Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : YC08 - YC11 Full Version

Effect of Short-term Respiratory Proprioceptive Neuromuscular Facilitation on Peak Expiratory Flow Rate and Six-minute Walk Test in Patients with Stable Chronic Obstructive Pulmonary Disease: A Quasi-experimental Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55928.16458
Parkavi Kumaresan, Umarani Ravichandran, Dhanpal Singh, Mangaleswaran Seraman

1. Research Scholar, Lecturer in Physiotherapy, Department of Physical Medicine and Rehabilitation, Annamalai University, Chidambaram, Tamil Nadu, India. 2. Professor, Department of Medicine, RMMCH-Annamalai University, Chidambaram, Tamil Nadu, India. 3. Professor and Head, Department of Physical Medicine and Rehabilitation, RMMCH-Annamalai University, Chidambaram, Tamil Nadu, India. 4. Postgraduate, Department of Physical Medicine and Rehabilitation, RMMCH-Annamalai University, Chidambaram, Tamil Nadu, India.

Correspondence Address :
Parkavi Kumaresan,
Lecturer in Physiotherapy, Department of PMR, RMMCH, Annamalai University,
Chidambaram-608002, Tamil Nadu, India.
E-mail: parkavikarthik2010@gmail.com

Abstract

Introduction: Proprioceptive Neuromuscular Facilitation (PNF) of respiratory muscles was found to improve lung function and haemodynamic parameters in mechanically ventilated patients. It has been proven that respiratory PNF had immediate significant effects in Chronic Obstructive Pulmonary Disease (COPD) patients. As pulmonary rehabilitation for COPD patients is a long-term hospital based service, there arises a need to provide a therapy that provides optimal benefit in short term.

Aim: To study the effect of short term respiratory PNF on Peak Expiratory Flow Rate (PEFR) and six-minute walk test in patients with stable COPD.

Materials and Methods: This quasi-experimental study was carried out in the Department of Physical Medicine and Rehabilitation, Rajah Muthiah Medical College and Hospital at Annamalai University, Chidambaram, Tamil Nadu, India. Twelve male COPD patients attending Medicine Department outpatient service between December 2020 to January 2021 were conveniently recruited. They were assessed for their PEFR using peak flow meter and exercise tolerance by six-minute walk test. They were treated with three respiratory PNF techniques namely, intercostal stretch, vertebral pressure high and anterior stretch by lifting posterior basal area for five consecutive days. Each treatment session lasted for about 30-40 minutes. The post intervention assessment of PEFR and six-minute walk was made. The pre and post intervention data were statistically analysed using paired samples t-test.

Results: In this study, the mean age of the participants was 63.0 ± 5.80 years. The mean post intervention measurement of PEFR (226.67±51.09 L/min) and six-minute walk distance (271.92±50.55 m) was found to be significantly higher (p=0.001) than the mean pre interventional values (165.42±46.19; 219.58±43.24 respectively).

Conclusion: Implementation of respiratory PNF techniques on short term basis optimally improves the functional exercise capacity and PEFR in patients with stable COPD.

Keywords

Anterior stretch lift, Functional exercise capacity, Intercostal stretch, Vertebral pressure high

The burden of Chronic Obstructive Pulmonary Disease (COPD) is increasing and it accounts for the second most common cause of non communicable disease related deaths in India. The mean rise in disability adjusted life years (DALYs) for COPD was found to be 36% from year of 1990 to 2016 (1),(2). Chronic obstructive pulmonary disease is a preventable and treatable disease mainly characterized by limitation in airflow which is progressive and not fully reversible. The anatomical and inflammatory changes in the lungs affect the elastic support which traps the air during expiration. It results in dynamic hyperinflation of the lungs (3).

Pharmacological therapy for COPD reduces the symptoms and prevents complications. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report, 2018 recommends the appropriate non pharmacological therapies to complement the management strategies in stable COPD patients. The COPD is considered as being ‘stable’ when its symptoms are well managed and decline in lung function is minimal. The reduced functional capacity in COPD hints at the progression of the disease severity, frequent hospitalisation and mortality (4).

The pulmonary rehabilitation is a well known multidisciplinary non pharmacological intervention in COPD patients. It reduces dyspnea, hospital admissions and improves exercise tolerance and health related quality of life (4),(5),(6). The common techniques used to improve breathing pattern in COPD were purse lip breathing, relaxed diaphragmatic breathing and thoracic mobility exercises (6),(7). Recent literatures suggest that Proprioceptive Neuromuscular Facilitation (PNF) of respiratory muscles have some role in gaining chest expansion and improving lung function in patients with COPD (3),(8).

The PNF techniques improve respiratory muscle strength through three dimensional spiral large scale resistive exercises. The PNF pattern of exercises induces large scale spiral movements in the lower rib cage and promotes pulmonary function in young adults (9). The Intercostal stretch technique of respiratory PNF has profound effects on improving oxygen saturation and reducing respiratory and heart rate in mechanically ventilated patients. The PNF provides a facilitatory stimulus that produces reflex respiratory movement as a response. This alters the rate and depth of respiration (10),(11),(12). The proprioceptive and tactile stimulus applied during respiratory PNF induces the reflex respiratory movement. In addition, intercostal stretch restores the normal breathing pattern, improves chest wall mobility thereby improving the chest expansion (13),(14).

The British Thoracic Society Standards of Care proposed that in pulmonary rehabilitation any intervention is said to be effective when it was implemented for 20-30 minutes, 2-5 sessions per week over a period of 4-12 weeks (9). On considering the practical issues of visiting the healthcare setup and adherence to the therapy, a therapy with optimal benefit in short term basis should be identified. Mistry HM and Kamble RV assessed the immediate effect of PNF in COPD by applying the intercostal stretch alone over the 2nd and 3rd rib only. It was found that the respiratory rate was reduced and the chest expansion, peak expiratory flow rate was improved (8).

The literature evidence on PNF stretching of respiratory muscles in patients with COPD was limited. Among the six facilitatory stimuli, most studies applied intercostal stretch technique and some involved the anterior stretch basal lift as well (3),(8),(10),(11). Other techniques of respiratory PNF’s are underutilized and their effects still has to be studied. The present study involved three techniques of respiratory PNF namely the intercostal stretch, anterior basal lift and vertebral pressure high and was designed to find out the short term effects of respiratory PNF on PEFR and six-minute walk test in patients with stable COPD.

Material and Methods

A quasi-experimental pilot study was carried out in the Department of Physical Medicine and Rehabilitation at Rajah Muthiah Medical College and Hospital, Annamalai University, Chidambaram, Tamil Nadu, India, from December 2020 to January 2021. The present study was a part of doctoral research work whose protocol had been approved by Institutional Human Ethics Committee (IHEC/596/2019), Rajah Muthiah Medical College and Hospital. The subjects and their attendees were clearly explained about the purpose and procedure of the study and the informed written consent was obtained.

Twelve stable COPD patients attending the Medicine outpatient Department on Mondays and Tuesdays at Rajah Muthiah Medical College and Hospital were recruited by convenient sampling method as per the selection criteria.

Inclusion and Exclusion Criteria: Males, age between 45-70 years, normal BMI (18.5-24.9), COPD grade 1 and 2 (as per GOLD standards) (4), those who could ambulate independently were included while patients on dyspnoeic episodes, SpO2 < 85 %, patients on supplemental O2 therapy, associated lung and cardiac diseases, any orthopaedic limitations to walk like surgeries, fractures, disabling deformities, intake of oral steroids and psychiatric illness were excluded from the study.

The pre and post interventional evaluation of peak expiratory flow rate (15) and six-minute walk test (16) was made using standard protocols.

Study Procedure

In this study, peak expiratory flow rate was measured by mini peak flow meter. The six-minute walk was performed by the participants (barefoot) on a levelled corridor of 30 m long. The corridor was calibrated at every 5 metres. The PNF techniques like intercostal stretch, vertebral pressure high and anterior stretch by lifting posterior basal area were applied over the bare chest of participants (13).

Intercostal stretch: A firm downward pressure was applied over the upper border of the ribs. The intercostal stretch was given bilaterally using the therapist fingers. The stretch force applied during the expiration was maintained as the patient continues to breath. The intercostal stretch was maintained for 10 breaths at 2nd, 3rd, 4th, 5th and 6th intercostal areas on both sides (Table/Fig 1).

Vertebral pressure high: Therapist stood at the head end of the couch. A firm manual pressure was applied by the therapist hands over the T2-T5 thoracic vertebrae while the patient was lying in supine position. The stretch was performed thrice and maintained for five breaths (Table/Fig 2).

Anterior stretch by posterior basal lift: Therapist hands were placed bilaterally around the lower ribs of patient. A gentle upward lift was given.The technique was performed thrice with the stretch maintained for five breaths (Table/Fig 3).

The intervention session lasted for about 30-40 minutes with appropriate rests. The post intervention evaluation was made an hour later the treatment session on 5th day. The outcome variables were peak expiratory flow rate (PEFR) in L/minute and six-minute walk distances in metres.

Statistical Analysis

The pre and post intervention assessment data were analysed using Statistical Package for the Social Sciences (SPSS) version 21. Descriptive statistics were used for age and pre and post values of outcome variables. The comparison of mean values was made using paired t- test at 5% level of significance.

Results

Almost 50% of the study samples (n=6) were in the age range of 61-70 years and 75% of the COPD patients (n=9) were of grade 2 severity (Table/Fig 4).

The mean pre intervention PEFR was 165.42±46.19 L per minute and six-minute walk distance was 219.58±43.24 meters. The mean post intervention PEFR and six-minute walk distance was found to be increased by 61.25 L/min and 52.34 metres respectively (Table/Fig 5).

It was observed that both the outcome variables differ significantly between their pre and post assessment values with the p-value of 0.001 (Table/Fig 6).

Discussion

Any intervention advocated in pulmonary rehabilitation requires a minimal time frame of four weeks to establish its effect. It has been observed that respiratory PNF performed for four weeks increased exercise tolerance, chest expansion at nipple and xiphi sternal level and decreases the dyspnoea score in patients with stable COPD (3),(8). Kyochul seo and Misuk Cho performed respiratory PNF patterns in normal young adults and reported a significant improvement in pulmonary function parameters (9). Though many studies (8),(9),(10),(11),(12) support the use of respiratory PNF in improving the pulmonary function parameters, a review by Gupta S and Mishra K concluded that PNF respiratory exercise is no superior than pursed lip breathing and diaphragmatic breathing in COPD patients (14).

The present study showed a significant improvement in post evaluation PEFR values whose performance was effort dependent. This coincides with the findings of Mistry HM and Kamble RV (2021) who studied the immediate effect of PNF in COPD patients. In addition, the mean difference in PEFR of the present study showed four fold increased from their study (8). This might be due to the increased treatment sessions. It has been observed that the improvement in six-minute walk distance in the present study was obviously greater than the observations made by Dangi A et al., who implemented PNF for four weeks in stable COPD (3).

On comparing the observations of present study with the findings of Dangi A et al., Mistry HM and Kamble RV (3),(8), the obtained difference in the outcomes were found to be greater, irrespective of the duration of intervention. The above studies delivered PNF technique of intercostal stretch alone to COPD patients whereas the present study involves vertebral pressure high and anterior stretch by lifting posterior basal area in addition to Intercostal stretch. Gupta P, et al established intercostal stretch as good in improving respiratory rate, SpO2 and heart rate than anterior basal lift in Intensive Care Unit (ICU) patients (17). In COPD no such comparison has been made.

Abstaining from work to participate in pulmonary rehabilitation on long-term basis and frequent hospital visits might be difficult for COPD patients. The findings of the present study signify the role of respiratory PNF techniques in COPD patients. It was also observed that combination of respiratory PNF techniques produced a better effect than treating with single technique alone. In the present study the PNF was applied to the whole chest by intercostal stretch. The upper chest was treated by vertebral pressure high and the lower chest by anterior stretch by lifting posterior basal area. This can be applied to the inpatients who got admitted during acute exacerbations of COPD after they get medically stable.

Limitation(s)

The present study had only experimental group and involved male patients with COPD. The pressure applied on chest wall mainly depended on patient’s tolerance and comfort. It has not been quantified objectively. Further studies on long-term effects and follow up effects of respiratory PNF with control group should be carried out for better understanding. Sample size was small , so the findings of the study could not be generalised.

Conclusion

The administration of respiratory PNF techniques on short term basis was found to improve the PEFR and six-minute walk distance in patients with stable COPD. This might help in reducing the length of optimal period of pulmonary rehabilitation for patients.

Acknowledgement

The authors would like to acknowledge Dr. M. Senthilvelan, Professor and Head, Dr. S. Sudharsan, Professor, Department of Medicine - RMMCH for referring the COPD cases and all our participants those who willingly gave their consent to participate in this study.

References

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Rajkumar P, Pattabi K, Vadivoo S, Bhome A, Brashier B, Bhattacharya P, Mehendale SM. A cross-sectional study on prevalence of obstructive pulmonary disease (COPD) in India: rationale and methods. BMJ Open. 2017;7:e015211. [crossref] [PubMed]
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Mistry HM, Kamble RV. Immediate effect of chest proprioceptive neuromuscular facilitation on respiratory rate,chest expansion and peak expiratory flow rate in patients with chronic obstructive pulmonary disease. International journal of physiotherapy. 2021;9(1):3723-29. [crossref]
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DOI and Others

DOI: 10.7860/JCDR/2022/55928.16458

Date of Submission: Feb 26, 2022
Date of Peer Review: Mar 14, 2022
Date of Acceptance: Apr 08, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 03, 2022
• Manual Googling: Apr 06, 2022
• iThenticate Software: Apr 12, 2022 (3%)

ETYMOLOGY: Author Origin

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