Efficacy of 12-week Pulmonary Rehabilitation Program on .... Amal.pdf · 3.3. Results of pulmonary...

American Journal of Research Communication www.usa-journals.com

Efficacy of 12-week Pulmonary Rehabilitation Program on Exercise Capacity of Burned Children: A Randomized Control Study

Amal. M. Abd El Baky1,2, Sahar. M. Adel3

Physical Therapy Department for Surgery Faculty of Physical Therapy, Cairo University,

Giza, Egypt1. Collage of Applied Medical Science (CAMS)- Majmaah University, Kingdom

of Saudi Arabia2. Physical Therapy Department of Basic Science, Faculty of Physical

Therapy, Cairo University, Giza, Egypt3

Corresponding author: Amal. M. Abd El Baky, E-mail: [email protected],

[email protected], PO box 66Almajmaa 11952, KSA, Tel: 00966595702464

Abstract

The purpose of this study was to evaluate the therapeutic efficacy of 12 weeks of

pulmonary rehabilitation program with a treadmill on exercise capacity of burned children

measured by maximum oxygen consumption (VO2max). Methods: thirty children from both

sexes with healed partial thickness thermal burns participated in this study one month after

being discharged from hospital. The patients’ age ranged from 7-17 years with total body

surface area (TBSA) of 20-40 %. Patients were randomized to either group A (control) who

received their traditional physical therapy program, or group B (pulmonary rehabilitation

group) who received in addition to traditional physical therapy program a pulmonary

rehabilitation program in the form of aerobic exercises on a treadmill. The treatment was

continued for 12 weeks at the frequency of 3 times per week. VO2max and treadmill time were

measured before treatment and after 12 weeks after treatment. Results: there were significant

differences between the groups. VO2max and treadmill time improvements for groups A and B

were 26.9%, 25.6% and 58.6%, 60.5% respectively. Conclusion: adding aerobic exercises to

traditional rehabilitation program is more effective in improving exercise capacity of burned

children rather than performing traditional rehabilitation program alone, which accelerates

the return of the children to their schools and perform their daily living activities.

Key words: Burn; Aerobic exercise; Exercise capacity

{Citation: Amal. M. Abd El Baky, Sahar. M. Adel. Efficacy of 12-week pulmonary

Abd El Baky and Adel, 2013: Vol 1(7) [email protected]

13

mailto:[email protected]



rehabilitation program on exercise capacity of burned children: a randomized control study.

American Journal of Research Communication, 2013, 1(7): 13-25} www.usa-journals.com,

ISSN: 2325-4076.

1. INTRODUCTION

Burns have a catastrophic impact in terms of loss of human life, suffering, disability,

and financial loss (Edlich et.al.,2010). Severe burns represent a major physical and

psychological event in a child's life. Progress in the treatment of burns, such as fluid

resuscitation, early burn wound excision, new antibiotics, and nutritional support has reduced

burn mortality (Przkora et al., 2005). Burned children living beyond the acute phase of injury

often have extensive physical functional limitations (Suman et al., 2002). In addition they

suffer from a decrease in pulmonary function, marked prolonged skeletal muscle weakness

and low physical and functional capacity (exercise capacity), which are major obstacles

preventing the burn victim from returning to school and performing daily living activities

(Suman et al., 2001; Dasu et.al., 2004; Willis et.al., 2011).

The majority of existing rehabilitation programs were designed focusing on short term

outcomes. They emphasize relief of scar contractures and generally do not incorporate a

quantifiable exercise prescribed to increase musculoskeletal strength and functional outcome

(Cucuzzo, 2001). Such reduction in exercise capacity of burned patients indicates a need for

rehabilitative interventions that improve physical function and performance (Suman et al.,

2002).

Pulmonary rehabilitation is a multidisciplinary program for patients with respiratory

disease. Potential benefits include reduced symptoms, improved exercise tolerance and

quality of life. It varies widely in duration, frequency and structure as well as the nature of

health care professionals involved (Rochester, 2000). The exercise session lasts from 20- 90

minutes and therapy duration ranges from 6 to 12 weeks with 2 or 3 sessions/week (Reina-

Rosenbaum, 1997). Some programs routinely include upper extremity exercises such as

pulley weights and arm ergometry, and exercise training to lower extremities such as floor or

treadmill walking, bicycling ergometry or stair climbing, they may include also breathing

retraining such as diaphragmatic breathing and pursed lip breathing (Rochester, 2000) .

Aerobic exercises are considered an important component of pulmonary rehabilitation

programs as they improve the patient’s functional status and if the intensity of training is


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adequate, they result in a physiological training effect in patients with pulmonary

dysfunctions (Larson et.al., 1999; Cheng et.al., 2003). Aerobic exercise is any activity that

uses large muscle groups which overloads the heart and the lungs and causes them to work

harder than at rest for a period of 15 to 20 minutes or longer while maintaining during 60-

80% of this period maximum heart rate (Panton et al., 2004). Randomized controlled trials

have demonstrated consistently that lower limb training of several types increases exercise

capacity (Rochester, 2003). The motorized treadmill is the most common device used in

pulmonary rehabilitation programs (Cucuzzo et.al., 2001).

VO2max is the gold standard measurement of cardiovascular fitness. It provides an

objective and reproducible assessment of patient’s functional capacity or exercise capacity

(Opasich et al., 2002).

Therefore the aim of this study was to evaluate the therapeutic efficiency of aerobic

exercise using treadmill on the burned children’s exercise capacity. As these results may help

in planning a physical therapy program, which enhances the improvement of exercise

capacity of burned children.

2. MATERIAL AND METHODS

2.1. Subjects:

Thirty children from both sexes and of age 7-17 years with healed partial thickness

thermal burn injuries of 20- 40% TBSA were included in this study one month after their

discharge from hospital. The patients were selected from teaching hospitals in Cairo, Egypt.

The study was conducted in the out clinic of the Faculty of Physical Therapy, Cairo

University. The faculty’s Human Research Committee approved this study and written

informed consents were obtained from the parents of all participants prior to their

involvement. Patients were excluded from the study if they had one or more of the following:

leg amputation, limitation of range of motion (ROM) of lower limb joints, anoxic brain

injury, psychological or severe behaviour disorders (Suman et al., 2002). Patients were

randomized into two equal groups; group A (control group) received traditional physical

therapy program only (activities of daily living ‘ADL’, stretching, strengthening, and

breathing exercises) three times per week for 12 weeks, and group B (pulmonary

rehabilitation group) who received pulmonary rehabilitation program inform of aerobic


15


exercise using a treadmill in addition to their physical therapy traditional program three times

per week for 12 weeks.

2.2. Measurement procedures:

Zan-680 Ergospiro “Ergospirometry System” was used to measure patients’ exercise

capacity (VO2max) and treadmill time in both groups, before and at the end of conducting

treatment period (12 weeks). A treadmill exercise test was done by following the Modified

Bruce protocol as shown in (Table 1). The mask was fixed by straps then the triple V. tube

was connected to the mask. The starting speed and angle of elevation were 1.7 miles/ hour

and 0% respectively; they were subsequently increased every 3 minutes. Patients were

constantly encouraged to complete 3 minutes for each stage and the test was terminated once

the peak volitional effort was achieved (Suman et al., 2002; Suman et al., 2001). The patients

were instructed not to tightly grasp the side rails of the treadmill since this leads to decrease

VO2max and increases the time of exercise (Fletcher et al., 2001).

Table 1.The Modified Bruce protocol for treadmill exercise testing

Duration of interval

(minutes)

Treadmill speed

(miles/hour)

Grade of elevation

(%)

3

3

3

3

3

3

3

3

3

1.7

1.7

1.7

2.5

3.4

4.2

5

5.5

6.0

0

5

10

12

14

16

18

20

22


16


2.3. Treatment procedures

Treatment was started one month after the patients’ discharge from hospital for 12

weeks for both groups. RAM model 770 CF electronic treadmill was used for exercising

group B at a rate of 3 sessions/week, each session was lasting from 20-40 minutes. The

participant exercised at 70-85% of his previously determined individual VO2max (Suman et.al.

,2002). Treadmill running exercises at a moderate pace began and ended with warming-up

and cooling-down periods in the form of walking on the treadmill for about 3-5 minutes at

speed 1- 1.5 kilometre/hour with zero inclination. With cooling down the speed was

gradually decreased until reaching to zero (Perna et.al.,1999; San Juan et.al.,2007).

Traditional physical therapy program for both groups was in the form of stretching and

strengthening exercises of all involved areas in addition to diaphragmatic breathing exercises

while activities of daily living were performed daily.

2.4. Data analysis

Student’s t-test was used to compare pre and post- treatment program VO2max and treadmill

time values within each group. Paired t-test was used to compare both groups. P-value < 0.05

was considered statistically significant. Statistical analyses were performed with Statistical

Package for Social Science (SPSS Inc., Chicago, Illinois), version 17 for Windows.

3. RESULTS

3.1. Patients’ demographic data:

Table 2 shows patients’ demographic data, and it demonstrates that there were no

significant differences between both groups regarding the patients’ age, weight , height and

TBSA.

Table 2. Patients demographic data

Groups Variables

Group (A) Group (B)

Age(years) 12.5±3.1 11.4±3.02

Weight (Kg) 38.2±6.55 37.9±6.33

Height (cm) 137.9±9.2 135.7±10.9

TBSA(%) 32.89±6.56 29.45±5.11

Gender (M/F) 9/6 7/8


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3.2. Results of control group (group A):

The mean values and standard deviations of VO2max and treadmill time for the control

group before and after treatment showed that there were significant improvements in the

patients’ VO2max and treadmill time with P value <0.05 and with 26.9% and 25.6%

improvement respectively (Table 3).

Table 3. The statistical analysis of mean differences of VO2max, and treadmill time pre

and post treatment (after 12 weeks) for control group

VO2max

(mL/Kg/ min) Time

(minute) Statistical value

Pre Post Pre Post _

X ± S.D

18.98±4.12

24.1±4.21

11.22±1.61

14.1±1.23 t- value 24.3 -10.1

% of improvement 26.9% 25.6% P- value < 0.05

3.3. Results of pulmonary rehabilitation group (group B):

The mean values and standard deviation are represented in table 4 and showed

highly significant improvements in the patients’ VO2max and treadmill time after pulmonary

rehabilitation for 12 weeks with 58.6% and 60.5% improvement respectively.

Table 4. The statistical analysis of mean differences of VO2max and treadmill time pre

and post treatment (after 12 weeks) for pulmonary rehabilitation group

VO2max

(mL/Kg/ min) Time

(minute) Statistical value

Pre Post Pre Post _

X ± S.D

17.9±4.2

28.4±3.2

10.94±1.72

17.56±1.65t- value 18.56 -18.88

% of improvement 58.6% 60.5% P- value 0.0001


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3.4. Comparative Analysis of VO2max and treadmill time between both groups of the

study:

Figure 1 shows the mean values of patients’ VO2 max and treadmill time for groups A

and B at the beginning of the study .The mean values were 18.98±4.12, 17.9±4.2 and

11.22±1.61, 10.94±1.72 respectively. The results represented that, there were no significant

differences between both groups for VO2 max and treadmill time with P value =0.34 and 0.71

respectively.

Figure 1. The mean value of VO2max and treadmill time at the beginning of study for both groups.

After 12 weeks from the beginning of the study (post treatment ) the results showed

that there were significance differences regarding the patients’ VO2 max and treadmill time

between both groups with P value = 0.001.The mean values for group A and B were

24.1±4.21, 14.1±1.23 and 28.4±3.2, 17.56±1.65 respectively (Figure 2).


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0

5

10

15

20

25

30

VO2max(mL/Kg/mim)

Treadmill time(min)

24.1

14.1

28.4

17.56

Group A Group B

Figure 2. The mean value of VO2max and treadmill time at post treatment for both

groups (after 12 weeks).

4. DISSCUSION

The results of the current study pointed out that (1) there was reduction in the burned

children exercise capacity represented by reduction in the VO 2max and treadmill time. This

finding is supported by the results achieved by (Mlcak et.al., 1995), who reported abnormal

cardiopulmonary functions in a patient survived after thermal injury, in addition to (Suman

et.al., 2002; Abd El Baky et.al., 2006; willis et.al., 2011), who documented that there were

deteriorations in both pulmonary function and exercise capacity resulting from burn injury, in

addition our results showed that (2) there were improvement in the burned children exercise

capacity and treadmill time after 12 weeks of pulmonary rehabilitation program in the form

of aerobic exercise to the lower limbs using electronic treadmill.

There is a large body of literature supports the effectiveness of pulmonary

rehabilitation program especially lower limb aerobic exercise; it is reported that an exercise

training program consisted of aerobic exercise of 30-40 minutes duration for 59 patients

suffering from obstructive pulmonary disease significantly improved the patient’s peak

exercise oxygen consumption (exercise capacity), and work output (Carter et.al.,1988).


20


Brdareski et.al.,2012 showed that, training involvement two times a week moderate intensity

for 15 minutes is enough to achieve some improvement in aerobic capacity. Moreover,

improvements in VO2max and treadmill time were demonstrated following the application of

moderate to high intensity aerobic exercise (Punzal et.al.,1991). In addition (Ortega et.al.,

2002; Rhoades and Tanner, 2003) concluded that aerobic exercise resulted in improvements

in exercise capacity, treadmill time and dyspnea of patients with varying degree of

obstruction who experienced low VO2max. Significant increase in patient’s exercise capacity,

forced vital capacity (FVC), and forced expiratory volume after 1 second (FEV1) were

achieved by the application of pulmonary rehabilitation program consisted of 10 minutes

warm up, 25 minutes aerobic exercise and 10 minutes cool down (Finnerty et.al.,2001).

(Suman et al, 2002) succeeded to conclude that children with thermal injury also benefit from

exercise training, which was evidenced by increase in pulmonary function (PF) and exercise

capacity.

It is reported that running, bicycling and other forms of aerobic exercise provide a

sufficient stimulus to improve cardio-respiratory function (Porcari et.al.,2002). Similar

findings were also supported by (Normandin et.al., 2002; and Rochester 2003), who showed

improvement in PF and exercise capacity of patients with obstructive disease.

Several studies had shown that leg exercise program benefits patients with lung

disease. Peripheral muscle training on treadmill has proven to be a valid tool for improving

symptoms of dyspnea, quality of life, and capacity for exercise in patients with chronic

obstructive pulmonary disease (COPD) (Ruiz de Oña Lacasta et.al., 2004). (Janos et.al.,

2005) concluded that, lower extremity training for 8 weeks caused improvement in exercise

capacity and dyspnea reduction measured with Modified Borg Scale.

Improvement in the VO2max may be due to an increase in the blood flow to the active

muscle mass because of an increase in maximal cardiac output and the changes within muscle

also contribute to this increase, primarily the increases in capillarization, myoglobin and

oxidative enzyme activity (Bouchard et.al.,1999). In addition, it was suggested that the

significant increase in VO2max might be related -in part- to the effect of aerobic exercise that

improves the respiratory function and - on the other hand- to an increase in the stroke volume

of the heart by the effect of regular exercise. These respiratory adaptations facilitate oxygen

supply to tissues and add further evidence to the improvement of respiratory fitness (Carsten

et.al., 2004). Recently (Kolt and Snyder-Mackler, 2007) concluded that The mechanism

underlying improvement in VO2max after aerobic training may be attributed to improved


21


central adaptations (increased heart rate and stroke volume at maximal exercise would

produce elevated cardiac output) along with peripheral adaptations (improved cardiac output

redistribution, improved endothelial function, increased capacity of the muscle to extract

oxygen owing to an increase in capillary density). Additional benefits of increased capillary

density include decreased diffusion distance, and increased red blood cell transit time,

providing enough time for oxygen diffusion which is facilitated by the increase in the number

of mitochondria that increase the surface area for oxidation. Also, temperature elevation and

decreased pH in the active muscle facilitate oxygen unloading from haemoglobin. The

combined effects of increased capillarity and enhanced oxygen unloading result in an

increase in the arteriovenous oxygen difference . Current theory states that, the increases in

the arteriovenous oxygen difference and increases in cardiac output contribute equally to the

increased VO2max observed after aerobic training.

The results of this study and previous studies prompt us to conclude that addition of

aerobic exercise to the traditional rehabilitation program is effective means for improving

burned children exercise capacity rather than application of the traditional rehabilitation

program alone.

5. ACKNOWLEDGMENTS

We would like to acknowledge the contribution of physical therapy faculty’s

members to accomplish this work. We would also like to thank the participants for their

involvement.

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435

Evaluation of Low Level Laser Therapy with Different Types on Recurrent Aphthous Stomatitis: A Randomized

Control Study

Asmaa Fawzy El- Sayed Attalla1*, Amal M Abd El Baky1,2

1Physical Therapy Department for Surgery, Faculty of Physical Therapy, Cairo

University, Giza, Egypt 2College of Applied Medical Science (CAMS) - Majmaah University, Kingdom of Saudi

Arabia

Abstract : Recurrent aphthous stomatitis (RAS) is the most frequent ulcerative lesion of the

oral cavity which is associated with pain. Low level laser therapy (LLLT) has been evaluated

for its effectiveness in pain reduction and acceleration of ulcer healing. The purpose of this

study was to determine the effect of LLLT on RAS in addition to, compare the effect of

Helium Neon laser (He-Ne) and Gallium Aluminum Arsenide laser (Ga-Al-As) on pain

modulation and healing process in RAS. A total of 45 patients of both sexes, with RAS were

included in the current study. The patients were divided randomly into three groups (15

patients in each group); group A (He-Ne, 632 nm, 1.56 mW, 1.22 J/cm2), group B (Ga-Al-As,

830 nm, 50 mW, 6.3 J/cm2) and group C (medical treatment group).Both pain and size of

ulcer diameter were evaluated before and after treatment by three days. The results showed

significant reduction in pain scores in group A and B (P< 0.05) while non-significant

reduction was recorded in group C (P= 0.21) with percentage of improvement 82.53 %, 61.72

% and 6.6 % respectively. However ulcer diameter results represented that the percentages of

improvement were 86.27%, 65.01% and 10.41% for group A, B and C respectively. He-Ne

laser is effective than Ga-Al-As laser in management of RAS.

Keywords : Recurrent aphthous stomatitis, LLLT, Ulcer size, Pain.

Introduction

Recurrent aphthous stomatitis (RAS), canker sores or Aphthous ulcer is the most common ulcer in oral

cavity. The prevalence of RAS ranges from 5-60% of the population all over the world1,2

.It is characterized by

recurrent, painful, multiple or a single shallow, ovoid or round ulcer as well as, it usually appears as

erythematous haloes with grey or yellow floors. RAS has three clinical forms which are minor, major and

herpetiformis1.The exact etiology of this lesion is unknown, but it may be related to autoimmune condition. In

addition, there are some precipitating factors that have a role in the etiology of Aphthous as; genetic factors,

trauma, stress, deficiency in vitamin B1,B2 ,B6 or B12, cessation of smoking or systemic diseases. Moreover

thermal injury or chemical irritation may contribute to develop RAS34,5,6

.The manifestations range from mild to

severe, however it causes moderate to severe pain and burning sensation that may interfere with the person

ability to eat, ingest food, drink, or speech7.Healing process duration differs according to the RAS form. As it

lasts up to 7-14 days in minor form, 15 days in the Herpetiform form, while in the sever form it may take about

20-30 days1,8

.

International Journal of ChemTech Research CODEN (USA): IJCRGG, ISSN: 0974-4290, ISSN(Online):2455-9555

Vol.10 No.5, pp 435-442, 2017

Asmaa Fawzy El- Sayed Attalla et al /International Journal of ChemTech Research, 2017,10(5): 435-442.

436

Numerous treatment modalities have been used to control RAS lesions. Many drugs have been

described as topical corticosteroid, antibiotics and topical anesthetics. Recently laser therapy has been used to

manage these cases9.Laser is defined as "an acronym for Light Amplification by Stimulated Emission of

Radiation "10

.Low-level laser therapy (LLLT) is also known as ‘soft laser therapy’ or bio-stimulation. It is

usually settled in wave length of 650-1200 nm. He-Ne laser (633nm) and Ga-Al-As laser (780-820-870nm) are

types of low level lasers11

.Several studies reported the benefits of LLLT on pain reduction in addition to

promote healing process in RAS by different mechanisms2,12

.Maiya et al., 13

succeeded to demonstrate the

effectiveness of He-Ne laser in management of RAS. Recently, Albrektson et al., 14

represented also that Ga-

Al. As laser has beneficial effect in the healing of recurrent aphthous ulcers.

To our knowledge there is no study has been conducted to compare the effect of LLLT with different

types (He-Ne and Ga-Al-As laser) on pain modulation and healing process in RAS. Therefore, the aim of this

study was to assess and to compare the efficacy of different types of LLLT on reduction of pain and ulcer size

in the cases of recurrent Aphthous ulcers.

Methods

Subjects

Of 50 eligible patients, 45 patients of both sexes, with recurrent aphthous stomatitis (RAS) in their oral

cavity, accepted to participate in the current study, fig 1. Patients were referred by the teaching hospital of the

college of Dentistry, Cairo University. The participants with the following inclusive criteria were enrolled in

this study; (1) Aged 20-40 years; (2) Patients had pain and redness at the ulcer site; and (3) Enrolment of the

patients within 2 days after the appearance of ulcer. Exclusion criteria included patients presenting with chronic

non healing ulcers or any systemic diseases that might be a cause of RAS, or smokers.

Figure 1. The Participants Flow Chart

The study was conducted in the out-patient clinic of the faculty of Physical Therapy, Cairo University,

after the approval of the Postgraduate Institutional Ethical Committee at faculty of Physical Therapy, Cairo

University. Each patient was informed about the procedure and technique, and his/her consent was obtained.

Participants who had fulfilled the eligibility criteria were randomized to three groups (15 patients in

each group); group A (He-Ne laser group), group B (Ga-Al-As laser group) and group C (control group).

Measurement procedures

Both pain and size of ulcer were evaluated at the baseline, and after three days post treatment.

Elig

ible

su

bje

cts

(n =

50

)

Enrollment

Randomized (n = 45)

He-Ne laser (GA) n = 15

Completed the study (n=15)

Ga-Al-As laser (GB) n= 15

Completed the study (n=15)

Control (GC) n=15 Completed the study ( n= 15)

Refused (n=5)


437

Pain measurement

The patients were asked to grade their pain by using visual analogue scale (VAS). VAS is a horizontal

10 cm line with 0 represented no pain and 10 is used to describe maximum pain15

.

Size of ulcer measurement

A calibrated periodontal probe was used to measure the ulcer's size while the patients were placed in a

comfortable sitting position. The probe is a long, tapered, rod like tool that is calibrated in millimeters with a

tip16

Treatment procedures

He-Ne laser therapy

Helium-neon laser (ASA srl laser system) was applied to group (A) with the following parameters: as

632 nm, 1.22 J/cm2and 1.56 mW.13

Ga-Al-As Laser Therapy

Ga-Al-As laser device (Doctor Smile Diode Laser, Italy)with 830 nm, 6.3 J/cm2, power output of 50

mW was applied to group (B).17

Prior to the application of laser therapy the patient and the therapist wore a protective eyewear. Patient

was placed in comfortably sitting position. Laser therapy was conducted for one sitting that consisted of four

sessions. Treatment lasted for 45 seconds, with a gap of about 30-60 seconds between each session. Total laser

application time was about three minutes. Non-contact mode was used with a distance of 2-3 mm between the

laser tip and the ulcer surface. The laser beam was applied in a continuous sweeping and circular motion.2

Medical Treatment

Patients received Salivex-L Paint 10ml (Anthraquinone glycosides 500 mg + Salicylic acid 100 mg +

Lidocaine hydrochloride 60 mg) every 6 hours per day for group C.

Data Analysis

Data were analyzed with Statistical Package of Social Science (SPSS) version 22.0. The data were

compiled together and they were evaluated. Means, standard deviations, paired t-test, ANOVA test and P values

were calculated. Statistical significance was set at P < 0.05. Percentage of improvement was calculated using

the formula of post-pre/pre*100.

Results

The study comprised of a total of 45 patients, of which 22 were males and 23 were females. All the

patients completed the study. Table 1 shows the distribution of sex and age among groups and it represents that

there were no significance differences between the patients' sex and age with P= 0.92and 0.80 respectively.

The statistical analyses of the pre and post measurements of ulcer diameter for all groups are

represented in table 2.The results shows that there were significant reduction differences between the baseline

and after 3 days post treatment diameter measurements for group A and B with P< 0.05, while there was no

significance difference between measurements in control group with P= 0.21. The percentages of improvement

were 86.27%, 65.01% and 10. 41% for He-Ne group, Ga-Al-As group and control group respectively.

In table 3 the mean of reduction in the VAS scores are demonstrated. The results of pain scores showed

significant reduction between the pre and post measurements in group A and B (P< 0.05) with percentage of

improvement 82.53%, 61.72% respectively. In addition to, no significance difference was observed in group C

measurements (P= 0.32) and the percentage of improvement was 6.6%.


438

Table 1 . Demographic data of the patients

Variables Groups

Group A Group B Group C

Gender

Male

Female

8

7

7

8

7

8

Age 29.07±6.05 29.40±6.631 27.87±7.13

Table 2. Statistical analysis of ulcer diameter in all groups

Variables Groups Pre Post

Mean± SD

Group (A) 5.90±1.23 0.81±0.39*

Group (B) 5.63±1.29 1.97±0.54*

Group (C) 5.57±1.49 4.99±1.43

±SD : standard deviation , *Significant (P < 0.05) improvement between the pre and post measurements

Table 3. Statistical analysis of VAS scores in all groups

Variables Groups Pre Post

Mean± SD

Group (A) 6.47±1.06 1.13±0.64*

Group (B) 6.27±1.39 2.40±1.06*

Group (C) 6.07±1.56 5.67±1.45

±SD : standard deviation , *Significant (P < 0.05) improvement between the pre and post measurements

Fig 2 .Ulcer diameters in all groups

Fig 3 .VAS pain score in all groups

0

1

2

3

4

5

6

Pre-diametermeasurements

Post- diametermeasurements

He-Ne Group

Ga-Al-As Group

Control Group

0

1

2

3

4

5

6

7

Pre pain scores Post pain scores

He-Ne Group

Ga-Al-As Group

Control Group


439

Fig 2, represents the statistical analysis of ulcer diameter among groups where, there was no

significance difference among the baseline measurements of all groups with P= 0.77. Moreover the post

treatment measurements demonstrated significance difference among groups with P< 0.001.

The results of pain scores by VAS concluded that the pre measurements among groups were not

significant with P= 0.89, while after three days the post measurements showed significant difference among

groups (P< 0.001) , Fig 3.

Discussion:

The current study provides evidence that a single session of LLLT is effective in management of RAS

than conventional medical treatment, as the results showed significant reduction of pain score and ulcer

diameter with the application of LLLT in group A and B than group C.

Recently, LLLT was suggested to be one of the important treatment modalities for wound repair

processes and pain control.18,19

Clinical and laboratory studies explained different mechanisms through which

LLLT can accelerate wound healing. These mechanisms includes: local vasodilatation and increased of blood

flow10

, cellular bio-stimulation20

, in addition to analgesic and anti-inflammatory effects.21

Moreover, researchers claimed that LLLT is effective in pain reduction and they provided some

explanations such as: the role of LLLT in increasing the production of opioid peptides22

, decreasing the

histamine release23

, reducing the prostaglandin and bradykinin production22,23

, increasing local circulation and

oxygen supply23

, as well as blocking of the action potential generation in the primary afferent neuron.24

The results also showed that He-Ne laser was more effective than Ga- Al-Ar in management of both

pain (82.53% and 61.72% respectively) and ulcer diameter (86.27% and 65.01% respectively).

It was shown that He-Ne laser exerts analgesic, anti-inflammatory and regenerative effects in managing

chronic RAS12,14,25

. Many investigators examined the effect of He-Ne laser in management of RAS ulcer.

Earlier, Kitchen and Bazin26

stated that He-Ne laser (632 nm, 1.56 mW and 1.22J/cm2) was effective in

controlling pain and healing of recurrent aphthous ulcers. Furthermore, Maiya et al13

examined He-Ne laser

with the same parameter on thirty patients complaining from minor RAS and they recorded its efficacy in

reducing pain, lesion size and healing time, while Anand et al27

applied the same parameters on patients

suffering from major RAS and they reported that lesions healed completely within 3-4 days with reduction of

pain and lesion recurrence.

De Souza et al28

conducted a comparative study between the effect of He-Ne laser and conventional

medical treatment on RAS, where both treatments were applied until the disappearance of the lesions. The

results showed that He-Ne laser is superior to medical treatment in its analgesic and healing effects with regard

to RAS. Recently, Aggarwal et al2also confirmed the effectiveness of He-Ne laser in relieving pain and

reducing the healing time of patients suffering from aphthous ulcers.

On the other hand, several researchers preferred using Ga-Al-As laser to control pain and promote

healing process in patient suffering from RAS. Earlier, Rocha Junior et al29

examined the effects of Ga-Al-As

laser with a wavelength of 830 nm, 50 mW power output and a dose of 6.3 J/cm2 on ten patients with recurrent

aphthous ulcers and the results showed significance reduction in pain as well as healing time. Furthermore Ga-

Al-As laser was diagnosed for its efficacy in preventing recurrence of minor RAS. As, kjuhn et al17

reported

that a single sitting of 830 nm Ga-Al-As laser can effectively reduce the healing time, pain severity, size, and

recurrence of the lesion in patients with minor RAS. Recently, the same results were supported by Albrektson

et al14

who tested the same parameters of Ga Al As semiconductor laser but for three consecutive days.

According to our results, He-Ne laser appeared to be superior to Ga-Al-As laser in management of

RAS. This is in consistence with the findings of the study that conducted by Reddy, as he reported that the

biomechanical and biochemical analysis of healed wounds determined that He-Ne laser resulted in greater

healing effects than Ga-Al-As laser.30


440

It is suggested that the LLLT wavelength have an important role in the results related to RAS

treatment.31

Furthermore, it is concluded that He-Ne laser would accelerate wound healing with significant

collagen fibers production and deposition32,33

, combined with rapid neovascularization and re-

epithelization.34

As well as, the results may be attributed to the He-Ne and Ga-Al-As laser photochemical

interaction with cells, as it was suggested that the absorption of radiation emitted by He-Ne laser at 632 nm

begins at the components of respiratory chain, whereas it starts at the membrane level with the radiation emitted

by the Ga-Al-As laser at 830 nm, which leads to photochemical response of the tissue.30

Earlier, Sommer et al35

concluded that high significant biological effects were expected with predominant dose values of LLLT, i.e. up

to 5 J/cm2. Moreover, it is suggested that higher doses reduce cell proliferation as well as it may damage cell

membrane.36

In addition to, Reddy reported that the differences in coherent properties of lasers may also affect

healing process, as it is known that the radiation emitted by the He-Ne laser has more coherence in its nature

than that of the radiation emitted by the Ga-Al-As laser, and he added that these specific differences in the

absorption of radiation by tissue and discrepancies in coherence properties may explain some of the variations

between the He-Ne and Ga-Al-As lasers in promoting wound healing.30

Furthermore, we also suggest that the

results may be affected by patient's cooperation.

The current study may be limited by the small sample size, which limits generalization. Therefore, large

sample size is recommended.

Conclusion:

Based on the finding of this study, it is concluded that LLLT is effective than medical treatment in

reducing pain and promote healing of RAs. Furthermore He-Ne laser was observed to be superior to Ga-Al-As

Laser in management of RAS. Further studies are needed to evaluate the influence of LLLT with different

wavelength, output powers and energy densities.

Acknowledgement

We would like to acknowledge the teaching hospital of the college of dentistry, Cairo University

members to accomplish this work.

Conflict of interest

The authors have no conflicts of interest to disclose.

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*****

IJTRR 2017; 6 (2):137-145

Original Research Article doi: 10.5455/ijtrr.000000255

International Journal of Therapies & Rehabilitation

Research http://www.scopemed.org/?jid=12

E-ISSN 2278-0343

Impact of Aerobic Exercise on Physical Fitness and Fatigue in Children with

Acute Lymphoblastic Leukemia Amal. M. Abd El Bakya, Sahar. M. Adel Elhakkb

a Physical Therapy Department for Surgery ,Faculty of Physical Therapy, Cairo University, Giza, Egypt &

Physical Therapy and Rehabilitation Department ,Faculty of Applied Medical Science (CAMS), Majmaah

University, Kingdom of Saudi Arabia

b Physical Therapy Department of Basic Science, Faculty of Physical Therapy, Cairo University, Giza,

Egypt & Physical Therapy and Rehabilitation Department, Faculty of Health and Rehabilitation Sciences-

Princess Nourah Bint Abdul Rahman University, Kingdom of Saudi Arabia

ABSTRACT

Background: Acute lymphoblastic leukemia (ALL) is one type of childhood cancer. In the past decades,

cure rates of ALL have increased and the survivor’s quality of life and physical fitness have become a

growing concern. Furthermore cancer-related fatigue (CRF) is reported to be the most distressing symptom

in cancer. Objective: We aimed to examine the effect of aerobic exercise on the physical fitness and

fatigue in children suffering from ALL. Methods: Thirty patients of 8 to 16 years with ALL participated in

this study. Participants were randomized to study group (Group A), who participated in supervised aerobic

exercise program in addition to home program, and control group (Group B), who were instructed to

maintain their usual level of activity in addition to home program. Measurement of physical fitness and

fatigue were done at the baseline and after 16th weeks. Results: Post measurement results suggested that,

there was significance difference between both groups (P< 0.05). The percentage of improvement of

physical fitness and fatigue level for group A was 31.06% and 21.56% respectively, while the percentage of

improvement for group B was 4.16 % and 2.78% respectively. Conclusion: Aerobic exercise is effective in

improving physical fitness and management of CRF in children with ALL.

Key Words: Acute lymphoblastic leukemia, Cancer related fatigue exercise training, Physical fitness.

INTRODUCTION Acute Leukemia is a malignant disease that

affects bone marrow and results in the accumulation of immature, functionless cells in the marrow and blood [1]. It is reported that ALL is a common form of childhood malignancy. ALL is classified into Acute Myelocytic Leukemia (AML) and Acute Lymphoblastic Leukemia (ALL) [2, 3].

Patients suffering from cancer, especially who are receiving chemotherapy, mostly experience fatigue. Today, it is observed that fatigue is the untreated side effect for cancer [4]. Moreover it is suggested that it also affects the patient's physical performance and daily activities [5].

Physical fitness is considered as an important health marker for functional status of different body functions. It has been reported that impairment of

physical fitness commonly represented during and after childhood cancer treatment [6, 7, 8]. In addition to, it is suggested that low physical fitness may be a cause of fatigue [9]. Maximal oxygen consumption (VO2 max) has been used to assess physical fitness [10].

Various physical therapy techniques are used to reduce fatigue and improve physical fitness in cancer patients such as aerobic exercises, stretching, or strengthening exercises [11,12]. Aerobic exercise is defined as "sub maximal, rhythmic, repetitive exercise of large muscle group, during which the needed energy is supplied by inspired oxygen" [13]. It is considered to be valuable in the management of cancer-related physical outcomes as well as the quality of life in other forms of cancer [14,15].

This study was conducted with the aim of determining the efficacy of adding moderate intensity

http://www.scopemed.org/?jid=12

IJTRR 2017; 6 (2):137-145

aerobic exercise to home program on both physical fitness and cancer related fatigue in children with Acute Lymphoblastic Leukemia.

METHODS

Study Design:

This is a prospective, randomized controlled study. It was conducted in the Cardiorespiratory Lab at Faculty of Physical Therapy, Cairo University, Giza, Egypt. The study was approved by Postgraduate Institutional Ethical Committee at Faculty of Physical Therapy. Each patient and their parents individually received written and verbal information about the study. Written informed consent was obtained from the parents or legal guardian of each patient, and also from each patient aged 12 years and older. Participants

Of 36 eligible patients, 30 patients (boys and girls) with Acute Lymphoblastic Leukemia agreed to participate in this study. The patients were referred by an Oncologist from Children's Cancer Hospital Foundation 57357 to participate in this study. They were chosen on the basis of the following criteria: 1) Patients' age from 8 to 16 years, 2) Patient complained from fatigue, 3) There were absence of musculoskeletal disturbances that may limit participation in the exercise training program, 4) Preserved cardiac structure and function, as assessed by an echocardiogram, 5) Ambulant without need for human assistance in addition to 6) The elapsed time since their last chemotherapy had to be at least 6 months. Children were excluded when they suffered from cardiovascular disease, acute or chronic respiratory disease, acute or chronic bone, joint, or muscular abnormalities, or immune deficiency that might compromise the patient’s ability to participate in

the exercise rehabilitation program. Participants who had fulfilled the eligibility

criteria were randomized using simple randomization method to either study group (Group A) (n= 15, 8 boys and 7 girls), who participated in supervised moderate intensity aerobic exercise program in addition to a home-based exercises program, and control group (Group B) (n= 15, 9 boys and 6 girls), who were instructed to maintain their usual level of activity as well as to perform home-based exercises, Fig. 1 Measurement procedures

Assessment for both physical fitness and fatigue were done at the baseline and after 16th weeks. Physical fitness measurement

Vo2max was used to measure the patient's physical fitness. Participants performed a Graded Exercise Test (GXT) on treadmill using the modified Bruce protocol, table (1).

Patients were constantly asked to complete 3 minutes for each stage and once the peak volitional

effort was achieved the test was terminated [15,17]. During GXT, the patient breathed through a face mask (Hans Rudolph Inc, Kansas City, MO, USA) that connected to a calibrated expired gas analysis system (Zan-680 Ergospiro Ergospirometry System, manufactured by ZAN Me Bgerate GmbH, Germany). Gas analyzers and flow meter were connected to a computer and calculate oxygen uptake. Heart rate (HR) was monitored continuously during the graded exercise test. VO2max was calculated as the average value over the last 30 seconds during the exercise test [18]. Table -1: The Modified Borg Scale for Breathlessness,(Adapted from Deturk et al.,) [16]

0 Nothing at all

0.5 Very very slight

1 Very slight

2 Slight

3 Moderate

4 Somewhat sever

5 Sever

6

7 Very sever

8

9 Very very sever (almost maximal)

10 Maximal

Fatigue measurement:

Fatigue level was assessed by the subscale fatigue of The Checklist Individual Strength (CIS) [19].

Earlier the CIS was used to investigate cancer survivors [20,21]. It is reported as a useful and a valid multi-dimensional instrument, for both assessment and scoring. CIS is designed to measure four aspects of fatigue; subjective experience of fatigue, concentration, motivation, and physical activity. It consists of eight items scored on a seven-point Likert Scale, with scores ranging from eight to 56 (with 1 indicating best and 7 worst function) [22,23].

Exercise Intervention

Aerobic exercise: Group (A) started aerobic exercise program

approximately 24 hours after assessment and lasted for 16th weeks in addition to home-based exercises. An exercise session would be only cancelled if a patient was experiencing fever (temperature > 38°C/100.4°F), low blood platelet levels (< 50.000 per μl), a neutrophil

count lower than 500 cells per μl, marked anemia

(hemoglobin < 8 g/dl) or severe cachexia (i.e., weight mass loss > 35%) [24]. Patients had participated in a supervised aerobic exercise program by one of the

IJTRR 2017; 6 (2):137-145

researcher (3 sessions /week with each session lasting from 20–40 minutes). A RAM model 770 CF electronic treadmill was used for aerobic exercise. Each participant exercised at 70–85% of his/her previously determined individual VO2max. The exercise program was divided into 5 min stretching exercise, warm up period, followed by moderate intensity of aerobic exercises, and finishing with a cool down period. Warming-up and cooling down periods were in the form of walking on the treadmill for about 5–10 minutes at a speed of 1–1.5 km/h with zero inclination. In the cooling down period, the speed was gradually decreased until reaching zero [7]. Participants were regularly monitored throughout the exercise program, and their heart rates were recorded during the exercise sessions. Home program:

The children in both groups were instructed to exercise at home for at least two times per week. The exercises were outlined by photos, and verbally by us at the first session. Furthermore parents were asked to supervise the home exercises. The home training program was based on the ‘Royal Canadian Air Force

Exercise Plans for Physical Fitness’ and was composed

of five basic exercises to enhance strength, flexibility and aerobic fitness. At each home training session the children accomplished five exercises a given number of times in 11 min, stepwise increasing intensity and the number of times during the 16th weeks [25]. The children or their parents were asked to record training frequency and training progression. Data Analysis:

Data were analyzed with Statistical Package of Social Science (SPSS) version 22.0 (Chicago USA). Normal distributed data (Kolmogorov-Smirnov test, P > 0.05) were expressed as mean and standard deviation (SD). The paired t-test was used to compare variables at the baseline and after 16th weeks within each group, while independent-t test was used to compare variables between both groups. For fatigue level nonparametric statistical analysis was used including the Wilcoxon Signed Rank test for variable comparison within groups and the Mann-Whitney U test for comparison between groups. All P-values in the analysis were considered statistically significant when P < 0.05.

Figure 1. The Participants Flow Chart

RESULTS Table 2 summarizes the demographic characteristics of

the participants in both groups. A total of 30 patients (17 boys and 13 girls) with Acute Lymphoblastic Leukemia were involved in this study. No significant differences were observed between both groups regarding age (P= 0.853), weight (P=0.935), height (0.57), BMI (P=0.895) as well as the elapsed time since the patients' last chemotherapeutic treatment (P= 0.798).

Table 3, reports the mean values of the pre and post VO2max measurements for both groups. There was a significant difference between the pre and post VO2max for group A with a percentage of improvement 31.06% (P > 0.05), while no significant difference was

recorded between them for group B with 4.16% (P > 0.05).

For fatigue scores (CIS), the results demonstrates significance improvement in the post CIS for group A (P > 0.05) with 21.56 %, while there was no significant difference between the pre and post measurements for group B with percentage of improvement 2.78% (P > 0.05), Table 4.

Fig. 2 shows that there was no significant difference between the pre measurements of VO2max for both groups, while the post measurements represented a significance difference with (P> 0.05). As well as, the results represents no significance difference between

Eligible subjects (n = 36)

Enrollment Family refused (n=6)

Randomized (n = 30)

Study group (GA) n= 15 Control group (GB) n= 15

Completed study (n= 15) Completed study (n= 15)

IJTRR 2017; 6 (2):137-145

the pre fatigue scores of both groups (p= 0.97), while there was significance difference in the post fatigue

scores (P> 0.05), fig 3.

Table- 2. Statistical analysis of demographic characteristics of patients in both groups

Variables Group M±SD T P

Age GA 12.51±3.40

- 0.185 0.853* GB 13.2±3.83

Height (m) GA 1.25±0.2

-0.568 0.570* GB 1.27±0.3

Weight (kg) GA 40.59±6.97

-0.092 0.935* GB 41.90±9.19

BMI (kg/m2) GA 19.70±3.04

-0.154 0.895* GB 19.99±2.23

Elapsed time (month)

GA 7.90±1.75 -0.269 0.798*

GB 8.1±1.7

Data are presented as the mean (SD), * not significant Table- 3. Statistical analysis of aerobic capacity variables within each group

Variables Groups Pre Post % of improvement

Vo2max

(ml/kg/min)

GA 25.56±4.50 33.50±3.72 31.06 %*

GB 25.25±4.69 26.30±4.70 4.16 %

Data are presented as the mean (SD),*Significant (P < 0.05) improvement between the pre and post measurements. Table-4. Statistical analysis of fatigue within each group

% of improvement

Z Post Pre Groups Variable

21.56 %* -2.823a 34.20±4.94

(30-44)

43.60±4.5 (37-51)

GA Fatigue

CIS-score 2.78% -1.732a

42±5.34

(38-54)

43.20±5.4 (38-54)

GB

*Significant (P < 0.05) improvement between the pre and post measurements, a. Wilcoxon Signed Ranks Test

IJTRR 2017; 6 (2):137-145

Figure 2. Statistical analysis between Pre and Post VO2max between both groups

Figure 3. Statistical analysis between Pre and Post Fatigue between both groups

DISCUSSION

The main findings of the present study reported a significant improvement of both physical fitness and fatigue level in children who survived ALL by adding of a 16-week of aerobic exercise training program to home exercise program.

There is growing evidence for the positive effects of aerobic exercise training on physical fitness, fatigue and physical well-being of children during and after treatment for cancer [19, 26, 27, 28].

Regarding the physical fitness, a study conducted by San Juan et al., [7] supported our results, as he reported positive results of a 16-week supervised aerobic exercise program among children with ALL. Moreover, Adamsen et al., [29] showed that a high-intensity exercise program for 6 weeks led to improvement in VO2max by 16% in patients who suffering from cancer including leukemia. Earlier, Sharkey et al.,[30] examined the efficacy of a 12-week aerobic training program on the peak oxygen uptake among childhood cancer survivors and he also reported an improvement in the patients' peak oxygen uptake. Furthermore a pilot study conducted by Kolden et al., [31] on women who had breast cancer, they suggested significant improvement in cardiorespiratory fitness after completion of a 16-week exercise training.

In contrast Marchese et al., [32] evaluated the effect of four months of exercise on cardiovascular response in children with ALL who received

maintenance therapy. They failed to show improvement in the cardiovascular response assessed by a nine minute run walk test. Moreover, Takken et al.,[14] found no cardiopulmonary response to 12-week community-based exercise training program in 9 children with ALL (aged 6–14 years) as assessed by standardized cardiopulmonary exercise testing. Recently, Alibhai et al.,[33] decided significant improvements in 6MWT distance post-exercise (p=0.006) within group but no significant improvement were recorded for Vo2max (p=0.486).

This inconsistency across the literatures might be related to the variability in the population's age, evaluation time post chemotherapy treatment, the intensity, and duration of the intervention.

It was suggested that increasing in aerobic capacity by aerobic exercise program may due to the effect of aerobic exercise on respiratory function and the stroke volume of the heart. These respiratory adaptations help facilitation of oxygen supply to tissues which lead to the improvement of respiratory fitness [34].

Our results are in consistent with prior studies that reported highest level of fatigue during and immediately following cancer treatment [35]. Moreover it was determined that improvements in aerobic fitness have been accompanied with improvement in fatigue level [29, 36, 37]. These agreed with the findings of Adamsen et al., [29], where they reported significant improvement of cardiovascular capacity (VO2max) of

eighty-two patients suffering from various cancers with significant reduction in fatigue.

Significant reduction in fatigue level in response to exercise programs of various modes, designs, intensities, duration, and with different types of cancer patients was reported in many studies [36, 38, 39]. Recently , Yeh et al.,[40] recorded reduced levels of fatigue (P = 0.03, Cohen’s d = 0.54) among children

with ALL , who completed a 6- week home-based aerobic exercise program when compared to a control group , as well as Blaauwbroek et al.,[41] demonstrated reduced levels of fatigue with increased levels of physical activity (P < 0.005, Cohen’s d = - 0.92 and 0.94 respectively) after 10 weeks of a homebased physical activity in childhood with cancer survivors. In addition to the results of a study by Keats and Culos-Reed [42] who revealed a reduction in fatigue (P = 0.01, Cohen’s d = 0.69) after a 16-week group of physical activity intervention in survivors of pediatric cancer. The current study has several limitations including: First, the relatively small sample size therefore a large sample size is needed to be studied. Second, the subjects were recruited from only one regional center, thereby limiting generalization. Finally, lacks of follow-up after the intervention period, so further researches are needed for following up measurements. Moreover this study can be further extended by conducting on patients with different types of cancer.

Conclusion The results of our study suggest that adding supervised aerobic exercise to home program is an effective approach to improve physical fitness and fatigue level in children with ALL. Therefore, these results can guide therapists in creating rehabilitation programs that focus on the specific difficulties faced by patient undergoing chemotherapy.

Acknowledgement We would like to acknowledge the contribution of physical therapy faculty’s members to accomplish

this work. As well as, all thanks to the Children's Cancer Hospital Foundation 57357 for their supports.

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Sahar. M. Adel et al JMSCR Volume 2 Issue 12 December 2014 Page 3258

JMSCR Volume||2||Issue||12||Page 3258-3271||December-2014 2014

Low Frequency Ultrasonic Versus Microcurrent Effect on Tissue Healing

After Tendon Suture

Authors

Sahar. M. Adel 1, Amira H. Draz

2, Amal. M. Abd El Baky

3

1,2 Physical Therapy Department of Basic Science, Faculty of Physical Therapy, Cairo University

Giza, Egypt. 3Physical Therapy Department for Surgery Faculty of Physical Therapy, Cairo University

Giza, Egypt.

Collage of Applied Medical Science (CAMS)-Majmaah University, Kingdom of Saudi Arabia

ABSTRACT

Background: Tendon injury has poor healing process. Therapeutic US has a positive role to play in providing

the growth factors, also Microcurrent therapy has been used to increase the rate of healing.

Purpose: this study was conducted to investigate the difference between high frequency ultrasound versus

microcurrent therapy on the tissue healing of Achilles tendon after suture.

Methods: Thirty female albino rats were surgically transected Achilles tendons, were randomly and assigned

into three groups with ten rats in each group (group I served as a control, group II was treated with high

frequency US and group III was treated with microcurrent). The treatments were administered with ultrasound

and microcurrent day other day starting immediately from the day after injury for 5 weeks. Wound size

measurements were evaluated till complete healing.

Results: Both low frequency ultrasonic and microcurrent have a significant effect on decreasing wound size

where the mean value of the wound treated with low frequency ultrasonic decreased from 0.2 mm ± 0.03 to 0.0

mm in the fifth time of measurement while the wound size of the control group decreased from 0.2 mm± 0.08

mm in the fifth time of measurement. Comparing wound size in Micro-current group among the times of

measurements Vs the control has shown a significant decrease of wound size where the mean value decreased

from 0.2 mm ± 0.06 to 0.0 mm in the fifth time of measurement. The t test of group II has shown significant

decrease in wound size measurement where the t value and P value showed that it was significant during 3rd

and 5th

times of measurement. The t test of group III has shown significant decrease in wound size measurement

where the t value and P value showed that it was significant during 2nd

, 3rd

and 5th

times of measurement.

Conclusion: low frequency ultrasonic has more significant effect thanmicrocurrenton decreasing wound size

after tendon suture.

Keywords: Ultrasound, Microcurrent, Achilles tendon, Tissue healing.

www.jmscr.igmpublication.org Impact Factor 3.79

ISSN (e)-2347-176x



INTRODUCTION

Tendons are metabolically active tissues requiring

vascular supply but, in some (Achilles tendon,

tibialis posterior and supraspinatus), hypovascular

or watershed areas have been identified (1)

.

Tendons receive their blood supply from three

main sources: the intrinsic systems at the

myotendinous junction and osteotendinous

junction, and the extrinsic system through the

paratenonor the synovial sheath (2,3).

Tendon degeneration may lead to reduced tensile

strength and a predisposition to rupture. Indeed,

histological evaluation of ruptured Achilles

tendons has demonstrated greater degeneration

than was found in tendons that were chronically

painful as a result of an overuse injury(4).

The

golden aim of the repair of tendon injury is to

achieve a permanent repair that could reestablish

the smooth mobility of the regenerating tendon

and to have significant tensile strength loads.(5,6).

The healing process is a balance between the

intrinsic and extrinsic healing processes. The

mechanism for achieving this balance may lie in

the differential ability of the cells to respond to

local factors(7).

The penetration (or transmission)

of ultrasound (US) is not the same in each tissue

type, it is clear that some tissues are capable of

greater absorption of US than others. Generally,

the tissues with the higher protein content will

absorb US to a greater extent, then tissues with

high water content and low protein content absorb

little of the US energy (e.g. blood and fat) while

those with a lower water content and a higher

protein content will absorb US far more

efficiently. Tissues can be ranked according to

their relative tissue absorption and this is critical

in terms of clinical decision making (8).

During the proliferative phase (scar production)

US also has a simulative effect (cellular up

regulation), though the primary active targets

which are now the fibroblasts, endothelial cells

and myofibroblasts cells(8,9,10).

It also enhance

fibroplasia and collagen synthesis(11,8).

(Therapeutic US has a positive role to play in

providing the growth factors (12,13).

Micro electrical current stimulation (MES) is a

physical therapy modality providing electric

current in millionths of an ampere.(14)

MES

appears to play a significant role in the healing

process, as it can promote healing in variety of

bone and skin lesions. The evidence for other

tissues is encouraging but presently scant. MES

uses electric currents similar to those produced by

the body during tissue healing. It may be

particularly beneficial where endogenous healing

has failed (15).

An effective mean of promoting

tendon healing either an US or electrical

stimulation will be the concern of this study.

METHODOLOGY

Instrumentation:

Ultrasound apparatus: Sonopuls 464

ultrasound unit manufactured by Enraf-

Holland; pulse repetition rate 100 Hz;

pulse duration 2 ms; model 1464-900;

serial number 9-043

MES apparatus was used to deliver

microcurrent stimulation, model: EMSI-

4250, serial no.:A358612, made in

Taiwan.

Sahar. M. Adel et al JMSCR Volume 2 Issue 12 December 2014 60


Plastic sheet: was used to measure the

wound size and wound total

circumference, before MES application

and every session during the treatment

period.

Q tips to measure depth of the wound.

Surgical Procedures

Following the protocol of Sharifi et al., (2007)(16).

Preparation of the animals

In preparation for surgery, the rats were fasted 12

hours for food while water was withheld 3 hours

only before the operation. Immediately before the

surgery the hair was removed from the site of

the operation, at the posterior and medial aspects

of the hind limb using hair removal cream, the

remaining hair was short cut using hair scissor.

Each rat was weighed before the operation to

determinate the dose of anesthesia.

Anesthesia

On the day of surgery each rat was weighed and

anesthetized by general anesthesia using

intramuscular injection of ketamine hydrochloride

(35 mg/kg body weight) (Ketalar (Parke _Davis

SA Barcelona _Spain) and Xylazin hydrochloride

(5 mg/kg body weight) (Rompun 2% (Bayer

Leverkusen, Germany).

Surgical Technique

All surgical techniques were done under complete

standard sterile conditions. The animal was

immobilized on the surgical table in a prone

position. Achilles tendon of right hind limb of

each rat was exposed and isolated, through about

3cm of incision at the hind limb. Achilles tendon

was sharply transected with a scalpel, about 1cm

apart from calcaneal insertion Each end of the

served Achilles tendon was approximated and

immediately sutured by 4/0 proline (Ethicon, NJ,

USA) using modified Kessler suture technique.

The skin was then left opened. Afterward; the

operated hind limb was immobilized using plaster

of Paris cast leaving opening for E.S.

Immobilization

After tenotomy and suture, the served hind limb

was immobilized in a plaster of Paris cast. The

cast extended from mid-thigh to the toes, with the

knee in flexion and ankle held in 45 degree of

planter flexion to make the calf muscles in

shortened position. A window was done at the site

of tenotomy for wound dressing and MES

application in the treatment groups

All animals were returned back to cages and were

injected intra-muscularly by prophylactic

antibiotic.

Treatment procedures

Before treatment the skin was cleaned and

any growing hair was removed to decrease

the electrical resistance of the skin over the

site of the electrode placement.

Ultrasound was applied from the first day

post injury and continued throughout the

study at a frequency of three sessions per

week for 5 weeks. Ultrasound was applied

on the site of injury with frequency 1MHZ

and intensity of 0.5 W/cm2 for 5 minutes.



MES was applied from the first day post operative

and continued throughout the study at a frequency

of 3 sessions per week. MES was applied

transcutaneously.

Micro-current electric stimulator, model:

EMSI-4250 (made in Taiwan) was used

for the treatment. The active electrode

(cathode) (1.0 x 1.0 cm) was placed over

the tendon injury site, while the inactive

electrode (anode) was placed proximally

on the thigh region of the same side,

approximately 3 cm apart. Clip electrode

were used.

Intensity 100 micro ampere , frequency 10

Hz ,duration 30 min, pulse width 50 ms,

and constant mode of application was used

in the study.

Only one person was responsible to

provide treatment for all animals, to

standardize the handling process.

Wound size measurements:

By using clear and sterilized plastic sheet to

measure the wound length x width x depth, to get

the total wound size, Wound circumference had

taken by multiplying length x width x depth of the

skin wound of all groups (both study groups and

control group). This procedure took place before

starting the treatment protocol, immediately after

the surgical procedure was performed, and it was

repeated each session during the treatment period

throughout the study.

RESULTS

The data presented in table (1) showed the mean

and the standard deviation of the wound

measurements of the area of tenotomized tendon

of the study group which received low frequency

ultrasound were lower than the control group

which did not receive the ultrasound treatment.

The wound size measurements every other day

between low frequency ultra sound and control

groups showed significant decrease in wound size

till complete healing, where the mean size

decreased from 0.2388 ± 0.08206 to 0.0.

Application of ANOVA showed significant

decrease of wound size, where F value was 0.503

and p value was (P ≤ 0.02) as shown in table (1

and 2). Application of post hoc test showed a

significant decrease in wound size during all

periods of measurements except the first period of

measurement (before treatment)



Table (1): Wound size measurement through treatment periods between control group low ultrasound and

Micro-current group (mean ± standard deviation).

Times of measurements Control Group

X±SD

low ultrasound group

X±SD

Micro-current group

X±SD

1st 0.236±0.041 0.2388 ±0.08206 0.213±0.0612

2nd

0.177±0.034 0.1280* ±0.05098 0.148±0.026

3rd

0.146±0.033 0.0554* ±0.02984 0.064* ±0.0182

4th

0.11±0.032 0.0213* ±0.0238 0.0386* ±0.0152

5th

0.04±0.021 0.0* 0.0*

*significant at ≤ 0.05

Table (2) ANOVA between low frequency ultra sound and control

Comparison Degree of freedom F value P value

Group 2 Vs control 29 0.503 ≤ 0.02

Table (3): Application of Analysis of Variance between Micro-current group during periods of

measurements.

Micro-currentvs

Control g

Degree of freedom F value P value

1st 29 0.3571 0.7029

2nd

29 3.506 0.0443*

3rd

29 21.923 < 0.0001*

4th

29 0.5182 0.6014

5th

29 33.058 < 0.0001*

*significant <0.05

Comparing wound size in low frequency

ultrasonicgroup among the times of measurements

Vs the control has shown a significant decrease of

wound size where the mean value decreased from

0.2 mm ± 0.03 to 0.0 mm in the fifth time of

measurement while the wound size of the control

group decreased from 0.2 mm± 0.08 mm in the

fifth time of measurement. The t test has shown

significant decrease in wound size measurement

where the t value and P value showed that it was

significant during 3rd

and 5th

times of

measurementas shown in table(4).



Table (4): t-test between low frequency ultrasonic group and Control group among evaluation periods

low frequency ultrasonicvs

Control g

Degree of freedom T value P value

1st 9 0.6331 0.24520

2nd

9 3.531 0.5312

3rd

9 6.000 < 0.0001*

4th

9 0.6432 0.2843

5th

9 7.83 < 0.0001*

Comparing wound size in Micro-current group

among the times of measurements Vs the control

has shown a significant decrease of wound size

where the mean value decreased from 0.2 mm ±

0.06 to 0.0 mm in the fifth time of measurement

while the wound size of the control group

decreased from 0.2 mm± 0.08 in the fifth time of

measurement. The t test has shown significant

decrease in wound size measurement where the t

value and P value showed that it was significant

during 2nd

, 3rd

and 5th

times of measurements

shown in table (4).

Table (4): t-test between Micro-current group and Control group among evaluation periods

Micro-current vs

Control g

Degree of freedom T value P value

1st 9 0.8771 0.3920

2nd

9 2.631 0.0169*

3rd

9 8.000 < 0.0001*

4th

9 0.7902 0.4397

5th

9 10.83 < 0.0001*

*significant at <0.05 ,t:test ,p: probability.



Morphological changes:

Achilles tendon morphology:

The normal Achilles tendon of female rat which

was not subjected to the experiment showed

normal parallel arrangement of acidophilic

collagen bundles separated by flattened Fibrocytes

with dark flattened nuclei.

Group I (After one week):

One week following injury of Achilles tendon of

untreated group (group I) revealed few collagen

bundles arrangement with fibroblasts migrated to

the area of injury with newly formed blood

capillaries. In contrast, Achilles tendon of rats

treated with low frequency ultrasound (group II),

showed more abundant irregular arranged

collagen bundles with numerous fusiform

fibroblasts at the site of injury. Inflammatory cells

and new blood vessels are also seen.

In cathodal treated achilles tendon of the same

group, an apparent increase in the amount of

regenerating collagen bundles was observed.

Fibroblasts with pale oval nuclei and fibrocytes

with dark flattened nuclei were aligned on the

regenerating collagen bundles, infiltrating cells

were scattered in-between the collagen bundles.

Two weeks following injury, the Achilles tendon

in the untreated group (group II) showed collagen

bundles invading the injured area with cellular

infiltration and blood vessels. In contrast, rat

Achilles tendon of (group II) treated with low

frequency ultrasound showed denser collagenous

bundles filling the injured area with areas of

heavy cellular infiltration.Fig (1).

Fig (1): photomicrograph of Achilles tendon of

female rat in group II after two weeks showing

condensed collagen bundles (arrow head ) filling

most of injured area with cellular infiltration.

(H&EX100)

Two weeks following injury Cathodal treated

achilles tendon of the same group showed

regularly arranged regenerated acidophilic

collagen fibers. Few Infiltrating cells were

observed.Fig (2).

Fig.(2): Photomicrograph of a section in cathodal

treated Achilles tendon in group III showing

regularly regenerated acidophilic collagen bundles

(arrow) (H & E, x100).

Five weeks following injury sections in Achilles

tendon in untreated group (group I) showed

collagen bundles (dense but in different

directions), abundant fibroblasts with few

fibrocytes, with also some blood vessels are still



seen. While group II showed parallel arrangement

of the dense collagen bundles with less spacing

and more fibrocytes.(Fig. 3).

Fig (3): photomicrograph of Achilles tendon of

female rat in group II treated with low frequency

US for four weeks showing more regular

arrangement of collagen bundles with less

spacing. (masson’s X400).

Regularly arranged collagen bundles intermingled

with many fibroblasts were recorded in group III.

regularly arranged collagen bundles occupied

most of the field(Fig4 ).

Fig. (4): Photomicrograph of a section in cathodal

treated Achilles tendon demonstrating regularly

arranged collagen bundles occupying most of the

field (arrow) (Masson’s Trichrome, x400).

DISCUSSION

The results of this study showed significant

decrease of wound size among the low frequency

ultrasonic and Microcurrent groups compared

with the control group. Application of Bonforrini

multiple trial test showed significant decrease in

wound size during second, third, and fifth periods

of measurements. Group (II): showed that wound

size has shown a significant decrease from 0.2

mm ± 0.03 to 0.0 mm during three weeks where P

value was< 0.0001. On the other hand, in the

control group, the wound size decreased from 0.2

mm± 0.08 where P value was < 0.0001 but this

takes longer period than the experimental group.

Selection of ultrasound application parameters is

based on the desired effect and the location and

density of the tissue to be treated. These decisions

are best made by the physician and the therapist

experienced in performing therapeutic ultrasound.

Common indications for high frequency

ultrasound therapy include treatment of tendon

injuries and short-term pain relief. Ultrasound has

also been shown to promote healing of some acute

bone fractures, venous and pressure ulcers, and

surgical incisions. However, conventional

therapeutic ultrasound can cause burns or

endothelial damage if applied incorrectly.

Recently, low frequency ultrasound was tested

and introduced to the market. The motivation of

looking for alternative ultrasound parameters was

due to the fact that application of high-frequency

US in clinical medicine is limited due to tissue

heating. Thus, using low-frequency US with less

tissue heating, thereby acting as a "slow release"

mechanism, may become the standard care in

treating slow-to-heal lesions, skin ulcers and

nonunion fractures. In addition it may be able to

facilitate protein secretion and enzymatic

reactions.



Based on the results of Marie et al., (2008)who

reported that, low frequency ultrasound energy are

thought to be primarily attributed to the

mechanisms of cavitations and micro streaming.

Cavitations involve the creation and oscillation of

microscopic bubbles that concentrate acoustic

energy into shearing and micro streaming fields.

The movement and compression of these bubbles

can cause changes in cellular activities(17)

Furthermore, Micro streaming is the physical

forces of sound waves that are capable of

displacing ions and small molecules. The

mechanical pressure applied by the micro

streaming wave produces a unidirectional

movement of fluid along and around cell

membranes. Based on laboratory studies on both

vivo and vitro, the combination of cavitations and

micro streaming, which occur more frequently

with low frequency ultrasound, appear to provide

a mechanical energy capable of altering cell

membrane activity and, therefore, cellular activity.

In contrast, Watson (2008)showed that

enhancement of wound healing using the

properties of high ultrasound suggested that the

higher the US frequency, the greater the

absorption rate; raising the temperature above

normal thermal levels by a few degrees may be

attributed to numbers of beneficial physiological

effects(8)

.

In this study, the wound size measurements were

taken every other day for low frequency ultra

sound and control groups. It showed significant

decrease in wound size till complete healing,

where the mean wound size decreased from

0.2388 mm ± 0.08206 to 0.0 (P value≤ 0.02), and

application of post hoc test showed the significant

decrease were in all times of measurement except

the first period of measurement (before treatment).

One of the objectives of the use of therapeutic

ultrasound in wound healing is to reduce the

inflammatory phase and accelerate the migration

and proliferation of fibroblasts, which are critical

to the healing process. The results of this study

went in accordance with several studies, that

showed the same effect of low frequency

ultrasound on the wound healing (18,19,20).

Low-frequency ultrasound therapy is a modality

used to promote healing in chronic wounds by

cleansing and maintenance debridement to remove

yellow slough, fibrin, tissue exudates, and

bacteria. The mechanisms by which low

frequency ultrasound energy stimulates wound

healing have been previously described (21).

Breuing et al., (2005)provided further support on

the effectiveness of low frequency ultrasound

therapy in a group of 17 patients with acute and

chronic wounds of varying etiology. These

patients also received adjunct wound therapy,

which included moist dressings, alginate and

Panafil. A total of nine wounds (47%) healed

primarily or were sufficiently debrided to receive

skin grafting, while six wounds (29%) achieved

greater than 50% healing. The remaining 2

wounds achieved 20% and 30% healing of the

original wound area. It should be noted that due to

the varying etiology of wounds within this patient

cohort, the frequency of treatment varied

substantially, ranging from twice / week to

fortnightly sessions and the average number of



treatments per wound ranged from 6 to 15 over

the 3-month period(22).

In this study, group(III): showed that wound size

has shown a significant decrease from 0.2 mm ±

0.06 to 0.0 mm during two weeks where P value

was< 0.0001. On the other hand, in the control

group, the wound size decreased from 0.2 mm±

0.08 mm where P value was < 0.0001 but this

takes longer period than the experimental group.

It was suggested that, electrode placement

significantly affected field strength in the target

tissue. Furthermore, the presence of many

surrounding structures reduces field strength in

the target tissue considerably. These factors

should be taken into account when establishing

protocols for electrical current based therapeutic

devices once it has been proven that these devices

are clinically effective. It was concluded that

tissue composition and electrode placement of

electrical therapeutic devices strongly affect the

effective field strength in the target tissue.

Knowledge about these effects were necessary for

the further assessment of these devices with

respect to their potential value for clinical use(23).

There was another point with respect to the

direction of current application. Physiological

electric fields can also control the direction of cell

migration (24).

In general, cells orientated parallel

to an electric field will retract, and reorient

perpendicular to the electric field (25).

After injury

tenocyte proliferation and collagen synthesis were

randomly organized, and may result in the

formation of inferior tissue.

In an attempt to identify the optimal method for

applying microcurrent in this study totenocytes in

culture, the results revealed that the direct contact

between the electrodes and the culture medium or

the cells themselves resulted in extensive cell

death. It was suggested that, this phenomenon

could be a result of electrolysis, whereby

dissolved positive and negative ions in the

medium were discharged at the cathodal and

anodal electrodes, respectively, and was probably

mediated through formation of H2O

2 at the anodal

electrode. The use of bridges to allow indirect

current transmission avoided this. However, only

the paper bridges worked satisfactorily. The

agarose bridges most likely had an intrinsic

resistance that was high enough to prevent

sufficient current to generate a biological effect to

pass to the cells.(26).

Similar results was reported by Mehmandoust at

al., (2007)that, the use of positive polarity

augments the migration and proliferation of

epithelial cells and therefore hasten wound

closing. It was suggested that, the wound closing

in a shorter periods was due to the antibacterial

effect of negative polarity and the epithelialization

effect of positive polarity(27).

Also Mehmandoust

et al.,(2007)added that some useful effects of

negative polarity include killing microorganisms,

removing necrotic tissues due to decreasing pH of

the wound environment, limiting protein molecule

infiltration and therefore limiting the formation of

edema in the injury site, and increasing fibroblast

cell proliferation and collagen synthesis(27).

This study was in agreement with Rowley et al.,

(1974) who study that the use of negative polarity

for the first 3 days and positive polarity for the

remaining days throughout the healing period. As



the negative polarity has antibacterial effects(28).

In

contrast, Bayat et al., (2006)Reported that, in both

vivo and vitro studies the application of positive

polarity has some useful effects, including

destruction of microorganisms, increased

migration and proliferation of the epithelial cells,

increased attraction of macrophage cells to the

wound site, and better stimulation of endogenous

currents of the wound(29)

.

It was known from the past that cathode was

superior to anode in wound healing process.

Robert I. and Pcker,(30)

reported that, the cathodal

(negative) current has been shown to be successful

in stimulating bone deposition and repair if

applied at the fracture site as an indwelling

electrode. Consistent with this empirically

successful clinical approach to stimulating bone

repair is the observation that injury to bone

produces negative voltage-potential gradients in

the area of injury relative to the undamaged bone.

Short-lived potential differences are also induced

by stressing the bone with a mechanical load.

Areas of compressive stress are electronegative

relative to the unloaded portion of the long bone.

In addition PoltawskiL, and Watson Tadded that

MES promotes healing in variety of bone and skin

lesions. The evidence for other tissues is

encouraging but presently scant. MES uses

electric currents similar to those produced by the

body during tissue healing. It may be particularly

beneficial where endogenous healing has

failed(31)

.

The effect of the electrical stimulation on

biological structures was related to the current

flow through the target tissue. This study clearly

demonstrates that the effective field strength in the

target tissue may vary greatly with the plane in

which the current is applied and with the tissues

located between electrodes and target tissue. Main

conclusion from this study is therefore that the

current output of any therapeutic device has to be

considered a very unreliable indicator of actual

field strength in the target tissue, and hence of

potential therapeutic effect. We did not vary the

direction of the current, i.e. the positions of the

negative and positive electrodes. To the authors’

knowledge there was no data on possible semi-

conductivity of biological tissues, but it is an item

that might be addressed in future studies.(26)

Regarding the morphological changes

Andres and Murrell 2008 reported that the healing

process is a balance between the intrinsic and

extrinsic healing processes. The mechanism for

achieving this balance may lie in the differential

ability of the cells to respond to local factors(7)

.

In 2003 Joan and his colleagues reported that, the

phases of wound healing are overlapping, but are

described in a linear fashion for the purpose of

clarity. They suggested that the five phases that

characterize wound healing include (1)

homeostasis, (2) inflammation, (3) cellular

migration and proliferation, (4) protein synthesis

and wound contraction, and (5) remodeling(32)

.

In the present study, group (II) during the first two

weeks post injury, the wound was heavily

populated by inflammatory cells and vasculature;

as the healing progressed fibroblasts and

endothelial cells were predominated; mainly after

the 3rd

week fibroblasts became inactive and



changed into fibrocytes. After the 4th

week

fibrocytespredominanted.

In the current study the morphometric results

regarding the ratio between fibroblasts

&fibrocytes showed significant increase in the

numbers of fibroblasts which are responsible for

collagen production and healing process in

response to US in low subgroup when compared

to both untreated and high subgroups after 1st two

weeks of the study. This is in accordance with

previous work of Yeung et al., 2006 who found an

improvement in the quantity of fibroblasts and

collagen alignment in Achilles tendons of rats

treated with low ultrasound after the 3rd week of

this study there was significant increase in the

fibrocytes numbers in low subgroup when

compared to both untreated and high

subgroups(33).

In group, (III) (Two weeks following injury),

H&E stained sections showed thatcollagen

bundles were disrupted, irregularly arranged and

infiltrated with active fibroblasts that exhibited

pale oval nuclei .Mononuclear cell infiltration was

clearly evident in between the bundles together

with congested capillaries, these changes were

gradually replaced by acidophilic regularly

arranged collagen bundles that occupied most of

the field. Resident and quiescent fibrocytes with

dark flattened nuclei were aligned in- between

these bundles and with gradual disappearance of

the inflammatory cells and congestion.

Fereshte, 2007added that the negative polarity

(cathode) exhibited other useful effects in means

of killing microorganisms, removing necrotic

tissues due to decreasing pH of the wound

environment, limiting protein molecule infiltration

and therefore limiting formation of edema in the

injury site and increasing fibroblast cell

proliferation and collagen synthesis(34)

.

Going along with results of the present study, it

was reported by Sharifi et.al, 2007thatincreased

blood supply enhanced the rate of protein

synthesis in fibroblasts responsible for collagen

production, therefore, an adequate blood supply is

necessary for tendon healing(16).

CONCLUSION

Both low frequency ultrasonic and microcurrent

electrical stimulation is an effective mean for

promoting wound healing. Despite many studies

on wound healing, the electrical stimulation is still

in its infancy, an important parameter of electrical

stimulation in wound healing is the type of

applied polarity. The present study revealed the

following findings. that "low frequency ultrasonic

has more significant effect than microcurrenton

decreasing wound size after tendon suture".

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Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.1

Severe burn injuries are associated with hypermeta-bolic responses and increased catabolism. These lead to a vast loss of muscle mass, reduced muscle strength and endurance, limited walking ability, and reduced functional mobility.1–7 These are worsened by decon-ditioning (eg, prolonged bed rest, immobilization, and inactivity).5 Previous studies have suggested that sensory neurons impeded in dermal tissue are dam-aged secondary to burn injuries resulting in impaired perception and postural imbalance.8–11 These will influence the ability to execute a range of activities and function in both the short and long term.

Persistence of muscle weakness is well known in both adults6,12 and children who sustained injury and had more than 30% of burned TBSA (burned TBSA).13,14 However, there are limited studies on the use of the isokinetic dynamometer to quantify recov-ery of muscle strength following burn injury.6,12–19 In addition, the use of the Biodex balance system has not yet been described in the literature, and only a few studies have tested walking and mobility levels following burn injury.12,16,20–24 Therefore, this study determined the impact of thermal burn injuries on the lower-limb muscular strength, balance, and func-tional mobility in adults and compared results with norm values of a matched nonburned group.

METHODS

Burned ParticipantsThis is a cross-sectional descriptive study, which was approved by the postgraduate institutional ethical committee at Faculty of Physical Therapy. Burned

Copyright © 2017 by the American Burn Association 1559-047X/2017

DOI: 10.1097/BCR.0000000000000495

J Burn Care Res

Severe burn injuries are associated with hypermetabolic response and increased catabolism. These lead to a vast loss of muscle mass and reduced muscle strength and function. Therefore, the aim of this study is to determine the impact of severe burn injuries on lower-limb muscular strength, balance, and mobility level in adults. Forty burned adults with burned TBSA (burned TBSA) ≥40% participated in this study. The peak torque and total work of quadriceps and knee flexors were calculated at 150°/sec using Biodex isokinetic dynamometer. Balance and mobility were tested via the Biodex balance device and the high mobility assessment tool, respectively. Twenty-three matched nonburned healthy adults were evaluated and served as a control group. Severely burned adults exhibited significantly lower peak torque and total work in their quadriceps (27.50 and 22.58%, P < .05) and knee flexors (23.72, and 21.65%, P < .05) relative to the nonburned adults. Burned adults had a significant decrease in stability index and balance including the dynamic limits of stability (P < .05). The high mobility assessment tool scores were significantly lower (42 ± 7.64, P < .05) when compared with control subjects (51 ± 1.62). Patients who had severe burns (burned TBSA ≥ 40%) showed muscular weakness, limited balance, and mobility levels between 16 and 24 weeks after discharge from the hospital compared with matched nonburned control subjects. These results can guide therapists in creating rehabilitation programs that focus on the specific difficulties faced by burned patients. (J Burn Care Res 2017;XXX:00–00)

From the *Physical Therapy Department for Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt; and †Collage of Applied Medical Science (CAMS) - Majmaah University, Al Majmaah, Kingdom of Saudi Arabia.

Address correspondence to Mohammed T. A. Omar, PhD, PT, Physical Therapy Department for Surgery, Faculty of Physical Therapy, Cairo University, 7 Ahmad Alzayat St., Bain El-Sarayat, Giza 12612, Egypt. Email: [email protected].

Lower-Limb Muscular Strength, Balance, and Mobility Levels in Adults Following Severe Thermal Burn Injuries

Mohammed T. A. Omar, PhD, PT,* Amal M. Abd El Baky, PhD, PT,*† Anwar A. Ebid, PhD, PT*

ORIGINAL ARTICLE


Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

Journal of Burn Care & Research2 Omar et al XXX 2017

adults (men and women) were recruited from OM El-Masrien Hospital, Giza, Egypt. The participants with following criteria were enrolled in this study: 1) Aged 18 to 35 years; 2) sustained second to third degrees burns to the dominant or both lower extremities; 3) burned TBSA ≥ 40% as estimated by the rule of nine; 4) completion of skin grafting at least 3 months at the time of assessment. The exclusion criteria were existing leg amputation, psy-chiatric, neurological, and cognitive disorders. All participants received similar standard medical care and rehabilitation services from the time of emer-gency admission throughout discharge.

Nonburned GroupBased on the previous study of St-Pierre et al,6 and Grisbrook et al,25 the burned participants were matched to nonburned control healthy adults who were voluntarily recruited from the community through personal contact according to sex, age, weight, height, body mass index, and level of physical activity. Participants in both groups were sedentary (not involved in regular physical activity, defined as 1 hour of moderate intensity exercise that performed three times per week) in the past 3 months. They did not engage in any rehabilitation program and/or use medications that may affect muscle strength.

Data Collection ProceduresThe assessment procedures and data collection were performed in the Biodex lab at the Faculty of Physical Therapy, Cairo University, Giza, Egypt. Outcomes included muscle strength, balance, and mobility level. These outcomes were measured between 16 and 24 weeks after discharge from the hospital. On the first visit, the therapist provided the participant a brief description of the testing procedures. Demo-graphic data (eg, age, sex, weight, and body mass index) and medical data (eg, extent of burn, location of burns, skin grafting, length of hospital stay, dura-tion since discharge) were collected for all partici-pants. All participants signed an informed consent form before engaging in the study.

Isokinetic Muscle Strength AssessmentA Biodex isokinetic dynamometer (Biodex Medical System, Shiley, NY, linked to IBM PC computer soft-ware) was used to measure the muscular strength after calibration according to the manufacturer’s instruc-tions. A therapist reported the values of knee flex-ors and quadriceps muscle strength of dominant leg regardless the location of burns at an angular velocity of 150°/sec.6,12,14 The details of the protocol and test

procedures were described in our previous study.12,15,16 Values of peak torque (PT) and total work (TW) were calculated using the Biodex software system.

Balance AssessmentA Biodex Balance System (Biodex Medical Systems, Shirley, NY) consists of movable balance platform that provides 20° surface tilt through 360° range of motion. The platform interfaces with computer soft-ware that enables the device to serve as an objective assessment of balance. Before the start of each testing session, the Biodex was calibrated according to the manufacturer’s manual. The participants were famil-iarized with testing procedures through free practical sessions to minimize the learning effects that occur during testing. All measurements were performed at level eight of stability (the most suitable level), and the test duration was set at 20 seconds for three suc-cessive trials. Each participant was tested for stability index (SI) and limits of stability (LOS). The LOS is defined as the area that the subject safely moves without changing the base of support. The SI rep-resents the patient’s ability to control balance and motor control skills at 50% LOS.26–29

To test SI, the participants were asked to step on the platform and instructed to grasp the support handles at the beginning and then release them as the test proceeded with open eyes and barefoot. Then, the participants were informed to assume the proper centered position as soon as the platform was released by shifting the foot position on the plat-form, and the foot position was recorded by using coordinates on the platform’s grid.26–29

The LOS test prompted participants to move a cursor, viewed on the visual feedback screen by leaning toward a target while standing on the fully unstable platform to keep the cursor at the center of the screen grid. The LOS test measures the time and accuracy with which participants transferred their estimated center of gravity while moving the cursor to intercept each of eight successive targets on the display screen. The targets were positioned at 45° intervals around a central target that represented the participant’s center of pressure under static condi-tions. Each target was randomly highlighted, and the participant reached the target by leaning and return-ing to the center position before the next target was selected and displayed on the screen. The test was completed when all eight targets had been reached. Target placement was preset by the manufacturer at 50% of the LOS. The system calculated balance indi-ces including the SI and the LOS scores. These were collected and used for further analysis.26–29


Journal of Burn Care & Research Volume XXX, Number XXX Omar et al 3

Mobility AssessmentThe high mobility assessment tool (HiMAT) is a valid unidimensional assessment tool developed to exam-ine high-level mobility function in a population with traumatic brain injury.30–32 The HiMAT can be used for mobility assessment following burn injuries.23

The HiMAT includes 13 items that assess a range of high-level activities including walking tasks (eg, walk-ing, walking backwards, walking on toes, and walking over an obstacle), running, skipping, hopping for-ward, bounding, and going up and down stairs. Each item is scored on a scale 0 to 4, where zero represents the inability to perform an item, and four represents increasing levels of ability (based on the time/dis-tance they receive). All items are summed for a total score of 54. Higher scores show a higher level of per-formance. Norms for healthy adults aged 18 to 25 are 50 to 54 for men and 44 to 54 for women.23,30–32 The HiMAT was performed according to published recommendations.30 The participants were given standardized verbal instructions and one visual dem-onstration for all items. Then, participants completed one practice trial and one “real” timed trial for each item. The scores for the normal healthy subject were matched with the reported norm scores.

Data AnalysisData were analyzed with Statistical Package of Social Science version 22.0 (Chicago, IL). Normal dis-tributed data (Kolmogorov–Smirnov test, P > .05) were described as the mean and SD. Otherwise, the data were represented as frequency, median, and range; they were then nonparametrically analyzed. Baseline characteristics, muscular strength, balance indices, and mobility level between groups were compared with an independent sample t-test and the Mann–Whitney U test. The differences in PT and TW were calculated from the following equa-tion based on work of St-Pierre et al,6 as following: “100 − burn value/control value × 100) at 150°/sec”, where “burn values” are obtained from burn patients, whereas “control values” are the measure-ments obtained from the control healthy subjects.

Using norm values from the nonburned group, results were converted to a Z score to report individual performance. Then, the mean of normalized scores was calculated at the group level.19 Pearson correlation coef-ficients were calculated between the outcome variables (muscular strength, balance, and mobility) and burn characteristic variables (eg, burned TBSA and length of time since discharge). Variables that showed signifi-cant correlations were included in a logistic regression analysis. Statistical significance was set at P < .05.

RESULTS

Participant CharacteristicsTable 1 summarizes the demographic characteristics of both groups. Forty burned adults (26 males and 14 females) and 22 matched, nonburned healthy adults (13 males and 10 females) were involved in this study. No significant differences were observed between groups with regard to age (P = .75), weight (P = .11), height (P = .91), BMI (P = .17), and dis-tribution of sex (P = .33). The mean extent of the burned TBSA was 45.02% (range 40 to 55%). The extent of full-thickness burned TBSA was 18.50% (range 15 to 25%). The average extent of burns to lower limb burned TBSA was 18% (range 15 to 27%). All the burned participants had burns to their lower limbs. Eighteen of the participants also had bilateral upper limb burns; five also had injuries to the face. Forty participants had skin grafting surgery during hospitalization, partial thickness skin grafts (n = 10), and full-thickness skin grafts (n = 5) in their dominant lower limb. None of the subjects had sur-geries for at least 3 months before assessments. The mean length of stay was 76.75 ± 16.21 days (range 42 to 98 days), and 52.50% (21 participants) were discharged within 11 weeks of the burn.

Muscle StrengthTable 2 reports the mean values of PT and TW for the participants’ quadriceps and knee flexors. The PTs for quadriceps and knee flexors significantly differed (P = .03) in the burned participants (62.89 ± 7.38 and 57.17 ± 5.87 Nm), relative to the nonburned

Table 1. Participants characteristics and demographic data

VariablesBurned Group

(n = 40)Control Group

(n = 23)

Sex, males/females, N (%) 26/14 13/10Age (yr) 26.32 ± 4.02 24.60 ± 3.49Weight (kg) 73.57 ± 15.65 76.31 ± 16.60Height (cm) 170.30 ± 7.09 169.40 ± 11.3BMI (kg/cm2) 25.36 ± 5.26 26.59 ± 4.59Burned TBSA (%) 45.02 ± 3.58 (40–55) NA Full-thickness burn (%) 18.50 ± 6.82 (15–25) NA Average % TBSA of LL 18 ± 3.85 (15–27) NA Average % TBSA of UL 13 ± 3.58 (10–20) NALength of hospital

stay (d)76.75 ± 16.21

(42–98)NA

Duration since discharge (wk)

20 ± 3.31(16–24) NA

Data presented as mean ± SD, or number, and range as in bracket, no sig-nificant (P > .05) differences between groups.BMI, body mass index; LL, lower limb; N/A, nonavailable; UL, upper limb.



group (86.75 ± 8.50 and 74.94 ± 8.50 Nm). The TW performed for quadriceps and knee flexors were significantly (P = .03) decreased in burned partici-pants (57.37 ± 5.62 and 49.05 ± 5.28 J) vs the non-burned group (73.63 ± 10.37 and 62.61 ± 5.56 J). The burned participants exhibited significantly (P = .02) lower PT in the quadriceps (27.50%) and knee flexors (23.72%) and produced less (P = .02) TW in the quadriceps (22.58%) and knee flexors (21.65%) compared with the nonburned group. In general, the individual mean Z score for PT and TW for both quadriceps and knee flexors was significantly lower (P < .05) in all burned participants vs the non-burned group.

Balance AssessmentTable 3 reports the mean values of the SI and dynamic LOS. There was a significant difference (P = .02) in SI between the burned participants (4.42 ± 0.35) and the nonburned group (1.92 ± 0.50). The dynamic LOS showed significant differences (P = .03) between the burned participants (15.50 ± 2.30) when com-pared with the nonburned group (21.22 ± 3.62).

These differences demonstrated lower balance abil-ity in patients with severe burn injuries. In total, all burned participants had significantly lower Z scores. There was also a significant deviation from the norm in the group mean for SI and LOS.

High Mobility Assessment ToolThe total HiMAT score and all subscores for the burned and nonburned groups are presented in Table 4. The mean total HiMAT score in the burned adults was 42 ± 7.64 compared with 51 ± 1.62 in the nonburned group (P = .01). Eight of the 13 mobil-ity task scores differed significantly from the non-burned group: “walking backwards,” “running,” “hop forward,” “bound affected leg,” and “four-stair activities.” Five males had a normal average total HiMAT score, whereas 35 participants scored lower than normal (14 females and 21 males) in the burned group. The HiMAT scores were lower in females than males in the burned (39.19 ± 5.7 and 46.00 ± 7.84, P = .03) and nonburned (52.07 ± 1.49 and 49.70 ± 1.05, P = .01) groups. The Mann–Whit-ney U test showed a significant (P = .03) difference between sex distributions in total HiMAT scores between the two groups.

Source of Variation in the Strength MeasuresFor the burned group, significant correlations were observed between burned TBSA with muscular strength (r = .40, P = .01) and mobility level on HiMAT (r = .30, P = .03). Moreover, there was a

Table 2. Mean values of peak torque (Nm) and total work (J) for quadriceps and hamstrings of dominant leg in both burned and matched control groups.

Isokinetic Test (150°/sec)

Groups

Burned Group (n = 40)

Control Group (n = 23)

Mean ± SD Mean ± SD

Quadriceps Peak torque (Nm) 62.89 ± 7.38* 86.75 ± 8.50 Total work (J) 57.37 ± 5.62* 73.63 ± 10.37Hamstrings Peak torque (Nm) 57.17 ± 5.87* 74.94 ± 8.50 Total work (J) 49.05 ± 5.28* 62.61 ± 5.56

*Significant (P < .05) decrease compared with control group.

Table 3. Mean values of SI and total dynamic LOS in both burned and matched control groups.

Groups




Balance SI 4.42 ± 0.35* 1.92 ± 0.50 LOS 15.50 ± 2.30* 21.22 ± 3.62

*Significant (P < .05) decrease compared with control group.LOS, dynamic limit of stability; SI, stability index.

Table 4. Total HiMAT score and item scores in the burned group compared with matched control group.




Walk 4 ± 0.60 4 ± 0.30Walk backwards 3 ± 0.51* 4 ± 0.20Walk on toes 3 ± 0.70 3 ± 0.31Walk over obstacle 3 ± 0.70 3 ± 0.20Run 2 ± 1.20* 3 ± 0.70Skip 3 ± 1.81 3 ± 0.61Hop forward 3 ± 1.31* 4 ± 0.51Bound (affected) 3 ± 1.21* 4 ± 0.60Bound (less affected) 3 ± 1.20* 4 ± 0.60Up stair dependent 4 ± 0.80* 5 ± 0.31Up stair independent 3 ± 0.70* 4 ± 0.21Down stair dependent 4 ± 0.61 5 ± 0.30Down stair independent 3 ± 0.81* 4 ± 0.20Total score of HiMAT 42 ± 7.64 51 ± 1.62

*Significant (P < .05) decrease compared with control group.HiMAT, high mobility assessment tool.



trend indicating an effect of the extent of burn on muscular strength and mobility level. There was no significant relationship between length of time since discharge and muscular strength, mobility level, and balance indices.

DISCUSSION

The current study indicates a significant decrease in the amount of PT and TW generated by quadriceps and knee flexors in our burn patients. Furthermore, a significant loss of balance and high-level mobil-ity problems were presented in adults with burned TBSA ≥ 40% relative to the nonburned group.

Regarding muscle strength, our findings agreed with our earlier study.12,15 The PT of the knee exten-sors and flexors in the burned group were significantly lower (28 and 24%, respectively) when compared with the nonburned adult.12 Moreover, the PT of knee extensor demonstrated a 30% decrease in the burned group vs the nonburned group.15 Recent study by Ebid and Elsden16 concluded that the PTs of eccentric, concentric, and isometric muscles con-traction increased by 24.50, 32.48, and 52.38% in nonburned subjects when compared with burned adults at 12 weeks post burn. Moreover, the find-ings of the current study are consistent with previ-ous results that demonstrated persistence muscular weakness in burned adult (TBSA > 35%)6,17 and chil-dren (TBAS; 18–42%).13,14,33 In contrast to our find-ings, Grisbrook et al25 and Disseldrop et al19 failed to show a significant difference in muscle strength between burned and nonburned subjects.

This inconsistency across the literatures might be related to the variability in the population (adults vs children), evaluation time post burn injury (range 4–40 months), discrepancies in average percent-age of TBSA (18–42%), and sample size. Finally, muscle strength was tested using isokinetic at differ-ent angular velocities (60 and 150°/sec), different instruments (isokinetic vs hand-held dynamometer), and different muscles groups (knee extensors and flexors, elbow flexors and extensors, back muscles and handgrip strength).

The decrease in muscle strength might be attrib-uted to deconditioning after burn injury and insuf-ficient rehabilitation.5,34 In addition, severe burns can lead to a change in metabolism that might per-sist up to 24 months after the initial injury. These cause significant muscle wasting and decondition-ing.1–3 Recent studies suggested that burn has a direct impact on the mitochondrial function and gene expression of skeletal muscles in a nonburned

limb. However, a complete understanding of these processes is still lacking.35,36

In this study, we used isokinetic testing to assess muscle function. Isokinetic testing also allows mea-surement of dynamic muscular parameters under a predetermined rate. The rate chosen for this experi-ment was 150°/sec, which approximates the motion of walking activities.6,12,14 For practicality, we chose this value because rehabilitation programs should focus on helping the patient to resume normal walk-ing and daily living activities or goal-oriented tasks—these are dynamic muscular functions.16,17

To the best of our knowledge, the current study is the first to use Biodex balance in burned participants, and the results should encourage further develop-ment of using balance assessment. Our findings of reduced balance indices in adult participants with severe burns are consistent with existing literature. However, previous studies used other outcome mea-sures for balance assessment such as the Berg Balance Scale, single leg stance, time-up-and-go test, and tandem walk test.20,21 These results agreed with find-ings of Schneider et al,20 who reported lower scores (26-medium risk of fall) on Berg Balance Scales in the burned group on admission.

The defect in balance following burn injuries might contribute to multiple factors such as loss of tactile sensation, proprioception, and muscle strength, as well as limited joint mobility and cognition. All are potentially affected in severe burn injury.20 Bal-ance can further worsen due to burn complications including prolonged hospitalization, poor nutri-tion, pain, and neuropathies. In addition, Nedelec et al8 and Malenfant et al37 reported that burn injury affects dermal tissue that contains sensory neurons. These neurons send conscious and automatic feed-back, which controls balance and coordination.

The current study used the HiMAT to assess mobility level. Our findings of mobility problems in adults with severe burns are consistent with the lit-erature.12,15,23 In our study, the burn-injured partici-pant displayed decreased mobility activities (42/54) relative to the nonburned group (51/54). Some tasks did not reach full functional capacity such as hopping, skipping, and running, walking on toes, walking backwards, and walking over an obstacle. These results agreed with findings of Grisbrook et al,23 where the authors showed a significant decrease in the total HiMAT score in burned injury subjects vs a nonburned group.

Recently, Ebid and Elsden16 found that ambulation speed differed markedly between burned subjects (mean = 2.80 seconds) compared with age-matched healthy subjects (mean = 4.30 seconds). Data from



our previous study showed a significant decrease in walking speed on the treadmill in burn-injured par-ticipants (72.60 m/min) 6 m/min compared with age-matched health subjects (99.70 m/min) 7 m/min after 6-month post burn in the adult with TBSA ≥ 40%.12,16 Despite these similarities between our results and the existing literature, the previous stud-ies used other outcome measures for mobility assess-ment, such as walking speed and distance,12,15 and three-dimensional motion analysis.23 Only female participants (n = 9) were tested with variation in assessment time from 1 to 12 weeks following burn injury in the study conducted by Grisbrook et al.25

There was a lack of information in the literature regarding assessment of muscle function by an objec-tive and reliable method. Furthermore, there were only a few trials that described mobility level follow-ing burn injuries, and no study described the effect of burn on balance. We thought our study results would share in documenting data in this field. Moreover, it has potential clinical importance in the field of burn rehabilitation because this information can evaluate and compare muscle function, balance, and mobility of burned patients to nonburned individuals. More-over, it can help in planning a rehabilitation protocol.

Furthermore, we used two different strategies to control for possible confounding factors in this study: matching and logistic regression analysis. Controls were matched on age, sex, BMI, and physi-cal activity. Thus, these variables should not be con-founding factors. Furthermore, age ranged from 18 to 35 years in all groups. This is a relatively narrow range, and age-related differences regarding muscu-lar strength, balance, and mobility outcome within this range are unlikely. This further suggests that age is unlikely to be a confounding factor. Sex distribu-tion was matched between burned and nonburned subjects. However, sex distribution differed within the burned group (26 M/14 F). This may have influenced the comparison on the raw scores and total mean scores because the normative values are sex specific.

The current study had several limitations includ-ing the small sample size and local burn site recruit-ment. These limit generalization. Therefore, large sample size associate with multiple sites recruitments are recommended. Location of burn (eg, traversing the joint, near to joint or away from joint) may affect the results in a disproportionate manner. Therefore, additional studies are required to investigate all these factors. Normalizing data by lean body mass can facilitate data interpretation. However, in our study, mean values of PT were not corrected by lean body mass. Therefore, further study should use lean body

mass of leg muscles as a correction factor for the observed values of PT and TW. However, the effects of lean body mass may be secondary to changes in neuromuscular efficiency, fiber recruitment, or intrinsic contractile characteristics of muscle. Nor-mative values of undefined population were used as reference standards to compare our findings. How-ever, these studies were from different countries, and involved participants of different ages, sex, and eth-nicities. Discrepancies in assessment and follow-up times were reported between studies.13,14,17–19,23,25,33

CONCLUSION

Muscular strength, balance, and mobility are deter-minately affected by severe burn injuries. Because functional outcomes are the prime focus in burn rehabilitation, the current study used objective mea-sures that provide a more detailed assessment of muscle strength, balance, and mobility in a severely burned adult population. Therefore, these results can guide therapists in creating rehabilitation pro-grams that focus on the specific difficulties faced by each patient.

REFERENCES

1. Pereira C, Murphy K, Jeschke M, Herndon DN. Post burn muscle wasting and the effects of treatments. Int J Biochem Cell Biol 2005;37:1948–61.

2. Hart DW, Wolf SE, Mlcak R, et al. Persistence of muscle catabolism after severe burn. Surgery 2000;128:312–9.

3. Diaz EC, Herndon DN, Porter C, Sidossis LS, Suman OE, Børsheim E. Effects of pharmacological interventions on muscle protein synthesis and breakdown in recovery from burns. Burns 2015;41:649–57.

4. Ibebunjo C, Martyn J. Disparate dysfunction of skeletal muscles located near and distant from burn site in the rat. Muscle Nerve 2001;24:1283–94.

5. Baker CP, Russell WJ, Meyer W 3rd, Blakeney P. Physical and psychologic rehabilitation outcomes for young adults burned as children. Arch Phys Med Rehabil 2007;88(12 Suppl 2):S57–64.

6. St-Pierre DM, Choinière M, Forget R, Garrel DR. Muscle strength in individuals with healed burns. Arch Phys Med Rehabil 1998;79:155–61.

7. Grisbrook TL, Reid SL, Edgar DW, Wallman KE, Wood FM, Elliott CM. Exercise training to improve health related quality of life in long term survivors of major burn injury: a matched controlled study. Burns 2012;38:1165–73.

8. Nedelec B, Hou Q, Sohbi I, Choinière M, Beauregard G, Dykes RW. Sensory perception and neuroanatomical struc-tures in normal and grafted skin of burn survivors. Burns 2005;31:817–30.

9. Schneider JC, Qu HD. Neurologic and musculoskeletal complications of burn injuries. Phys Med Rehabil Clin N Am 2011;22:261–75, vi.

10. Schneider JC, Holavanahalli R, Helm P, Goldstein R, Kowalske K. Contractures in burn injury: defining the prob-lem. J Burn Care Res 2006;27:508–14.

11. Kowalske K, Holavanahalli R, Helm P. Neuropathy after burn injury. J Burn Care Rehabil 2001;22:353–7; discussion 352.



12. Ebid AA, Omar MT, Abd El Baky AM. Effect of 12-week isokinetic training on muscle strength in adult with healed thermal burn. Burns 2012;38:61–8.

13. Suman OE, Herndon DN. Effects of cessation of a struc-tured and supervised exercise conditioning program on lean mass and muscle strength in severely burned children. Arch Phys Med Rehabil 2007;88(12 Suppl 2):S24–9.

14. Alloju SM, Herndon DN, McEntire SJ, Suman OE. Assessment of muscle function in severely burned children. Burns 2008;34:452–9.

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16. Ebid AA, Elsden AM. Long-term assessment of eccentric, iso-metric, concentric muscles strength and functional capacity after severely burned adult. Int J Physiother Res 2015;3:1024–31.

17. Cronan T, Hammond J, Ward CG. The value of isokinetic exercise and testing in burn rehabilitation and determination of back-to-work status. J Burn Care Rehabil 1990;11:224–7.

18. Benjamin NC, Andersen CR, Herndon DN, Suman OE. The effect of lower body burns on physical function. Burns 2015;41:1653–9.

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20. Schneider JC, Qu HD, Lowry J, Walker J, Vitale E, Zona M. Efficacy of inpatient burn rehabilitation: a prospective pilot study examining range of motion, hand function and balance. Burns 2012;38:164–71.

21. Finlay V, Phillips M, Wood F, Edgar D. A reliable and valid outcome battery for measuring recovery of lower limb func-tion and balance after burn injury. Burns 2010;36:780–6.

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24. Leblebici B, Adam M, Bağiş S, et al. Quality of life after burn injury: the impact of joint contracture. J Burn Care Res 2006;27:864–8.

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impairments demonstrate the same response to resistance training as uninjured controls. Burns 2013;39:680–6.

26. Huang MH, Lin YS, Yang RC, Lee CL. A comparison of various therapeutic exercises on the functional status of patients with knee osteoarthritis. Semin Arthritis Rheum 2003;32:398–406.

27. Hinman MR. Factors affecting reliability of the Biodex Balance System: a summary of four studies. J Sport Rehabil. 2000;9:240–252

28. Kauffman TL, Nashner LM, Allison LK. Balance is a critical parameter in orthopedic rehabilitation. Orthop Phys Ther Clin North Am. 1997;6:43–78.

29. Nashner LM. Balance Master Systems: summary of key clini-cal findings in the literature. Clackamas, OR: NeuroCom International, Inc; 1998.

30. Williams G, Robertson V, Greenwood K, et al. The high-level mobility assessment tool (HiMAT) for traumatic brain injury. Part 2: content validity and discriminability. Brain Inj 2005;19:833–43.

31. Williams G, Robertson V, Greenwood K. Measuring high-level mobility after traumatic brain injury. Am J Phys Med Rehabil 2004;83:910–20.

32. Williams GP, Greenwood KM, Robertson VJ, Goldie PA, Morris ME. High-level mobility assessment tool (HiMAT): interrater reliability, retest reliability, and internal consisten-cy. Phys Ther 2006;86:395–400.

33. Suman OE, Thomas SJ, Wilkins JP, Mlcak RP, Herndon DN. Effect of exogenous growth hormone and exercise on lean mass and muscle function in children with burns. J Appl Physiol (1985) 2003;94:2273–81.

34. Diego AM, Serghiou M, Padmanabha A, Porro LJ, Herndon DN, Suman OE. Exercise training after burn injury: a survey of practice. J Burn Care Res 2013;34:e311–7.

35. Porter C, Herndon DN, Sidossis LS, Børsheim E. The im-pact of severe burns on skeletal muscle mitochondrial func-tion. Burns 2013;39:1039–47.

36. Merritt EK, Thalacker-Mercer A, Cross JM, Windham ST, Thomas SJ, Bamman MM. Increased expression of atro-genes and TWEAK family members after severe burn in-jury in nonburned human skeletal muscle. J Burn Care Res 2013;34:e297–304.

37. Malenfant A, Forget R, Amsel R, Papillon J, Frigon JY, Choinière M. Tactile, thermal and pain sensibility in burned patients with and without chronic pain and paresthesia prob-lems. Pain 1998;77:241–51.

Indian Journal of Physical TherapyAn Indian National Journal

www. indi anjournalofphysicaltherapy.com

M

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-

L*t, December 2014 ]

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Indian Journal of Physical Therapyu'u'u'. indi anj ounalofphysic a ltherapy. c om

EditorDr. Dinesh M. Sorani.M.P.T. (Physical & Fturctional Diagnosis),Senior lecttuer,Gover:rment Physiotherapy College. Januragar

Eruail:editor@ indianj otrmalof,ihys icalthelapy. c omPlrone: +91-94267 86167

Associate EditorDr. Palas JoshiM.P.T. (Neurological Conditions)VC H.O.D. Physiothelapy Depattrnent,Civil Hospital. Rajkot.

Advisory BoardDr. Nita Vyas (Ph. D.)Principal.S.B.B. College of Pltysiotherapy,Alunedabad

Dr. Anjali BhiseM.P.T. (Cudio-hlmonaty Conditions)Principal.Governruent Physiotherapy Colle ge.

Alunedabad

Dr. Yagna ShuklaM.P.T. (Or"thopedic Conditions).Senior Lecttuer,Government Physiotherapy Colle ge.

Alunedabad

Dr. Sarla BhattFomrer Principal.Sh'i. K. K. Sheth Physiotherapy College.Rajkot

INDIAN JOURNAL OF PHYSICAL TrrERApy VOLUME 2 rSSUE 2 (ruL-DEC 2014)

PHYSICAL THERAPY PROFESSION PERCEPTION BY PHYSICIANSAI\D MEDICAL STI'DENTS IN SIJDAYR REGION

Amal Mohamed Abd El BakyrPhysical Therapy Department, Collage of Applied Medical Science (CAMS)- MajmaahUniversity, Kingdom of Saudi Arabia, Physical Therapy Department for Surgery Facultyof Physical Therapy, Cairo University, Gba, Egtpt

ABSTMCTBackground: Physiotherapy has been detined as a dynamic health carc profession with establhhed theorctical andwidespread clinical opplications in lhe presertation, development and reslorotion oloptimal physicallanctiorr:s. Wilephysicol therapisl is a member ofprlmary care ream. He has an importont rcle in improving public health ond meetingnational larget* Physical therupy mainly depends on relerrals lrom physicians of differenl fields of medicine so poorknowledge aboul physicol therapy prolession may lead to misconceptions about the prolession and inler-pmfesionalconflicts.Subjects: 150 persons "phlxicians of many facilities in Sudayr region and medical sladents ftom the foculE ofmedicine at Al Majnaah Lhh,ersitl," participoted in this stutly. Methotls: A suney rould be done about phl,sicoltherapy prolession lrom views ofphyicians and medicol students A se[-developed closed --cnded quesrionnaire wasdesigned. The questionnaire incluited infon rdtiorrs on participonts' demognphic dato, percErtion of phl,sieal therup1's ubspecialties, roles, and modalities.Objeaivus: The aims of this study wsTs n rinlt to cbrtly the importance of phpical therapy professlon and to highlightthe role of physiotherapist as a member of medical leam.Results: The resuhs reveoled that there wos high awareness about physicol therapy (P7) subspecialty regadingorlhopedics wlth a percenlage of 95,i% os well as to exercises os one of physical therapy modalitl, nirn a persenhgeof 95,i%. ln confia,:st it showed lack of awareness regarding the PT nodality as hydrolherapy with o percenlage of56o/q

Conclusion: The study concluded that there is deficits in the perception in dffirent areos regarding to PT professionThis lack of atareness musl be overcoma

KEYI{ORDS: Physlcal therapy; Rob of physiotheropy; PT modafirtes; PT perception

INTRODUCTION

Physiotherapy (PT) is defured by theWorld Confederatiou of Physical Therapy(WCPT) as "sen'ices to people aud populatiorx tode'r'elop. uraintain and restore uuxinrunrurovemerrt aud frurctiorml ability tluotrgdrout thelife span" l. It also corrunonly knour as physicaltherapy. \[4rile physiotherapist (also physicaltha'apist) is a rueurber of primary care teaor2' 3.

The physiotherapy sen'ice gained its importancein developed rratious rvhich is offered tluouprhprinury health centers and frurded by the ptrblichealth systeru after having rulderctood the need ofthis service iu prevention. prourotiorr. cruative arrd

rehabilitation of health for the individual andpopulatiou. Heuce the professiou has a gooddevelopmeut and the scope is grou'ing each year.

but. there is not equal iurportauce given tophysiotherapy sen,ice and its profession iudevelopilg worlda.

As a result of increasing incidenceof disability aud deficits resulting froru trafficaccidents. the deurand to ruedical rehabilitation isincreasiug. For this reasoll the govenuuerrt of theKingdom of Satrdi Alabia represented by theMinistry of Health is interested in providingrehabilitation serrices to rehabilitate these cases

tluough providing hospitals. rehabilitation centers

and rnedical departruents in all regious of the

Kingdout'.Physicians have profourd infltrence on

other health professious incltrding physiotherapyas they are at the 'top of the pyraruid' of lrealthcare professiolrals6. Generally. patieuts still relyon physicians for reconuuendation to other healthcare professionals. Medical referrals sen'e notonly as a tool for corruuunication. but as alindicator of the level of a$%reness ofphysiotherapy by referring health careprofessionals?.As'*'ell as turdergradtnte rnedicalstudents represent a key target becarrce they are

the ftlhue physicians. Also. shrdents lrave beenfouM to be socially represelltative ofthe geueralpopulation in their assessutertss.

According to Jackson (2004)e. lack oflorowledge about a profession may lead toruisconceptions about the profession aud iuter-professional conflicts. Thus. turderstanding ofphysiciaus' and medical students' perception ofPT professiou u'ould help the uredical teaur toprovide better health care sen'ices.

OBJECTIVES

The objectir.es of this research are to:clarify the iurporlance of physical therapyprofession and highlight the role of

-----54-----

TNDIAN JOURNAL OF PI{YSICAL THERAPY VOLUME 2 ISSUE 2 (ruL-DEC 2014)

physiotherapist as a meruber of medical tearnexplore the perceptious. r'iews of physician and

rnedical studeuts abotrt the physiotherapyprofessiou. ideutifu areas ofdeficit in physicials'and medical students' perception ofPT profession

in Sudayr region- and update the knowledge ofptrblic about physiotherapy profession to benefitthe health eare process.

REVIEW OF LITRATURE

A profession is a vocation obtainedtluotrgh edtrcation in a college or ulirersity whichgives identification. shares coruuron valtres and do

sen'ices for public good by also having

responsibility for knowledge de't'elopurent and

researchlo Wlrile professiouals are the people

u'ho pmctice specialized lurou'ledge i.u the fieldfor a feerr. In addition healthprofessionals are the

one u'ho deliver health care serwice tluoughprerentive- pronrotire. cruative and rehabilitativeacti'i'itie s for individuals and conmunityl2.

PT is considered as one of health care

professiol carried out by physiotherapists rihorntlu'ougrh their exaurination. evaltration. and

physical inten'ention skills q'orks on healing ofiurpainuents and disabilities aud also helps inpromoting anrbrrlation. frurctional abilities.quality of life and nroventettt2. However. oue ofthe rnajor objectives that should not be igrrored byphysical therapy professiou is to 'l>rornote the

health and uell -being of people with disabilities"t3. PT involves the interaction betrl'een the

physical therapist. patients/clients. other healthprofessionals, farnilies. care givers and

conunturities in a ptocess w'here ruoveluentpotential is assessed and goals are agreed upon.

rsing knou,ledge aud skills rurique to physical

therapists" t1. Physiotherapists often urainlydepend on referrals frour physicians frour the

different fields of practice of tuediciner5. Since ahigh standard of patieut care is the goal of the

medical teanl so effective conunturicationbetu'een the physician and the physical therapistis necessary to enstue this level of carel6.

The extensil'e knou'ledge inphysiotherapy and the broad scope ofphysiotherapy par,ed the way of uruchspecialization within the physiotherapyprofession. The specializatiorx which are

registered in Arnerican Board of Physiotherapythat list eight specialist certificatiotrs . q'hich are

(l) cardiovascrrlar' &pulmonary physicaltherapists rx'ho treat a u'ide variety of individtralsu'ith cardiopulrnonary disorders or those rrhohar.e lmd cardiac or pttlmonary strrgery. (2)clinical electrophysiology is a specialty area

vl'hich ellcourpasses electrotherapy.electrophysiological evaluation. physical agents.

and wourd rnanagement. (3) geriatric

physiotherapist co\€rs a wide area of isstres

conceming people as they go tluough nonrmlaging asl arthritis. balance disorders. etc.. (4)

neuological physical therapy is a field foctued on

working with individuals'*'ho have a neuologicaldisorder or disease as Palkinson's disease. spinal

cord injury. and stroke. (5) orthopedic physical

therapists diagnose. manage. and treat disorders

aud injruies of the muscriloskeletal system

incltrdiug rehabilitation after orthopedic sugery.(6) pediatric physiotherapist assists in early

detection of health problenx and uses a u"ide

rariety of modalities to treat disorders in the

pediatric populatiou. (7) sports phlsical therapists

are irn olved in the care of athletes fromrecreational to professional and Olyurpians. Tlisarea of practice incltrdes athletic irr.j.oy

ruarup(ement. incltrding acute care. treatmeut and

rehabilitation. preveution. and edtrcation. aud (8)

women's health PT addresses rl'ouren's issttes

related to child birth, and post-parttun. These

conditions include lynrphederua. osteoporosis.

pelvic pain. prenatal and post-parturnperiods. and

urinary incontineucel ?'I8.

There ale u'ide r.ariety of iaten entions

in physiotherapy they are: therapeutic exercises.

u'lrich are plarured physical fllot:eulents. Postu'esand actir,ities to pter.ent itnpainuents. Protuotefrrnction. redtrce risk. optimize or.erall health aldiurpror,e fitness and u'ell-being le'20.

electrotherapy: it is using the electrical energy fortreatluent of uredical conditiottsle'2l. aimayclearance teclutiqtres. which irn'olves clearing the

ainray for an irnproved breathing using differenttecluriqtres like posttual draiuage. deep breathingexercises. spinal nrobilizatiott. vigorots chest

urassage. suctiordngr. positioling etc le'22. nranual

therapy tecluriqtres: these are hands ou tecluriques

like nuniptrlation and mobilization for assessmellt

and treatnrent ofjoht strucflu'e and soft tissrresle'23

. physical ageuts aud mechanical nrodalitieslphysical agents are different fonns ofenergy ardnraterials used for theraperrtic purpose byapplylng or.er the body and they include heat and

colcl while urechauical nodalities are trsed toapply rnechanical force which can increase ordecrease presstue in the body . prescriptiorr and

applicatiorr of mobility aids like u'heel chair'.

crutches. canes. walker and assistive devices likeorthotics and prostheticsle .and therapeutic

uussagel that pror.ides pain reliefto soft tissues.

decrease rntrscle toue. inrprove lynrphaticdrainage aM induce relaxatiou (physical&rnental) to the bodyre'24.

MATERIALS AND METHODS

Study Design: Ctoss-sectional shrdyu'as approved by the Research Ethical Couunitteeof Basic and Health Scieuce Research Centre

---55---

INDIAN JOURNAL OF PHYSICAL THERAPY VOLUME 2 iSSUE 2 (ruL-DEC 2OI4)

*BHSRC". Majuraah University. Kingdom ofSatrdi Arabia.

Subjects: A sauple of 150 person(73.3o/o nrale and 26.70/o felll:lr,le) was participatedin this shrdy. It cousisted of I l0 physiciaus frourdifferent specialties $tro are practicing hr variousfacilities in Sudayr regiou iu addition to 40uredical sftideuts frorn faculty of ruediciue-Ivlajruaah University. Table.I slrorl'ed thedenroplaphic data of the sanple.

Qucstionnairc Dcsign: A self-developed qtrestioruraire was trsed to explore theperceptiots and \tews of physician and uredicalstudeuts about the physiotherapy plofessiou. Lrorder to ascertain conterrt r,alidity.nvo copies ofthe initial draft of the qtrestioruraire seut to t,\,ophysiotherapy educators fi'om the College ofApplied Medical Sciences. Pilot tested of thequestioruraile was conducted on l0 practiciugphysicians to eostue that the questious are clearlystated aM easily be turderstood by therespoudeuts.

The questiorulaire consisted of 3

sections: section A: incltrded collectedinfor:nation ou persoual characteristics such as:

age, sex. nationaliry. specialty and city,section B;included collected infonuation on educatioualattairuneut. ruriversity of gadtration. yeal ofgu:aduatiou. working relatiorxhip u'ithphysiotherapists. rate of referral forphysiotherapy. section C: incltrded infonlationabout the perceptiou of physical therapysubspecialties, urodalities. physical thelapy role.soruces of infonuatiou concenriru physicaltherapy professiou. and the extent of iruportanceofphysical therapy role as a rnenrber ofuredicaltearu. and sectiou D: for other snggestiorx.

The airus of the study u,otrld be clearlystated irr a cover letter *ns attached to each copyof the qtrestioruraile to clarifu tlre iurportarrce ofthe study.

Proccdures: A total ruuuber of 200questioruraires distrtbuted frorn Octobel lil to 30e2013. to the physiciau arrd ruedical shrdent inSudayr region. The parlicipants \\'ere griven l0urLnrtes to review the strn'ey for auy queries orrequired explanatiou. and they rvere given a oneweek to courplete the suvey.

Data Analysis: Data were aualyzedusing SPSS statistical software. versiou 20.Descriptive statistics u'ere done to deteuninerespouse frequencies and perceutages.

RESULTS

Of the total 200 questiorurailesdistribtrted, I 50 questiorurailes *'ere retruled.

Demographics

Analysis of demopraphic data revealedthat the majority of the rcspondetts for tlus studywere male u,ith a perceutage of 73.3% ard26.70/oof this percentage were sttrdents frorn the facultyof medicine Majmaa'h University. Theparticipants age percentages rn'ere 32% fronr 20-

-30 y. 28% frour 30-40 y, 30o/o frour ,10-50y andl07o above 50y. It also slrou,ed that intenraluedicine specialty is the urajor specialty rvith a

perceutage of 13.3% ard theu orthopedic andpediatric u.ith 10.7% aud 8.7 respectively.(Tablel)

TABLE I . SUMMARY OF DEMOGRAPHICDATA

Variables N o/o

SexlvlaleFmela

11040

73.3o/o

26.7o/o

Agc (v)20-30304040-50above 50

484245t5

32o/o

28o/o

30%lU/o

Srudeut 40 26.1ot'o

Specialty of physiciao:OrfiopedicPediatrics

NeurologyIntml

mcdicineObstetrics and

gloccologyCoouoity medicine

Swgeryothers

l613t720l05

t2l7

10.7o/o

8.7o/o

ll.3o/olJ.3o/o6.1o/o

3.3o/o

8o/o

ll.Jo/o

llesults of tlre lirst question '\vltich ofthese subspecialtl' are consideled to be relatedto physiotherapy?"

Table 2 shoued that the ldgltestpercentage of awareness of PT subspecialty u'ereorthopedic. netuolopry and interual uredicine u'itha percentage of 95,3yo,82% aud 680/o

respectil'ely. u'hile the lowest awareuess wereotrstetrics & gyrecology , pediatrics and burrs

'a'ith a percelrtage of 660r'o. 63.70/o alod 56.'10/o

resPectively.

Results of the second question "which of thefollowing is consldered os PT modality?"

As revealed il fig 2 about 95.37o of thetotal sarnple was aware of exercises as a PTurodality. Respondent perceptiorl of urauualtlra'apy. ruassage and electrotherapy were 87.3o/o.

827o and 71.37o respecti\:ely. In addition itshowed that the lorvest a\rarelless of PTruodalities were ['actiou and hydlotherapy with a

perceutage of 56.7o/o ard 56Yo respectively.

-----56-----

PT subspecialty SR R UC U SU

N(%) N( 7c) N(%) N( o/") N( o/")

Orthopedics 77.Jo/o

il6l8o/o

274.'l a/o

Y" yo

Pediatrics 4.7 o/o

732o/o

4816.7 o/o

55l8o/o27

8.7 o/o

13

Neurology 553o/oR1

26.7 o/o

404.7 o/o

7

4.7 o/o

7

8.7 o/o

l3Cardiopuluonary 24 o/o

3624o/o

3616o/o

2424 o/o

1612o/o

l8Swgery 10%

15

36o/o

5474o/o

2ll4o/o

2t26 o/o

t9Bums ZQ"/o

302J.J Uo

3532o/o

48l@/o

l514.7 s/o

22Intemal medicine and Geriatric 26.7o/o

4041.3 o/o

62

13.3 o/o

2018.7o/o

28yo

Obstarics and Gynccology 4.7 o/o

7

29.)o/o

4446.7 o/o

70l9.l o/o

29V/o

SR: StrorEly related R: Rolatad UC: Unertain U: Unrelated SU: Slrongly unrolsted

INDIAN JOLTRNAL OF PHYSICAL THERAPY VOLLME 2 ISSUE 2 (ruL-DEC 2014)

TABLE 2. THE FREQUENCIES AND PERCENTAGES OF PHYSICAL THERAPY SUBSPECIALTYAWARENESS

Fig 1. Perception of physical therapy modalities

1m

EO

60

do i;i:

Electrotherapy Hydrotherapy Exerclses Manual Therapy Marsage Tractlon

1SR rtR rUC rU IsU

': iiiiiHf; r ir,,H*tl .',iim, ,,,i'm*,- i.,, ffi*" :ii'',ilnll

TABLE 3. PERCEPTION OF PHYSICAL THERAPY ROLE

PI roleSR R UC U SUN o/o N% N o/o NVo N o/o

Mahtain and improve physicalfunction

77 .f o/o

ll618 o/o

27 v' 4.7 o/o

7

lf/o

Lnprcve mobfity 82 o/o

t2113.3 o/o

20yo 4.7 o/o

7yo

Reliefpain 40 o/o

6035.1q/o53

OYo5

Wol5

47 Vo

7

Improve balancc46Yo

69

4V/o60

l4o/o

2ltJYo 0"/o

Rehabiliution of postopcratil'eoatimt

l8o/o27

l4o/o

2l18o/o27

ll "/o4t

2)"/o34

Mainuin aod ioptove rrusclesstreccth

7lo/o

107

lCP/o

15

JYo

7

4"/o

6

Wol5

Luprove noovement dlsfiinctionl).3Yoilo

22%33

4.7o/o

7

OYo lf/o

Improve endurance36.7o/o55

36.7o/o55

21.3o/o

1)5.3%R

0o/o

---57---

INDIAN JOURNAL OF PHYSICAL TlrERApy VOLUME 2 ISSUE 2 (ruL-DEC 2014)

Fig2. Source of information about PT profession

iiir: mffiHnConferences

MEWork experiences

ID lSD

mfftlnternet a nd resea rchesStudylng ertperlences

'n,SA IA Stjf

Fig 3. lmportance of physicaltherapy role as a member of

I f lessthan 20% ry20-4}o/o fi4}-6}o/o ii:i60-80% i:::80-100%

Results of the forth question " Whot are yoursources of lnformation about PTprofession?'

The restrlts of this srudy represented thatthe nrost comluon sotuce of itfonrution abotrt PTprofession was iutenret& researches u'ithpercentage ofawaleness 8 l .3% while confereuceswas cousidered as the lowest soruce withpercentage of awareuess 36.70/o. The results alsorevealed that snrdyirg and work experiencesrepreseuted high level of awareuess with a

percentage of 76.7Yo and 63.3% respectively.(Fig2)

Resulrs of the third questlon "whlch of thefollowtng do you thlnk ls one of PT role?"

Coucemiug of this qtrestion. rnost of thel€spor$es represented that the respoudeuts had a

good perception in relation to PT role. PT roles'luaintain &inrprove ftlnction, iurpro'r'e mobiliry.

aud inrprove uloveme[t dysfrurction" represented95.3% for each of the total sarnple. The resultsalso shou'ed that the respondents had a lou'estal'afelress by 680/o for the PT role related torehabilitation of postoperative patieut. (Table 3)

Resulfs ol the fifth question: "To whot extentyou are convlnced of the importance ofphysical therapy role as o member ofmedical team?"

Fig 3. Showed that 66 of the respondents( 44'O were corwinced of the irnportance ofphysical therapy role as a meruber of rnedicaltearn by 60o/o-80oh. nhile 48 of the total saurple(32%) were convinced by 80%o- 100%.

DISCUSSION

This srudy was conducted to ideutifyaleas of defrcits in physical thelapy professiou

medicalteam

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60

40

INDIAN JOURNAL OF PTTYSICAL THERAPY VOLUME 2 iSSUE 2 (ruL-DEC 2OI4)

perception by physician and ruedical shrdents inSudayr region. in addition to clarifu the

iurportance of physical therapy profession and

highlight the role ofphysiotherapist as a ureurber

of medical team.The results of this shrdy ildicated tlut

there was a higilr awareuess of PT subspecialg'asorthopedic. netuology and iutemal ruedicine. Thisfindings suppofi other furdings strggesting tlmtphysical therapists are best l<rrowu for treattueut ofmtrsculoskeletal conditions2s'26. Additionallytreatment of neurological conditious is urore

conunonly recoprized. Other subspecialty such as

obstetrics aud gynecology. bum and stugerylacked fauriliarity and this is sirnilar to a previonsstudy conducted by Sheppald25.

Regarding PT ruodality the restrltsrevealed that. there u''as a hipilt auareness ofexercises and also for uranual therapy.electrotherapy and nrassage iu contrast there was

lack of awalelless regarding traction aMhydrotherapy. Pafti and Litr2t concluded that

taditional treatrnent such as physical exercise.massage. versus nrodent treahneut. such as

electrical stinrulation aud ultrasourd are stillu'idely associated with PT. The furding of ousnrdy related to exercise and massage is sttpportedby public an?reuessl4

According to the results. the participantshou'ed au?reness regarding the physical therapyrole related to impror.e mobility. improve frurctionand relief pain which u'as supported by previotrsshrdyla'2?.

Regarding the strbjects' a$'|aleress

related to soruces of infonnation abotrt PTprofession the shuly shou'ed that intemet.researches and confereuces are tlte conunonsoruces respectir,ely. in contrast sttrdying andu'ork experiences are less conuuon. Sixty sex ofthe shrdy saurple represeuted that physiotherapistis considered as an inrportant nrember of thenredical tearn by a percentage of 60Yo-80o/o.

CONCLUSION ANDRECOMMENDATION

Frour the preriorts. the study concltrdedthat thete is deficits il the perception of PT indifferent areas. This lack of a\j!'arerress must be

o\ercome. As a high standard of patient care is thenrain goal of uredical tearn so effectivecouunurication betu'een physician and physicaltherapist is necessary to eustue this level of care'

As well as physical therapists shorild center effortson nmrketing to physician and rnedical studetrts28.

Continuing edrrcation progranx is strggested toincrease PT profession awalerless. Additiorully itis reconmended that urass uredia should beiurproted in its accruacy about PT2e.

Further shrdies shotrld be conducted ou

Saudi physiciau ouly. As well as perception of PTshould be evaluated in relation to patients.

AKNOWELEGEMENT

First of all I u'ould like to thanli and

appreciate the Deanship of Scientific Research forits fumrcial strpport. As well as I thank all ofindir.idual those involved directly or indirectly inhelping ure to cornplete ury sttrdy.

REFERENCES

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The Nahue of Physical Therapywebpagel20l lAr-ailable frour: IIRL : htt ://rl'urr'. wcpt.orp/polic ies/description Ailhatis .lrtml.

2. Wikipedia. Physical therapy. Wikimediafourdations hrc.: 2012 [last cited 2012 April22l.Arailablefr our: htt://en.r*'ikipedia. orp/wiWphysicaltherapy

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Physical Therapist: Examination and Triage.Elser.ier Saunders. Philadelphia: 2005.

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I l. Wikipedia. Professional: Wikimediafoturdation Inc. 2012 [ast cited April 2012].Available from:lrttp : /ien.u'ikipedia. org/u'iki/Professional

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lrqr :/lunr"rv. hea lthypeopl e. go t- i 20 20 /abotrt/default.aspx.Sheppard L, Changing the public perceptionof physiotherapeutic treatmeut. Health andMarketing Qtrarterly. I 99 4: 12 (2): 7 1 -95.Stnrber JC. Plrysiotherapy in Austalia -Where to now?The Joruual of Allied HealthScieuce and Practice. 2003:19(2): l0-25.Jauet BH. Betsy WB and Jolur WL.Couuurnication Betu'eeu Physiciaus andPhysical Therapists. PIfYS THER. 1988:68:26-3 1.

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slraped and defined bypatieuts. PT Magazi.ne.2005 Febnrary: I3(2):46-52.Ogiu'alaS.Knou'ledge of physiotherapy: Astudy of Ishikarva HiCh Schoolsftrdents.2O04: 17(l): 9-16

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