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   Table of Contents - Current issue
Coverpage
July-December 2019
Volume 13 | Issue 2
Page Nos. 53-123

Online since Monday, December 30, 2019

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EDITORIAL  

Clinical Establishments Act, 2010: Improving clinical standards or proscribing physiotherapy p. 53
Akhoury Gourang Kumar Sinha
DOI:10.4103/PJIAP.PJIAP_34_19  
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REVIEW ARTICLE Top

Systematic review of recovery protocols for athletes following ACL injuries: Surgical vs. conservative treatment p. 58
Manish Shukla, Vishnu Dutt Bindal, Vivek Pandey
DOI:10.4103/PJIAP.PJIAP_5_19  
Injuries to anterior cruciate ligament (ACL) are common in sports. The treatments prescribed for torn ACL are surgical reconstruction (ACLr) and conservative management. While both treatments do not offer relief from long-term osteoarthritis (OA), the choice of the best treatment for athletes remains unclear. To assess the effectiveness of surgical versus conservative treatment for treating torn ACL in sports, a literature search in PubMed, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Library Central Register of Controlled Trials was done for randomized controlled trials/quality randomized controlled trials (RCTs/QRCTs) that compared surgical reconstruction with conservative treatment of ACL rupture in active participants. Studies were assessed for quality using PEDro clinical appraisal tool. Since the studies were heterogeneous, meta-analysis was not performed, and a “best evidence synthesis” was reported. There were four studies (RCTs/QRCTs), which met the inclusion criteria. The mean age of participants in ACLr group ranged 25.3–45.8 years, while in CON group, it was 25.5–49.3 years. Tibiofemoral OA ranged from 23% to 80% in surgery group and 28%–68% in conservative group. Three studies reported no difference between surgical and conservative group in terms of long-term OA at 10–20 years' follow-up. When assessed in terms of functional knee outcomes (Lysholm score, IKDC score, and Tegner score) and knee laxity, ACLr group showed significantly better outcomes. Thus, it may be suggested, based on functional knee outcome scores, that ACLr may help athletes resume their sporting career postinjury. Further good quality RCTs involving a large number of participants are required to strengthen the claim.
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CONTINUING PROFESSIONAL EDUCATION Top

Guidelines for the physiotherapy management of chronic obstructive pulmonary disease p. 66
Subin Solomen
DOI:10.4103/PJIAP.PJIAP_46_18  
The purpose of the article is to provide guidelines for the physiotherapy management of patients with chronic obstructive pulmonary disease (COPD). The various publications on the same topic were brought together with input from several textbooks in the field of cardiorespiratory physiotherapy and translated into clinical practice. This article briefs with definition, risk factors, prevalence, clinical features, investigations, differential diagnosis, and management of COPD patient. Then, information on physiotherapy management during acute exacerbation phase and during stable phase is detailed. The article provides specific details on the rationale of why and especially how to implement exercise training in patients with COPD.
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Importance and usage of patient-reported outcome measures in clinical physiotherapy practice p. 73
Gaurav Shori
DOI:10.4103/PJIAP.PJIAP_7_19  
Interest in patient-related outcome information is a prerequisite for patient-centered care, which has increasingly been recognized as an ethical imperative in modern health care. Patient-reported outcomes assess aspects of a patient's health status coming directly from the patient. Patient-reported outcome measures (PROMs) intent to profoundly change the face of modern health-care delivery. PROMs are increasingly used by clinicians to guide and audit routine care and are already firmly embedded in clinical research. These important patient-centered measures are likely to have a growing impact on physiotherapists all over the world. Patient-reported outcome research findings will increasingly guide policymakers and clinicians in providing evidence-based treatment. In addition, the routine clinical use of PROMs may allow physiotherapists to more effectively track treatment impact, thus aiding the development of optimal management strategies. The Chartered Society of Physiotherapy encourages as well as promotes at every level that physiotherapists must demonstrate measurable improvements in the clinical outcomes of their patients as part of daily practice. The use of PROMs to measure health status in routine practice has some distinct advantages over the traditional research-based outcome measures, as they may directly facilitate change behavior for patients, clinicians, managers, and policymakers. Widespread adoption of PROMs across physiotherapy is, therefore, something for the profession to embrace as it has the potential to empower patients, support clinical decision-making, and drive forward quality improvement. Thus, this article aim towards highlighting the importance and usage of PROMs in clinical physiotherapy practice.
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ORIGINAL ARTICLES Top

Injury pattern among fencing players in India p. 84
Nithin Prakash, AG K. Sinha
DOI:10.4103/PJIAP.PJIAP_42_18  
BACKGROUND: Fencing is an Olympic game, played in three disciplines of the Epee, the Foil, and the Saber. Despite the long history and international scope, very few epidemiological studies on injuries in modern competitive fencing are available. A study on the injury patterns of Indian fencing players is not yet reported. OBJECTIVE: The objective of this study is to explore the injury pattern among fencing players and to examine the association of occurrence of injury with certain risk factors. METHODS: The sample comprised 113 fencers (79 males and 34 females). Scheduled questionnaire was the tool of data collection. RESULTS: Point prevalence and 2 years prevalence of injuries were 12.38% and 13.27%, respectively. Acute injuries more common (78.5%) than the injuries of gradual onset (21.42%). Lower limb (100%) was the most common site of injuries. The ankle was the most frequently injured body part (64.28%). The event of the Epee had the highest proportion of injuries (15.69%) followed by the Foil (10.36%) and Saber (9.09%). Injured players were found to have spent significantly more time in footwork; although; the age, level of play, sex, and type of events, previous injuries, and training habits were not found significantly associated with the occurrence of injuries. Conclusion: It is concluded that Indian fencing players presented with a less prevalence of injury, out of which majority of injuries were in the lower limb.
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Influence of the asymmetric tonic neck reflex on handgrip strength in healthy adults p. 90
Tittu Thomas James, Jarapla Srinivas Nayak
DOI:10.4103/PJIAP.PJIAP_51_18  
BACKGROUND: Primitive reflexes are stereotypic motor behavioral responses that are necessary for the normal development of infants. Retention of these reflexes is mostly pathological and can lead to developmental delays. Few reflexes are also seen in normal adults, and the influence of the retained reflexes on functional activities is evident. This study identified the effect of the asymmetric tonic neck reflex (ATNR) on handgrip. MATERIALS AND METHODS: One hundred adults within the age group of 18–25 were selected for the study. Handgrip strength was measured using hand-held dynamometer on the dominant hand in three different neck positions, neck in neutral, neck actively rotated to the right, and rotated to the left. Data collected were statistically analyzed to identify the difference between the three mean values. RESULTS: The Friedman test performed to analyze the handgrip strength between the groups of three head positions demonstrated a statistically significant difference, χ2 = 110.479, P = 0.000. Post hoc analysis with the Wilcoxon signed-rank tests was conducted with a Bonferroni correction applied, resulting in a significant level set at P < 0.017. There was a significant difference in the handgrip measured between the group of head rotated to the left with head in neutral (P = 0.000) and head rotated to the right and the left (P = 0.000), but failed to demonstrate a significant difference between the groups of head in neutral and head rotation to right (P = 0.041). The results of this study thus infer a significant increase in handgrip of the right hand when head is rotated toward the left side. CONCLUSION: The study identified that there is an increased handgrip power on the dominant side when the head is rotated to the opposite side. This can be attributed to the increased flexor tone due to the retained effects of ATNR. Effects of ATNR can be seen in normal adults while assessing handgrip strength. This must be taken into consideration while assessing the same during diagnostic, prognostic, and rehabilitation purposes.
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Awareness, attitude, belief, and utilization of physiotherapy services among the general public in major cities of Gujarat state p. 95
Vivek H Ramanandi, Dhara N Panchal, Mukund M Prabhakar, Disha J Shah, Janki C Mavani
DOI:10.4103/PJIAP.PJIAP_3_19  
BACKGROUND AND OBJECTIVE: Physiotherapy is considered an integral part in the health-care delivery system, with the provision of services to improve the quality of life of an individual. Utilization of physiotherapy services by the general public can be influenced by knowledge of the role of physiotherapy in health-care delivery. This study investigated the awareness of, attitude toward, belief about, and utilization of physiotherapy services in the general public of four major cities of Gujarat state in India. MATERIALS AND METHODS: A cross-sectional survey of 500 conveniently selected participants from the general public in selected areas of Ahmedabad, Vadodara, Rajkot, and Surat in Gujarat was conducted using a self-administered, validated questionnaire. Data were analyzed using descriptive statistics of mean, percentages, and standard deviation. RESULTS: Participants (n = 245 males, n = 255 females) were aged 36.66 ± 12.2 years. A large proportion, 427 (85.4%), of the participants was aware of physiotherapy through various medium. Out of all the participants, 436 (87.2%) participants were familiar with physiotherapy services. Most of the participants, i.e., 288 (67.4%), reported that physiotherapists treat disorders affecting just bones and joints. About half (216 [49.5%]) and over one-third (157 [36%]) participants reported physiotherapy to be always and sometimes effective, respectively. Around 334 (76.6%) participants stated that they would prefer physiotherapy to Indigenous Health Services, while majority of respondents (398 [89.4%]) claimed that they would recommend physiotherapy. CONCLUSION: A large proportion of the participants are aware of physiotherapy services. Positive attitude toward and belief about physiotherapy services were reported. Furthermore, physiotherapy services utilization of participants was fairly high.
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Recognition of central nervous system sensitization and its risk factors in patients with unilateral musculoskeletal shoulder pain p. 102
Thangamani Ramalingam Alagappan, S Nagarajan Senthilkumar, Disha Pravin Dhanani, Ruchi Hemantsinh Vashi, Dhruti Narendrakumar Barot, Malvi Niteshbhai Savani
DOI:10.4103/PJIAP.PJIAP_17_18  
BACKGROUND: Overall, inferences from the majority of the literatures reviewed provide increasing evidence on the presence of central nervous system sensitization in unilateral shoulder pain. The possibility of presence of central sensitization (CS) among patients with unilateral musculoskeletal shoulder pain has not been adequately explored till date. The term “unilateral shoulder pain” in this study will be used to refer to nonneuropathic shoulder pain of different etiologies including rotator cuff pathology, adhesive capsulitis, or labral lesion. OBJECTIVES: The purpose of this study was to determine the presence of a subgroup of patients among patients with unilateral musculoskeletal shoulder pain and to further explore what extent the central nervous system sensitization correlates with other clinical measures. METHODS: Ninety-one patients with unilateral musculoskeletal shoulder pain participated in this cross-sectional study. Standardized outcome measures such as Central Sensitization Inventory-Gujarati (CSI-G) for the presence of CS, pressure pain threshold by pressure algometry, and Shoulder Pain and Disability Index for disability were administered as per standardized protocol. RESULTS: The results of the present study showed that 17 (18.7%) patients had CS. The CSI score had mild correlation with the demographic and clinical outcome measures and comorbidities such as gender (r = 0.208), duration of the condition (r = 0.208), hypertension (r = −0.238), sleep disturbance (r = −0.327), numbness (r = −0.238), and fatigue perception (r = −0.314) by the pain and disability score also had mild correlation with CSI score (P, 0.05). The risk ratio for sensitization was 2.40 for female gender, 3.07 for hypertension, 3.19 for sleep disturbance, 2.06 for numbness, and 3.87 for perceived fatigue in patients with unilateral musculoskeletal shoulder pain. CONCLUSION: The present study showed that the central nervous system becomes hypersensitive in a subgroup of patients and weakly related to factors such as female gender, chronicity of shoulder pain, hypertension, pain and disability, sleep disturbance, and perceived fatigue in patients with unilateral musculoskeletal shoulder pain.
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The effect of binocular peripheral vision blocks (partial and complete), on balance in healthy young Indian adults: An experimental study p. 109
Apeksha Besekar, Vimal Telang
DOI:10.4103/PJIAP.PJIAP_52_18  
QUESTION: How does the dynamic balance during functional tasks change with partial and complete peripheral vision blocks (CPVBs) as compared to full vision and no vision? DESIGN: Randomized, within-participant experimental study. PARTICIPANTS: Sixty young Indian adults (18–39 years) with normal 6/6 vision. METHODS: Dynamic balance was tested and compared in functional activities on a long force plate (Neurocom Smart Version 8.6 Balance Master) with eyes open (EO), partial peripheral vision blocks (PPVB), Complete peripheral vision blocks (CPVB), and eyes closed (EC). OUTCOME MEASURES: Center of gravity (COG) sway velocity in Sit to Stand (STS); Movement Time in Step up and Over (SUO); Step length, Step width and Speed in Walk Across (WA). RESULTS: (1) Walk across: A significant linear trend was observed in the reduction of step length when the visual alterations were intensified, and there was no significant difference between EO versus PPVB (d = 0.06, 95% confidence interval [CI] - 1.78–3.41). With CPVB versus EC (d = 0.35), walking speed showed a considerable decrease. (2) Step quick turn: No significant difference between (a) turn time (EC vs. CPVB: d = 0.28; EO vs. PPVB: d = 0.13) and (b) turn sway (EC vs. CPVB: d = 0.24; EO vs. PPVB: d = 0.09). (3) Sit to stand: The sway velocity was least with CPVB with a nonsignificant linear trend (P = 0.71). (4) Step up and over: A clinically significant difference was obtained in EO versus EC, EC versus CPVB and EC versus PPVB but not with EO versus PPVB, EO-CPVB and PPVB versus CPVB. CONCLUSION: These results reveal that in the normal young population, balance performance deteriorates as the availability of peripheral vision decreases, to the extent that in some functional activities, dynamic balance with CPVB is similar to the EC condition.
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CASE REPORTS Top

Effectiveness of physiotherapy interventions in a case of postoperative onset brachial neuritis in 7 weeks pregnant woman p. 116
Hemal M Patel
DOI:10.4103/PJIAP.PJIAP_26_18  
Brachial neuritis (BN) is an uncommon condition characterized by the acute onset of excruciating unilateral shoulder pain followed by flaccid paralysis of the shoulder and parascapular muscles. Treatment is largely symptomatic in patients with BN, and opiate analgesia often is necessary in the initial period. The purpose of this case report is to describe the physiotherapy intervention strategies and report its effectiveness in the management of BN in a 28-year-old pregnant female who presented with the complaints of sharp pain over the left shoulder, arm, and scapula for 15 days. The condition was managed on the basis of clinical presentations with supervised and unsupervised physiotherapy intervention for 4 months, without any medications, as she denied taking any nonsteroidal antiinflammatory drug or steroid for the management of pain. The supervised physiotherapy interventions consisted of patient education, postural correction, exercise therapy, electrotherapy, and counseling for approximately 45–60 min a day for 5 days a week. The effectiveness of the physiotherapy intervention was followed for 4 months, and the symptom-specific outcome measures were reapplied. Physiotherapy interventions were found to have promising positive outcomes in the symptom management of the BN with increased patient satisfaction.
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Step toward diagnosing a rare condition: Klippel–Feil syndrome p. 121
Heta Rajnikant Patel, Krishna Bhatt
DOI:10.4103/PJIAP.PJIAP_41_18  
Klippel–Feil syndrome (KFS) was first delineated by Maurice Klippel and Andre Feil in 1912 in a patient with congenital fusion of cervical vertebrae. The traditional clinical triad of KF disorder is low posterior hairline, short neck, and restriction of head-and-neck range of motion (ROM). In general, the symptoms and radiographic changes go hand in hand if there is an occurrence of KF disorder. However, the present case has pain in neck and stiffness without any neurological signs correlating with the positive radiological findings of lower cervical spine fusion and dysplasia. A young 35 year old female presented to the outpatient department of physiotherapy with complaints of pain in the neck and morning stiffness. On examination, a clinical triad, i.e., lower posterior hairline, short neck, and restriction of head and neck range of motion were noted. Single-level cervical fusion was reported on radiological investigation. Axial symptoms such as neck pain, neck stiffness, and neck ROM restriction are the predominant symptoms of KFS. The present case fitted into KFS Type II patients' category where patients exhibit a solitary combined cervical portion.
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