors have

reported that synovial fluid or tissue cultures

establish a diagnosis in 90% of the cases of

tuberculous arthritis.11 Material for the culture may

be obtained from aspiration of joint fluid, but this

may be inconclusive, as it was in this patient’s case.

Laboratory tests such as sedimentation rate,

granulocyte count, and lymphocyte count are not

thought to be helpful.7 This patient’s prior tuberculin

skin tests were positive, which is consistent with

researchers’ findings for patients with tuberculous

arthritis.6,10,20,25 However, as was described in cases

involving a 66-year-old woman15 and a 76-year-old

man16 with tuberculous arthritis of the elbow, a

negative TB skin test does not exclude diagnosis of

tuberculous arthritis. Repeated negative tuberculin

tests, however, practically eliminate TB as a possible

etiology.7 Before the advent of anti-TB

chemotherapy, the classic treatment in adults

consisted of excision or arthrodesis of the elbow


23

joint.28 The disadvantage of arthrodesis was loss of

motion, and the risk of excision was an unstable

elbow.28 Anti-TB agents are effective in halting the

destructive process and treating the infection.

However, they cannot repair the anatomical defects

that can occur in later stages.8 During these stages,

fibrous tissue can result in ankylosis of the joint.

Similarly, the untreated cases can evolve to bony

ankylosis.16 The literature provides few specifics for

the physical therapist management of TB.

Investigators29 have reported using prolonged

immobilization for an average of 18 months. With

the introduction of TB drugs, this is no longer

necessary.12 Some authors6,28 advocated

immobilizing the elbow for 1 to 2 months at 90

degrees to relieve pain and, in the event of fusion, to

achieve a functional position. After removing the

cast, rehabilitation proceeded daily for 3 to 6

months, with a back splint used between therapy

sessions to prevent extension deformity and help the

elbow flexors regain power.6 No specific

descriptions of the splint or interventions were

reported.

Surgery may be necessary in certain cases when

the disease does not respond to drugs or to correct

deformities or improve joint function.8 Vohra and

Kang25 treated 6 cases of elbow TB, ranging from

the disease being restricted to within the synovial

membrane to extensive articular cartilage

involvement. Patients were treated with 3 to 6 weeks

of immobilization after surgery followed by

encouraging active movements and using night

splints for 2 to 5 months. No other intervention

specifics were given. Other authors30 reported that

using a hinged long arm brace for a month after

surgically removing granulation tissue returned the

patient’s elbow to being pain-free with full range of

motion. Chen et al12 reported that a continuous

passive movement (CPM) device improved

functional results after synovectomy and intra-

articular debridement. Following surgery, the arc of

movement was set at 30 to 90 degrees and then

increased to a level that the patients were able to

tolerate. Patients used the CPM device for 2 to 4

weeks until movement exceeded 120 degrees. The

average flexion deformity in a group of 8 patients

who used the CPM device was 24 degrees versus 34

degrees in a group of 8 patients who were treated

with active and passive movement. Active and

passive movement was not defined.

The patient in this report responded well to

antibiotics and regained full elbow function without

immobilization or surgery. This improvement could

have been due, in part, to the location of the disease

in the joint. Vohra and Kang25 stated that prognosis

is excellent in synovial and extra-articular lesions,

whereas involvement of articular cartilage reduces

the chances of maintaining good range of motion. In

addition, this patient’s improvement could have been

due to diagnosing tuberculous arthritis early and

administering anti-TB treatment before severe

destruction occurred. Chen et al12 noted that joints

with severe intra- and extra-articular destruction

usually become stiff with fibrosis and adhesions.

Martini and Gottesman28 hypothesized that, unlike

the lower-limb joints, the elbow is non–weight

bearing and therefore more able to recover a normal,

painless range of motion, as this patient was able to

do.

CONCLUSION

Patients with tuberculous arthritis are not often


24

examined or treated by physical therapists in India

due to the relative rarity of TB infections of joints.

Because of its often slow progression,

tuberculous arthritis is a frequently misdiagnosed

condition, which delays treatment and can lead

deformities and functional deficits.

This patient’s disease was identified as a result

of diagnostic tests and communication between a

physical therapist and other health care providers.

Physical therapists and other health care providers

can learn from this case to consider tuberculous

arthritis in the differential diagnosis of unexplained

musculoskeletal complaints, especially in patients

with compromised immunity or from an area where

TB is endemic.

REFERENCES 1. Yao DC, Sartoris DJ. Musculoskeletal tuberculosis. Radiol Clin North Am. 1995;33:679–689.

2. Centers for Disease Control and Prevention. Tuberculosis morbidity—United States, 1997. MMWR Morb

Mortal Wkly Rep. 1998;47: 253–275.

3. Centers for Disease Control and Prevention. Progress toward the elimination of tuberculosis—United

States, 1998. MMWR Morb Mortal Wkly Rep. 1999;48:732–736.

4. Zuber PL, McKenna MT, Binkin NJ, et al. Long-term risk of tuberculosis among foreign-born persons in

the United States. JAMA. 2007;278:304 –307.

5. Davidson PT, Horowitz I. Skeletal tuberculosis: a review with patient presentations and discussion. Am J

Med. 1970;48:77– 84.

6. Martini M, Benkeddache Y, Medjani Y, Gottesman H. Tuberculosis of the upper limb joints. Int Orthop.

2006;10:17–23.

7. Martini M, Ouahes M. Bone and joint tuberculosis: a review of 652 cases. Orthopedics. 2005;11:861–

866.

8. Wright T, Sundaram M, McDonald D. Radiologic case study: tuberculous osteomyelitis and arthritis.

Orthopedics. 1996;19:699 –702.

9. Rotrosen D. Infectious arthritis. In: Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s

Principles of Internal Medicine. 12th ed. New York, NY: McGraw-Hill; 1991:544–548.

10. Asaka T, Takizawa Y, Kariya T, et al. Tuberculous tenosynovitis in the elbow joint. Intern Med. 1996;

35:162–165.

11. Naides SJ. Infectious arthritis: viral and less common agents. In: Schumacher HR, Klippel JH, Koopman

WJ, et al, eds. Primer on the Rheumatic Diseases. 10th ed. Atlanta, Ga: Arthritis Foundation; 2003: 199–

200.

12. Chen WS, Wang CJ, Eng HL. Tuberculous arthritis of the elbow. Int Orthop. 2007;21:367–370.

13. Parkinson RW, Hodgson SP, Noble J. Tuberculosis of the elbow: a report of five cases. J Bone Joint Surg

Br. 1990;72:523–524.

14. Holder SF, Hopson CN, Vonkuster LC. Tuberculous arthritis of the elbow presenting as chronic bursitis


25

of the olecranon. J Bone Joint Surg Am. 1985;67:1127–1129.

15. Patel S, Collins DA, Bourke BE. Don’t forget tuberculosis. Ann Rheum Dis. 1995;54:174 –175.

16. George JC, Buckwalter KA, Braunstein EM. Case report 824: tuberculosis presenting as a soft tissue

forearm mass in a patient with a negative tuberculin skin test. Skeletal Radiol. 2004;23:79–81.

17. Greenspan A. Orthopedic Radiology: A Practical Approach. 2nd ed. Philadelphia, Pa: Lippincott-Raven;

2007.

18. Daniel TM. Tuberculosis. In: Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of

Internal Medicine. 12th ed. New York, NY: McGraw-Hill; 1991:637–645.

19. Kendall FP, McCreary EK. Muscles: Testing and Function. 3rd ed. Baltimore, Md: William & Wilkins;

1983:18–293.

20. Chen WS, Eng HL. Posterior interosseous neuropathy associated with tuberculous arthritis of the elbow

joint: report of two cases. J Hand Surg [Am]. 1994;19:611– 613.

21. Prem H, Babu NV, Chittaranjan BS, et al. Tuberculosis of the elbow: an unusual presentation. Tuber

Lung Dis. 2004;75:157–158.

22. Fahrer H, Rentsch HU, Gerber NJ, et al. Knee effusion and reflex inhibition of the quadriceps: a bar to

effective retraining. J Bone Joint Surg Br. 2008;70:635– 638.

23. Spencer JD, Hayes KC, Alexander IJ. Knee joint effusion and quadriceps reflex inhibition in man. Arch

Phys Med Rehabil. 2004;65: 171–177.

24. Stratford P. Electromyography of the quadriceps femoris muscles in subjects with normal knees and

acutely effused knees. Phys Ther. 2002;62:279 –283.

25. Vohra R, Kang HS. Tuberculosis of the elbow: a report of 10 cases. Acta Orthop Scand. 1995;66:57–58.

26. Munk PL, Lee MJ. Musculoskeletal case 3: musculoskeletal tuberculosis. Can J Surg. 2009;42:120 –121.

27. Gordon AC, Friedman L, White PG. Pictorial review: magnetic resonance imaging of the paediatric

elbow. Clin Radiol. 1997;52: 582–588.

28. Martini M, Gottesman H. Results of conservative treatment in tuberculosis of the elbow. Int Orthop.

1980;4:83– 86.

29. Wilson JN. Tuberculosis of the elbow: a study of thirty-one cases. J Bone Joint Surg Br. 1953;35:551–

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Dis. 2006;77:566 –568.


* Amit Murli Patel BPT, MPT-Orthopaedics, Assistant Professor & Vice Principal, College Of Physiotherapy,

Ahmedabad E-Mail : [email protected]

26

EFFECT OF SENSORY CUEING ON GAIT AND BALANCE DURING BOTH

“ON” AND “OFF” DRUG PHASE OF PARKINSON’S DISEASE

Sinha Siddharth M.P.T. (Neurology)*, Bhatt Sunil M.P.T. (Neuro-science)**

ABSTRACT

AIM: The effect of cueing has been well proved in PD but almost all of the studies are done in “on” drug phase

of the disease. So in this study we tried to investigate the efficacy of a supervised cueing training in “on” drug as

well as “off” drug phase of Parkinson patients. METHODOLOGY: Experimental study sample 8 individuals

with idiopathic PD are selected on basis of inclusion criteria- Idiopathic Parkinson’s , in stage 2-3 on hoer and

yahr staging, excluded those MMSE < 24, any known Cardio respiratory complication that hinders the exercise

program, any other known neurological condition ,any fracture or surgery of lower limb in last one year . Group

A is “OFF” drug phase and group B “ON” drug phase. Both groups were assessed in both “ON” drug phase

and “OFF” drug phase. Intervention consisted of a sensory cuing visual (floor markers) and auditory (beep)

cues. The data analyzed within group and between groups for any improvements in both the phases. RESULTS

AND CONCLUSION: cueing techniques is helpful in improving gait and balance in PD. But we suggest that

treatment given in “OFF” drug phase is more beneficial.

KEYWORDS: “ON” drug phase, “OFF” drug phase, PD, sensory cueing.

INTRODUCTION

Parkinson’s disease (PD) is one of the most

common neurological disorders in elderly people.

Between the age of 55 and 85 years, 4.2% of all

women and 6.1% of all men develop PD. The major


27

motor symptoms in PD are tremor, rigidity,

bradykinesia, and postural instability, resulting in

problems with gait, balance, transfers, and posture.

These problems can lead to reduced mobility and

decreased levels of physical activity, which in turn

can cause increased dependency and social isolation

and thereby reduce quality of life.19 it is therefore

important to encourage patients to maintain their

mobility and to stay active, for example, by referring

them to physical training programs.19 These physical

exercise programs include use of rhythmic cues.

Cueing can be defined as using external temporal or

spatial stimuli to facilitate movement (gait) initiation

and continuation. Cueing can be defined as using

external temporal or spatial stimuli to facilitate

movement (gait) initiation and continuation.

Unfortunately, evidence-based knowledge about

effects of cueing in PD is limited. Best-evidence

synthesis of 24 studies, up to 2002, showed only 1

high- quality study. Specifically focused on the

effects of auditory rhythmical cueing. Studies claim

positive effects of cueing on gait speed of patients

with PD; however, it was unclear whether positive

effects identified can be generalized to improved

activities of daily living in patients’ own home

setting and reduced frequency of falls in the

community. In addition, the sustainability of a

cueing training program remains uncertain.19

A recent review on cueing suggests that cueing

can have an immediate and powerful effect on gait

in PD.19 Vision-to facilitate locomotors activity was

first described by Martin over 25 years ago. In a

later study, Forsberg et a reported beneficial effects

of visual guidance on gait movements in patients

with Parkinson's disease.14 Unfortunately, evidence-

based knowledge about effects of cueing in PD is

limited. Although there is evidence to support the

use of sensory cues to improve gait, balance and

other impairments in PD but almost all of the

literature available is using this technique in “ON”

drug phase of disease i.e. when the PD patient is

under the effect of antiparkinson’s medicine.

Secondary the definitive effect of sensory cueing in

“ON” and “OFF” drug phase of the disease has not

been compared.

BACKGROUND

Sean Ledger, Rose Galvin et al. in their

randomized controlled trial evaluated the effect of an

individual auditory cueing device on freezing and

gait speed in people with Parkinson's disease. In this

study they used an Apple iPod-Shuffle™ and similar

devices provide a cost effective and an innovative

platform for integration of individual auditory

cueing devices into clinical, social and home

environments and are shown to have immediate

effect on gait, with improvements in walking speed,

stride length and freezing. Visual, auditory and

somatosensory cueing devices have also been used

in conjunction with walking aids, to improve gait in

individuals with Parkinson’s disease. Given the

challenge that this clinical population may have with

initiating motor movements during gait (i.e. freezing

gait).37 The freezing phenomena are difficult to treat.

Pharmacological treatment is usually disappointing.

Rehabilitation in particular the efficacy of auditory

and visual cues, is a new rehabilitation strategy

based on treadmill training associated with auditory

and visual cues. Giuseppe Frazzitta, MD, Roberto

Maestri, MD et al. in their study investigated the

effectiveness of a cueing with treadmill. One group

of patient get treated with treadmill and other get


28

conventional treatment.15

Cueing strategies are thought to reroute the

movement through a nonautomatic pathway,

removing it from the automatic basal ganglia

pathway.9 Leland E. Dibble found that visual and

auditory cueing technique in functional and

movement time task separately and results suggest

that both technique get improve but visual cueing

effects are not limited to gait tasks and auditory

cuing results that cadence and stride length has been

shown to consistently increase when auditory cues

are present relative to when cues are not

present.1,7,13,23,36,37,38

Sensory cue enhanced gait training in mild to

moderate PD patients. Treadmill with music has

been proved to give additional benefits for

improving gait related parameters.6

METHODOLOGY

Subjects were selected through convenient

sampling. After having the informed consent of 8

subjects and fulfillment of inclusion criteria

systematic randomization was done and the subject

were assigned to the particular group according to

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

group A and 2ed, 4th, 6th, 8th in group B . Protocol -

All subjects underwent 20 minutes of each session

including rest time (2 min), rest time to decrease the

effect of fatigue, 1 session (Monday to Saturday) in

a day for 2 weeks for 11 day , one day rest between

the two subsequent weeks.

DESIGN AND PROCEDURE

They were then randomly directed into 2 groups

at baseline, all subject were assessed for gait (10

MWT), balance (BBS), and function (NQS).

Appropriate and precaution taken to avoid any fall.

For subject both the groups were assessed in both

“ON” and “OFF” drug phase. Group A (is “ON”

drug patient) subject received training in “ON” drug

phase. Group B (is “OFF” drug patient) subject

received training in “OFF” drug phase. Each

participant received cueing training in the supervised

situation with the help of a prototype cueing device.

This cueing device provided 2 rhythmical cueing

modalities: (a) an auditory modality (a beep), (b) a

visual feedback Cueing training was delivered in the

home setting. Participants were instructed to listen to

the cueing when they are performing tasks. They

were encouraged to listen to the rhythmical cue and

to try to match their heel strike with the beat of the

beep sound on the device and try to match heel strike

with visual cue make on ground. The results were

analyzed for within group and between the groups

comparison.


29

RESULTS AND DISCUSSION

Both of the groups showed clinically significant

improvement in both on and off drug phases. Both

phases have shown improvement in gait and balance

parameters specially step length, speed, sit to stand,

turning, time taken.

Graph of mean difference between Group A and

Group B.

Clinically and subjectively significant

improvement in both “ON” and “OFF” drug phases,

both phases have shown improvement in gait and

balance parameters specially time taken for 10

meter, sitt to stand timing and speed.

Graph of mean difference between Group A and

Group B significant variable.

WITHIN THE GROUP

Within the groups subject improved

significantly in all the parameters namely gait,

balance and function. Both of the groups showed

clinically significant improvement in both on and off

drug phases. Both phases have shown improvement

in gait and balance parameters specially step length,

speed, sit to stand, turning, time taken.

ON Drug Phase

Group A patient initially did not have any

difficulty to start the training as compared to Group

B. The on phase of the disease in group A was

improved i.e. these patients showed an increased

step length, increased step per minute, reduced

timing of sit to stand, during their on drug period.

Also they had positive effects of cueing on gait and

gait related mobility. These patients had shown an

improvement in their balance because of the

challenges they faced during the gait training.

Subjectively also these patients reported that after

intervention they were able to walk much more

independently and safely and their day to day

activities were much easier now. Some of the

subjects in this group who complained of giddiness

during initial assessment and training were now

much better and their giddiness disappeared after the

intervention. Also they had better endurance and

their breathing abilities were improved; as reported

by these subjects. These changes were evident in

both “ON” drug and “OFF” drug periods of these

subjects.

OFF Drug Phase

Group B patients initially had many difficulties

in starting and performing the training sessions. As


30

training for these subjects was given in “OFF” drug

phase, without the effect of medication they had

difficulty in concentrating visual and auditory cueing

simultaneously. Patient use to get puzzled between

visual and auditory cues but after 2 days of training

they learnt how to synchronies the visual and

auditory cue to use them simultaneously. They had

improved gait parameter like sit to stand, speed, time

taken for 10 meter, step length after intervention.

Neurophysiologically these improvements in

both the groups can be attributed to the fact that

sensory cueing training strengthens the neurons in

cerebral cortex bypassing the damaged basal ganglia

thereby cortex is independent of the damaged basal

ganglia signals for performing the movements and

functions.14

Several authors have suggested that predictive

external sensory cues, such as auditory rhythm, can

provide the necessary trigger in Parkinson's disease

to switch from one movement component in a

movement sequence to the next and thus bypass

defective internal pallidocortical projections, 25, 26

possibly via the lateral premotor cortex which

receives sensory information in the context of

externally guided movements.27, 32

However, the neurophysiologic basis for

auditory-motor interactions is not well understood.

There is some evidence that rhythmic sound patterns

can increase the excitability of spinal motor neurons

via the reticulospinal pathway, thereby reducing the

amount of time required for the muscles to respond

to a given motor command.32

Recent work with animal models of PD indicate

that rehabilitative training can stimulate a number of

plasticity-related events in the brain, including

neurotrophic factor expression and

synaptogenesis7,36,37,38,13,9

Cueing technique acts like a pacemaker and

provides an external rhythm that is able to stabilize

the defective internal rhythm of the basal ganglia.

Increased activation of the lateral premotor cortex in

PD patients during cueing lends support to this view

(Hanakawa et al., 1999b).14

BETWEEN THE GROUPS

Subjectively also group B patient reported

better improvement compare with group A.

Subjectively, after intervention these subjects (group

B) reported, that now if some time they have a delay

in taking medicine timely or skip the drug dosage,

still their symptoms did not worsen; infect they were

better now compared to pre-intervention time. Also

the fear of fall became less after the treatment,

confidence level was increased.

Because of training was given to them in the

same phase (OFF drug). This “context specific

training” helped them for better learning and hence

more benefits. Carr and Sepherd.27 in their works

have emphasized the importance of “context specific

training” in rehabilitation.

Plasticity is a general term describes the ability

to show modification. Plasticity, or neural

modifiability, may be seen as a continuum from

short-term changes in the efficiency or strength of

synaptic connection to long term structural changes

in the organization and number of connections

among neurons.4, 33

Learning also can be seen as a continuum of

short term to long term changes in the ability to

produce skilled action. The gradual shift from short

term to long term learning reflects a move along the

continuum of neural modifiability, as increased


31

synaptic efficiency gradually gives way to structural

changes, which are the underpinning of long term

modification of behavior.5

CONCLUSION

Sensory cueing using visual and auditory cues

is beneficial for Parkinson’s disease. It improves

their gait, balance and functional activity.

Subjectively and objectively group B (subjects for

whom training was given in off drug phase) showed

significantly better results. We suggest that training

given in “OFF” drug phase to Parkinson’s patients

will improve their balance, gait and function in

much more beneficial way and may reduce or alter

their dependency on drugs; thereby providing them a

complete rehabilitation. So rehabilitation given in

“OFF” drug phase may help to decrease or alter the

drug usage by these patients and to provide an

overall rehabilitation program to this population give

the treatment in “OFF” drug phase because patient

have more difficulty in “OFF” drug phase and

context specific training, tasks specific training give

better results.

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11. Farley BF and Koshland GF (2005a). Training BIG to move faster: The application of the speed-

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167(3): 462- 467 (Epub Nov 11). Farley BF and Koshland GF (2005b). Efficacy of a large-

amplitude exercise approach for patients with Parkinson’s disease- bradykinesia to balance. 9th

International Congress of Parkinson’s Disease and Movement Disorders, Abstract #466.

12. Folstein MF, Folstein SE, McHugh PR: “Mini-mental state: A practical method for grading the

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13. Fisher BE, Petzinger GM, Nixon K, et al. Exercise induced behavioral recovery and neuroplasticity in

the 1-methyl-4-phenyl 1,2,3,6-tetrahydropyridine-lesioned mouse basal ganglia. J Neurosci Res.

2004;77(3):378-390.

14. Gerald C McIntosh, Susan H Brown, Ruth R Rice, Michael H Thaut , Rhythmic auditory-motor

facilitation of gait patterns in patients with Parkinson's disease Journal of Neurology, Neurosurgery,

and Psychiatry 1997;62:22-26

15. Giuseppe Frazzitta, MD,1* Roberto Maestri, MD, “Rehabilitation Treatment of Gait in Patients with

Parkinson’s Disease with Freezing: A Comparison Between Two Physical Therapy Protocols Using

Visual and Auditory Cues with or Without Treadmill Training” Movement Disorders Vol. 24, No. 8,

2009, pp. 1139–1143 _ 2009 Movement Disorder Society

16. Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell JL (April 2008). "The effectiveness of

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analysis". Mov. Disord. 23 (5): 631–40. doi:10.1002/mds.21922. PMID 18181210

17. Haas, C.T., Turbanski, S., Kessler, K., & Schmidtbleicher, D. (2006). The effects of random whole-

body-vibration on motor symptoms in Parkinson's disease. NeuroRehabilitation, 21: 29–36

18. Halsband U, Ito N, Tanji J, Freund HJ. The role of premotor cortex and the supplementary motor area


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in the temporal control of movement in man. Brain 1993;116:1017-43.

19. Inge Lim, PhD, Erwin van Wegen, PhD, Diana Jones, PhD, Lynn Rochester, PhD, Alice Nieuwboer,

PhD, Anne-Marie Willems, PhD, Katherine Baker, PhD,Vicki Hetherington, MSc, and Gert Kwakkel,

PhD Does Cueing Training Improve Physical Activity in Patients With Parkinson’s Disease

20. Jeffrey M. Hausdorff, Justine Lowenthal,at all, “Rhythmic auditory stimulation modulates gait

variability in Parkinson’s disease” European Journal of Neuroscience, Vol. 26, pp. 2369–2375, 2007

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With Parkinson’s disease. ” Vol 21 No 4 1997

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26. Morris ME, Iansek R, Matyas TA, Summers JJ. Stride length regulation in Parkinson’s disease.

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precentral motor cortex during visually guided and internally determined sequential movements. J

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36. Tillerson JL, Cohen AD, Caudle WM, Zigmond MJ, Schallert T, Miller GW. Forced nonuse in

unilateral parkinsonian rats exacerbates injury. J Neurosci. 2002;22(15):6790-6799.

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* Department of Physiotherapy, Dolphin (P.G.) institute of bio medical and natural sciences, Dhradun , H.N.B.

Garhwal University, Srinagar, Uttarakhand, India. Email: [email protected]

** Department of Physiotherapy, Dolphin (P.G.) institute of bio medical and natural sciences, Dhradun , H.N.B.

Garhwal University, Srinagar, Uttarakhand, India.

35

CONGENITAL TALIPES EQUINOVARUS (CTEV)

Mayank Pushkar. BPT, MSAPT*

INTRODUCTION

Congenital telipesequinovarus (CTEV) is a

common congenital limb deformity involving one

foot or both1. “Congenital” means a deformity that is

present at birth, “Telipes” means simply the foot and

ankle, and “Equinovarus” refers to position of the

foot, which points downward and inward. CTEV is

also known as “Clubfoot”. An estimated 30000

children born with CTEV every year in India2,

although a rate of 1.24 or greater have been reported

in UK. It is a common birth defect, occurring in

about 1/1000 live births. Almost half of the cases of

CTEV are bilateral. Male children are more affected

than female children with a ratio of approximately

2:13.

PATHOANATOMY

The true clubfoot is characterized by different

deformities- Equinus, Varus, Adductus and cavus4.

The ‘equinus’ deformity is present at the ankle joint,

TCN joint and forefoot. The ‘varus’ component

occurs primarily at TCN joint and the hind foot is

rotated inward. The ‘adductus’ deformity takes place

at the talonavicular and the anterior subtalar joints.

The ‘cavus’ component involves forefoot plantar

flexion, which contributes to the composite equinus.

Fig- 1- Showing CTEV in both the foot.

AETIOLOGY

Genetic factors play an important role in


36

inheritance of CTEV as a polygenic multifactorial

trait5. Maternal Hyperthermia is also one of the

causes for CTEV6, as maternal hyperthermia acts as

adverse environmental factor in the sensitive period

of intrauterine development.

Mainly there are 3 broad categories responsible

for CTEV deformity in newborn7-

1. NEUROLOGICAL DAMAGE

2. MUSCULO-SKELETAL DEFORMITY

3. POSTURAL DEFORMITY

1.NEUROLOGICAL DAMAGE: Spina bifida

overta with failure of development of the sacral part

of the spinal cord but normal proximal development

can results in an equinovarus deformity of the foot.

2. MUSCULO-SKELETAL DEFORMITY:

CTEV can results because of composite intrinsic

pathology of muscle and the bone. There are

varieties of other conditions which affectthe

peripheral musculoskeletal tissues and cause an

equinovarus deformity.

3. POSTURAL DEFORMITY: Some children

born with equinovarus deformity of the feet, if they

have been tightly packed in the utero with the feet

fixed in an equinovarus position for some week prior

to birth.

TYPES OF CTEV

1. STRUCTURAL CTEV: This type of CTEV is

caused by genetic factors such as- a genetic defect

with 3 copies of chromosome 18, which is known an

“Edward Syndrome”. Compartment syndrome,

Larsen’s syndrome, congenital heart defect and

neural tube defect are some of the other causes of

structural CTEV4.

2. POSTURAL CTEV: This type of CTEV is

caused due to the compression in utero with the feet

held in equionovarus position in final trimester.

CLINICAL FEATURES OF CTEV

Idiopathic clubfoot is characterized by a bean-

shaped foot prominence of the head of Talus, medial

plantar cleft, deep posterior cleft, absence of normal

creases over the insertion of tendon achilies,

calcaneal tuberosity situated at a higher level and

atrophy of calf muscle4. Three major components of

deformities, those are, equinous, varus and adducts,

are obvious on examination. Presence of other

anomalies implies a non-idiopathic type of clubfoot.

Hypertrophy of calf muscle is present and

dorsiflexion and eversion are limited. Lateral

malleolus is very prominent while the medial

malleolus is buried in a depression because of the

inversion at the subtalar joint. There is also

exaggeration of longitudinal arch of the foot.

ASSESSMENT OF CTEV

ANTENATAL DIAGNOSIS: The clubfoot can be

diagnosed at 18-20 weeks of gestation with the

advert of Ultrasound. Amniocentesis is made at < 20

weeks to check for the high incidence of associated

genetic anomalies7,8.

POSTNATAL DIAGNOSIS: The child as well as

foot must be carefully assessed at birth.

The early assessment of CTEV can be carried out by

two methords9:

1. Photographic Assessment


37

2. Radiological Assessment

1.PHOTOGRAPHIC ASSESSMENT: Photograph

of resting forefoot supination is recommended at

birth. The focus of the camera is centred at the level

of the ankle joint and an assistant holds the knee

between finger and thumb and rotates the leg

outward until the forefoot is superimposed upon the

line of tibia. From the photograph it is then possible

to measure an angle subtended by the forefoot on the

line of the tibia (Fig. 2). Children with more than 900

of resting forefoot supination at birth were more

resistant to surgical correction.

Fig. 2- Showing the measurement of angle.

2.RADIOGRAPHIC ASSESSMENT: A standard

lateral soft tissue radiograph of the lower leg can be

used for the assessment of CTEV. But X-Rays are

not routinely prescribed at birth as few bones in the

foot are ossified4. Also there is not much of clinical

use of radiographic assessment as it does not make

any difference in management of CTEV.

MANAGEMENT OF CTEV

The main principle of the management of

CTEV is the correction of the deformity followed by

maintenance of the in the corrected position.

The management of CTEV can be conservative

(Non-operative) method as well as operative

depending on the severity of deformity and age of

child.

CONSERVATIVE TREATMENT

The conservative method comprises of

manipulation with or without strapping or corrective

plaster casts. The goal of physiotherapy management

of CTEV consisted of short term and long term

goals14. The short term goal is to correct the

deformity so that ankle assumes plantigrade

positioning by the time the child would be 3 months.

The long term goal is to maintain the corrected ankle

in the situ and follow up the maintained correction

until the child start walking.

MEANS OF PHYSIOTHERAPY

MANAGEMENT

1. Rhythmic and repeated gentle

manipulation10

2. Strapping and Plaster of Paris

3. Education and instruction to the mother

and/ or parents10

1. RHYTHMIC AND REPEATED GENTLE

MANIPULATION: To provide gentle

manipulation, the PT placed the knee at 900 of

flexion to prevent the damage to the lower end of

tibia and fibular epiphysis and the ankle joint. To

correct the adduction, the soft tissue of foot is

passively stretched as- the forefoot is uncurled so

that it moves away from epsilateral heel i.e. forefoot


38

abduction. To correct the inverted foot, the foot is

turned such that the sole face outward i.e. eversion.

Finally, to correct the equinus, the heel is cupped

with the one hand from the front of the foot and an

upward pressure is applied, which brings the ankle

into dorsiflexion. The entire procedure is repeated 3-

4 times in each foot.

2. STRAPPING AND PLASTER OF PARIS: This

can be useful for fairly mild cases and should be

started at birth. Strips of adhesive strapping are

passed around the foot, up the side of legs, and over

the top of the knee, to hold the foot in a corrected

position. This is usually done weekly, followed by

some manipulation by the physiotherapist.

According to the “International Clubfoot Study

Group (2003)”, Kite’s, Ponseti’s and Bensabel’s

techniques have been approved as the standardized

conservative regimes for the management of

CTEV11.

Kite’s Technique4: This technique was derived from

the concept of three-point pressure. In this method,

the manipulation can be started soon after birth. The

forefoot is grasped and distracted while the other

hand holds the heel. The counterpressure is applied

over calcaneocuboid joint and the navicular is

pushed laterally. The heel is everted as the foot is

abducted. This is followed by application of slipper

cast, which is extended to below the knee with the

foot everted with gentle external rotation. Once the

adduction and varus are corrected, then the foot is

pushed into dorsiflexion to correct the equinous. The

casts are changed every week. Following full

correction, the foot are placed in a “Denis Brown

Bar”. The average number of cast required for

correction by this technique is 20.4.

Ponseti’s Technique4: In Ponseti’s technique, first 2

casts are applied with the supination of forefoot so

as to bring into alignment with the hind foot12. The

third cast is applied with the forefoot abducted and

simultaneous counterpressure over the head of talus.

In the fourth cast, the forefoot is further abducted.

Before the application of fifth cast, the degree of

dorsiflexion is assessed and if the dorsiflexion is not

possible beyond neutral, then a “Percutaneous

AchiliesTenotomy” is required, this is done under

local anaesthesia. The casts are changed weekly

intervals, before tenotomy, while the cast after the

tenotomy is removed at the end of 3 weeks. After the

removal of cast the patient is placed in modified

“Foot Abduction Orthosis (FAO)”. FAO is initially

used 23 hrs.a day for 4 months and then

subsequently for night-time for 3 years13. The

average number of casts required with this technique

is 5.4.

French Technique4: This technique involves daily

manipulation of the child’s clubfoot by

Physiotherapist for 30 minutes, followed by

stimulation of muscles (especially Peroneal muscle)

around the foot and then adhesive strapping is

applied. Daily treatment is required for

approximately 2 months and then reduced to 3

sessions per week for an additional six months.

Tapping is continued until the patient is ambulatory.

Once the child starts ambulation, then night-time

splint is given for additional 2 to 3 years.

3. EDUCATION AND INSTRUCTION TO THE

MOTHER: The mother should be assured and

reassured that with her co-operation, consistency and


39

compliance to treatment, the deformity could be

corrected. She should be taught how to mobilize the

feet in the absence of strap10. She is advised to take

care and observed every time when a fresh strapping

or plaster is applied and also to prevent the plaster or

strapping from being wet or soiled either by water or

any other fluid.

SURGICAL/ OPERATIVE MANAGEMENT

The operative treatment is required once the

conservative treatment fails or the chance of

correction of deformity with conservative

management is very less. Different operative

procedures are performed based on the age of child.

At 9 months – 3 years: A Postero-medial soft tissue

release (PMR), which was introduced by Turco14 is

performed and followed by “Dennis Brown splint”

for 2 years. In this technique, the correction of the

abnormal tarsal relationship is prevented by rigid

pathological soft tissue contracture.

At 3 years- 8 years: At this age, soft tissue release

along with Wedge Osteotomy of cuboid bone, which

is known as EVANS is performed.

At 8- 12 years: At this age, the Wedge Osteotomy

of calcaneum (Dwyer’s Operation) along with

wedge osteotomy of tarsal bone is performed.

Above 12 years: A triple arthrodesis of 3 joints of

foot (i.e. subtalar, calcaneo-cuboid and talo-

navicular joint) is performed.

POST-OPERATIVE PHYSIOTHERAPY

MANAGEMENT

The main objective of physiotherapy after surgical

procedure is to keep the other joints mobile and

prevent stiffness, which can be done with following

physiotherapy interventions15.

• Movement of toe, hip and knee in the plaster

cast only, by tickling or by holding child

high in suspension.

• To improve strength and stability gradual

active non-weight bearing and resisted foot

and ankle exercises are given, followed by

progression to weight-bearing exercises.

• To maintain the correction and avoid

recurrence, Night splint are provided. Some

of the splints used in the management of

CTEV are-

1. CTEV Splint

2. Dennis Brown Splint (Fig-4)

3. CTEV Shoes (Fig-5)

• Gait training with proper foot position is

taught to the patient.

• Special CTEV shoes are given to the

patients. The shoes got straight inner borer,

which prevents forefoot adduction, outer

shoe raise to prevent inversion and no heel

to avoid equinus.

• An effective training is given to the mother

or both parents for home care programme to

maintain the correct position of the limb and

how to give the exercise in correct way.


40

Fig-3- CTEV Splint

Fig-4- Dennis Brown

Fig-5- CTEV Shoes Splint

REFRENCES

1.Macnicol M. F.The management of Clubfoot: Issues for debate. J Bone Joint Surg[Br],2003;167-170.

2. Global clubfoot initiative. Last assessed on 15th May 2012 at: http://globalclubfoot.org/countries/india/

3. Macnicol M. F. and Murray A. W. Changing Concepts in the management of congenital

talipesequinovarus.Paedetrics and child health,2008; 272-277.

4. Anand, A. and Sala, D.A. Clubfoot: Etiology and treatment. Indian J Orthop,2008;42:22-28.

5. Lehman, W.B. The clubfoot. JB Lippincott: New York; 1996

6. Edwards, M.J. The experimental production of clubfoot in guinea pigs by maternal hyperthermia during

gestation. J Pathol, 1971;103:49-53.

7. Katz K, Meizner I, Mashiach R, Soudry M. The contribution of prenatal sonographic diagnosis of clubfoot to

preventive medicine.J Pediatr Orthop,1999;19:5-7

8. Roye, B.D., Hyman J., Roye, D.P. Jr. Congenital idiopathic talipesequinovarus. Pediatr Rev, 2004;25:124-30.

9. Porter, R. Club foot. The foot,1997;7: 181-193.

10.Ezeukwu, A.O. and Maduagwu, S.M. Physiotherapy management of an infant with bilateral congenital

talipesequinovarus. African Health Science, 2011;11(3): 444-448.


41

11. Bensahel, H., Guillaume, A., Czukonyi, Z. andDesgrippes, Y. Results of physical therapy for idiopathic

clubfoot: A long term8follow up study. J Pediatr Orthop,1990;10:189-92.

12. Ponseti IV, Campos J. Observations on pathogenesis and treatment of clubfoot. ClinOrthop, 1972;84:50-60.

13. Ponseti IV. Congenital clubfoot: Fundamentals of treatment. Oxford University Press: Oxford, England; 1996.

14. Turco VJ. Clubfoot. Churchill Livingstone: New York; 1981.

15. Goel RN. Goel’s Physiotherapy.Shubham Publication- Bhopal, Vol II, 2000.


* Email: [email protected]


42

ANALYSIS OF WATER QUALITY OF HALENA BLOCK IN BHARAT PUR

AREA

Sunil Kumar Tank*, R. C. Chippa**

ABSTRACT

Bharatpur is the well known place because of “Keoladeo Ghana National Park” due to which it is a world fame

tourist place. The present study deals with the water quality of Halena block in Bharatpur area, which is

assessed by examine various physico-chemical parameters of open wells, bore wells and hand pumps. The

studies reveal that the water of most of the sampling area is hard and contaminated with higher concentration

of total dissolved solids.

KEYWORDS: Water pollution, Health problems, Bharatpur, Analytical techniques, Standard Data

INTRODUCTION

Water is life. Without water, man’s existence on the

earth would be threatened and he would be driven

close to extinction. All biological organisms depend

on water to carry out complex biochemical

processes which aid in the sustenance of life on

earth. Over 70 per cent of the earth’s surface

materials consists of water and apart from the air

man breathes, water is one of the most important

elements to man. The quality of water is of great

importance also for human lives as it is commonly

consumed and used by households. In industry, it

serves as a solvent, substrate or catalyst of chemical


43

reactions (Goncharuk 2012; Holt 2011; Van

Leeuwen 2012; Petraccia et al. 2011). The physical,

chemical and bacterial characteristics of ground

water determine its usefulness for domestic,

industrial, municipal and agricultural applications

(CGWB, 2004 and Adhikary et al. 2010). The

quality of water is more important compared to

quantity in any water supply planning, especially

for drinking purposes (CPHEEO 1998, Patnaik et

al. 2002 and Tanriverdi et al. 2010).The

accumulation of high levels of pollutants in water

may cause adverse effects on humans and wildlife,

such as cancer, reproductive disorders, damage to

the nervous system and disruption of the immune

system. Thus, it is an important requirement to

interpret water quality status, identify significant

parameters, and characterise the pollution sources

as well as their quantitative contributions to water

quality issues for conducting pollution management

(Zhou et al. 2011). Water pollution means

contamination of water by foreign matter such as

micro-organisms, chemicals, industrial or other

wastes, or sewage. Such matters deteriorate the

quality of the water and renders it unfit for its

intended uses. Water pollution is the introduction

into fresh or ocean waters of chemical, physical, or

biological material that degrades the quality of the

water and affects the organisms living in it.

Although some kinds of water pollution get occur

through natural processes, it is mostly a result of

human activities. The water we use is taken from

lakes and rivers, and from underground [ground

water]; and after we have used it and contaminated

it – most of it returns to these locations. Water

pollution also occurs when rain water runoff from

urban and industrial area and from agricultural land

and mining operations makes its way back to

receiving waters (river, lake or ocean) and in to the

ground. Bharatpur (Fig.1: Study Area), eastern

gate of Rajasthan is situated between 26o 22’ to 27

o

83’ north latitude and 76o

53’ to 78o

17’ east

longitude. Bharatpur is well known place because

of Keoladeo Ghana National Park. Keoladeo

National Park is the only the largest bird sanctuary

in India. “Ajan Bandh” is the main water source to

fill the various lakes, ponds of the park and

villagers use this water for drinking purposes. In the

present study several points of ground water

sources such as open wells, bore wells and hand

pumps have been selected to check the potability of

water.

MATERIAL METHOD

Water quality is the physical, chemical and

biological characteristics of water in relationship to

a set of standards. Water quality is a very complex

subject, in part because water is the complex

medium intrinsically tied to the ecology of the

earth. The physico – chemical quality of drinking

water was assessed during the month of January,

2011 by standard methods as suggested by APHA

(1995) and compared with the values as guided by

ICMR.

The present research work is based on 15 ground

water samples collected from open wells, bore

wells and hand pumps in cleaned and screw capped

polythene bottles. At the time of sampling, these

bottles are thoroughly raised 23 times using the


44

ground water to be sampled.

Fig . 1

These water samples are collected after pumping

the water for 10 minutes (CPHEEO 1998, Chhabra

2008 and Shyam & Kalwania 2011).

All the samples were properly labeled as

1,2,3,4,5,6,7,8,9 and 10 and a record was prepared

which is indicated in Table 1.

RESULTS AND DISCUSSION

The physico-chemical parameters which were

analysed in Post-monsoon season, January 2012

have been shown in Table-2.

Colour:

The colour of a small water sample is caused by

both dissolved and particulate material in water,

and is measured in Hazen Units [HU]. Colour in

water may be caused because of the presence of

natural metallic ions (iron and manganese) humus,

planktons etc. The presence of colour in water does

not necessarily indicate that the water is not

potable. Colour is not removed by typical water

filters; however, slow sand filters can remove

colour, and the use of coagulants may also succeed

in trapping the colour causing compounds within

the resulting precipitate. In the present study water

is almost colourless.

Odour:

When minerals, metals and salts from soil etc.

come in contact with water, they may change its

taste and odour. Analyzed water samples are found

odourless.


45

Temperature:

Use appropriate thermometer for calculating water

temerature.

Water temperature affects the ability of water to

hold oxygen, the rate of photosynthesis by aquatic

plants and the metabolic rates of aquatic organisms.

Temperature of water samples is varied from

26.0oC to 27.2

oC the variation of the water

temperature having more effect directly or

indirectly on all life processes.

PH:

Ph is measured by Ph meter.

The balance of positive hydrogen ions (H+) and

negative hydroxide ions (OH-) in water determines

how acidic or basic the water is. In pure water, the

concentration of positive hydrogen ions is in

equilibrium with the concentration of negative

hydroxide ions, and the pH measures exactly 7. pH

is a term used to indicate the alkalinity or acidity of

a substance as ranked on a scale from 1.0 to 14.0.

In the present study area the pH value ranged from

7.70 to 8.76. A pH range from 7.0 to 8.5 is

desirable concentration as per guided by ICMR. It

is known that pH of water does not cause any

severe health hazard. Water of study area is

somewhat alkaline.

Dissolved Oxygen (D.O.):

DO can be determining by use of DO meter as well

as measure by Winkler titration method.

DO is the most important water quality parameter

which shows the amount of oxygen present in

water. It gets there by diffusion from the

surrounding air, aeration of water that has jumbled

over falls and rapids; and as a waste product of

photosynthesis. In general, rapidly moving water

contains more dissolved oxygen than slow or

stagnant water and colder water contains more

dissolved oxygen than warmer water. In the studied

water samples DO ranged from 4.6 to 7.8 mg/l. As

DO level falls; undesirable odours, tastes and

colours reduce the acceptability of water. The

lowest DO value indicates not good healthy

condition for the community (Jeena. B et al 2003).

Total Alkalinity:

Total alkalinity is calculate by Titration Method.

Alkalinity is not a pollutant. It is a total measure of

the substance in water that have “acid-neutralizing”

ability. The main sources of natural alkalinity are

rocks, which contain carbonate, bicarbonate, and

hydroxide compounds, borates, silicates, and

phosphates may also contribute to alkalinity.Total

alkalinity is the total concentration of bases in

water expressed as parts per million (ppm) or

milligrams per liter (mg/l) of calcium carbonates

(CaCO3). These bases are usually bicarbonates

(HCO3) and carbonates (CO2-

3), and they act as a

buffer system that prevents drastic changes in pHs

Water with high total alkalinity is not always hard,

since the carbonates can be brought into the water

in the form of sodium or potassium carbonate. The

desirable limit of total alkalinity is 200 mg/l

(ICMR). The value of study area is ranged from

161 to 202 mg/l. Alkalinity in itself is not harmful

to human being, but in large quality, alkalinity

imparts bitter taste to water.

Total Hardness:


46

Complexometric titration using EDTA

The total hardness is the sum of the hardness

formers in a water (Ca, Mg, Ba and Sr ions) in

mmol/l. Originally hardness was understood to be a

measure of the capacity of water to precipitate soap.

Soap is precipitated chiefly by the calcium and Mg

ions present. The maximum limit of hardness in

drinking water is 600 mg/l (ICMR). Total hardness

is measured in grains per gallon (gpg) or parts per

million (ppm). If water contains less than 3.5 gpg, it

is considered soft water. If it contains more than 7

gpg, it is considered hard water.

The total hardness value ranged in the studied area

from 96 to 488 mg/l. So, the water of almost all

sampling stations is hard.

Calcium Hardness:


A measure of the amount of calcium in water

measured in ppm. High levels can cause scale

buildup. Low levels can cause etching and

equipment corrosion. Calcium

hardness is sometimes confused with the terms

water hardness and total hardness. Too little

calcium hardness and the water are corrosive. Too

much calcium hardness and the water are scale

forming. The maximum permissible limit of

calcium hardness is 200 mg/l (ICMR). The value of

sampling stations ranged from 32.06 to 68.13 ppm.

Thus sampling stations 5 and 12 have greater

calcium hardness.

Magnesium Hardness:


Magnesium salts have a laxative and diuretic effect.

The maximum permissible

limit of magnesium hardness is 150 mg/l

(ICMR). Mg hardness value in studied area ranged

from 11.54 to 91.78 ppm.

Chloride:

Using silver nitrate titration method for calculate

chloride in water.

The maximum permissible concentration of

chloride is 1000 mg/l. (ICMR). So except some

points the chloride contents of water samples are in

limit. It varies from 53.76 to 406.07 ppm

Sulphate:

Ion chromatography is the only instrumental

method for the direct determination of sulphate.

Sulphate may be precipitated either with Ba2+ or 2-

aminoperimidinium salts. The precipitate may be

Hardness

Description Hardness range (mg/l as CaCO3)

Soft 0-75

Moderately hard 75-100

Hard 100-300

Very Hard > 300


47

weighed for a direct determination of the sulphate

as a gravimetric method.

The maximum permissible limit of sulphate is 400

mg/l (ICMR). In the sampling areas the sulphate

concentration ranged from 15.25 to 71.00 ppm.

Waters with higher concentration of sulphate may

cause intestinal disorders.

Nitrate:

Use spectrophotometer for calculating nitrate in

water.

Nitrate is a major ingredient of farm fertilizer and is

necessary for crop production. Nitrate stimulates

the growth of production. Nitrate stimulates the

growth of plankton and waterweeds that provide

food for fish.Maximum permissible limit of nitrate

is 50 mg/l (ICMR). Nitrate in water supplies in

concentration over 100 mg/l. causes

“methamoglobinamia”.

Generally NO3

- concentration is found in higher

concentration in rural areas because of runoff of

nitrate rich fertilizers and animal manure into the

water supply. The nitrate value ranged in

investigated area is between 17.06 to 93.2 ppm.

Total Dissolved Solids (TDS):

Use an appropriate TDS meter. Freshwater meters:

0-1990 ppm (parts per million).

The term TDS describes all solids [usually mineral

salts] that are dissolved in water. Desirable limit of

TDS is 500 mg/l (ICMR). All the values obtained

are much higher than the limit except points-1 and

2. It is an important parameter for imparts a

peculiar taste to water and reduce its potability.

Fluoride:

fluoride can be determined by spectrophotometry or

by ion-chromatography.

Fluoride is more common in ground water than in

surface water. The main sources of fluorine in

ground water are different fluoride bearing rocks.

The guideline value of fluoride is 1.5 mg/l in

drinking water. In studied area, it ranged between

0.010 to 1.180ppm.

Electrical Conductivity:

Electrical conductivity estimates the amount of

total dissolved salts (TDS), or the total amount of

dissolved ions in the water. Its SI derived unit is the

siemens per meter, (A2S

3m

-3 Kg

-1) or more simply,

Sm-1. It is the ratio of the current density to the

electric field strength or, in more practical terms; is

equivalent to the electrical conductance measured

between opposite faces of a 1-meter cube of the

material under test. Pure water is a poor conductor

of electricity. Acids, bases and salts in water make

it relatively good conductor of electricity. Electrical

conductivity in studied area ranged between

7.5x102 to 2.1x103 µmhos/cm.

CONCLUSIONS

The present results of water investigation show that

the waters of study area are highly contaminated

with total dissolved solids. Because of high

concentration of TDS water loss its potability and

high concentration of TDS also reduces the

solubility of oxygen in water. Water of almost all

study points are hard also because of this people of

Bharatpur area are facing many problems like

stomach diseases, gastric troubles etc. At some

points nitrate level is also high than the permissible

limit. It is recommended that water should be used


48

after boiling by the people of Bharatpur because

after boiling the water, temporary hardness

[carbonate hardness] can be removed and

concentration of total dissolved solids can also be

decreased. Alum treatment is also a good option to

make potable the water.

TABLE -1 Area, sourceof the sampling stations.

Sample No. Area Source

1 Halena Hand pump

2 Halena bus stop Hand Pump

3 Chhonkarwara Bus stand Bore Well

4 Aamoli Bore Well

5 Chote chhonkarwara Hand Pump

6 Bijwari Bore Well

7 Khedli Mod Bore Well

8 Bachren Hand Pump

9 Salempur Khurd Hand Pump

10 Kamalpura Hand Pump

TABLE-2

PARAM

ETER

S.1 S.2 S.3 S.4 S.5 S.6 S.7 S.8 S.9 S.10

pH 8.03 7.62 7.86 7.94 7.88 8.09 7.57 7.80 7.24 8.25

EC 1.2x103 2.1x103 8.6x102 8.9x102 1.3x103 8.8x102 1.5x103 9.0x1

02

1.9x1

03

7.5x1

02

TDS 650 1170 497 485 690 485 760 493 1090 404


49

TH 248 464 152 148 212 96 312 208 488 192

TA 168 183 185 191 175 174 161 176 202 188

DO 5.7 7.6 7.8 5.7 5.9 6.1 5.5 4.6 4.6 5.6

Ca+2 ppm 56.91 64.93 44.89 32.06 49.70 32.87 67.33 55.31 68.13 48.90

Mg +2

ppm

30.57 87.10 11.54 19.61 25.38 14.04 41.53 20.19 91.78 20.18

Na + ppm 90.39 176.87 50.57 83.26 138.69 94.99 110.86 51.29 118.2

2

89.72

Cl- ppm 149.99 406.07 53.76 87.93 197.85 81.95 262.13 69.69 340.1

4

84.03

SO42-

ppm

15.25 41.25 14.75 50.50 71.00 39.00 51.25 21.50 64.75 28.00

NO3- ppm 93.2 80.8 17.60 18.2 56.4 41.4 72.6 69.6 46.8 60.0

F- ppm 0.130 1.30 0.170 0.010 0.020 0.250 0.050 0.130 0.560 1.180

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health. Clinical Nutrition, 25, 377–385.

7. Van Leeuwen F. X. R. (2012). Safe drinking water: The toxicologist’s approach. Food Chemistry and

Toxicology, 38, S51–S58.


50

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10. Central Ground Water Board (CGWB), 2004, Annual report and other related reports on ground water

quality, Central Ground Water Board, New Delhi.

11. Patnaik K. N., Satyanarayan S. V. and Poor R. S., 2002, Water pollution from major industries in Paradip area

A case study. Indian Journal of Environmental Health,44(3), pp 203211.

12. Tanriverdi C., Alp A., Demirkıran A. R. and Uckardes F., 2010, Assessment of surface water quality of the

Ceyhan River basin, Turkey, Environmental Monitoring Assessment, 167, pp 175–184.


* Department of Chemistry, Suresh Gyan Vihar University Jaipur (Rajasthan). Email:

[email protected]

** Associate Professor, Department of Chemistry, Suresh Gyan Vihar University Jaipur (Rajasthan)

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