RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
ANNEXURE II
Performa for registration of subjects for dissertation.
1 / Name and address of candidate / PATHAK JAY KUMAR BHANUPRASAD Alva’s College of Physiotherapy,Moodbidri
574227.
2 / Name of institution / Alva’s College of Physiotherapy,
Moodbidri,
Karnataka
574227
3 / Course of study and subject / Master of Physiotherapy
(Musculoskeletal and Sports Physiotherapy)
4 / Date of admission to the course / 16th july-2012
5 / Title of study / CONCURRENT VALIDITY OF FLEXICURVE METHOD IN MEASURING THORACIC KYPHOSIS WITH TRADITIONAL PROTRACTOR METHOD
6. BRIEF RESUME OF THE INTENDED WORK
Kyphosis(from Greek –kyphos, a hump), also calledroundbackor Kelso's hunchback, is a condition of over-curvature of thethoracic vertebrae (upperback). It can be either the result of degenerative diseases such asarthritis, developmental problems, osteoporosiswithcompression fracturesof thevertebrae, or trauma. The thoracic kyphosis angle increases with age and the increase are greater in females than males.
There are several kinds of kyphosis, Postural kyphosis the most common type, normally attributed toslouching can occur in both the old and the young Scheuermann's disease is considered a form of juvenileosteochondrosisof the spine. It is found mostly in teenagers and presents a significantly worse deformity than postural kyphosis congenital kyphosiscan result in infants whose spinal column has not developed correctly in the womb. Nutritional kyphosiscan result from nutritional deficiencies, especially during childhood, such as vitamin D deficiency. Post-traumatic kyphosisafter untreated or not treated effectively vertebral fractures. An increased thoracic kyphosis has also been associated with diminished physical function, impairment of respiratory function, an increase in cervical pain, headaches and shoulder conditions such as subacromial pain syndrome. The rationale for the relationship between the thoracic kyphosis and the development of subacromial pain syndrome is complex. It has been proposed that as the kyphosis increases the scapulae become more protracted and downwardly rotated leading to a potential compression under the acromion and the subacromial tissues included the subacromial bursa and rotator cuff.
While most cases of kyphosis are mild and only require routine monitoring, serious cases can be debilitating. High degrees of kyphosis can cause severe pain and discomfort, and also causes orthopaedic problems like low back pain, Scapular muscle weakness, compromising respiratory capacity and digestion difficulties,cardiovascularirregularities,neurologicalcompromise and, in the more severe cases, significantly shortenedlife-spans .The structural kyposis do not respond well to conservative treatment, and almost always warrant spinalsurgery, which can successfully restore the body's natural degree of curvature.
There are handful of radiological methods to measuring thoracic kyposis available universally. The use of those instruments such as the Moir´e topography the spinal pantograph, the recognition of spine malformations and measuring the back curve angle is possible through a variety of invasive like protractor method, cob, alternative cob angle and non-invasive methods. Methods as CT scan, MRI, and radiography images are among the invasive methods which facilitate such measurement 19. The most popular technique of assessing spinal curvature on radiographs has remained for more than five decades the Cobb method. In this technique, the angle of interception sustained by the most tilted upper and lower vertebrae of a spinal curvature is measured manually using a protractor; the so-called traditional method.
The non-invasive methods are divided in two groups of contact methods (using kyphyometer and inclinometer, flexible rulers, spinal panthograph, electro set-square meter, spinal mouse, and image processing methods), and non-contact methods (including NewYork Test, observational sieve )20. So far, the validity of the flexible ruler has been reported as acceptable in various reports 21,22,23,24,25,26. There have been various experiments in which the validity of spinal mouse was reported to be relatively high and acceptable27,28 , though in some of these researches, the validity was not reported to be adequate enough , this technique an investigation of the inter-rated reliability of the procedure is required. Takahashi and Atsumiwere the first to describe the Non radiological method of flexicurve. Milne and Lauderdescribed the first method of utilization of the flexicurve in the clinical setting.
6.1 NEED FOR STUDY
There are few non radiological tools to assess thoracic kyphosis their validity and reliability are still questioned. Flexicurve method is one of the non radiological evaluating methods to measure thoracic curve so for flexicurve studies have proved its validity and reliability. As Dreyfuss et al21 stated, before additional resources are spent on improving reliability of the flexicurve device, a validity study comparing the surface measurements to radiographic measurements of cervical lordosis is warranted. Up to date there are few studies are supported.
Thus it is necessary to come out a study to prove its reliability and validity to be used is clinical practice and non radiological measurement tool for research aspect.
OBJECTIVES OF STUDY
To compare concurrent validity of flexicurve method in measurement of thoracic kyphosis with traditional protractor method.
Keywords: - Thoracic kyphosis, Traditional protractor, flexicurve
HYPOTHESIS
HYPOTHESIS
Null hypothesis
There will be no significant result difference between in the measurement of thoracic kyphosis by flexicurve method and traditional protractor method.
Experimental hypothesis
There will be significant result difference between in the measurement of thoracic kyphosis by flexicurve method and traditional protractor method
6.2 REVIEW OF LITERATURE
Tatiana Scheeren de Oliveira, Cl´ audia Tarrag et al 1, (2012) conducted a study on the validity and reproducibility of using flexicurve method measure thoracic spine curvature. In this flexicurve method is non radiological method while measurement of cobb’s angle is radiological method. Evaluation was done on 47 subjects by the method of palpitation and marking on spine by lead marker. Using x-ray to measure cobb’s angle. Flexicurve method to measure the spine curvature. Drawing the contour of the flexicurve on the graph paper. conclusion was found that no difference were found between the cobb’s angle and angle in the thoracic curvature (p>0.05) correlation were strong and significant for the thoracic (r=0.72) (p<0.01) result shows no significance difference between values obtained from flexicurve method by cobb’s angle, Suggested Both methods are excellent and recommendation for use of clinical practice.
Deed E. Harrison, DC, Jason W. Haas, DC, Donald D, et al2;(2005) conducted a study on to evaluate reliability of a simple instrument the flexicurve in determining cervical sagittal skin contour. This study was done by using flexicurve method to measure cervical spine curvature. This study completely based on non radiological method. This study is based on repeated random measurement. This study done on 30 subjects randomly (23 men, 7 women) by 3 investigators once per day over a 2 day trial period. 30 subject examined twice by 3 separate investigators with one day delay. The investigators were not privy to the results of each other’s measurements.
In examination, investigators placed the flexicurve on the external occipital protuberance to the vertebral prominence and traced a flexicurve shape on to the paper. Interexaminer and intraexaminer corretation coefficients (ICCS) were calculated to determined reliability. Result were obtained that the flexicurve showed marginal reliability with most ICCS in the poor range (ICC<0.4) and 4 values in the fair range (0.4<ICC<0.5).
Revista brasileira de fisioterapia et al3:(2007) conducted study thoracic kyphosis of 56 people was evaluated from sagittal radiography of the thoracic column using cobb’s method and by means of the flexicurve method by two evaluators. The result was found that the intraclass correlation coefficient (ICC) between the measurement from the cobb’s and flexicurve method was 0.906 for diagnosing thoracic hyperkyphosis the sensitivity was 85%and the specificity was 97%. The conclusion was that the flexicurve method is more suitable quantitative clinical method for measurement of thoracic kyphosis.Flexicurve method is more cheaper and based on non radiological method.
Greendale, G. A; Nili, N. S; Huang, M.-H; Seeger, et al8: (2005) In this study 113 subject were taken whose aged 40-60 with kyphosis angle is 35-400. A cobb’s angle was measured on a standing lateral thoracolumbar radiography and in non radiological method kyphosis made 3 times by single rater and 4th time by blinder second rater.( Debrunner kyphosis angle, flexicurve kyphosis index, and flexicurve kyphosis angle) From this results was found that inter-rater reliabilities for non radiological assessment were high (intra correlation of 0.96 to 0.98)From this result concluded that non radiological measurement had similar reliability and validity. It is the low cost, easy to use method. The approximate conversion factors provided will permit translation of non radiological measure to cobb’s angles.
Teri l yanagawa, keith burgess; liz young,david hanley, et al9 ;(2000) study is based on non invansive measurement and non radiological technique. It can be applied in clinical practice. The purpose of study was to assess the test- retest reliability of the measurement of thoracic kyphosis using flexicurve method. In this study 67 years (mean age osteoporotic female had taken and measurement of kyphosis by flexicurve method. Before and after 12 week exercise program was given to the patients and data analysis Intraclass Correlation Coefficient (ICC) was indicated that the reliability between the trials of the measurement of kyphosis height (0.89) and index of kyphosis (0.93) were high. The reliability estimate of kyphosis length was less with an ICC value (0.54) hence this support the flexicurve method in measurement of thoracic kyphosis.
Yves Miaux, ali guermazi, anke fierlinger, Chun-Ying wu et al 6(2005): this study describe an instrument protractor, which is simple to use measuring angle in spine radiograph.
This is a compared conventional method, measurement obtained with this instrument is reproducible and less time consuming. In this study 40 subjects selected and lateral flexion extension cervical radiography was taken. Radiography measurement of intervertebral flexion and extension motion at two to three cervical joints (range c3 –c6) were taken for each patient all measurement were obtained independently by three physician in blinded fashion. Result was found that the angulations between the superior end plate of lower vertebra and the inferior end plate of higher vertebra for the given cervical disc space was measure independently by three radiologist. An intraclass correlation and coefficient were determined to asses inter reader. , ICC values for Reader1 & 2, reader 2 & 3, reader 1 & 3 were 0.91, 0.86, 0.86 respectively for Interclass. For intra reader value Reader 1, 2, 3, were 0.94, 0.93, 0.90 respectively,
Lippincott Williams and Wilkins, et al 7: (2005): This study is completely based on radiological method. In this study 53 subject of scoliosis curve were measured by 3 examiner and 2 measurement sets were performed using traditional method while 2 measurement sets using oxford cobbometer and result has found that is protractor method, intraobserveres variability was 9.010 (95% confidence interval 7.32 – 10.88) for the cobbmeter method, the value was 5.1770 (95% confidence interval3.25 – 7.63) the difference between for construction and cobbometer methods were significant(p<0.001) for this it was concluded that oxford cobbometer is easy to use and doesn’t required the drawing of lines on films or use of wide diameter radiographic markers and hence removes some source of intrinsic error compared to traditional method.
7. METHODOLOGY AND MATERIALS
7.1 SOURCE OF DATA –
· 44 subject
7.2 METHODS OF COLLECTION OF DATA –
Research design – cross-sectional reliability study.
Sampling design – Convenient sampling.
SAMPLE SIZE –
Total sample – 44
Group: - 22 flexicurve method + 22 traditional protractor method.
INCLUSION CRITERIA
· Age –25 to 60 years
· Gender –Both
· TB thoracic spine
· Scuremanns disease conformed by orthopaedic surgen
· All pronounced round shoulder participants and patients
· Ankylosing spondylosis conformed by orthopaedic surgen
· Orthopaedic spinal developmental thoracic kyposis
EXCLUSION CRITERIA
· Presence of spinal instrumentation.
· Unstable fracture spinal cord injury .
· Disability
PROCEDURE
Subjects who fulfill the inclusion criteria will be selected for the study. Consent will be obtained from every participating patient. All the subjects will be conveniently divided and the subject will be explained about the importance of purpose of the study.
All the subjects will be assessed by using the
(1)Traditional protractor.
(2) Flexicurve
In the traditional protrctor method 44 subject’s x-ray were taken antero-posterior and lateral view. The radiographs which we used for the study were those of which the end plates were clearly visible. Anonymity and confidentiality of subjects whose radiographs were used were preserved. Radiographs were of kyphotic spines. Each radiograph was labeled with a number for identification purposes and the angle of curvature then measured the traditional protractor. The upper and lower end vertebrae (end plates) were pre selected for each radiograph. The end-vertebrae are the vertebra at the upper and lower limits of the curve which tilted most severely towards concavity of the curve.
In the flexicurve method, patients taken where patient stand in the straight line standing position with normal body posture. Although the spinous processes (T1 –T12) were identified using palpation by only one of the evaluators, the following steps when using the flexicurve to assess spinal curvature. While molding the flexicurve to the contour of the spine, the, T1, T12, spinal process were and recorded using the metric scale incorporated in the instrument. After molding the contour of the spine the flexicurve was removed and the internal edge (the side of the flexicurve in contact with the skin) was traced onto graph paper, thus representing the thoracic. Introduced in an algorithm developed in Matlab software.
The algorithm produce the angles of curvature, occurring between the points representing the spinous process of T1 to T12 for the thoracic curvature and from, based on the following procedures
(1) Two 3rd order polynomial were fitted representing, respectively, the shape of the thoracic curve of the subject under assessment.
(2) The 1st derivative of the fitted 3rd order polynomial was calculated. This procedure provides the equation representing the family of tangents to the 3rd order polynomial. This equation was used to extract the inclination of the tangents to the points T1 and T12 (thoracic)
(3) With the inclination of the tangents and the coordinates of each end point (T1, T12,) it was possible to obtain the equations corresponding to the tangents of these points.
(4) Based on the tangents the equations of the perpendicular lines crossing the meeting points T1and T12 were calculated.