scientific research journal of india (srji vol-2 issue-2 year-2013)

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

ISSN: 2277-1700 Vol: 2, Issue: 2, Year: 2013

Editor in Chief

Dr. Krishna N. Sharma (PT)

Editors

Dr. Popiha Bordoloi

Dr. Kuki Bordoloi

Dr. Sudeep Kale

Dr. Waqar Naqvi

Junior Editor

Mrityunjay Sharma

Office Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403

Website http://www.srji.info.ms

URL Forwarded to http://sites.google.com/site/scientificrji

Email [email protected]

Contact +91-9320699167, 9839973156

CONTENTS

Title Author/s Department Page

Editorial Dr. Krishna N. Sharma i

The Sustained Effect of Short

Durations of Warm Up and

Stretching Exercises on Shoulder

Joint Proprioception

Bala Jyoti, Pacheri Bari,

Gupta Manish, Shaina

Sandeep, Kumar Satish

Physiotherapy 1

Impact of Ageing on Depression

and Activities of Daily Livings in

Normal Elderly Subjects Living in

Old Age Homes and Communities

of Kanpur, U.P.

Vanshika Sethi,

Vijeylaxmi Verma,

Udhbhav Singh

Physiotherapy 9

To Assess the Relationship

between Temporomandibular

Joint Dysfunction and Cervical

Spine Dysfunction

Khyati Harish Sanghvi,

Amrit Kaur, Ganesh

Subbiah

Physiotherapy 17

Effectiveness of Neuromotor Task

Training Combined with

Kinaesthetic Training in Children

with Developmental Co-

Ordination Disorder - A

Randomised Trial

Sundaresan

Chockalingam, Agnel

Kevin Gomes

Physiotherapy 24

Cognitive Rehabilitation in MS Krishna N. Sharma Physiotherapy 39

Network Border Patrol Eradicates

the Over Loading of Data Packets

and Prevents Congestion Collapse

thereby Promoting Fairness Over

TCP Protocol in LAN /WAN

Lakshminarayanan T., Dr.

Umarani R. Computer Science 44

Use of Fuzzy TOPSIS Model for

Evaluating Cooling Towers

Dr. Ali Kheradmand,

Mahdi Naqdi Bahar, Ali

Ghani Abadi

Industrial Management 54

Correction Notice - - 63

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

iv

i

EDITORIAL

Dear Readers! I am very pleased to present this issue of the Scientific Research Journal of India (SRJI).

With this issue. This issue of the multidisciplinary and open access Journal of science contains total 5 papers

in Physiotherapy, 1 paper in Computer Science, and 1 paper in Industrial Management. Hopefully you’ll find

these papers informative.

Here I would like to bring one more thing to your notice that our URLs are hacked so from now our

permanent URL will be http://sites.google.com/site/scientificrji .

Do drop a mail to us ([email protected]) if you have any comment and suggestion.

Happy Reading.

Regards,

Dr. Krishna N. Sharma

Editor in Chief

1

THE SUSTAINED EFFECT OF SHORT DURATIONS OF WARM UP AND

STRETCHING EXERCISES ON SHOULDER JOINT PROPRIOCEPTION

Bala Jyoti*, Pacheri Bari, Gupta Manish**, Shaina Sandeep, Kumar Satish

ABSTRACT

OBJECTIVE: To study the sustained effect of Short Durations of Warm up and Stretching Exercises on

Shoulder joint Proprioception. DESIGN: Pre-test and Post test control group design. SETTING: Inpatient

and rehabilitation hospital. PARTICIPANTS: A total number of 75 subjects free from pain and discomfort

and any pathology in and around shoulder joint are allocated randomly into 1 of 5 groups.

INTERVENTION: Group A received 1 min. of warm up and stretching(n=15),Group B received 2 min. of

warm up and stretching (n=15), Group C received 3 min. of warm up and stretching (n=15), Group D

received 4 min. of warm up and stretching (n=15) and Group E control group received no warm and

stretching (n=15)). All groups received intervention. MAIN OUTCOME MEASURES: A CPM Machine

was used to move a desired joint continuously through controlled ROM without the subject’s active effort. To

measure the JPS, passive CPM was used. Outcomes were measured before and immediately after

intervention and 5 min. after 2nd data. All JPS scores were measured on same day. RESULTS: Outcome

measures for all groups showed the effect of warm up and stretching still persisted after 5 min of 2nd data

collection, except at 150 degrees of shoulder flexion in Group A. At 2 min, 3 min and 4 min of warm up and

stretching, the improvement in joint position sense appreciation were significant at all ranges/target positions

checked and this improvement sustained even after 5 min of 2nd data collection. Also group C i.e. 3 minutes

warm up had the maximum gains, Group A had the minimum gains and Group D had the fewer gains due to

the effects of muscular fatigue as reported by the subjects after performing this warm up.The control group


2

showed the minimum non-significance across all the groups. CONCLUSION: This study concludes that

warm up and stretching exercises improve shoulder joint position sense appreciation and this improvement

sustained even after 5 min of 2nd data collection.

KEYWORDS: Contract-Relax Stretch, Performance, Proprioception, Sports, Injury Prevention

INTRODUCTION

Proprioception is defined as the cumulative

input to central nervous system from specialized

nerve endings called mechanoreceptors. They are

located in the joint capsules, ligaments, muscles,

tendon and skin1. It is currently acknowledged

that proprioception is a complex entity

encompassing several different components such

as sense of position, velocity, movement detection,

and force and that the afferent signals that give rise

to them may well have origins in different types of

receptors2. Proprioception is the ability to

determine the location of a joint in space where as

kinesthesia is the ability to detect movement. Joint

position sense is mediated by joint and muscle

receptors as well as visual, vestibular and

cutaneous input3.

Early research suggested that the joint

receptor had the predominant role in

proprioception and kinesthesia. Joint receptors

have been identified in joint capsules, ligaments,

menisci, labrum and fat pads3. Recent research has

identified ruffini−like ending in the glenohumeral

joint capsules, found pacinian corpuscles in

glenohumeral ligaments, and free nerve endings in

the glenoid labrum of human cadavers3. Most

proprioception research has examined the elbow,

wrist, knee, and ankle. Some authors have

attempted to generalize their findings to other

joints. However, proprioceptive control may differ

depending on the joint tested.

The exact mechanism of proprioceptive

control remains unclear, particularly in the

shoulder. Shoulder proprioception is

indispensable because the glenohumeral joint

relics primarily on dynamic restraint of rotator cuff

to maintain stability. Proprioception may also

affect injury predisposition and rehabilitation.

Several studies suggest that shoulder

proprioception is impaired after fatigue, injury and

in overhand athletes.

Clinicians commonly use proprioception

exercise during rehabilitation of shoulder because

the rotator cuff is vital for glenohumeral joint

stability4. In the present study our focus is on

position sense here in defined as the awareness of

actual position of the limb.

Many researchers have used joint position

sense appreciation tests to evaluate knee joint

performance after the administration of warm up

exercises and stretching of different duration and

intensities. 5,6,7,8,9,10.Stretching is used as a part of

physical fitness and rehabilitation programs

because it is thought to positively influence

performance and injury prevention 11.

Many researchers have used different

durations and intensities of stretching for different

purposes viz. soft tissue extensibility modulation,

prevention of injury during sporting activity and

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

3

also to increase proprioception in human joints. 12,13,14,15,16.Therefore this study is aimed to

investigate whether varying intensities of warm up

and stretching exercises helps in improving

shoulder joint position sense appreciation

METHODOLOGY

A total number of 75 subjects(N-15 X 5

groups) were included in the study, were recruited

from the physiotherapy department of Sir Ganga

Ram Hospital, NewDelhi, India.Subjects (N-15 X

5 groups) were included in the study.

Inclusion criteria were:

1. Mean Age of subject is 20-30 years,

2. Right Hand Dominant

3. Free from pain and discomfort in and

around shoulder joint

4. No pathological conditions affecting

musculo-skeletal and neuromuscular

system.

5. Only Males are included.

Exclusion criteria were:

1. Patients with previous shoulder surgery

2. Patients who have signs and symptoms of

gross shoulder instability

3. Patients who had red flags suggesting

serious shoulder pathology

4. Patients with cardio –pulmonary diseases

5. Patients with tumor, infection and fracture

6. Patients with History of soft tissue injury

within one last year

7. Patients pathological conditions affecting

musculo-skeletal and neuromuscular

system

Subjects who are willing to participate were

interviewed and examined by a clinical

physiotherapist of Sir Ganga Ram Hospital who

was unaware of their group. By using random

sampling method, the subjects were assigned to 1

of 5 treatment groups. Group A received 1 min. of

warm up and stretching(n=15),Group B received 2

min. of warm up and stretching (n=15), Group C

received 3 min. of warm up and stretching (n=15),

Group D received 4 min. of warm up and

stretching (n=15) and Group E control group

received no warm and stretching (n=15)). The joint

position sense score was measured before warm up

and stretching, after warm up and stretching and 5

min. after 2nd data with the help of CPM Machine.

CPM machine was considered most appropriate

and yield reliable and valid data. The subjects

were instructed to remove their shirt and vest to

allow for acclimatization to room temperature for

10 minutes.

The rig of CPM machine and chair was

adjusted so that the rotation axis of the rig was

congruent with centre of glenohumeral joint. The

rotation axis of shoulder was adjusted by laser

detection ray, which was present in machine.

Subjects were seated in chair and blind folded and

cotton gauge was put in the ear.

All movements were performed on right shoulder

joint.

Subjects were required to match a

previously presented angle from starting position

to target position by machine respectively i.e.

Flexion 30-90°, flexion 60-120° and flexion 90-

150°. The shoulder joint (arm) was passively

moved at 2 degree/sec to predetermined target

position. The arm remained at target position for 5

sec. (Same duration for all trials) and returned at a

speed 2°/sec to starting position. Three

familiarizing trails were given before data was


4

collected. Stop switch was given to subjects.

When the button was pressed by the subject, it

indicated recognition of target position. Each

movement data was collected two times

measurements of JPS difference between the

perceived angle and angle of flexion was recorded

with the +ve sign of error. After recording data,

warm-up and stretching were performed by the

subjects for 1 min (Group A), 2 min (Group B), 3

min (Group C), 4 min (Group D) and no exercises

for control group (Group E).

Again data was collected immediately after

warm up and also 5 min. after 2nd data .

RESULTS

Since the data did not follow normal

distribution, therefore, repeated measure Anova

was not used, instead Non-parametric tests were

used. Wilcoxon-signed ranks test was used to

compare the pre-intervention, post-intervention

data collection errors among themselves (between

group comparison) for all the 5 groups.

One way Anova was used to calculate the

significance value of pre-intervention and post-

intervention data collection of all the 5 groups for

both between-group comparison and within group

comparison. Post-HOC and Mann-Whitney tests

were used to compare significance values among

all the groups (multiple comparisons).

The gains in joint position sense appreciation

were significant after 1 min of warm up at all the

target positions checked. The effect of warm up

and stretching still persisted after 5 min of 2nd

data collection, except at 150 degrees of shoulder

flexion.

Table 1: Wilcoxon Signed Ranks Test.

Similarly, at 2 min, 3 min and 4 min of warm

up and stretching, the improvement in joint

position sense appreciation were significant at all

ranges/target positions checked and this

improvement sustained even after 5 min of 2nd

data collection.The control group result indicated

no improvements at all target positions checked.

Examining the results (through master chart)

from a clinical perspective, we observe that the

third group i.e. 3 minutes warm up had the

maximum gains, 1 minute warm up had the

minimum gains and 4 minute warm up had the

fewer gains due to the effects of muscular fatigue

as reported by the subjects after performing this

warm up.

Examining Mann Whitney multiple group

comparison test results the 3 minute warm up

group showed maximum significance across all the

groups. And the control group showed the

minimum non-significance across all the groups.

findings of this study indicate that warm up and

stretching exercises improve shoulder joint

position sense appreciation. This improvement in



5

enhances with increase in duration and intensity of

warm up upto 4 minutes. At 4 minutes there are

lesser gains in joint position sense because

muscular fatigue starts setting in.

Table 2: Mann Whitney Tests (Multiple Group

Comparison)

Graph 1: Mann Whitney Tests (Multiple

Comparison 30-90)


Comparison)


Comparison 60-120)


Comparison)


Comparison 60-120)


6

Interpretation: The Table-1 showed that

Wilcoxon-signed ranks test was used to compare

the pre-intervention and post-intervention

(between group comparison) for all the 5 groups.

the gains in joint position sense appreciation were

significant after 1 min, 2 min, 3 min and 4 min of

warm up and stretching,

The table-2,3,4 showed that three Examining

Mann Whitney multiple group comparison test

results the 3 minute warm up group showed

maximum significance across all the groups. And

the control group showed the minimum non-

significance across all the groups.

The improvement in joint position sense

appreciation still persisted after 5 min of 2nd data

collection, except at 150 degrees of shoulder

flexion in Group A.

At 2 min, 3 min and 4 min of warm up and

stretching, the improvement in joint position sense

appreciation were significant at all ranges/target

positions checked and this improvement sustained

even after 5 min of 2nd data collection.

DISCUSSION

The findings of this study indicate that warm

up and stretching exercises improve shoulder joint

position sense appreciation. This improvement in


enhances with increase in duration and intensity of

warm up upto 4 minutes. At 4 minutes there are

lesser gains in joint position sense because

muscular fatigue starts setting in.

In this study, the gains in joint position sense

appreciation were significant after 1 min of warm

up at all the target positions checked. The effect of

warm up and stretching still persisted after 5 min

of 2nd data collection, except at 150 degrees of

shoulder flexion.

Similarly, at 2 min, 3 min and 4 min of warm

up and stretching, the improvement in joint

position sense appreciation were significant at all

ranges/target positions checked and this

improvement sustained even after 5 min of 2nd

data collection.

The control group result indicated no

improvements at all target positions checked.

Examining the results (through master chart) from

a clinical perspective, we observe that the third

group i.e. 3 minutes warm up had the maximum

gains, 1 minute warm up had the minimum gains

and 4 minute warm up had the fewer gains due to

the effects of muscular fatigue as reported by the

subjects after performing this warm up.

Examining Mann Whitney multiple group

comparison test results the 3 minute warm up

group showed maximum significance across all the

groups. And the control group showed the

minimum non-significance across all the groups.

The results of this study match with the

results of previous studies done on same subject

indicating that warming up exercises improve joint

position sense appreciation5,20.

CONCLUSION

The findings of this study support that the

larger amount or duration of warm up and

stretching will give more accuracy of joint position


7

sense before the occurrence of muscular fatigue.

Also the effect of warm up and stretching still

persisted after 5 min of 2nd data collection,

Clinicians should be aware of this information

in making decisions during rehabilitation of

shoulder injuries or proprioceptive training of

athletes. The results suggest that shoulder joint

position sense alter across the ROM with

potentially greater position sense acuity in the

outer range of shoulder flexion where there is

more tension upon the restraints of motion.

Muscular fatigue should not be allowed to set

in during warm up period so as to prevent the loss

of proprioceptive acuity.

REFERENCES

1. Voight L.M., Allen J., Turner A,Tippett S. and Gary C., The effect of muscle fatigue and

relationship of arm dominance to shoulder proprioception, J.O.S.P.T., 2(6), 348-352(1996)

2. Lonn J., Albert M.S. and Pederson., Position sense testing: influence of starting position and

type of displacement, APMR., 81, 592-593(2000)

3. Marnic A., M Scott S.L., J.I.and F.H., Shoulder kinesthesia in healthy unilateral athletes

participating in upper extremity sports, J.O.S.P.T., 21(4), 220-226( 1995)

4. Drover G., M.S., C.A.T., A.T.C and Powers M.E.,Cryotherapy does not impair shoulder joint

position sense, APMR., 85, 1241-1246(2004)

5. Br. J. SP., Effect of warm up exercises on knee proprioception before sporting activity,

Med.,36,132-134(2002)

6. Effects of static stretch and warm up exercises on hamstring length over the course of 24 hours,

J.O.S.P.T., 33(12), 727-33(2003)

7. In sports & exercise:- A randomized trail of pre-exercise stretching for prevention of lower

limb injury, Med. & Sc.

8. After effects of resisted muscle contraction on accuracy of joint position sense in elite male

athletes, A.P.M.R.,79,1250-1254(1998)

9. Effects of age and activity on knee joint proprioception, Am.J.Phys.Med. Rehab., 9,235-

241(1997)

10. Knee proprioception: A review of mechanism, measurements, and implications of muscular

fatigue, Orthopedics., 21(4),463-471 (1998)

11. Effect of superficial heat, deep heat, active exercises warm up on extensibility of plantar

flexors, Phys. Ther., 81, 1206-1214(2001)

12. The effect of time on static stretch on flexibility of hamstring muscles, PHY. THER.,74(9),845-

850(1994)

13. The effect of duration of stretching of hamstrings for increasing ROM in people aged 65 years

or older, PHY. THER., 81(5),1110-1117(2001)

14. Duration of stretching effect on ROM in lower limb, A.P.M.R., 66,171-173(1985)

15. Effects of static stretch versus static stretch and U.S. combined on triceps surae muscle

extensibility in healthy women, PHY. THER.,67(5), 674-679 (1987)


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16. SWD and prolonged stretching increase hamstring flexibility more than prolonged stretching

alone, J.O.S.P.T.,34( 1), (2004)

CORRESPONDENCE

*Research Scholar, Singhania University. Rajasthan, India

**Consultant Orthopaedics, Kapoor Medical Center

9

IMPACT OF AGEING ON DEPRESSION AND ACTIVITIES OF DAILY

LIVINGS IN NORMAL ELDERLY SUBJECTS LIVING IN OLD AGE

HOMES AND COMMUNITIES OF KANPUR, U.P.

Vanshika Sethi*, Vijeylaxmi Verma**, Udhbhav Singh***

ABSTRACT

INTRODUCTION: Ageing is a progressive generalized impairment of functions resulting in loss of adaptive

response to stress and increasing the risk of age related disease. METHODOLOGY: A sample of 200 elderly

subjects i.e. 100 from the community (group A) and 100 from Old age home (group B) of sixty & above years

of age were taken by the convenience sampling method. The subjects were collected through various old age

homes and community which includes Vaikunth Dham Old Age Home, Ishwar Prem Ashram, Swaraj Ashram,

Ramkrishna Mission old age home and nearby community located in the Kanpur and Varanasi. The subjects

were assigned a number to maintain the confidentiality of the subjects and then the scales were used to assess

the scores i.e., Geriatric Depression Scale (GDS) and Barthel index of daily livings were used to check the

level of depression & ADL’s and then the scores were compared. THE RESULTS: The mean GDS scores for

group A were 11.32 and for group B were 16.42 with a value of -6.981 with a p value of 0.00* and mean

ADL’s scores on the Barthel index for group A were16. 54 and 17.98 for group B within value of -2.898 with

a p value of 0.004* which shows there is a significant difference. Conclusion: Elderly subjects living in Old

age home are more affected in terms of depression and ADL’s as compared to community dwelling elder

subjects as old people living in their own homes were most able to cope in their homes. They received more

support from relatives and friends than from health and social services16


10

KEY WORDS: Elderly, ADLs, Depression, Community, Old age home

INTRODUCTION

Age classification varied between countries

and over time, reflecting in many instances the

social class differences or functional ability related

to the workforce, but more often than not was a

reflection of the current political and economic

situation. Many times the definition is linked to the

retirement age, which in some instances, was

lower for women than men. This transition in

livelihood became the basis for the definition of

old age which occurred between the ages of 45 and

55 years for women and between the ages of 55

and 75 years for men1.

Elderly people are classified into: - 1) 60 yrs

to 70yrs- Young old 2) 70 yrs to 80yrs- Middle old

3) 80yrs &above- Old old 2

The risk factors for reduced physical function

in elderly people, as identified in longitudinal

studies, relate to comorbidities, physical and

psychosocial health, environmental conditions,

social circumstances, nutrition, and lifestyle3

As the western population is increasingly

ageing, problems connected with old age will

dominate healthcare. Depression, one of the most

prevalent psychiatric disorders, is expected to take

an even more prominent position than presently, as

the risk for developing depression increases with

old age. Depressive symptoms are present in

almost one third of the elderly populations and

major depression may be present up to 4%

Furthermore, once present, the prognosis for

elderly with depression is poor4

There have always been elderly people, but

what is new today that they now form the largest

sector of the population in industrialized societies.

However elderly are not preparing themselves for

long life, nor are we receiving any information

about the aging process at home, school,

community in general. Society tends to exclude the

elderly. They are considered incompetent and are

denied any responsibilities. This is far removed

from previous societies in which, given their

experience, the eldest members enjoyed a much

higher status. They considered wise, the teachers,

and traditions. A great number of people in this

sector are slightly depressed and tend to consider

themselves less productive than they really are5

Between the year 2000 to 2050, the

worldwide proportion of persons over 65 years of

age is expected to more than double, from the

current 6.9% to 16.4%. As healthcare facilities

improve in countries, the proportion of the elderly

in the population & the life expectancy after birth

increase accordingly. This is the trend which has

been in both developed & developing countries. It

is commonly believed that the majority of the

elderly population resides in developed countries.

However, this is a myth, as about 60% of the 580

million older people in the world live in

developing countries, and by 2020, this value will

increase to 70% of the total older population 6

Depression is common in medically ill elderly

and associated with greater morbidity and

mortality, increased health service use and medical

costs. Studies have shown that antidepressant and

structured psychotherapy, alone or combined, are

effective in reducing depressive symptoms among

older adults7

Depression and anxiety lead to a serious

impairment of daily functioning and quality of life.


11

In frail elderly, the effects of depression and

anxiety are especially deep encroaching .The

number of elderly is rapidly growing. Almost a

third of elderly subjects in the community with sub

threshold depression or anxiety will develop a

major depressive or anxiety disorder in three years 8

The prevalence of major depressive disorder

at any given time in community samples of adults

aged 65-67 older ranges from 1-5% in larger scale

epidemiological investigations in the United States

and internationally, with the majority of studies

reporting prevalence at the lower end of the range.

Clinically significant depressive symptoms are

present in approximately 15% of the community-

dwelling older adults 9

Major depressive disorder is one of the most

common forms of psychopathology, one that will

affect approximately one in six men and one in

four women in their lifetimes. It is also usually

highly recurrent, with at least 50% of those who

recover from a first episode of depression having

one or more additional episodes in their lifetime,

and approximately 80% of those with a history of

two episodes having another recurrence. Once a

first episode has occurred, recurrent episodes will

usually begin within five years of the initial

episode, and, on average, individuals with a

history of depression will have five to nine

separate depressive episodes in their lifetime10

Disability in Activities of Daily Living

(ADL) , which are the essential activities that a

person needs to perform to be able to live

independently , is an adverse outcome of frailty

that places a high burden on frail individuals,

health care professionals and health care systems .

Frail elderly people have a higher risk of ADL

disability compared to non-frail elderly people11

The model of the International Classification

of Functioning, Disability and Health can describe

the consequences of dementia that eventually lead

to deterioration in BADL and loss of autonomy. In

the context of this review, dementia (health

condition) has a negative influence on mobility,

endurance, lower-extremity strength and balance

(body functions and body structures). Those body

functions are important for BADL functioning

(activity). Depending on the quality of the BADL

performance, patients are less or more restricted in

their participation (participation). By training

physical components underlying ADL, or by a

direct influence of exercise on ADL, healthy

elderly subjects can stabilize or improve their

ADL score12

The mechanisms by which depression has an

effect on physical disability are not completely

understood. Both behavioral (depressed patients

may have poor lifestyle, such as nonadherence to

medication and self-care regiments) and biological

mechanisms (depression may worsen medical

diseases through changes in hypothalamic-

pituitary-adrenal axis and the sympathetic nervous

and immunological system) have been proposed.

Each could lead to more disability13

One might expect that elevated body mass

index (throughout life) could also promote

impairments in ADL through other mechanisms

that include associations with diabetes and

possibly knee joint injuries in later life or

difficulties in walking around the house (more

common in Hawaii but unrelated to body mass

index in the current sample). It may be that

impairments in the ADL are more frequent in the

presence of subclinical frailty where weight loss is

a problem. Long-term follow-up of the effects of

body mass in middle adulthood on the risk of late-


12

life ADL impairment might reveal a clearer

association14

In a study of patients with and without

depression during the immediate period after

stroke but with similar impairments in ADL

scores, we found, 2 years later, that the depressed

patients had significantly less recovery in their

ADL functions than the no depressed patients. The

recovery curves for ADL function were not

significantly different between patients with major

depression versus those with minor depression,

suggesting that both moderate and severe forms of

depression lead to impaired recovery in ADL

functions. Morris et al who used an abbreviated

version of the Barthel index, also reported that at

15 months after stroke, patients with major

depression and those with minor depression had a

significantly greater physical disability than no

depressed patients15

As in elderly people living in community &

old age home depression and impairment in

performing activities of daily livings are major

problem therefore assessing the prevalence of

depression and impairment in ADL’s forms the

basis of the study.

MATERIALS & METHODS:

This study is a survey type of study which

intends to find changes in levels of depression and

activities of daily livings scores in elderly subjects

living in the community and in old age home.

A sample of 200 elderly subjects i.e. 100 from

the community and 100 from Old age home of

sixty & above years of age were taken by the

convenience sampling method.

The subjects were collected through various

old age homes & which includes Vaikunth Dham

Old Age Home, Ishwar Prem Ashram, Swaraj

Ashram, Ramkrishna Mission old age home and

nearby community located in the Kanpur

&Varanasi.

All subjects signed consent forms & were

ready to take part in the study .The subjects were

given the instructions regarding the procedure &

the subjects who fulfilled the inclusion criteria &

were ready to actively participate, were selected.

Inclusion criteria

1. Normal elderly male & female with age of

≥ 60 years.

2. Able to understand verbal instructions &

completed 8-10 years of formal education.

3. Subjects with stable medications

Exclusion criteria

1. Any neurological problems such as

Parkinsonism, stroke, cerebellar disorders,

balance disorders, myopathy, myelopathy

which can influence the psychological

status of the subjects.

2. Any cardiovascular or orthopedic problems

which affects their day to day routine

activity & further may become the cause

of depression.

3. Significant hearing & vision impairment.

4. Uncontrolled hypertension.

5. Any speech deficit interfering the survey.

6. Unstable seizure / disorder affecting the

psychological status of subjects.

7. Smoking or alcohol intake.

Procedure

Group Mean Standard

Deviation T P

Community

(gp A)

11.32

4.29

-6.981

0.000*

Home

(gp B)

16.42

5.90


13

Subjects were introduced to the study

followed by the signing of consent forms ,general

assessment regarding of socio-demographic data (

name, gender, age), education level, past medical

history, personal history, family history were

gathered from the participants assessment forms.

The subjects were collected from community &

various old age homes & were divided into two

groups a (community) and b (old age home) for

comparison. Total 200 numbers of subject’s data

was collected, 100 for Group A(community) and

group B (old age home).The subjects were

assigned a number to maintain the confidentiality

of the subjects and then the scale was used to

assess the scores i.e., Geriatric Depression Scale

(GDS) and Barthel Index (BI) was used to check

the level of depression and impairment in ADL’s

and then the scores were entered in the data

collection form.

RESULTS

Reading on GDS and BI were taken during

first interview contact with the subject and were

tabulated as data.

The mean value of GDS for the old age

home (group B) was 16.42 with standard deviation

5.90 and mean value for subjects living in

community (group A) was 11.3 with SD 4.29 and

p value was 0.000 which shows there is a

significant difference in the score hence level of

depression is more in elderly people living in an

old age home town community.

Table 1: Analysis of GDS score in group A and

group B

*Significant difference

The mean value of the Barthel index for the old

age home was 16.54 with standard deviation

4.001and mean value for subjects living in the

community was 17.98 with SD 2.947 and p value

was 0.004 which shows there is a significant

difference in the scores hence Activities of daily

livings are more affected in elderly people living

in an old age home town community.

Table 2: Analysis of Activity Of Daily Living

by Barthel index between group ‘A’ & group

‘B’

*Significant difference

DISCUSSION

As results of the study shows that depression

level is more in elderly living in an old age home

than in community. It is supported by a study

which suggests that urbanization promotes

nucleation of the family system and a decrease in

care and support for the elderly. Depression and

physical illness often coexist in the elderly as they

both occur commonly in old age. There is a close

relation between depression and physical illness.

Depression may be caused by a specific physical

disorder possibly as a direct consequence of the

cerebral organic effect of these conditions.

Therefore strategies to decrease depression should

be utilized for persons living in an old age home.

The literature shows the institutionalized

participants were more likely to report depressed

Group Mean Standard

Deviation T P

Community

(gp A) 16.54 4.001

-2.898 0.004*

Home

(gp B) 17.98 2.947


14

mood, crime, wishing to be dead, future looking

bleak and staying away from others. Therefore the

persons living in an old age home should be

encouraged to intact with the society and family

members to cope up depression.

Literature shows that older people living in

their own homes were most able to cope in their

homes. They received more support from relatives

and friends than from health and social

services3.Result of the present study also shows

that elderly people living in an Old age home were

more affected in terms of ADLs than elderly

people living in the community.

Relevance to clinical practice:

This research study may serve as a basis for

development and implementation of a new

rehabilitation program to cope up depression and

to improve daily living skills for subjects living in

an old age home and in community by which

further their level of dependency and depression

can be reduced.

Future research:

1. This study is a survey type study in which

no training was given to the improvement

of ADLs and to decrease the depression

hence in a future training program can be

administered and its after effects may be

noted down.

2. As sample size was small hence large

sample size may be taken to generalize

the results.

3. Task oriented

goals/activities/training/may be used to

improve the efficiency of subjects living

in an old age home and community.

4. Group involvement and interaction with

society may be suggested for subjects

living in an old age home as loneliness

may be the factor affecting ADLs and

depression.

15

REFERENCES

1. Definition of an older or elderly person .

www.int/healthinfo/survey/agingdefinolder/en/index.html.

2. Mascarenhas Steffi ,Yardi Sujata . Retrospective study on limitation of activity of daily living

in geriartric women. Indian Journal Of Physiotherapy And Occupational Therapy .2012 ; 6(1)

3. Beswick DA , Rees K , Dieppe P, Ayis Salma , Hill Gooberman R , Horwood J And Shah E.

Complex study to improve physical function and maintain independent living in elderly

people : a systemic review and meta analysis . Lancet.2008 ; 371(9614): 725-735

4. Most IS Els, Scheltens Philip, Someren Van JW Eus. Prevention of depression and sleep

disturbances in elderly with memory-problems by activation of the biological clock with

light- a randomized clinical trial. Most et al. Trials. 2010:11-19

5. Hernandezequena Carmen, Gonzalez Zubiaur Marta .Effects of Intergenerational Interaction

on Aging. Educational Gerontology.2008;34:292-305

6. Taqui Ather M, Itrat Ahmed, Qidwai Waris, Zeeshan Qadri. Depression in the elderly: Does

family system play a role? A cross-sectional study.BMC Psychiatry.2007;7: 57

7. Ell Kathleen , Unutzer jurgen, Aranda Maria, Gibbs E.Nancy, Lee Jiuan ,Xie Bin .Managing

Depression in the Home Health Care: A Randomized Clinical Trial. Home Health Care

servQ.2007;26(3):81-104

8. Veer-Tazelaar, Marwick Harm van, Oppen Van Patricia, Ninpels Giel, Hout Van Hein,

Cuijpers Pim, Stalman Wim, Beekma Aartjan. Prevention of anxiety and depression in the

age group of 75 years and over: a randomized controlled trial testing the feasibility and

effectiveness of a generic stepped care programme among elderly community residents at

high risk of developing anxiety and depression versus usual care. BMC Public Health .2006;

6:186

9. Fiske Amy, Wetherell Loebach Julie, Gatz Marget.Depression In Older Adults.Annu Rev Clin

Psycho. 2009: 363-389

10. Burcusa L. Stephanie, Locono G.William.Risk for Recurrence in Depression. Clin Psychol.

2007 ; 27(8):959-985

11. Vermeulen Joan , Neyens Jacques Cl , Rossum Van Erik , Spreewenberg Marieke D and Witte

De P Luc.Predicting Adl Disability In Community –Dwelling Elderly People Using Physical

Frailty Indicators : Systemic Review . Bmc Geriatrics .2011;11:33

12. Canhota Da Nogueira Manuel Carlos. Depressive disorders in elderly chienese patients in

macau: a comparison of general practitioners consultations with a depression screening

scale.Australian and New Zealand Journal of Psychiatry .2001;35:336-344

13. Li W. Lydia, Conwell Yeates. Effects of changes in depressive symptoms and cognitive

functioning on physical disability in home care elders. J Geronetol A Boil Sci Med Sci .2009;

64 (2):230-236


16

14. Abbott Robert D. , Kadota Aya , Miura Katsuyuki , Hayakawa Takehito, Kadowaki Takashi ,

Okamura Tomonori , Okayama Akira , Masaki H. Kamal , Ueshima Hirotsugu . Impairment

in activity of daily living in older japanese men in hawaii and japan .Journal Of Aging

Research .2011 ;Article Id 324592

15. Chemerinski Eran, Robinson G. Robert, Kosier T. James. Improved recovery in activity of

daily living associated with remission of post stroke depression. Journal of the American

heart Association Stroke. 2001; 32:113-117.

16. Rogers C. Joan, Holm Margo B., Raina Ketki D., Dew Amanda Mary, Shih Min-Mei, Begley

Amy, Houck R. Patricia , Majumdar Sati , Reynolds F. Charles.Disability in late life major

depression : patterns of self-reported task ability, task habits and task performance .

Psychiatry Res . 2010 ; 178(3): 475-479

CORRESPONDENCE

* Assistant Professor, Physiotherapy Dept., Saaii College of Medical Science and Technology, Kanpur, U.P.

** B.P.T. Student, Saaii College of Medical Science and Technology, Kanpur, U.P.

*** B.P.T. Student, Saaii College of Medical Science and Technology, Kanpur, U.P.

17

TO ASSESS THE RELATIONSHIP BETWEEN TEMPOROMANDIBULAR

JOINT DYSFUNCTION AND CERVICAL SPINE DYSFUNCTION

Khyati Harish Sanghvi (BPT)*, Amrit Kaur (MPT)**, G anesh Subbiah (MPT)***

ABSTRACT

The temporomandibular joint is directly related to the cervical and scapular region. AIM- To assess any

possible relationship between temporomandibular dysfunction (TMD) and cervical spine dysfunction (CSD)

METHODS- Total 30 volunteers,15 volunteers that were presenting clinical signs and symptoms of TMD and

15 volunteers that were presenting CSD according to Temporomandibular Dysfunction Assessment

Questionnaire and Neck disability Index respectively were selected for this study. Individuals having TMD

were assessed for any signs and symptoms of CSD using Neck disability Index, Index of Cervical Mobility and

VAS score. Individuals having CSD were assessed for TMD using Temporomandibular Dysfunction

Assessment Questionnaire, Mandibular Mobility Index and VAS score RESULT-Correlation test (p ≤ 0.05)

was performed to verify the relationship between CSD & TMD. The increase in TMD signs and symptoms was

accompanied by increase in CSD severity. CONCLUSION- The result of this study concluded that TMD is

accompanied with CSD and vice-a-versa.

KEYWORDS: Cervical pain, cervical spine dysfunction, Temporomandibular Joint; Temporomandibular

joint dysfunction.

INTRODUCTION

Cervical spine dysfunctions are common

conditions affecting the cervical region and related

structures, with or without radiating pain towards


18

the Shoulder, Arms, Inter scapular region and

Head 1, 2, 3. There are estimates that 67% of the

population will suffer from neck pain at some

stage of life 3. Neck pain is often the major

symptom in cervical spine dysfunction related to

post-traumatic or to chronic micro-traumatic

lesions of the joints and periarticular structures1.

Temporomandibular dysfunctions are defined as

common non-dental cause of orofacial pain4.

Temporomandibular dysfunction is collective term

applied to all problem related to

temporomandibular joint and associated

musculoskeletal structures. Temporomandibular

dysfunction characterizes a cluster of disorders

marked by pain in the pre-auricular area,

temporomandibular joint and masticatory muscles,

as well as limitations or deviations during the

mandible range of motion, and temporomandibular

joint sounds during function 5.

Anatomically, the mandible and the base

of skull presents the muscular and ligamentous

connections with the cervical region, forming a

functional system known as cranio-cervico-

mandibular system6.

If cervical spine dysfunction is considered

a predisposing factor for temporomandibular

dysfunction, and supposing that the related

Orofacial pain is of cervical origin 7, there should

be a direct relationship between the increase of

temporomandibular dysfunction signs and

symptoms and the previously existing cervical

spine dysfunction severity. Thus, cervical spine

Lesions caused by repetitive movements8, head

and cervical posture alterations9, 10 likely lead to

cervical spine dysfunctions and, subsequently, to

the manifestation of temporomandibular

dysfunction signs and symptoms.

If temporomandibular dysfunction is

considered a predisposing factor for cervical spine

dysfunction, and supposing that the referred neck

pain is of orofacial origin7, there should be direct

relationship between the increase of cervical spine

dysfunction signs and symptoms and the

previously existing temporomandibular

dysfunction severity.

Mara Ines Baptistella Ferao (2008)

evaluated prevalance of temporomandibular

dysfunction in patients undergoing physiotherapy

treatment for cervical pain. They concluded that

90% of patients with cervical pain were found to

have temporomandibular dysfunction16.

However study done by BEVILAQUA-

GROSSI (2007) concluded that, cervical signs and

symptoms accompanied temporomandibular

dysfunction but the inverse was not true, the

temporomandibular dysfunction sign and

symptoms did not increase with cervical spine

dysfunction severity in female community cases17.

It is known that the balance of the body, as

well as the movements of the head, originated

from the positioning of the skull over the cervical

and scapular region; determine the posture of the

individual. Therefore, it is supposed that any

alteration in these structures can bring about

postural imbalance, not only in these locations, but

also in other muscle groups of the body11. In this

way, temporomandibular dysfunction may

represent a constant concern for Medicine,

Dentistry, Physiotherapy and Public Health who

wish to understand the behavior of the joint in its

biomechanical activities.

The present study was done to determine

any possible relationship between cervical spine

dysfunction and temporomandibular dysfunction

in individuals aging from 18 to 40years. The

findings of this study can be used to frame


19

assessment and management goals in patients with

cervical spine dysfunction and/or

temporomandibular dysfunction.

METHODS

30 patients were selected to participate in the study

on basis of inclusion criteria;

� Individuals aging from 18 to 40 years.

� 15 Individuals having temporomandibular joint

dysfunction (Group 1).

� 15 Individuals having cervical spine dysfunction

(Group 2).

Exclusion criteria was General Joint Disorder

involving Head and Neck (e.g. Rheumatoid

Arthritis); History of Jaw Fracture; Individuals

suffering through Facial Palsy; History of Cervical

vertebra fracture; Patients having Trigeminal

Neuralgia and Patients having braces applied for

proper alignment of teeth.

15 volunteers that were primarily presenting

clinical signs and symptoms of

temporomandibular dysfunction according to

Temporomandibular Dysfunction Assessment

Questionnaire12 were selected as Group 1 to

participate in the study. They were screened for

any exclusion criteria and then divided into

severity i.e., mild, moderate or severe of Temporo-

mandibular dysfunction on basis of their scoring in

temporomandibular dysfunction assessment

questionnaire12. The questionnaire is set of 10

questions regarding Temporo-mandibular

dysfunction and the symptoms. Answers were

collected in terms of “YES”, “SOMETIMES” or

“NO” and were scored 10, 5 or 0 respectively.

Maximum score can be 100 and minimum 0.

Table 1: TMDQ Scoring Total between 0 and 15 points No TMD Total between 20 and 40 points Mild TMD Total between 45 and 65 points Moderate TMD

Total between 70 and 100 points Severe TMD The mean of the patient’s age with

primary temporomandibular dysfunction was 25

years (SD=7). Temporomandibular Joint ROM and

VAS were recorded. Then they were assessed for

any signs and symptoms of cervical spine

dysfunction using Neck disability Index13, index of

cervical mobility (ICM)14 and VAS score.

Other 15 volunteers that were primarily

presenting cervical spine Dysfunction according to

Neck disability Index13 were selected as Group 2

for this study. They were screened for any

exclusion criteria and then divided into severity

i.e., mild, moderate or severe Cervical spine

dysfunction on basis of their scoring in Neck

disability Index13. The Neck Disability Index is

divided into 10 set of multiple choice questions

which have 6 options for each and each 5 options

are scored from 0 to 5 on basis of severity.

Maximum score can be 50 and minimum 0.

Table 2: NDI scoring Total between 0 and 4 No CSD Total between 5 and 14 Mild CSD Total between 25 and 34 Moderate CSD Total between 35 and 50 Severe CSD

The mean of the patient’s age with

primary cervical spine dysfunction was 24.1 years

(SD=6.65). Cervical Spine ROM and VAS were

recorded. Then they were assessed for

temporomandibular dysfunction using

Temporomandibular Dysfunction Assessment

Questionnaire, Index of Mandibular mobility

(IMM) 15 and VAS score.

The following Temporomandibular

movements were recorded: maximal mouth

opening (MMO), maximal lateral deviation to

right and left (MLDR and MLDE) and maximal

protrusion (MP). The cervical movements of

flexion, extension, right and left rotations and right


20

and left lateral flexions were recorded. To measure

Temporomandibular and Cervical range of motion,

a ruler (mm) and a universal Goniometer (°) were

used respectively.

This study was approved by the

Committee for Ethics and Research of the

NDMVP medical college and the patients signed a

term of free and informed consent confirming their

agreement to participate in the study.

Spearman’s rank correlation test was

performed to verify the relationship between

cervical spine dysfunction & temporomandibular

dysfunction.

RESULT

Descriptive data is given in table 3.

Table 3: Descriptive Data

Group 1

Total 15 individuals were selected under the

category of temporomandibular dysfunction after

performing screening test (TMDQ). The mean of

the patient’s age was 25 years (SD=7). On analysis

it was found that 26.67% patient had no cervical

spine dysfunction, 60% had mild, 6.67% had

moderate and 6.67% had severe cervical spine

dysfunction.

The mean VAS of two groups was;

Cervical pain: 2.64

Temporomandibular Joint pain: 4.25

The correlation test was applied to check

the association between the scores of index of

mandibular mobility and index of cervical

mobility. The Result was, spearman’s rank

correlation coefficient (SRCC) = 0.223214,

p>0.05. As coefficient of correlation value is

between 0 and +1, we can say that the two sets of

data show weak, positive correlation. But as P

value is more than 0.05, the result is not

significant, i.e., there is no correlation between

scores of IMM and CMI scores.


prevalence of cervical spine dysfunction in

patients with temporomandibular dysfunction. The

result was, spearman’s rank correlation coefficient

(SRCC) = 0.62857, p<0.05. As coefficient of

correlation value is between 0 and +1, we can say

that the two sets of data show good,

positive correlation. As P value is less than 0.05,

the result is significant, i.e., there is prevalence of

cervical spine dysfunction in patients with


Group 2

Total 15 individuals were selected under the

category of cervical spine dysfunction after

performing screening test (NDI). The mean of the

patient’s age was 24.1 years (SD=6.65). On

analysis it was found that, 40% had mild, 33% had

moderate and 26.67% had severe


The mean VAS of two groups was;

Cervical pain: 4.66

Temporomandibular Joint pain: 1.6


the association between the scores of index of

mandibular mobility and index of cervical

mobility. The Result was, spearman’s rank

correlation coefficient (SRCC) = 0.076786,

p>0.05. As coefficient of correlation value is

between 0 and +1, we can say that the two sets of

data show very weak, positive correlation. But as P

value is more than 0.05, the result is not


21

significant, i.e., there is no correlation between

scores of IMM and CMI scores.


prevalence of temporomandibular dysfunction in

patients with cervical spine dysfunction. The result

was, spearman’s rank correlation coefficient

(SRCC) = 0.657143, p<0.05. As coefficient of

correlation value is between 0 and +1, we can say

that the two sets of data show good,

positive correlation. As P value is less than 0.05,

the result is significant, i.e., there is a prevalence

of temporomandibular dysfunction in patients with

cervical spine dysfunction.

DISCUSSION

The result of this study demonstrated that

there is prevalence of temporomandibular

dysfunction in patients with cervical spine

dysfunction or cervical spine dysfunction is one of

the predisposing factors for temporomandibular

dysfunction and vice-a-versa. However, significant

differences in the values of Mandibular range of

motion among temporomandibular dysfunction

severity groups and in values of cervical range of

motion among cervical spine dysfunction severity

groups were not verified.

The ideal posture of head places the center

of gravity slightly anterior to the cervical spine.

For this reason, when sitting or standing the head

falls anteriorly if the muscles of the head and neck

are totaly relaxed. To maintain this postural

position, strong posterior cervical muscles are

needed. The anterior cervical muscles are small

and thin muscles which come from the clavicle,

sternum and rib cage to the hyoid bone (infrahyoid

muscles) and from the hyoid to the mandible

(suprahyoid muscles). Two other important muscle

which controls position and stability of head and

neck are anteriorly sternocleidomastoid and

posteriorly the levator scapula. The mandible is

controlled by the muscle of mastication and it is

connected to cranium through its articulation of

the teeth and the temporomandibular joint. This

complex relationship is important since mandible

is attached to both cranium and cervical spine and

any positional changes of either will produce

postural changes of mandible and hence

disturbances in its articulation. The inverce is also

true that if there is disturbances in

temporomandibular joint articulation, it can alter

the position of mandible and in turn cervical spine

and shoulder girdle.

Thus there is relationship between the

mandible, the cranium, the cervical spine,

suprahyoid and infrahyoid structures, shoulder

girdle, the thoracic spine and ultimately the

lumbosacral spine. These structures function as

inter related biomechanical unit. Dysfunction in

any one part of this unit may often lead to

dysfunction of unit as a whole. However in

reviewed literature, there were no studies that

varified the time required for development of of

orofacial pain signs and symptoms caused by head

postuer alteration and vice-versa.

The result of this study suggest that almost

all the individual with cervical spine dysfunction

had temporomandibular dysfunction and about

73% of individuals with temporomandibular

dysfunction had cervical spine dysfunction.

CONCLUSION

The result of this study concluded that

temporomandibular dysfunction is accompanied

with cervical spine dysfunction and vice-a-versa.

Almost all the individual with cervical spine

dysfunction had temporomandibular dysfunction


22

and about 73% of individuals with

temporomandibular dysfunction had cervical spine

dysfunction.

REFERENCES

1. Ciancaglini R, Testa M and Radaelli G (1999). Association of neck pain with symptoms of

temporomandibular disorders in the general adult population. Scand J Rehabil Med.;31(1):17-22.

2. De Wijer A, Steenks MH, Bosman F, Helders PJ and Faber J (1996). Symptoms of the stomatognathic

system in temporomandibular and cervical spine disorders. J Oral Rehabil; 23(11):733-741.

3. Visscher CM, Lobbezoo F, Boer W, van der Zaag J, Verheij JG and Naeije M (2000). Clinical tests in

distinguishing between persons with or without craniomandibular or cervical spinal pain complaints.

Eur J Oral Sci; 108(6):475-483.

4. Mcneill C (1997). Management of temporomandibular disorders: concepts and controversies. J

Prosthet Dent; 77(5):510-522.

5. Dworkin SF, Huggins KH, Leresche L, Von Korff M, Howard J, Truelove E, et al (1990).

Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in cases and

controls. J Am Dent Assoc; 120:273-281.

6. Arrelano JCV (2002). Relações entre postura corporal e sistema estomatognático. JBA; 2: 155-164.

7. Browne PA, Clark GT, Kuboki T and Adachi NY (1998). Concurrent cervical and craniofacial pain: a

review of empiric and basic science evidence. Oral Surg Oral Med Oral Pathol Oral Radiol Endod;

86(6):633-640.

8. Kirveskari P, Alanen P, Karskela V, Kaitaniemi P, Holtari M, Virtanen T, et al (1988). Association of

functional state of stomatognathic system with mobility of cervical spine and neck muscle tenderness.

Acta Odontol Scand; 46(5):281-286.

9. Gonzalez HE and Manns A (1996). Forward head posture: its structural and functional influence on

the stomatognathic system, a conceptual study. Cranio; 14(1):71-80.

10. Mannheimer JS and Rosenthal R (1991). Acute and chronic postural abnormalities as related to

craniofacial pain and temporomandibular disorders. Dent Clin North Am; 35:185-208.

11. Amantéa DV, Novaes AP, Campolongo GD and Barros TP(2004). A importância da avaliação

postural no paciente com disfunção temporomandibular. Acta Ortop Brás; 12:1-8.

12. Kariny Nomura, Mathias Vitti, Anamaria Siriani de Oliveria, Thaís Cristina Chaves, Marisa Semprini,

Selma Siessere, Jaime Eduardo Cecilio Hallak and Simone Cecilio Hallak Regalo (2007). Use of the

Fonseca’s Questionnaire to assess the prevalence and Severity of Temporomandibular Disorders in

Brazilian Dental Undergraduates. Braz Dent J; 18(2): 163-167.

13. Joy C. Macdermid, David M. Walton, Sarah Avery, Alanna Blanchard, Evelyn Etruw, Cheryl

Mcalpine and Charlie H. Goldsmith (2009). Measurement Properties of the Neck Disability Index: A

Systematic Review. Journal of orthopaedic & sports physical therapy; 39, 5:400-417.


23

14. Wallace C and Klineberg IJ (1993). Management of craniomandibular disorders. Part 1. A

craniocervical dysfunction index. J Orofac Pain; 7(1):83-88.

15. Helkimo M (1974). Studies on function and dysfunction of the masticatory system. II. Index for

anamnestic and clinical dysfunction and occlusal state. Swed Dent J; 67(2):101-21.

16. Mara Ines Baptistella Ferao and Jefferson Traebert (2008). Prevalence of temporomandibular

dysfunction in patients with cervical pain under physiotherapy treatment. Fisioter; 21(4):63-70.

17. Débora Bevilaqua-Grossi, Thaís Cristina Chaves and Anamaria Siriani de Oliveira (2007). Cervical

spine signs and symptoms: perpetuating rather than predisposing factors for temporomandibular

disorders in women. J Appl Oral Sci; 15(4):259-64.

CORRESPONDING AUTHOR:

* N.D.M.V.P College of Physiotherapy, Email: [email protected]

** Assistant Professor, Department Of Community Based Rehabilitation, N.D.M.V.P College of

Physiotherapy, Email: [email protected]

*** Associate Professor, Department of Musculoskeletal Sciences, N.D.M.V.P College of Physiotherapy,

Email: [email protected]

24

EFFECTIVENESS OF NEUROMOTOR TASK TRAINING COMBINED

WITH KINAESTHETIC TRAINING IN CHILDREN WITH

DEVELOPMENTAL CO-ORDINATION DISORDER - A RANDOMISED

TRIAL

Sundaresan Chockalingam* Agnel Kevin Gomes**

ABSTRACT

The aim and objectives of this study was to find out the prevalence of Developmental coordination disorder

(DCD, a chronic motor impairment affecting child’s ADL) in school children from 5 to 10 years of age and to

analyse the effectiveness of Neuromotor Task Training when combined with Kinaesthetic training in

managing them. Using Pretest-Posttest Quasi Experimental study design, 56 samples of children with

indication or suspect for DCD in DCDQ’07 who also obtained total scores below the 15th percentile on the

TGMD-2 were randomly assigned for two interventions, Neuromotor Task Training (NTT) combined with

Kinaesthetic training (Intervention Group 1) and NTT alone (Intervention Group 2) for a period of 7 weeks in

small groups. The outcome was assessed with Gross Motor Quotient of TGMD-2. The data were analysed

with Student’t’ tests comparing values within the groups and between the groups. Results showed that the

prevalence of DCD in the local population is 6.82% and there is no significance difference between the

improvements made in the two intervention groups but the differences in the mean value support the combined

therapy group to have some better effects.

KEYWORDS: Developmental Coordination Disorder (DCD), Developmental Coordination Disorder

Questionaire’07(DCDQ’07), Test of Gross Motor Development-2 (TGMD-2), Neuromotor Task Training,

Kinaesthetic Training.


25

INTRODUCTION

Developmental coordination disorder

affects about 6% of children between 5 and 11

years of age 1. Prevalence of movement

difficulties in children has been reported as high

as 19%. However, two studies undertaken in the

UK reported a prevalence of 5% and 8.5%

respectively 2. DCD is defined, using the

Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition (DSM-IV), as a

condition marked by a significant impairment in

the development of motor coordination, which

interferes with academic achievement and/or

activities of daily living (ADL). These difficulties

are not due to a general medical condition (e.g.,

cerebral palsy) and are in excess of any learning

difficulties if present 1. The symptoms of

developmental coordination disorder may include

marked delays in achieving milestones of motor

development, dropping things, clumsiness, and

poor performance in sports or poor handwriting. If

any of these symptoms interferes with a child’s

performance of daily activities, a diagnosis is

warranted 1. Observations of school-age children

with Developmental coordination disorder during

organized and free play show that these children

spend less time in formal and informal team play

than children without the disorder3.

DCD is defined on the basis of a failure

of the acquisition of both fine and gross motor

skills, which is not explicable on the basis of

impaired general learning and similar exposure to

opportunity to gain motor skills as their peers.

DCD is often seen as the ‘Cinderella’ of

developmental disorders and not always

considered routinely by clinicians 4. However,

there is extensive evidence that motor difficulties

have a pervasive effect on children’s lives. The

difficulties affect the child both in school and at

home, and in contrast with similar aged children

who acquire skills with little effort such as

dressing, playing ball games and handwriting,

these children take longer to learn and automate

motor skills. Increasing interest in these children,

in academic research and in clinical and

educational practice, has focused on the need not

only for early identification but also to consider

the presentation in adolescence and adulthood, as

around 70% of children continue to have

difficulties when grown up5.

Over the past forty years, various

treatment programs have been developed for

children with Developmental Coordination

Disorder (DCD). These treatment programs can

roughly be divided into two categories: the

process-oriented approaches and the task-oriented

approaches 6. The process-oriented approaches

concentrate on the treatment of deficits in

processes assumed to underlie poor motor

coordination. Task-oriented approaches, on the

other hand, focus directly at the functional skills

with which a child experiences problems.

Examples of process-oriented approaches are

kinesthetic training developed by Laszlo et al.

(1988) and Sensory Integration Therapy developed

by Ayres (1972). Neuromotor Task Training

(NTT) was recently developed for treating children

with DCD by pediatric physical therapists 7. The

training concerns a task-oriented program based

upon recent insights about motor control and

motor learning. The developmental coordination

disorder questionnaire 2007 (DCDQ’07) was


26

developed to screen for the presence of motor

problems and as an adjunct to standardized tests 8.

Over the past 10 years, it has also proven to be a

valid measure of everyday functioning, as

academic achievements or activities of daily

living. It is recommended that The Movement

Assessment Battery for Children (M-ABC) and

The Test of Gross Motor Development (TGMD-2)

should be considered for assessing the gross motor

performance of children with DCD in the first

instance. Both these tests give standardized scores

that are easily explained to the patient/parent, and

both have items that children would find

acceptable and relevant 9.

BACKGROUND

Developmental coordination disorders

may first become apparent in early childhood, but

they are difficult to assess reliably before the age

of 5 years. Children with DCD are usually first

noted in primary school when the condition clearly

interferes with school performance or activities of

daily living. Most of these children are therefore

diagnosed between 6 and 12 years of age. Some

may even go unnoticed 17. The teachers may

initially notice children on the basis of difficulties

and poor handwriting is now one of the major

reasons for the clinical referral of children with

DCD 18. The DCD population is considered to be

at risk for a range of associated psychosocial

difficulties, such as poorer than expected

educational achievement and low self-esteem.

Children with DCD may show functional deficits

over a range of motor tasks. Some are impaired in

whole body tasks such as running and jumping,

ball skills, and tasks involving balance, such as

riding a bicycle. Some children may have fine

motor difficulties, while others have difficulties

with both fine and gross motor tasks 18.

Use of the DCDQ’07 by occupational

and physical therapists, as well as researchers, to

both screen for DCD and to confirm the functional

consequences of a motor deficit, will support the

identification of children in need of services. The

DCDQ’07 will also allow international

collaboration and application of research results

across cultures 15.

Neuromotor Task Training (NTT) was

developed for treating children with DCD by

pediatric physical therapists. Within this approach,

physical therapists start with the assessment of the

strengths and weaknesses of a child’s functional

performance. Next, therapists will analyze which

cognitive or motor control processes might be

involved in deficient motor skill performance. A

child can fail to learn a specific motor skill

because of attention problems, fear of failure, lack

of motivation, or lack of understanding how to

execute a particular skill. In addition, motor-

control processes might hamper successful

performance, such as timing of the components of

a motor skill pattern, motor planning, or parameter

setting (the execution of a motor act with the

required speed and force).

In NTT, the functional exercises are

designed in such a way that the therapist can

analyze which motor control processes are

deficient. Another important characteristic of NTT

is that teaching principles derived from motor

learning research are applied. The ultimate goal of

treatment is not only to improve functional task

performance during treatment but also to transfer

learned skills to daily life performance.

Kinesthesia is integral to the acquisition

of motor skills in process-oriented treatment


27

approaches. Therapeutic intervention with process-

oriented treatment is based on specifically

designed kinesthetic training activities. As

described by Laszlo and Bairstow, this approach

has an inherent reward system built into it through

its use of positive reinforcement, presentation of

desirable activities within the capabilities of the

child, and judicious progression of the level of

difficulty. The usefulness of the process-oriented

treatment approach has been the subject of

considerable study. Sims and colleagues suggested

that much of the success of this approach can be

attributed to a strong motivation effect, fostered by

positive feedback and a sense of self-competence

19. Children with DCD benefit from using vision in

combination with touch information for standing

control possibly due to their less well developed

internal models of body orientation and self-

motion. Internal model deficits, combined with

other known deficits such as postural muscles

activation timing deficits, may exacerbate the

balance impairment in children with DCD 12.

Group-based motor skill training may

have its own advantages. First, the group setting

provides opportunities for social interaction.

Secondly, children are competitive, and this

motivates them to perform better. Furthermore, a

stronger sense of competence may be developed if

a child can successfully demonstrate the acquired

motor skills in front of his or her peers in the

group. This perceived competence may further

encourage the children’s participation in the

training and in other physical activities affecting

their motor competence 14.

Children with DCD do not form a

homogeneous group. It is possible that, just as

characteristics are showing differences across

clusters of children, differences are evident in the

manner to which children respond to intervention.

They also have stated that some children may

require varying amounts of exposure to activities

with the amount being the influential factor,

whereas with others, most notably the ones who

did not improve following intervention and

concluded that a qualitatively different type of

approach may be required in dealing with children

with DCD 10.

To date, combined approaches are

largely untested, research has provided limited

evidence to support combined approaches as they

made smaller effects than pure approaches. It will

be important for us to develop a systematic,

evidence-based approach to the treatment of these

children 13. To date there is no studies that have

clearly focused on finding out the incidence of

DCD in South Indian population. Considering

these statement, it is very clear that there is a need

for a good experimental trail on finding the

effectiveness of combined approaches (top down

and bottom up approaches) in children with DCD.

METHODOLOGY

Participants for this study included

children, both boys and girls, aged 5 to10 years

from Bharathidasan Matric Higher Secondary

School, Kanchipuram, Tamil Nadu, India. In two

stage selection process, sequential sampling was

used to screen 1407 students (boys and girls).

Among the subjects screened by staged procedure,

54 were selected and assigned randomly into two

groups and considered for intervention. All

children with indication or suspect for DCD aged

from 5 to 10 years in DCDQ’07, Obtained total

scores on the TGMD-2 below the 15th percentile

and their motor problems could not be attributed to

evident pathological neurological signs were


28

included. Only children attending schools for

general education were considered which implies

an IQ-score in the normal range.

The children those who had received or

were undergoing physical therapy or occupational

therapy and those who have any profound visual or

hearing deficiencies that could not be corrected by

external devices were excluded.

In the first stage selection process, 2

Physical Education Teachers 1 special skill

training staff and 63 Class Teachers from the

School, handling children from 5 to 10 years of

age forming standard I to standard V in State

Board of Education were called for a meeting for

about 2 hrs in school conference hall for two

consecutive days. On the first day of meeting, A

talk about the Developmental coordination

disorder, including the prevalence, nature of the

disorder, diagnostic criteria, complications, role of

health care professional, teachers and parents in

dealing with these children, and management of

the condition were given. On the second day, the

selection of children based on the DCDQ’07 was

demonstrated and the teachers were trained

individually to fill the questionnaire. The teachers

were instructed to observe their class students for 3

days on play ground activities like ball handling,

running, jumping and on class room activities like

writing and learning. With the knowledge and

practice obtained from the meeting, observation on

child’s activities, teachers were asked to fill

questionnaire for the average of 30 students they

handle in the class room. Under supervision the

process of filling up the questionnaire was made

and doubts in marking the questionnaire were

clarified then and there during the process. With

the total scores obtained from the questionnaire,

screening was done to find out the children who

are under indication, or suspect for DCD.

In the second stage of selection process,

the children under indication or suspect for DCD

underwent TGMD-2. The TGMD-2 was conducted

in the outdoor play area. 2 Physical Education

Teachers and 1 special skill training staff were

involved in this selection process, assisting the

procedure. On the first testing day, the procedure

was explained to the participants in details. Then,

their names were asked and a name tag was

provided for each of them for identification. The

TGMD-2 was operated with the following

sequences: run, gallop, hop, leap, horizontal jump,

slide, striking a stationary ball, stationary dribble,

catch, kick, overhand throw and underhand roll.

The participants were queued behind the first line

and performed the skill within 50 feet of clear

space, which was marked with tape and cones

were placed.

The assessment was preceded with an

accurate demonstration and verbal description of

the skill, i.e., run. Then, a practice trial was

provided for the child who queued at the front, to

assure the child understands what to do. After that,

two test trials were given to the subjects and the

raw skill score was given for each item ranged

from 0-2. When the first subject was done, the

second one at the queue was instructed to start the

test with the practice trial; an additional

demonstration was also been when he or she did

not appear to understand the two test trials. The

procedures were repeated until the last participant

was completed. The test was then followed by

second skill task, i.e., gallop and the process was

as same as before. However, the sequence of the

queue was alternate so that one child did not

always go first or last. Scoring was made with

observation of all participants’ performance. The


29

assessment protocols were also standardized for all

participants according to the test manual of

TGMD-2 (Ulrich, 2000) (38).

Locomotor Subtest-Run

50 feet of running space and 8 feet of

safe stopping distance were made for this test

(Ulrich, 2000). The child ran as fast as he or she

can from the green cone to the red cone when the

examiner said “Go”. For the second trial, the child

ran from the red cone back to the green cone and

then waited at the end of the queue. According to

Ulrich (2000), the performance criteria for run

were as follows: arms move in opposition to legs,

elbows bent; brief period where both feet are off

the ground; narrow foot placement landing on heel

or toe (i.e., not flat footed); and nonsupport leg

bent approximately 90 degrees (i.e., close to

buttocks).

Locomotor Subtest-Gallop

25 feet distance was made for this test

(Ulrich, 2000). From the green cone, the child

galloped to the line in middle between the green

and red cones and repeated a second trial by

galloping back to the green cone. According to

Ulrich (2000), the performance criteria for gallop

were as follows: arms bent and lifted to waist level

at takeoff; a step forward with the lead foot

followed by a step with the trailing foot to a

position adjacent to or behind the lead foot; brief

period when both feet are off the floor; maintains a

rhythmic pattern for four consecutive gallops.

Locomotor Subtest-Hop

15 feet of clear space was made (Ulrich,

2000). The child was told to hop three times on his

or her preferred foot and then three times on the

other foot towards the line next to the green cone.

The trial was repeated by hopping back to the

green cone. According to Ulrich (2000), the

performance criteria for hop were as follows:

nonsupport leg swings forward in pendular fashion

to produce force; foot of nonsupport leg remains

behind body; arms flexed and swing forward to

produce force; takes off and lands three

consecutive times on preferred foot; takes off and

lands three consecutive times on non-preferred

foot.

Locomotor Subtest-Leap

A minimum of 20 feet of clear space was

made and a 10 inch plastic ball was used (Ulrich,

2000). First, the ball was placed 10 feet away from

the green cone. The child stood behind the line of

the green cone and ran and leaped over the ball. A

second trial was made by leaping back to the line

of green cone. According to Ulrich (2000), the

performance criteria for leap were as follows: take

off on one foot and land on the opposite foot; a

period where both feet are off the ground longer

than running; forward reach with the arm opposite

the lead foot.

Locomotor Subtest-Horizontal Jump

10 feet of clear space was made (Ulrich,

2000). The child started behind the starting line of

green cone and jumped as far as he or she can. A

second trial was from the starting line again.

According to Ulrich (2000), the performance

criteria for horizontal jump were as follows:

preparatory movement includes flexion of both

knees with arms extended behind body; arms

extend forcefully forward and upward reaching

full extension above the head; take off and land on

both feet simultaneously; arms are thrust

downward during landing.

Locomotor Subtest-Slide

25 feet of clear space was made during

the test (Ulrich, 2000). The child was told to stand

sideway to the performing space, i.e., left foot


30

parallel to the starting (green cone) line. The first

trial began by sliding from the starting line to the

middle line between the green and red cone, i.e.,

slide to the left. Then, repeated a second trial by

sliding back to the starting (green cone) line, i.e.,

slide to the right. According to Ulrich (2000), the

performance criteria for slide were as follows:

body turned sideways so shoulders are aligned

with the line on the floor; a step sideways with

lead foot followed by a slide of the trailing foot to

a point next to the lead foot; a minimum of four

continuous step-slide cycles to the right; a

minimum of four continuous step-slide cycles to

the left.

Object Control Subtest-Striking a Stationary Ball

A plastic bat, a batting tee and two 4-

inch lightweight balls were used in this test

(Ulrich, 2000). The batting tee was adjusted to the

child’s waist level. In the performing area, the

child was told to hold the bat with both hand and

hit the ball hard. For time saving, a second trial

was done by using another ball. According to

Ulrich (2000), the performance criteria for striking

a stationary ball were as follows: dominant hand

grips bat above non-dominant hand; non-preferred

side of body faces the imaginary tosser with feet

parallel; hip and shoulder rotation during swing;

transfers body weight to front foot; bat contacts

ball.

Object Control Subtest-Stationary Dribble

An 8- to 10-inch playground ball was

used in this test (Ulrich, 2000). The test was held

in the performing area. The child was told to

dribble the ball four times without moving his or

her feet, using one hand, and then stop by catching

the ball. A second trial was done. According to

Ulrich (2000), the performance criteria for

stationary dribble were as follows: contacts ball

with one hand at about belt level; pushes ball with

fingertips (not a slap); ball contacts surface in front

of or to the outside of foot on the preferred side;

maintains control of ball for four consecutive

bounces without having to move the feet to

retrieve it.

Object Control Subtest-Catch

The 8- to 10-inch playground ball was

used as mentioned by Ulrich (2000) in the manual.

15 feet of clear space was also made (Ulrich,

2000). The child and the tosser stood 15 feet away

of each other and the latter tossed the ball

underhand directly to the child with a slight arc

aiming for his or her chest. The child was told to

catch the ball with both hands for two times.

According to Ulrich (2000), the performance

criteria for catch were as follows: preparation

phase where hands are in front of the body and

elbows are flexed; arms extend while reaching for

the ball as it arrives; ball is caught by hands only.

Object Control Subtest-Kick

Two 8- to 10-inch playground balls, a

plastic ring instead of a bean bag to place the ball

were used and 30 feet of clear space was made for

this test (Ulrich, 2000). The ball was placed on the

top of the ring between the green and red cones,

i.e., 10 feet away from the starting line. The child

waited behind the starting line and then ran up and

kicked the ball hard. A second trial was repeated

by using another ball. According to Ulrich (2000),

the performance criteria for kick were as follows:

rapid continuous approach to the ball; an elongated

stride or leap immediately prior to ball contact;

non-kicking foot placed even with or slightly in

back of the ball; kicks ball with instep of preferred

foot (shoelaces) or toe.

Object Control Subtest-Overhand Throw

Two tennis balls were used and 20 feet


31

of clear space was made this test (Ulrich, 2000).

The child was told to stand behind the starting line

and threw the ball hard. A second trial was done

by using another ball. According to Ulrich (2000),

the performance criteria for overhand throw were

as follows: windup is initiated with downward

movement of hand/arm; rotates hip and shoulders

to a point where the non-throwing side faces the

wall; weight is transferred by stepping with the

foot opposite the throwing hand; follow-through

beyond ball release diagonally across the body

toward the non-preferred side.

Object Control Subtest-Underhand Roll

Two tennis balls, a cone were used and

25 feet of clear space was made for this test

(Ulrich, 2000). The cone was placed between the

starting and ending line, i.e., 20 feet away from the

starting line. The child was told to stand behind the

starting line and rolled the ball hard towards the

bean bag. A second trial was repeated by using

another tennis ball. According to Ulrich (2000),

the performance criteria for underhand roll were as

follows: preferred hand swings down and back,

reaching behind the trunk while chest faces cones;

strides forward with foot opposite the preferred

hand toward the cones; bends knees to lower body;

releases ball close to the floor so ball does not

bounce more than 4 inches high.

In the TGMD-2, individual performance

was scored with 1 or 0 to show the presence or

absence of that particular skill while each skill

ranged from 6 to 10 points. Raw scores were

added up across skills to form a sub-set of

locomotor or object control, with ranged from 0 to

48 points. The two sub-set total raw score were

converted into standard scores so to achieve a

Gross Motor Development Quotient (GMDQ) by

summing them. Ninety-six children showing

descriptive rating of below average, poor and very

poor were considered for intervention.

Parental consent forms were sent out to

parents of those ninety-six children, and a total of

fifty-four signed forms were returned on time.

After obtaining informed consent from parents,

clinical observations were made to assess the

child’s musculoskeletal flexibility and movement

patterns. This ensured that the child met DSM IV

criteria. TGMD-2 scores of the selected subjects

were recorded as Pre test values. These children

were randomly assigned to one of the two

intervention groups. All underwent 20 minutes of

intervention for 5 days a week for 7 consecutive

weeks. The intervention includes NTT, based on

the assessment of child’s motor performance on

the range of tasks then the kinaesthetic training

based on Laszlo’s kinaesthetic approach. At the

end of 7 weeks of intervention TGMD-2 post test

values were taken for statistical analysis.

INTERVENTION

There were two intervention groups,

NTT combined with kinaesthetic training

(intervention group 1) and NTT alone

(intervention group 2). Fifty- four children from

different class sections of standard I to standard V,

by simple randomization using computer

generated random numbers from statistical website

were assigned to either intervention group 1 or

intervention group 2. Intervention groups had 27

participants each and both the groups were

subdivided into 5 instructional subgroups for the

purposes of instruction.

Intervention group 1

The group was the NTT combined with

KT group consisted of 27 children including 7

females and 20 males. NTT was given in group


32

intervention, in the school play ground, for 20

minutes of 3 sessions per week for 7 weeks (11). KT

was also given as group training for 20 minutes

sessions 2 times per week for 5 weeks (39). These

two interventions were administered on basis of

one intervention a day in alternate days.

Intervention group 2

This was the NTT only group. It consisted of

27 participants with 9 females and 18 males. NTT

was given as group intervention, in school, for 20

minutes of 5 sessions per week for 7 weeks.

Neuromotor task training.

During the training, the therapist noted

the extent to which motor tasks are performed

below the expected level, such as handwriting or

ball skill tasks. Second, they were analyzed for the

cognitive or motor control processes that were

involved in the deficient motor performance. The

reason for the failure to learn a specific motor skill

were found out , for e.g., attention problems, fear

of failure, lack of motivation, or lack of

understanding of how to execute a skill. In

addition, motor control processes might hamper

successful performance such as timing of

components of a motor skill pattern, motor

planning, or parameter setting (the execution of a

motor act with the required speed and force) were

also taken consideration (40).

Each session started with general warm

up program for 10 minutes which was followed by

intervention of task training (considering all the

principles of ntt) over the range of tasks which the

child failed to perform in tgmd2 (locomotor and

object control subsets) during the pre test. The

progression was made by combining two or more

tasks into a game in groups (e.g., tasks like hitting,

over head throw, under arm roll and catch

combined into a game activity of cricket). Each

children were given time to comment on their as

well as others performance. As the children were

trained in group of five, everyone was made to

perform their role as a leader once during the

week.

Kinaesthetic Training

Developed by Laszlo (1985). Training

was based on kinesthetic awareness – class room

and individual practice Performa from Therapy

skill builders (41). The activities included in the

training were, 1. Recognizing and Reproducing

line direction and length. 2. Awareness activities

for fingers and hands. 3. Controlling direction of

movements- Dot to dot designs. 4. Recognizing

and controlling grip position 5.Recognizing and

reproducing Size, Shapes- Glue drawing, Template

activities.

RESULTS

The results of prevalence of DCD in

children in age group between 5 and 10 years in

the school population considered shows that the

rate of prevalence is 6.82. The pre test and post


33

test values of Group 1 (Neuromotor Task Training

Combined with Kinaesthetic Training) was

analysed using paired‘t’ test. For 24 degrees of

freedom and at 5% level of significance, the

table‘t’ value is 2.064 and the calculated ‘t’ value

was 11.586 . As the calculated‘t’ value was greater

than the table ‘t’ value and P value < 0.05, there

was a significant effectiveness of Neuromotor

Task Training combined with Kinaesthetic

Training in children with Developmental

Coordination Disorder. The pre test and post test

values of Group 2 (Neuromotor Task Training

Only) was analysed using paired‘t’ test. For 25

degrees of freedom and at 5% level of

significance, the table‘t’ value is 2.060 and the

calculated ‘t’ value was 11.588. As the

calculated‘t’ value was greater than the table ‘t’

value and P value < 0.05, there was a significant

effectiveness of Neuromotor Task Training alone

in children with Developmental Coordination

Disorder.

The pre test values of both the groups were

analysed using independent‘t’ test. For 49 degrees

of freedom and 5% level of significance, the

table‘t’ value 1.960 and the calculated ‘t’ value is

0.207. As the calculated‘t’ value was lesser than

the table‘t’ value and P value > 0.05, there was no

significant difference between the pre test values

of both groups. Hence there was homogenicity

between both the groups before the experiment.

The post test values of both the groups were

analysed using independent‘t’ test. For 49 degrees

of freedom and 5% level of significance, the

table‘t’ value 1.960 and the calculated ‘t’ value is

1.292. As the calculated‘t’ value was lesser than

the table‘t’ value and P value > 0.05, there was no

significant difference between the effectiveness of

Neuromotor task training combined with

Kinaesthetic training against Neuromotor task

training alone in children with DCD. The results of

the post test values comparing two groups shows

COHEN’S d = 0.362229. The results suggest that

there was a Medium Effect size.

DISCUSSION

Out of 121 children suspected for DCD

with initial screening by DCDQ’07, One child was

diagnosed of having congenital hemiplegia, One

with ADHD and 5 dropped out as they were absent

during the sessions of screening. Thus 114

children underwent secondary screening with

TGMD-2. Out of 96 children identified with DCD,

only 54 who consented on time (before the start of

intervention) were included, as the study duration

is limited. Two randomized groups for

intervention had 27 subjects each on the initiation

of the study, 2 subjects from the intervention

group 1 and 1 subject from the intervention group

2 were excluded from the results reported as they


34

missed out many of the sessions during the

intervention period due to illness.

The result from our study on local school

population of Kanchipuram, South India on age

group between 5 and 10 years shows that DCD is

prevailing in 6.82 % of children. The result is

correlating with the previous statement of

‘Approximately 6% of children in mainstream

primary schools demonstrate motor competence

below normal range, although they appear both

physically and intellectually normal’ 1 (American

Psychiatric Association, 1994). But in contrast to

the study done on the local population group in

kattankulathur of South India by Ganapathy

Sankar U and Saritha S (2011) have shown that

there is prevailing (Prevalence rate=1.37%) of

Developmental Coordination Disorder among the

age group of 5–10 years(13). As this study was done

only with DCDQ’07 screening, the prevalence rate

is only the suspect and the methodology of survey

was also not clearly explained, so this is

incomparable with our results.

The UK population based study by Raghu Lingam

et al., (2009), found that 18 of 1000 7-year-olds

have DCD according to strict DSM-IV criteria and

that 49 of 1000 7-yearolds have DCD or probable

DCD (16). In our study the approximate of 68 of

1000 (5 to 10 years old children) have DCD and

approximately 86 of 1000 have probable or

suspect for DCD. The problem predominantly

affects boys in a ratio of 3–4: 1 (24) (Gordon &

McKinley, 1980). In our study the boys to girls’

ratio is 3.36: 1. Thus our results add support to the

previous studies.

Angela D. Mandich et al., (2001), have

stated that, 1. To date, combined approaches are

largely untested and research has provided limited

evidence to support combined approaches. 2.

Combined approaches have demonstrated smaller

effects than pure approaches. 3. The evidence for

bottom up approaches would suggest that no one

approach, or combination of approaches, is

superior to another in improving motor skill. 4. No

bottom up approach has been shown to be reliably

better than no treatment at all (11). Considering

these statements, Top down approach of

Neuromotor Task Training was combined with

Bottom up approach of Kinaesthetic Training.

With the hypothesis to prove the effectiveness of

Neuromotor Task Training combined with

Kinaesthetic Training in children with DCD, our

study compared the groups with interventions

combined (NTT with KT) on one group and NTT

alone on another group. The results are statistically

insignificant to prove the effectiveness of

combined group over group with NTT alone, but

there is a considerable difference in the mean

values and the medium effect size shown by

Cohen’s d effect size measure shows its beneficial

effect. The effectiveness of Neuromotor Task

Training in DCD is promising in this study,


35

because there is a significant improvement seen in

both the subsets of TGMD-2 in the two

intervention groups. Kinaesthetic training in

combined therapy group has added some benefits

by producing difference in mean value between

the groups.

The reason for the effectiveness of

intervention may be due to the physical activity as

running, jumping and aerobic game playing which

has a definite impact on children’s frontal lobe, the

primary brain area for mental concentration,

planning and decision making(25). It is also

commonly believed that children automatically

acquire motor skills as their bodies develop but

scientists now believe that the opportunities for

practice, encouragement and instruction are crucial

to the development of mature patterns of

fundamental motor skills (26). The benefits made

would have been due to the group training in both

the groups as this has provided opportunity for

social interaction and stronger sense of

competence (14).

The added benefits of Kinaesthetic training

may be due to the processing of visual information

about the body and external environment,

proprioceptive information about limb and body

position, and then the initiation of an appropriate

corrective response. The integration or mapping of

these two sources of sensory information is also a

critical ingredient in balance control (27).

CONCLUSION

The study was to find out the

effectiveness of Neuromotor Task Training

combined with kinaesthetic training in children

with Developmental coordination disorder. With

the DCDQ’07 questionnaire filled by the school

teachers the initial screening was done followed by

secondary screening with TGMD-2 administered

by the principle investigator. The diagnosis was

made with the children falling below 15th

percentile in the test. The intervention were given

in two groups , one with combined therapy and the

other with Neuromotor Task Training alone for a

period of 7 weeks in small groups. The outcome

was assessed with Gross Motor Quotient of

TGMD-2. The data were analysed with Student’t’

tests comparing values within the groups and

between the groups. Results showed that the

prevalence of DCD in the local population is

6.82% and there is no significance difference

between the improvements made in the two

intervention groups.

Thus it is concluded that the

prevalence of DCD in the locality, Kanchipuram

of South India is 6.82%. The conclusions drawn

from our results are, 1. There is a significant

effectiveness of Combined therapy of Neuromotor

Task Training with Kinaesthetic Training in

children with DCD. 2. There is a significant

effectiveness of Neuromotor Task Training in

children with DCD. 3. There are no statistical

significant differences between the effectiveness of

combined therapy Group against Neuromotor Task

Training alone in children with DCD. The

differences in the mean value support the

combined therapy group to have some better

effects.

LIMITATIONS AND SUGGESTIONS

This study was done with limited number of

samples from a single school of a locality in South

India. Intervention duration is not enough to

produce long term effects and the stability of the

effects produced cannot be determined. This

simple measure of gross motor development alone


36

is not enough to measure all the characteristics of

children with DCD. Movement Assessment

Battery for Children 2 (MABC-2) which was

proven to be a valid measurement tool for children

with DCD should be considered. Parental

participation in assessing and managing these

children to be considered. Stability of the effects

produced with the intervention to be studied. Other

combinations of approaches can be tried.

REFERENCES:

1. Disorders Usually First Diagnosed In Infancy, Childhood Or Adolescence. Diagnostical and

Statistical Manual Of Mental Disorders: DSM-IV-TR: 4th Edition Text Revision. American

Psychiatry Association. Pg. No. 56-58.

2. Developmental Co-Ordination Disorder: A Review Of Evidence And Models Of Practice

Employed By Allied Health Professionals In Scotland. Specification/PDU/AHP/2006/001.

3. Smyth, M. M., & Anderson, H. I. Coping with Clumsiness In The School Playground: Social And

Physical Play In Children With Coordination Impairments. British Journal of Developmental

Psychology, 2000, 18, 389-413.

4. Kirby, A. & Davies, R. Developmental Coordination Disorder and Joint Hypermobility Syndrome

- Overlapping Disorders? Implications for Research and Clinical Practice. Child Care Health and

Development, 2007, 33(5), 513-9.

5. Kirby, A., Sugden, D., Beveridge, S. & Edwards, L. Developmental Co-Ordination Disorder

(DCD) In Adults and Adolescents. Journal of Research In Special Education Needs, 2008, 8,120-

31.

6. Sugden, D. A., &Wright, H. C. Motor Coordination Disorders In Children. Thousand Oaks, CA:

Sage. 1998.

7. M.M. Schoemaker, A.S. Niemeijer, K. Reynders, B.C.M. Smits-Engelsman Effectiveness Of

Neuromotor Task Training For Children With Developmental Coordination Disorder: A Pilot

Study. Neural Plasticity Volume 10, No. 1-2, 2003

8. Wilson, BN, Kaplan, BJ, Crawford, SG, And Roberts, G., The Developmental Coordination

Disorder Questionnaire 2007 (DCDQ’07) October 2007 ©B.N. Wilson 2007

9. Leanne M. Slater, Susan L. Hillier, Lauren R. Civetta. The Clinimetric Properties Of

Performance-Based Gross Motor Tests Used For Children With Developmental Coordination

Disorder: A Systematic Review Pediatric Physical Therapy: Summer 2010 - Volume 22 - Issue 2

- Pp 170-179

10. David A. Sugden and Mary E. Chambers., Intervention In Children With Developmental

Coordination Disorder: The Role Of Parents And Teachers. British Journal Of Educational

Psychology (2003), 73, 545–561.


37

11. Angela D. Mandich, Helene J. Polatajko, Jennifer J. Macnab, Linda T. Miller. Treatment Of

Children With Developmental Coordination Disorder: What Is The Evidence? Physical &

Occupational Therapy In Pediatrics, Vol. 20, No. 2/3, 2001 51-68.

12. Woei-Nan Bair. Children With Developmental Coordination Disorder Benefit From Using Vision

In Combination With Touch Information For Quiet Standing. Gait & Posture. June 2011. Volume

34, Issue 2 , Pages 183-190.

13. Sankar U and Saritha S. A Study Of Prevalence Of Developmental Coordination Disorder (DCD)

At Kattankulathur, Chennai. Indian Journal Of Physiotherapy And Occupational Therapy. Year:

2011, Volume: 5, Issue: 1 :( 63-65)

14. Winnie W. Y. Hung And Marco Y. C. Pang.Effects Of Group-Based Versus Individual-Based

Exercise Training On Motor Performance In Children With Developmental Coordination

Disorder: A Randomized Controlled Pilot Study. J Rehabil Med 2010; 42: 122–128

15. Brenda N. Wilson, Susan G. Crawford, Dido Green, Gwen Roberts, Alice Aylott, Bonnie J.

Kaplan. Psychometric Properties of The Revised Developmental Coordination Disorder

Questionnaire. Journal Of Physical And Occupational Therapy In Pediatrics.2009. 29(2): 182-

202.

16. Raghu Lingam, Linda Hunt, Jean Golding, Marian Jongmans And Alan Emond., Prevalence Of

Developmental Coordination Disorder Using The DSM-IV At 7 Years Of Age: A UK

Population_Based Study. Pediatrics 2009; 123; E693-E700.

17. Reint H. Geuze., Static Balance and Developmental Coordination Disorder. Human Movement

Science. 22 (2003)527–548.

18. Margaret Cousins, Mary M. Smyth., Developmental Coordination Impairments in Adulthood.

Human Movement Science 22 (2003) 433–459.

19. Barnhart RC, Davenport MJ, Epps SB, Nordquist VM. Developmental Coordination Disorder.

Phys Ther. 2003; 83: 722–731.

20. Dale A Ulrich. Test Of Gross Motor Development. Examiner’s Manual - Second Edition. Pro-Ed,

2000.

21. Polatajko H, McNab J, Anstett B, Malloy-Miller T, Murphy K, Noh S. A Clinical Trial Of The

Process Oriented Treatment approach For Children With Developmental Coordination Disorder.

Developmental Medicine And Child Neurology. 1995. 37. 310-319.

22. Anuschka S. Niemeijer et al., Developmental Medicine & Child Neurology. 2007; 49: 406-411.

23. Kinesthetic Awareness – Class Room And Individual Practice Performa From Therapy Skill

Builders. A Division of Communication Skill Builders/ 602-323-7500 (1991).

24. Gordon N, McKinley I Helping clumsy children. Churchill Livingstone, Edinburgh.1980

25. http://www.ivyacademy.cn/MI/BodilyKinesthetic%20Intelligence.pdf. The Multiple Intelligences

Preschool - IVY Academy.


38

26. Wafaa Abd Elzafez Abd Elmaksoud Ghaly. The Effect of Movement Education Program by

Using Movement Pattern to Develop Fundamental Motor Skills For Children Pre School. World

Journal of Sport Sciences. 2010; 3 (S); 461-491.

27. Sharon A. et al. Developmental coordination disorder. Cengage learning.2001.


*M.P.T. (Neurology)., F.N.R., P.G.C.D.E. Health Care Consultant, Bharathidasan Matric Hr Sec School,

Kanchipuram, Tamilnadu, India. & Consultant Physical Therapist, Star Health Care Center, Kanchipuram,

Tamilnadu, India.

**Bachelors in Physiotherapy (India), PG Dip Sci - Exercise Rehabilitation (Clinical Exercise Physiology),

University of Auckland, New Zealand.

39

COGNITIVE REHABILITATION IN MS

Krishna N. Sharma. MPT (Neuro)*

INTRODUCTION

Cognition refers to the ‘higher’ brain

functions e.g. memory and reasoning. Sometimes

the MS patients associate the cognitive

dysfunction to severity of physical symptoms or to

duration of the disease which is actually a

misbelief.1,2 Cognitive problems are one of the

most frequent symptoms of MS, which is evident

in about 50% of the patients.3,4 Approximately

10% to 20% patients show significant cognitive

dysfunction. Symptoms may be exaggerated by

underlying depression.5 The most often affected

cognitive functions are - memory, attention, speed

of processing, abstract reasoning, verbal fluency,

and executive functions.6,7,8 Widespread

deterioration of intellectual function in MS is rare.9

Why do they occur?

The Cognitive problems in MS are actually

the result of demyelination in the cerebral tracts

that connect with primary sensory, motor, speech,

and integration areas of the cerebrum. It may result

in poor recognition of deficits as well as an

inability to store and retrieve new information. The

combination of these two issues becomes a major

obstacle in the way to rehabilitation.10

Testing Cognitive Dysfunctions:

Neuropsychological testing can assist in

determining the degree of cognitive impairment in

patients with MS. Wallin et al (2006) et al.

categorized the tests for cognitive dysfunctions

associated with MS in three main schools of

thought:11

1. Short screening with traditional measures

in a neurologist’s office i.e. BRB-N (Brief

Repeatable Battery of Neuropsychological

Tests). It is composed of the Buschke

Selective Reminding Test, the 7/24 Spatial

Recall Test, the Paced Auditory Serial


40

Addition Test (PASAT), and the

Controlled Oral Word Association Test

(COWAT).12

2. Testing by a neuropsychologist with a

minimal (but comprehensive)

neurocognitive battery i.e. MACFIMS

(Minimal Assessment of Cognitive

Function in Multiple Sclerosis). It is

composed of PASAT, COWAT, SDMT

etc.13

3. Testing with automated, computerized

measures in a neurologist’s office or as

part of a clinical trial i.e. ANAM

(Automated Neuropsychological

Assessment Metrics). It is composed of

Procedural Reaction Time, Code

Substitution, Sternberg Memory Search

etc.14

Such an evaluation could be helpful in the

following ways:

• It can identify impaired and intact

functions.

• The MS patient as well as the family

members may have a better understanding

of the nature and extent of the illness.

• The evaluation may help the person

develop realistic vocational and other life

goals.

The results can suggest compensatory techniques.

Designing Interventions:

Designing intervention is the second step of

the cognitive rehabilitation. It is intended to

improve the patient's ability to function in all

aspects - personal, family, social, and vocation

life. Since the disease is unpredictable,

progressive, and fluctuating in nature and there is a

complex interaction of motor, sensory, cognitive,

functional, and affective impairments, it requires

periodic reassessment, monitoring, and

rehabilitative interventions. The therapist

recognizes the deficit and includes the functionally

oriented therapeutic tasks accordingly.

There are two approaches - Restorative

Strategies and Compensatory Strategies, which are

believed to be helpful in the cognitive

dysfunctions. Since the effectiveness of

Restorative Strategies to cognitive rehabilitation is

largely inconclusive15, Compensatory strategies

(i.e. teaching to use intact skills with/without

external aids) are widely used and are suggested

by most authors.

Compensatory Strategies-

• Cognitive Structuring- The therapist

applies suitable learning theory and make

the patient practice the cognitive task to

turn it in a routine behaviors.

• Substitution Strategies- The therapist

teaches to use the intact cognitive abilities

to circumvent the impaired abilities. For

example- Using intact visual memory in

place of impaired verbal memory function.

• Scheduling and Timelines- The patients

are encouraged to use schedulers and

alarms.


41

• Using the recording devices- It helps the

patients remember and store the important

details.

• Memory strategies- The patients are taught

and encouraged to use mnemonics, lists,

clustering, and visualization techniques

etc. to remember things.

• Assistive Technology- The patients are

advised to use handheld computers,

electronic calendars, and memory logs etc.

• Creating structured environment- It helps

the patients find their things on certain

fixed places to avoid the hassle in

forgetting and searching things.

Restorative Strategies-

Though so many verities of therapeutic tasks/

games/ activities are available for restoring or

improving cognition, there is lack of evidence-

based-practice of the restorative strategies for the

cognitive deficits associated with MS. There are

very less researches which confirm significant

improvement by the cognitive games.16,17

There are many toy games for cognitive

rehabilitation e.g.- Peg Board, Puzzle-cubes,

Quoridor, Tenzi, Fiddlesticks etc. But in this age

of computer and technology few application

softwares e.g.- COGNIsoft-I, BrainTrain, MSTY

Games etc; and online cognitive rehabilitation

games available on multiplesclerosis.com18,

BICBrainInjuryCentre.co.uk19, Peartrees.com20,

Mind360.com21 etc. are proving to be effective and

easily administrable.

An MS Patient using COGNIsoft-I for Cognitive

Rehabilitation

Tips:

• The activities should be conducted in quiet

places to avoid distractions.

• The sessions should be well-designed and

engaging.

• The activity should be demonstrated first.

• The instructions should be simple and

short.

• The activities should be carried out with

the concept of Errorless Learning22 in

mind. Application of the principles of

Spaced Retrieval Learning,23 Story

Memory Technique,24 etc. would enhance

the outcome.

• Instructions may be given in the forms of

Audio/ video tape, printed material also. It

would help them remembering the

activities even when they are at home.

• The exercises should be done for the

shorter periods of time to avoid cognitive

fatigue.

New skills should not be taught before the

previous skill has been strongly established.

42

REFRENCES

1. Peyser JM. Edwanb KR, Poser CM, et al: Cognitive function in patients with multiple sclerosis. Arch

Neurol 37:577-579, 1980

2. Beatty WW, Goodkin DE. (1990) Screening for cognitive impairment in multiple sclerosis: An

evaluation of the Mini Mental State Examination. Arch Neurol, 47, 297–301.

3. Aronson K, G. E.; Socio-demographic characteristics and health status of persons with multiple

sclerosis and their care givers. MS Management 3(1), 5-15. 1996.

4. Lublin F, Reingold S; Defining the course of multiple sclerosis. Neurology 46(4):907-911, 1996.

5. Debra I. Frankel; Multiple Sclerosis. DA Umphred (Ed.), Neurological Rehabilitation, The CV Mosby

Company, St. Louis, pp. 714. 1995



7. Rao SM, Leo GL, Bernardin L, et al: Congnitive dysfunction in multiple sclerosis. I. Grequency,

patterns, and prediction, Neurology 41(5):685-691, 1991

8. Peyser JM. Edwanb KR, Poser CM, et al: Cognitive function in patients with multiple sclerosis. Arch

Neurol 37:577-579, 1980

9. Lublin F, Reingold S: Defining the course of multiple sclerosis. Neurology 46(4) :907-911, 1996.



11. Wallin et al. Cognitive dysfunction in multiple sclerosis. JRRD, Volume 43, Number 1, 63-71. 2006

12. Rao SM, Leo GJ, Bernardin L, Unverzagt F. Cognitive dysfunction in multiple sclerosis. I.

Frequency, patterns, and prediction. Neurology. 1991;41(5):685–91.

13. Benedict RH, Fischer JS, Archibald CJ, Arnett PA, Beatty WW, Bobholz J, Chelune GJ, Fisk JD,

Langdon DW, Caruso L, Foley F, LaRocca NG, Vowels L, Weinstein A, DeLuca J, Rao SM,

Munschauer F. Minimal neuropsychological assessment of MS patients: a consensus approach. Clin

Neuropsychol. 2002;16(3):381–97.

14. Wilken JA, Kane R, Sullivan CL, Wallin M, Usiskin JB, Quig ME, Simsarian J, Saunders C, Crayton

H, Mandler R, Kerr D, Reeves D, Fuchs K, Manning C, Keller M. The utility of computerized

neuropsychological assessment of cognitive dysfunction in patients with relapsing-remitting multiple

sclerosis. Mult Scler. 2003;9(2):119–27.

15. O’Brien AR, Chiaravalloti N, Goverover Y, Deluca J. Evidenced-based cognitive rehabilitation for

persons with multiple sclerosis: a review of the literature. Arch Phys Med Rehabil 2008;89(4):761–9.

16. Chooi, Weng-Tink; Thompson, Lee A. (2012). "Working memory training does not improve

intelligence in healthy young adults". Intelligence 40 (6): 531–42.


43

17. Redick, T. S.; Shipstead, Z.; Harrison, T. L.; Hicks, K. L.; Fried, D. E.; Hambrick, D. Z.; Kane, M. J.;

Engle, R. W. (2012). "No Evidence of Intelligence Improvement After Working Memory Training: A

Randomized, Placebo-Controlled Study". General J Exp Psychol Gen. 2012 Jun 18.

18. http://www.multiplesclerosis.com/us/index.php

19. http://www.bicbraininjurycentre.co.uk

20. http://www.pearltrees.com/#/N-play=0&N-s=1_4127047&N-u=1_487865&N-p=44503368&N-

f=1_4127047&N-fa=4055621

21. http://www.mind360.com/games

22. Wilson BA, Baddeley A, Evans J, et al. Errorless learning in the rehabilitation of memory impaired

people. Neurospsychol Rehabil 1994; 4(3): 307–26.

23. Heesen C, Kasper J, Segal J, et al. Decisional role preferences, risk knowledge and information

interests in patients with multiple sclerosis. Mult Scler 2004; 10: 1–8.

24. Camp CJ, Foss JW, O’Hanlon AM, et al. Memory interventions for persons with dementia. Appl Cog

Psychol 1996; 10: 193–210.


* Senior Physiotherapist. Multiple Sclerosis Society of India (Mumbai Chapter), Mumbai, India.

Cont: +91-9320699167. Email: [email protected]


44

NETWORK BORDER PATROL ERADICATES THE OVER LOADING OF

DATA PACKETS AND PREVENTS CONGESTION COLLAPSE THEREBY

PROMOTING FAIRNESS OVER TCP PROTOCOL IN LAN /WAN

Lakshminarayanan T.*, Dr. Umarani R.**

ABSTRACT

The Project flow chart algorithm is multicast service. It is very simple being LAN/WAN broadcasting tool.

The LAN/WAN links are often private Lines, unlike submarine and over network. A private network has the

advantage of being managed and by few people so to avoid many problems about the property and origin of

LAN/ WAN has been investigated in the literature for some use. The fundamental philosophy behind the

internet is expressed by scalability argument No protocol, mechanism or service should be introduced in to

the internet if it does not scale well. A key corollary to the scalability argument is the end to end argument

to maintain scalability algorithmic complexity should be pushed to the edges of the network to whenever

possible Perhaps the best example of the internet philosophy the TCP congestion control which is

implemented primarily to algorithms operating at end systems unfortunately TCP congestion control also

illustrates some of the shortcomings the end to end argument As a result of its strict adherence to end and

congestion control.

KEYWORDS: LAN/WAN, TCP Congestion Control

RELATED WORKS

The maladies of congestion collapse from

undelivered packets and of unfair bandwidth

allocations have not gone unrecognized. Some


45

have argued that there are social incentives for

multimedia applications to be friendly to the

network, since an application would not want to be

held responsible for throughput degradation in the

Internet. However, malicious denial-of-service

attacks using unresponsive UDP flows are

becoming disturbingly frequent in the Internet and

they are an example that the Internet cannot rely

solely on social incentives to control congestion or

to operate fairly. Some have argued that these

maladies may be mitigated through the use of

improved packet scheduling1 or queue

management2 mechanisms in network routers.

For instance, per-flow packet scheduling

mechanisms like Weighted Fair Queuing (WFQ)3,4

attempt to offer fair allocations of bandwidth to

flows Contending for the same link. So do Core-

Stateless Fair Queueing (CSFQ)5, Rainbow Fair

Queueing6 and Choke7, which are approximations

of WFQ that do not require, core routers to

maintain per-flow state. Active queue management

mechanisms like Fair Random Early Detection

(FRED)8 also attempt to limit malicious or

unresponsive flows by preferentially discarding

packets from flows that are using more than their

fair share of a link’s bandwidth.

All of these mechanisms are more

complex and expensive to implement than simple

FIFO queuing, but they reduce the causes of

unfairness and congestion collapse in the Internet.

Nevertheless, they do not eradicate them. For

illustration of this fact, consider the example

shown in Figure 1. Two unresponsive flows

compete for bandwidth in a network containing

two bottleneck links arbitrated by a fair queuing

mechanism. At the first bottleneck link (R1-R2),

fair queuing ensures that each flow receives half of

the link’s available bandwidth (750 kbps).

On the second bottleneck link (R2-S4),

much of the traffic from flow B is discarded. Due

to the link’s limited capacity (128 kbps). Hence,

flow A achieves a throughput of 750 kbps and

flow B achieves a throughput of 128 kbps. Clearly,

congestion collapse has occurred, because flow B

packets, which are ultimately discarded on the

second bottleneck link, unnecessarily limit the

throughput of flow A across the first bottleneck

link. Furthermore, while both flows receive equal

bandwidth allocations on the first bottleneck link,

their allocations are not globally max-min fair. An

allocation of bandwidth is said to be globally max-

min fair if, at every link, all active flows not

bottlenecked at another link are allocated a

maximum, equal share of the link’s remaining

bandwidth9.

Fig: 1, Example of a Network Which Experiences

Congestion Collapse

A globally max-min fair allocation of

bandwidth would have been 1.372 Mbps for flow

A and 128 kbps for flow B. This example, which is

a variant of an example presented by Floyd and

fall10, illustrates the inability of local scheduling

mechanisms, such as WFQ, to eliminate

congestion collapse and achieve global max-min

fairness without the assistance of additional

network mechanisms. Jain et al. have proposed

several rate control algorithms that are able to

prevent congestion collapse and provide global

max-min fairness to competing flows11.


46

These algorithms (e.g., ERICA, ERICA+)

are designed for the ATM Available Bit Rate

(ABR) service and require all network switches to

compute fair allocations of bandwidth among

competing connections. However, these algorithms

are not easily tailor able to the current Internet,

because they violate the Internet design philosophy

of keeping router implementations simple and

pushing complexity to the edges of the network.

Rangarajan and Acharya proposed a network

border-based approach, which aims to prevent

congestion collapse through early regulation of

unresponsive flows (ERUF)12. ERUF border

routers rate control the input traffic, while core

routers generate source quenches on packet drops

to advise sources and border routers to reduce their

sending rates.

While this approach may prevent

congestion collapse, it does so after packets have

been dropped and the network is congested. It also

lacks mechanisms to provide fair bandwidth

allocations to flows. That is responsive and

unresponsive to congestion. Floyd and fall have

approached the problem of congestion collapse by

proposing low-complexity router mechanisms that

promote the use of adaptive or “TCP-friendly”

end-to-end congestion control10. Their suggested

approach requires selected gateway routers to

monitor high-bandwidth flows in order to

determine whether they are responsive to

congestion. Flows determined to be unresponsive

to congestion are penalized by a higher packet

discarding rate at the gateway router. A limitation

of this approach is that the procedures currently

available to identify unresponsive flows are not

always successful5.

Fig: 2, The Core-Stateless Internet Architecture

Assumed By NBP

1.1 TCP congestion control has mainly two

phases:

Slow Start and Congestion avoidance. A

new connection begins in Slow-start, setting its

initial cwnd to 1 packet, and increasing it by 1 for

every received Acknowledgement (ACK). After

cwnd reaches ssthresh, the connection switches to

congestion-avoidance where cwnd grows linearly.

A variety of methods have been suggested in the

literature recently aiming to avoid multiple losses

and achieve higher utilization during the startup

phase. A larger initial cwnd, roughly 4K bytes, is

proposed in.

This could greatly speed up transfers with

only a few packets. However, the improvement is

still inadequate when BDP is very large and the

file to transfer is bigger than just a few packets.

Fast start uses cached cwnd and ssthresh in recent

connections to reduce the transfer latency. The

cached parameters may be too aggressive or too

conservative when network conditions change

Smooth start has been proposed to slow down

cwnd increase when it is close to ssthresh. The

assumption here is that default value of ssthresh is

often larger than the BDP, which is no longer true

in large bandwidth delay networks. Proposes to set

the initial ssthresh to the BDP estimated (Packet

Network Discovery) has been proposed to derive


47

optimal TCP initial parameters. SPAND needs

leaky bucket pacing for outgoing packets, which

can be costly and Problematic in practice.

TCP Vegas detects congestion by

comparing the achieved throughput over a cycle of

length equal to RTT, to the expected throughput

implied by cwnd and base RTT (minimum RTT) at

the beginning of a cycle. This method is applied in

both Slow-start and Congestion-avoidance phases.

During Slow-start phase, a Vegas sender doubles

its cwnd only every other RTT, in contrast with

Reno’s doubling every RTT. A Vegas connection

exits slow-start when the difference between

achieved and expected throughput exceeds a

certain threshold. However, Vegas are not able to

achieve high utilization in large Band width delay

networks as we will, due to its over-estimation of

RTT.

We believe that estimating the eligible

sending rate and properly using such estimate are

critical to improving bandwidth utilization during

Slow-start.TCP Westwood and Eligible Rate

Estimation Overview in TCP Westwood (TCPW),

the sender continuously monitors ACKs from the

receiver and computes its current Eligible Rate

Estimate (ERE). ERE relies on an adaptive

estimation technique applied to ACK stream. The

goal of ERE is to estimate the connection eligible

sending rate with the goal of achieving high

utilization, without starving other connections. We

emphasize that what a connection is eligible for is

not the residual bandwidth on the path. The

connection is often eligible more than that. For

example, if a connection joins two similar

connections, already in progress and fully utilizing

the path capacity, then the new connection is

eligible for a third of the capacity.

1. Problem Methodology

System Flow diagram are directed graphs

in which nodes specify processing activities and

arc specify data item transmitted between

processing nodes .Data Flow diagrams represent

the system between individual items in fig: 5.a,

Fig: 5.A, Backward Feed Back

2.1 System implementation

Egress module- Input parameters: (I) Data packets

from router. (II)Forward feedback from the router.

Egress module- Output parameters: (I) Data

packets. (II)Backward feedback.

Destination module: (I) Message received from the

egress router will be stored in the corresponding

folder as a text file depends upon the source

machine name.

2. Network border patrol

Network Border Patrol is a network layer

congestion avoidance protocol that is aligned with

the core-stateless approach. The core-stateless

approach, which has recently received a great deal

of research attention [13], [5], allows routers on

the borders (or edges) of a network to perform

flow classification and maintain per-flow state but

does not allow routers at the core of the network to

do so. Figure 2 illustrates this architecture. As in

other work on core-stateless approaches, we draw

a further distinction between two types of edge

routers. Depending on which flow it is operating

on, an edge router may be viewed as ingress or an

egress router. An edge router operating on a flow

passing into a network is called an ingress router,

whereas an edge router operating on a flow


48

passing out of a network is called an egress router.

Note that a flow may pass through more than one

egress (or ingress) router if the end-to-end path

crosses multiple networks. NBP prevents

congestion collapse through a combination of per-

flow rate monitoring at egress routers and Per-flow

rate control at ingress routers. Rate monitoring

allows an egress router to determine how rapidly

each flow’s packets are leaving the network,

whereas rate control allows an ingress router to

police the rate at which each flow’s packets enter

the network. Linking these two functions together

are the feedback packets exchanged between

ingress and egress routers; ingress routers send

egress routers forward feedback packets to inform

them about the flows that are being rate controlled,

and egress routers send ingress routers backward

feedback packets to inform them about the rates at

which each flow’s packets are leaving the network.

This section describes three important

aspects of the NBP mechanism: (a) the

architectural components, namely the modified

edge routers, which must be present in the

network, (b) the feedback control algorithm, which

determines how and when information is

exchanged between edge routers, and (c) the rate

control algorithm, which uses the information

carried in feedback packets to regulate flow

transmission rates and thereby prevent congestion

collapse in the network.

Fig: 3- An Input Port of an NBP Egress Router.

3.1 Architectural Components

The only components of the network that

require modification by NBP are edge routers; the

input ports of egress routers must be modified to

perform per-flow monitoring of bit rates, and the

output ports of ingress routers must be modified to

perform per-flow rate control. In addition, both the

ingress and the egress routers must be modified to

exchange and handle feedback. Figure: 3,

illustrates the architecture of an egress router’s

input port. Data packets sent by ingress routers

arrive at the input port of the egress router and are

first classified by flow. In the case of IPv6, this is

done by examining the packet header’s flow label,

whereas in the case of IPv4, it is done by

examining the packets Source and destination

addresses and port numbers. Each flow’s bit rate is

then rate monitored using a rate estimation

algorithm such as the Time Sliding Window

(TSW) [14].

These rates are collected by a feedback

controller, which returns them in backward

feedback packets to an ingress router whenever a

forward feedback packet arrives from that ingress

router. The output ports of ingress routers are also

enhanced. Each contains a flow classifier, per-flow

traffic shapers (e.g., leaky buckets), a feedback

controller, and a rate controller. See Figure 4. The

flow classifier classifies packets into flows, and

the traffic shapers limit the rates at which packets

from individual flows enter the network. The

feedback controller receives backward feedback

packets returning from egress routers and passes

their contents to the rate controller. It also

generates forward feedback packets, which it

occasionally transmits to the network’s egress


49

routers. The rate controller adjusts traffic shaper

parameters according to a TCP-like rate control

algorithm, which is described later in this section.

Fig: 4, an Output Port of an NBP Ingress

Router.

3.2 The Feedback Control Algorithm

The feedback control algorithm

determines how and when feedback packets are

exchanged between edge routers. Feedback

packets take the form of ICMP packets and are

necessary in NBP for three reasons. First, they

allow egress routers to discover which ingress

routers are acting as sources for each of the flows

they are monitoring. Second, they allow egress

routers to communicate per-flow bit rates to

ingress routers. Third, they allow ingress routers to

detect incipient network congestion by monitoring

edge-to-edge round trip times. The contents of

feedback packets are shown in Figure 5. Contained

within the forward feedback packet are a Time

stamp and a list of flow specifications for flows

originating at the ingress router. The time stamp is

used to calculate the round trip time between two

edge routers, and the list of flow specifications

indicates to an egress router the identities of active

flows originating at the ingress router. A flow

specification is a value uniquely identifying a

flow. In IPv6 it is the flow’s flow label; in IPv4, it

is the combination of source address, destination

address, source port number, and destination port

number. An edge router adds a flow to its list of

active flows

Fig: 5, Forward and Backward Feedback Packets

Exchanged By Edge Routers.

Whenever a packet from a new flow

arrives; it removes a flow when the flow becomes

inactive. In the event that the network’s maximum

transmission unit size is not sufficient to hold an

entire list of flow specifications, multiple forward

feedback packets are used. When an egress router

receives a forward feedback packet, it immediately

generates a backward feedback packet and returns

it to the ingress router. Contained within the

backward feedback packet are the forward

feedback packet’s original time stamp, a router

hop count, and a list of observed bit rates, called

egress rates, collected by the egress router for each

flow listed in the forward feedback packet.

The router hop count, which is used by the

ingress router’s rate control algorithm, indicates

how many routers are in the path between the

ingress and the egress router. The egress router

determines the hop count by examining the time to

live (TTL) field of arriving forward feedback

packets. When the backward feedback packet

arrives at the ingress router, its contents are passed

to the ingress router’s rate controller, which uses

them to adjust the parameters of each flow’s traffic


50

shaper. In order to determine how often to

generate forward feedback packets, an ingress

router keeps a byte transmission counter for each

flow it processes. Whenever a flow’s byte counter

exceeds a threshold, denoted TX, the ingress

router generates and transmits a forward feedback

packet to the flow’s egress router. The forward

feedback packet includes a list of flow

specifications for all flows going to the same

egress router, and the counters for all flows

described in the feedback packet are reset.

Using a byte counter for each flow ensures

that feedback packets are generated more

frequently when flows transmit at high rates,

thereby allowing ingress routers to respond more

quickly to impending congestion collapse. To

maintain a frequent flow of feedback between edge

routers even when data transmission rates are low,

ingress routers also generate forward feedback

packets whenever a time-out interval, denoted tf, is

exceeded.

On arrival of Backward Feedback packet p from

egress router e

Current RTT = current Time - p.time stamp;

if (currentRTT < e.base RTT)

e.base RTT = currentRTT;

delta RTT = currentRTT - e.base RTT;

RTTsElapsed = (current Time -

e.lastFeedbackTime) / currentRTT;

e.lastFeedbackTime = current Time;

for each flow f listed in p

rateQuantum = min (MSS / currentRTT,

f.egressRate / QF);

if (f.phase == SLOW_START)

if (deltaRTT × f.ingressRate < MSS × e.hopcount)

f.ingressRate = f.ingressRate × 2 ^ RTTsElapsed;

else

f.phase = CONGESTION_AVOIDANCE;

if (f.phase == CONGESTION_AVOIDANCE)

if (deltaRTT × f.ingressRate < MSS × e.hopcount)

f.ingressRate = f.ingressRate + rateQuantum ×

RTTsElapsed;

else

f.ingressRate = f.egressRate - rateQuantum;

Fig: 6, Pseudo Code for Ingress Router Rate

Control Algorithm.

3. The Rate Control Algorithm

The NBP rate control algorithm regulates

the rate at which each flow enters the network. Its

primary goal is to converge on a set of per-flow

transmission rates (hereinafter called ingress rates)

that prevents congestion collapse from undelivered

packets. It also attempts to lead the network to a

state of maximum link utilization and low router

buffer occupancies, and it does this in a manner

that is similar to TCP. In the NBP rate control

algorithm, shown in Figure 6, a flow may be in

one of two phases, slow start or congestion

avoidance, which is similar to the phases of TCP

congestion control. New flows enter the network

in the slow start phase and proceed to the

congestion avoidance phase only after the flow has

experienced congestion.

The rate control algorithm is invoked

whenever a backward feedback packet arrives at

an ingress router. Recall that BF packets contain a

list of flows arriving at the egress router from the

ingress router as well as the monitored egress rates

for each flow. Upon the arrival of a backward

feedback packet, the algorithm calculates the

current round trip time between the edge routers

and updates the base round trip time, if necessary.


51

The base round trip time reflects the best observed

round trip time between the two edge routers. The

algorithm then calculates delta RTT, which is the

difference between the current round trip time

(currentRTT) and the base round trip time (e.base

RTT). A delta RTT value greater than zero

indicates that packets are requiring a longer time to

traverse the network than they once did, and this

can only be due to the buffering of packets within

the network. NBP’s rate control algorithm decides

that a flow is experiencing congestion whenever it

estimates that the network has buffered the

equivalent of more than one of the flow’s packets

at each router hop. To do this, the algorithm first

computes the product of the flow’s ingress rate and

deltaRTT.

This value provides an estimate of the

amount of the flow’s data that is buffered

somewhere in the network. If the amount is greater

than the number of router hops between the ingress

and the egress router multiplied by the size of the

largest possible packet, then the flow is considered

to be experiencing congestion. The rationale for

determining congestion in this manner is to

maintain both high link utilization and low

queuing delay. Ensuring there is always at least

one packet buffered for transmission on a network

link is the simplest way to achieve full utilization

of the link, and deciding that congestion exists

when more than one packet is buffered at the link

keeps queuing delays low. A similar approach is

used in the DEC bit congestion avoidance

mechanism [15].

When the rate control algorithm

determines that a flow is not experiencing

congestion, it increases the flow’s ingress rate. If

the flow is in the slow start phase, its ingress rate

is doubled for each round trip time that has elapsed

since the last backward feedback packet arrived.

The estimated number of round trip times since the

last feedback packet arrived is denoted as

RTTsElapsed.

Doubling the ingress rate during slow start

allows a new flow to rapidly capture available

bandwidth when the network is underutilized. If,

on the other hand, the flow is in the congestion

avoidance phase, then its ingress rate is

conservatively incremented by one rateQuantum

value for each round trip that has elapsed since the

last backward feedback packet arrived. This is

done to avoid the creation of congestion. The rate

quantum is computed as the maximum segment

size divided by the current round trip time between

the edges routers. This results in rate growth

behavior that is similar to TCP in its congestion

avoidance phase. Furthermore, the rate quantum is

not allowed to exceed the flow’s current egress

rate divided by a constant quantum factor (QF).

This guarantees that rate increments are

not excessively large when the round trip time is

small. When the rate control algorithm determines

that a flow is experiencing congestion, it reduces

the flow’s ingress rate. If a flow is in the slow start

phase, it enters the congestion avoidance phase. If

a flow is already in the congestion avoidance

phase, its ingress rate is reduced to the flow’s

egress rate decremented by MRC. In other words,

an observation of congestion forces the ingress

router to send the flow’s packets into the network

at a rate slightly lower than the rate at which they

are leaving the network.

RESULT

In this paper, we have presented a novel

congestion avoidance mechanism for the Internet

called network border patrol. Unlike existing


52

internet congestion control approaches, which rely

solely on end-to-end control, NBP is able to

prevent congestion collapse from undelivered

packets. It does this by ensuring at the border of

the network that each flows packets do not enter

the network faster than they are to leave it NBP

requires no modification to core routers or to end

systems. Only edge routers are enhanced so that

they can perform the requisite per – flow

monitoring, per-flow rate control and feedback

exchange operations.

CONCLUSION

In this paper, we have presented a novel

congestion avoidance mechanism for the Internet

called Network Border Patrol. Unlike existing

Internet congestion control approaches, which rely

solely on end-to-end control, NBP is able to

prevent congestion collapse from undelivered

packets. It does this by ensuring at the border of

the network that each flow’s packets do not enter

the network faster than they are able to leave it.

NBP requires no modifications to core routers or

to end systems. Only edge routers are enhanced so

that they can perform the requisite per-flow

monitoring, per-flow rate control and feedback

exchange operations.

Extensive simulation results provided in

this paper show that NBP successfully prevents

congestion collapse from undelivered packets.

They also show that, while NBP is unable to

eliminate unfairness on its own, it is able to

achieve approximate global max-min fairness for

competing network flows when combined with

WFQ, Furthermore, NBP, when combined with

CSFQ, approximate global max-min fairness in a

completely core-stateless fashion.

As in any feedback- based traffic

mechanism, stability is an important performance

concern in NBP. Using techniques described in

(16), a plan as part of my future works to perform

an analytical study of NBP’s stability and

convergence toward max – min fairness.

Preliminary results already suggest that NBP

Benefits greatly from its use of explicit rate

feedback, which prevents rate over-corrections in

response to indications to indications of network

congestion.

REFERENCES

1. B. Suter, T.V. Lakshman, D. Stiliadis, and A. Choudhury, “Design Considerations for Supporting TCP

with Per-Flow Queueing,” in Proc. Of IEEE Infocom ’98, March 1998, pp. 299–305.

2. B. Braden et al., “Recommendations on Queue Management and Congestion Avoidance in the Internet,”

RFC 2309, IETF, April 1998.

3. A. Demers, S. Keshav, and S. Shenker, “Analysis and Simulation of a Fair Queueing Algorithm,” in Proc.

of ACM SIGCOMM, September 1989,pp. 1–12.

4. A. Parekh and R. Gallager, “A Generalized Processor Sharing Approach to Flow Control – the Single

Node Case,” IEEE/ACM Transactions on Networking, vol. 1, no. 3, pp. 344–357, June 1993.

5. I. Stoica, S. Shenker, and H. Zhang, “Core-Stateless Fair Queueing: Achieving Approximately Fair

Bandwidth Allocations in High Speed Networks,” in Proc. of ACM SIGCOMM, September 1998, pp.

118–130.28


53

6. Z. Cao, Z. Wang, and E. Zegura, “Rainbow Fair Queuing: Fair Bandwidth Sharing Without Per-Flow

State,” in Proc. of IEEE Infocom ’2000, March 2000.

7. R. Pan, B. Prabhakar, and K. Psounis, “CHOKe - A stateless active queue management scheme for

approximating fair bandwidth allocation,” in Proc. of IEEE Infocom ’2000, March 2000.

8. D. Lin and R. Morris, “Dynamics of Random Early Detection,” in Proc. of ACM SIGCOMM, September

1997, pp. 127–137.

9. D. Bertsekas and R. Gallager, Data Networks, second edition, Prentice Hall, 1987.

10. S. Floyd and K. Fall, “Promoting the Use of End-to-End Congestion Control in the Internet,” IEEE/ACM

Transactions on Networking, August 1999, to appear.

11. R. Jain, S. Kalyanaraman, R. Goyal, S. Fahmy, and R. Viswanathan, “ERICA Switch Algorithm: A

Complete Description,” ATM Forum Document 96-1172, Traffic Management WG, August 1996.

12. A. Rangarajan and A. Acharya, “ERUF: Early Regulation of Unresponsive Best-Effort Traffic,”

International Conference on Networks and Protocols, October 1999.

13. S. Blake, D. Black, M. Carlson, E. Davies, Z. Wang, and W. Weiss, “An Architecture for Differentiated

Services,” Request for Comments 2475, Internet Engineering Task Force, December 1998.

14. D. Clark and W. Fang, “Explicit Allocation of Best-Effort Packet Delivery Service,” IEEE/ACM

Transactions on Networking, vol. 6, no. 4, pp. 362–373, August 1998.

15. K.K. Ramakrishna and R. Jain, “A Binary Feedback Scheme for Congestion Avoidance in Computer

Networks with a Connectionless Network Layer,” ACM Transactions on Computing Systems, vol. 8, no.

2, pp. 158–181, May 1990.


* Research Scholar , Department of Computer Science , Periyar University College of Arts and Science,

Mettur Dam-636401. Email- [email protected]

** Associate Professor, Department of Computer Science, Sri Sarada College for Women, Salem -07


54

USE OF FUZZY TOPSIS MODEL FOR EVALUATING COOLING TOWERS

Dr. Ali Kheradmand*, Mahdi Naqdi Bahar**, Ali Ghani Ab adi***

ABSTRACT

Present paper applies Fuzzy TOPSIS Model for identification of indicators regarding to cooling towers and assigning weight to indicators and prioritizing Cooling Towers distributed questionnaires among 37 expert and specialist in Besat Electricity Production Company in Tehran – Iran. The current research concluded to this result that in most of the existing studies on decision making issue , the issue is supposed in an environment of definitive data but in some cases it seen that determination of exact values for the criteria is difficult and the value should be considered as Fuzzy Values.

KEY WORDS: Fuzzy TOPSIS (Technique for Order Preference by Similarity to Ideal Situation) Model, Cooling Tower, Technology Selection, Decision Making

INTRODUCTION

Technology selection is concerned with

choosing the best technology from a number of

available options. The criteria for a ‘best’

technology may differ depending on the specific

requirements of a company. (Shehabuddeen et al,

2006) technology selection process as

‘identification and selection of new or additional

technologies which the firm seeks to

master’.(Garegory,1995) technology selection

involves ‘gathering information from various

sources about the alternatives, and the evaluation

of alternatives against each other or some set of

criteria’.(Lamb and Gregory,1997) Technology

selection and justification involve decision

makings that are critical to the profitability and

growth of a company in the increasing competitive

global scenario.(Chan et al, 2000) One of the

technologies regarding the industry is cooling

tower which has many applications in industries.

Role of cooling towers for chemicals producing


55

units is like role of radiator in an automobile. As

cutting off flow of cooling water in automobile

and radiator break down causes irreparable

damages to engine and other parts of automobile,

in industry too, cutting off cooling water even for a

short time involves huge damages as consequence

so that operators in case of cooling water cut-off

for any reason often consider it a saving action to

put the system out of service in spite heavy costs

of production halt. This strong dependence of

production on cooling towers function indicates

their special economic importance. On the other

side, limitation of water sources and necessity of

their use make the towers’ economic role more

obvious and on the other side, incorrect selection

of this technology may in addition to loss of water

sources, bring irremediable damages to the

country’s industry. Hence, selection of this

technology is of very high importance. This paper,

using Fuzzy TOPSIS Model tries to evaluate and

prioritize cooling towers.

LITERATURE REVIEW

Some mathematical programming

approaches have been used for technology

selection in the past. Hsu et al. (2010) provided a

systematic approach towards the technology

selection in which two phase procedures were

proposed. The first stage utilized fuzzy Delphi

method to obtain two the critical factors of the

regenerative technologies by interviewing the

experts. In the second stage, fuzzy AHP was

applied to find the importance degree of each

criterion as the measurable indices of the

regenerative technologies. They considered eight

kinds of regenerative technologies which have

already been widely used, and established a

ranking model that provides decision markers to

assessing the prior order of regenerative

technologies. To select the best technologies in the

existence of both cardinal and ordinal data

Faerzipoor Saen(2006) proposed an innovative

approach, which is based on Imprecise date

envelopment analysis (IDEA). Lee and Hwang

(2010) proposed to use AHP as a tool for

prioritizing the strategically promising nuclear

technologies for commercial export from Korea.

Jaganathan et al (2007) proposed an integrated

Fuzzy AHP based approach to facilitate the

selection and evaluation of new manufacturing

technologies in the presence of intangible

attributes and uncertainty. However, AHP as two

main weaknesses First subjectivity of AHP is a

weakness. Second AHP could not include

interrelationship within the criteria in the model

this paper, using Fuzzy TOPSIS Model tries to

evaluate and prioritize cooling towers.

FUZZY TOPSIS METHOD

The TOPSIS is widely used for tackling

ranking problems in real situations. This method is

often criticized for its inability to adequately

handle the inherent uncertainty and imprecision

associated with the mapping of the decision-

makers perception to crisp values. In the

traditional formulation of the TOPSIS, personal

judgments are represented with crisp values.

However, in many practical cases the human

preference model is uncertain and decision makers

might be reluctant or unable to assign crisp values

to the comparison judgments (Chan & Kumar,

2007; Shyur & Shih, 2006). Having to use crisp

values is one of the problematic points in the crisp

evaluation process. One reason is that decision-

makers usually feel more confident to give interval

judgments rather than expressing their judgments


56

in the form of single numeric values. As some

criteria are difficult to measure by crisp values,

they are usually neglected during the evaluation.

Another reason is mathematical models that are

based on crisp value. These methods cannot deal

with decision-makers’ ambiguities, uncertainties

and vagueness which cannot be handled by crisp

values. The use of Fuzzy set theory (Zadeh, 1965)

allows the decision-makers to incorporate

unquantifiable information, incomplete

information; non-obtainable information and

partially ignorant facts into decision model (Kulak,

Durmusoglu, & Kahraman, 2005). As a result,

Fuzzy TOPSIS and its extensions are developed to

solve ranking and justification problems

(Büyükzkan, Feyzioglu, & Nebol, 2008; Chen &

Tsao, 2007; Kahraman, Büyükzkan, & Ates, 2007;

Onüt & Soner, 2007; Wang & Elhag, 2006; Yong,

2006). This study uses triangular Fuzzy number

for Fuzzy TOPSIS. The reason for using a

triangular Fuzzy number is that it is intuitively

easy for the decision-makers to use and calculate.

In addition, modeling using triangular Fuzzy

numbers has proven to be an effective way for

formulating decision problems where the

information available is subjective and imprecise

(Chang, Chung, & Wang, 2007; Chang & Yeh,

2002; Kahraman, Beskese, & Ruan, 2004;

Zimmerman, 1996). In practical applications, the

triangular form of the membership function is used

most often for representing Fuzzy numbers (Xu &

Chen, 2007).

NEED FOR A TECHNOLOGY SELECTION

METHOD

Technology based businesses rely on

renewal of existing technological resources and

exploitation of new technologies to remain

competitive and to sustain growth (McNamara and

Baden-Fuller, 1999). These firms engage in

various technology management practices, and

deploy technology strategies and planning in order

to meet these needs. This is becoming more

difficult due to increasing complexity of

technologies, convergence of technologies,

abundance of technological options, higher cost of

technological development, and rapid diffusion of

technologies (see Lei, 2000; Steensma and

Fairbank, 1999; Berry and Taggart, 1994). The

dispersion of technology sources across

organizations, geographical locations and

countries, and the resulting obscurity, makes the

task of accessing suitable technologies and

selection of the most suitable option more difficult

(Cantwell, 1992). Greenberg and Cazoneri (1995)

and Hackett and Gregory (1990), report that

projects to incorporate new technology, in a

majority of companies, are failing or are not

fulfilling expectations. Nabseth and Ray (1974) in

their study of the European and USA machine tool

companies found that similar problems still remain

although several investigations have been

undertaken to study these issues. As Huang and

Mak (1999) explain in their study of 100 British

manufacturing companies, the failure of a chosen

technology often results from poor management

and preparation of the change process. Some of the

causes have been attributed to the inability to

consider the wider relationship of technology to

the business and organizational context and

include these issues in the technology investment

considerations (Schroder and Sohal, 1999). This

finding is echoed by Efstathiades et al. (2000) who

assert the need for careful assessment of potential

problems before introducing a technology into an

organization.


57

RESEARCH PURPOSES

I. Identification of indicators regarding cooling

towers

II. Assigning weight to indicators and

prioritizing cooling towers

RESEARCH METHODOLOGY

This research in terms of purpose is of

applied type and the research execution method is

of descriptive and survey type. The research’s

statistical society includes two parts: the first part

is for identification of cooling towers’ indicators

including experts and specialists of cooling towers

of Besat Electricity Production Company. Given

that the statistical society was a limited society, 32

specialists were selected and the questionnaire was

distributed among them. The second part regards

weight assignment and prioritization of cooling

towers’ various options in which 5 connoisseurs

were questioned.

DATA COLLECTING TOOL

In this paper, to collect information with

regard to the research’s theoretical bases and

literature, index cards and tables have been used.

To gather the data from the 3 used questionnaires

(first questionnaire for identification of indices, the

two other questionnaires for weight assignment to

the indices and prioritization of cooling towers)

the validity of which has been confirmed by

professors and its stability using Cronbach Alpha

was found to be 75% and hence confirmed.

DATA ANALYSIS METHOD

After data collection for all the

alternatives, given the determined indicators, it

was found that this issue in the field of decision

making with multi indices and from among

various models existing in the area of decision

making with multi-indices, TOPSIS method due to

its advantages relative to other method has been

selected for weight assignment and prioritization.

Step 1: formation of Fuzzy Decision Making

Matrix in which m alternatives by n indices are

assessed. A Fuzzy multi-indicator decision making

matrix is defined as follows.

1)

njmi

XXX

XXX

XXX

A

A

A

D

CCC

mnmm

n

n

m

n

,...,2,1,,...,2,1,

~~~

~~~

~~~

~

21

22221

11211

2

1

21

==

=

L

MMMM

L

L

M

L

In which, m

AAA ,...,2

,1

represent alternatives,

nCCC ,...,

2,

1represent indices, and

ijx~

denotes Fuzzy value of the option i in terms

of the index j . Verbal variables and Fuzzy

numbers equivalent to each verbal variable

used in this study are presented in table (1).

Table(1)

Step 2: Make normalize matrix decision making

matrix as relation (2) which takes place by means

of relations (3) and (4). Relation (3) is used for

scale less making of indices with positive aspect

and relation (4) for scale less making indices with

negative aspect.


58

(2) [ ] njmirRnmij ,...,2,1,,...,2,1,~~ ===

×

(3) ijjj

ij

j

ij

j

ijij cc

c

c

c

b

c

ar max,,,~ =

= +

+++

(4) ijjij

j

ij

j

ij

jij aa

a

a

b

a

c

ar min,,,~ _

___

=

=

Step 3: calculation and make harmonic normalize

matrix as relation (5) using relation (6).

(5) [ ] njmivVnmij ,...2,1,,...,2,1,~~ ===

×

(6) jijij wrv ~~~ ⊗=

At this stage, we need to evaluate indices’ weights.

To calculate indices’ weight in this research the

suggested method by Wang and Chang (1995) has

been used. For this purpose, five connoisseurs

have been asked to determine indices’ importance

with verbal variables. To determine importance of

the constituents and the respective weights, the

respective verbal variables and Fuzzy numbers

suggested by Wang and Chang (1995) have been

used. Table 2 shows verbal variables and Fuzzy

numbers. This method has been used by Wang and

Chang (1995) and Chen (2000), Wang and Elhag

(2007) to determine the indices’ weights.

Table(2)

Source: (Wang & Chang, 1995; 2007)

Step 4: determining positive and negative ideal for

each index using relations (7) and (8).

(7) ( ) }{ miJjvv ijj,....,1max~~ =∈=+

(8) ( ) }{ miJjvv ijj,....,1min ~~ =∈=−

+

ijv~ And

−

ijv~ takes place in three stages and

using the following relations. Obviously, if at both

stages the greatest and smallest Fuzzy numbers are

found, there will be no need for other stages.

Stage 4.1: at this stage, using relation (9) we rank

Fuzzy numbers in order to find its greatest and

smallest quantity.

(9) ( )4

20,

~ cbaAS

++=

Stage 4.2: if at stage one there are numbers which

are placed in one group, or in other words, using

relation (9) we cannot determine their smallness or

greatness relative to each other, we take their tide

into consideration and using Fuzzy numbers’ tide

we rank them.

(10) ( )Ae~

mod

Stage 4.3: at third stage, if there are still numbers

which are placed in one group, for their ranking

we consider Fuzzy numbers’ Domain.

(11) ( )A~

Stage 5: distance of each alternative is found

through positive and negative ideal solution. This

is done using relations (12) and (13).

(12) ( )~~

(13)

In which by taking and into account as two

triangular Fuzzy numbers it calculated as relation

(14).

(14)

Step 6: calculation of relative closeness of each

alternative to ideal solution which is done using


59

relation (15).

(15) midd

dcc

ii

ii ,...,2,1,

_

_

=+

= +

Step 7: alternatives ranking; at which the existing

alternatives from the hypothetic problem are

ranked in ascending order starting from the most

important.

RESULT:

The questionnaire which had been provided to

the statistical society (32 persons) was analyzed

and 8 indicators were selected for cooling towers

evaluation. Next, 5 connoisseurs were asked to

assign weight to the indices the results of which

are presented in the table below:

Table 1: Weights Indices

Given identification of the identified indices

and weigh of each index, now using Fuzzy

TOPSIS method which has been explained in data

analysis method we prioritize the options. The

following results indicate relative closeness of

each option to the ideal solution.

Table 2: Closeness of Alternative to the Ideal

Solution

RANKING OF ALTERNATIVES:

Table 3: Ranking Based on the Preferred

Alternatives

Check rank the cooling tower can be seen

Tower with a suction fan(A4) rated first and

Tower with a blower fan(A3), Tower with normal

tension(A5), Tower with a Traction stokehole(A6),

Tower with normal tension(A2), Tower with

mechanical tension(A1) were next to the stars.

CONCLUSION:

In this paper, evaluation of level and prioritization

of cooling towers technology based on the

specified indices by experts using ranking method

based on similarity with ideal answer Fuzzy

TOPSIS was investigated. In most of the existing

studies on decision making issue, the issue is

supposed in an environment of definitive data but

in some cases, it is seen that determination of exact


60

values for the criteria is difficult and the values

should be considered as Fuzzy values. In this

paper, we have investigated the existing options in

Fuzzy environment and based on the Theory of

Fuzzy Sets and then based on TOPSIS method

approach which is a simple method and quickly

specifies the required answer, we calculated the

closest option to the ideal solution.

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Management 24 (4), 341–353.

• Büyükzkan, G., Feyzioglu, O., & Nebol, E. (2008). Selection of the strategic alliance partner in

logistics value chain. International Journal of Production Economics,113, 148–158.

• Cantwell, J., 1992. The internalisation of technological activity and itsimplications for

competitiveness, in: Granstrand, O., HakanSon, L.,Sjolander (Eds.), Technology Management and

International Business: Internationalisation of R&D and Technology. Wiley, New York, pp. 76–78.

• Chan, F. T. S., & Kumar, N. (2007). Global supplier development considering risk factors using

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* Department of Accounting, Zahedshahr Branch, Islamic Azad University (IAU), Zahedshar , Iran.

** Corresponding Author: Research Scholar, Thiruvananthapuram, Kerala, India, E mail:

[email protected], Mobile phone: +919623566206

*** Ali Ghani Abadi, Master of Industrial Management


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CORRECTION NOTICE

It is hereby informed to all the readers of Scientific Research Journal of India that the main author of

the article entitled “Effect of McConnell Taping on Pain, ROM & Grip Str ength in Patients with

Triangular Fibrocartilage Complex Injury” published in the Year: 2013, Vol:2, Issue:1 was Babloo

Sharma. So kindly read the authors as- Babloo Sharma, Dr. Shahid Mohd. Dar and Dr. R Arunmozhi

instead of Dr. Shahid Mohd. Dar, Dr. R Arunmozhi, Babloo Sharma.

Thanks for your kind cooperation.

Editor-in-Chief

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