Friday, April 1, 2011

Duchenne muscular dystrophy

Definition:it is one of genetic determined myopathy that are characterized by steady progressive degeneration and weakness of the is x linked disease and is insidious in its onset.
clinical presentation:
1-Delayed motor development.
2-Walking is clumsy and there is frequent falling.
3-Walking with wide BOS with waddling and lurching gait.
4-Walking on tips of foot.and relactance of walking and running.
5-As weakness increase , gower sign appear: as child climb him self for raising due to weakness of the back and abdominal muscle, calf, iliopsoas,iliotibial band and knee flexors.
6-Using wheel chair for ambulation.
7- Affection of respiration.
8-Positional deformity as scoliosis.
7-Obesity due to lack of activity and mobility and sitting on wheel chair.
By progression:
1- there is shortening in specific muscles.
2- Weakness and deposition of fibrous tissue.
Shortening of specific muscle help sitting before weakness but he can not maintain the upright posture.
Goal: maintainance of child functional and ambulant as much as possible.
1- Functional ability assessment:what he can do from his ADL activity according to his age:
At 6-7 years : he can walk and run.
At 9-10 years:child can walk with assisstance due to deterioration of the muscles.
Examples for functional assessment.
For upper limb: 1- bilateral abduction and elevation of both arms or one.
                            2- raise hand just above head.
                            3- mouthing only.
For lower limb:1-walking and ascending stairs without assistance.
                          2 -walking and ascending stairs mild assistance.
                          3-walking and ascending stairs with moderate assistance.
                          4-use wheel chair for mobility.
                          5-just getting off or raising from wheel chair.
2-Muscle power assessment: manual muscle test,we do group muscle test to avoid exhuation,
it is applied for the following muscles:1-upper and lower fibers of trapezius.
                                                                2- serratus anterior.
                                                                3- pectoralis .
                                                                5-gluteus maximus and medius.
                                                                6- rhomboids.
                                                               10-tibialis anterior.
                                                                11-latissimus dorsi. 
3- ROM assessment: active and passive range of motion.
limited active range of motion refers to muscle weakness.but if there is limitation in both active and passive range this refers to muscle tightness.
Prolonged sitting on wheel chair leads to limitation of range of hip extension ,knee extension,ankle dorsiflexion and elbow extension.
4- Flexability assessment: is used for test for tight muscles as
a- Iliopsoas muscle: thomas test.
b-Ilio tibial band: obar test.
c- Hamstring and calf muscles.
5- Muscle tone assesment:we can use gower test :patient sitting and therapist stand behind him and hold child shoulder from under axilla then elevate shoulder. there is increase in the upward displacement with sudden release , the shoulder drop sudden not gradually.
 6-Gait and wheel chair assessment:
a- By observation: we can see pattern of walking as walking on tip of toes with wide BOS.
b-wheel chair: if he can do his activities as transfere and the distance that patient can travel and the amount of energy expenditure.
7-Pulmonary function assessment: to evaluate vital capacity and oxygen consumption.
Respiratory failure is the common cuase of deathdue to weakness of the respiratory muscles and accumulation of secretions which lead to infection.
1- To prevent deformity:a- ROM exercise for all jointsin the early stage     
                                           b- Stretching exercise for hamstring and calf muscles.
                                           c- Application of braces as AFO and KAFO.
                                            d- Strengthening exercise .
2- To maintain functional ability: this can be achieved through proper exercises  which must be:
                                                    a- functional exercise.
                                                    b- aerobic exercise.
                                                    c- exercise for large group of muscles.
                                                    d- child must talk rest to avoid fatigue.
3- Family support: parents are depressed and feel guilt and furstration so we must help them to accept this problem and avoid giving false hope for them .
4- Pain control: proper exercise help reducing pain through prevention of deformity and delay appearance of complication.
For child who sits on wheel chair must change his position periodically and change  position of the propelling hand every 6months.
For child who is bed ridden ,we must use air matress to avoid development of pressure ulcers also we must do respiratory care in the form of breathing exercise and posture drainage.
5- To control obesity: it develops as child in put is more than the out put and decrease his activity level .so we advice for proper diet and exercise program and avoiding food with high caloric value.                                        
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Thursday, March 31, 2011

Congenital hip dislocation

Incidence: it occurs by 2 or 3 children per 1000 live births. it is common in female than male by ratio 5:1.
Etiology: there is many factors that may lead to this congenital anomaly:
1) Ligamentous laxity around hip joint result from familial mesenchymal tissue disorders and cartilagenous limbus which form the rim of the acetabulum  that is inverted inside the acetabulum.
2) The head of the femur is flattened.
3) Breech presentation during delivery.
4)Shallowing of the acetabulum.
5)Sever hypotonia with generalized joint laxity.
The dislocated femoral head is directed superior and posterior to the acetabulum leading to :
1)Elongation of the ligamentum teres .
2)Contraction of psoas, adductor,and hamstring muscles.
3) Separation of the gluetus medius from the ilium.
4) Stretching of the joint capsule.
Clinical presentation:
1) Skin fold on the gluteal and adductor region .
2) Limitation of passive hip abduction.
3) Old child who begins to ambulate show positive trendelenburg sign.
4) Child with bilateral CHD has waddling gait.
1) Plain X- ray:we can see shallowing of the acetabulum and shape of the femoral head.
2) CT ultrasonic : is used for intra utrine investigation.
Special tests for hip instability in infants.
1) The ortolani test: chid lies supine  with his hip and knee are flexed.
      Grasp: the therapist hold legs at the femoral condyles with his index and middle finger on the lateral aspect of the thigh on the greater trochanter.
both legs are rotated through full arcs of external rotation and abduction.
the normal hip can be brought into 90 degree of abduction but the dislocated hip blocks usually at 30 to 40 degee of abduction and external rotation.
2)Piston test: child lies supine with hip flexed 90 degree and adducted and the knee is flexed . the therapist grasp thigh  with the opposite hand and the infant pelvis is supported with the other hand then move thigh up and down through its axis.
Normally , the hip is felt stable without telescoping of the limb.
If there is dislocation , the axial compression cuases the leg to be short so that telescoping is obvious.
3)Barlow's test: child is supine with his hips and knees are flexed.
the therapist grasp the normal side of the pelvis  with the opposite hand to this side and the examined hip is held between tip of middle and thumb .
the hip is adducted  if it is dislocated it can be pushed out of the back of the joint and reduced by pressure on the greater trochanters.
1) Reduction of the joint with minimal soft tissue injury .the child is put in quadriped position and use splint that keep hip in abduction . it may be one of the following:
a- Traction :weight traction can be used to reduce dislocation . the hip is moved gradually in wide abduction  in either extension or flexion.
b- Splinting:
1-Frejka pillow.                                                              2-Von Rosen splint.
3-Denis brown hip splint.                                            4-Pavlik harness.
5-Plaster hip spica.
2)  physiotherapy:
1- Mobilization in warm water is very useful.
2- weight bearing activity as standing and walking.
3- Walking using crutch is better than using walker as it allow active hip and knee flexion.
4- Using tread mill for strengthening and endurance.
Surgical management:
1-Closed or open reduction may be done with or without musclotenotomies.the hips are placed in abduction and immobilized with plaster which is maintained for 9 months depending on child age and type of surgery .
2- Pelvic osteotomy : is used for children between 18 months and 10 years of age . they are immobilized in plaster hip spica for up to 8 weeks.
3- Steel triple osteotomy : is done for children with age of 12 years  and older child . they require 120 weeks for immobilization in hip spica

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Sunday, March 27, 2011

Shoulder - Reverse TSA Standard of Care

Standard of Care: Reverse/Inverse Total Shoulder Arthroplasty

Case Type / Diagnosis: 

The reverse or inverse total shoulder arthroplasty (rTSA), first described by Grammont et al.
has only recently gained popularity and FDA approval as a treatment option for patients
requiring a shoulder replacement for the treatment of glenohumeral (GH) arthritis when it is
associated with irreparable rotator cuff damage, complex fractures, as well as for a revision for a
previously failed conventional TSA in which the rotator cuff tendons are deficient/absent.
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varicose vien

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spina bifida

It is one of the congenital anomalies in which there is developmental defect in the spinal column
due to failure of fusion of the vertebral arches leading to protrusion of the spinal cord or its membranes .
Brief pathology.
During the intrauterine life, the neural plate is formed at the eighteenth day of the gestation, this neural plate divide into neural tube and neural arch. The neural tube forms the central nervous system (brain and spinal cord). The neural arch forms the peripheral nervous system. This defect appear within first few weeks of gestation, as the neural plate has  cranial part which close at the day of 26 of gestational life  ,if this closure not occur this will lead to encephalomyopathy which lead to death. The caudal part close at the day of 28 of the gestation, spina bifida result from failure of closure of this part.but wether the cuase is genetic or environmental is unknown.
Types of Spina bifida
1- Spina bifida oculta: there is defect only in the neural arch without neural tissue involvement, there is skin changes and hairy patches.
 2-Spina bifida cystica:it include two types:
a)Meningocele: the vertebral arch un fused , there is  herniation of the meninges , part of the cord or nerve roots may present in sac but conduct impulse normally.
b)Myelomeningocele: sac contain neural elements  that protrude through the spinal defect. The overlying skin is thin andleaks of spinal fluid. There may be secondary infection,neurological and orthopedic problems and hydrocephalus               
clinical picture : it will differ according to the affected level . the most common affected is lumbosacral region. it may include:
1- Fflaccide paralysis.
2- Muscle weakness and wasting.
3- Decreased or absent tendon reflexes.
4- Decreased or absent extroceptive and propioceptive sensation.
5-Rectal and bladder incontinance.
7-Sever vasomotor changes.
pt examination.
1) By sight:we can see on the back of the patient  one or more of the following:
                       a)Tuft of hair.
                        b)Subcutaneous lipoma.
                       c)Localized sac.
                       d)Increased head size.
                           e)Deformity of the lower limb .                                                                           
2)By palpation:a)bony defect
                          b)Subcutaneous lipoma.
                          c) Loss of sensation.
                           d)Muscle bulk.
3)Measurement and tests:
1-Tape measurement:a) round measurement for head circumferance and muscle contour.
                                      b)Long measurement for lower limb.
 2-Range of motion: child with age less than 3 years can not obey to command so we use test for tightness as indicator for limited range of motion.
3-Muscle test: we can do functional muscle test with the following grades:
    a-Functional : child can performs the task completely.
    b-Sub functional: it start from inability to do task completely to the ability to do flicker contraction in the muscle.
   c-Non functional: inability to perform the task.
Exercise for the upper limb:children with spina bifida need to compensate motor control of their legs and trunk. they use their arms as assistance for daily living activities:a- transferring from seat to bed and toilet.
b-Helping children without trunk stability to sit.
c- Standing up from the floor or from wheel chair.So, exercises to strengthen the arms are important part of the treatment as press up with pillows under the knees and feets.
poor sitting balance:many children with spina bifida have poor sitting balance and there is many factors lead to this problem as 1-Weak trunk muscles.
                                                     2- Paralyzed lower limb.
                                                     3- Lack of sensation.
We can deal with this problem through: 
1-Strengthening exercises for back extensors and balance exercise as sitting astride the legs of the therapist or stride aroll.
2- Special seats or wheel chairs are molded to provide  adequate support  for the trunk .
Pt modalities can be used in the management of the symptoms that result from spina bifida
1- In patient with partial paralysis an extensive program of physical application should be applied aiming to improve muscle power and to increase physical abilities of the patient.
2- Electric appliances may be used to relieve pain, induce relaxation or to improve function.
3- Passive movement and passive stretch should be used to prevent and correct contracture and deformities .
4- Active exercise to prevent muscle imbalance and to keep the gained range  during passive manibulation.
5-Hydrotherapy is very effective when skin is intact.
6-Gait training by using braces.
Many patients who have lower lumber lesion and in whom there is power 5 of the quadriceps and 4 of the medial hamstring have the potential to walk  with ankle / foot orthoses with or without external aids. the factors affecting ambulatory status are related expenditure and control of obesity. two orthoses have been introduced reciprocating gait pattern and to enable standing.these are reciprocating gait orthoses and hip guidance orthoses . apre-requisite fitting such an orthoses is that there is no more than 20 degree flexion  in the hip, the knee and the foot can be rendered in plantigrade position.

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Musculoskeletal Physical Examination

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Subjects, Materials, and Methods

In this part of the study the materials and methods were presented under the following headings:
Forty children with acute lymphoblastic leukemia, their ages ranged from 6: 12 years. These children were selected from the National Cancer Institute. These children randomly subdivided into two equal groups (twenty patients for each);  

Group (A) = (Exercise Program Group):
This group was composed of 20 children with acute lymphoblastic leukemia and represented the group who received the exercise program for 12 weeks in addition to perform the traditional medical intervention.

Group (B) = (Control Group):
This group was composed of 20 children with acute lymphoblastic leukemia and represented the control group who did not receive any form of physical therapy intervention but this group was instructed and encouraged to remain active during their cancer treatment approach.

Criteria of Patient Selection:
The patients had the following criteria:
a- Inclusive Criteria:
·        The age of the patients ranged from 6: 12 years.
·        All patients had the same medical care and have no evidence impairment of cardiac, pulmonary, renal, and hepatic function.
·        All patients received a good explanation of treatment and measurement devices.
·        Each child was evaluated by his/her oncologist before and every 2 weeks during training period.
·        The examination included a thorough physical evaluation and complete hematological and biochemical blood analysis.
b- Exclusive Criteria:
Children were excluded from the study for any of the following cases:
·        Children who underwent bone marrow transplantation because in this subpopulation of children with ALL treatment complication, side effects, and tumor recurrence are frequent which would compromise training adherence   .
·        Children with a history of antecedent neurological developmental of genetic disorder and those currently receiving physical therapy intervention will be excluded.
·        Severe anemia (hemoglobin <8 g.dl-1).
·        Neutrophil counts lower than 0.5x10µL-1.
·        Platelet count lower than 50 x 10µL-1.
·        Or anthracyclin–induce cardiac toxicity.

Equipment and Tools:
The main equipment and tools used in this study were classified into two types:
1-Measurement Tools:
   The measurement tools were:
1. a-Oxygen pro (zan-germany) cardio pulmonary exercise testing unit with the following parts: Fig (4)
·        Computer unit fed with software required for the control of the treadmill load, and manipulation and analyze the measured parameter as well, in addition to thermal printer to out the variables measured in the study. Fig (5).
·        Gas analyzer with flow (triple valve) sensor.
·        Treadmill, Fig (7).
·        A rubber mouthpiece (which is connected to the flow sensor and a face mask.
·        Weight and Height scales: it was used to measure weight and height of each subject involved.

Fig (5): A Computer Unit with a Thermal Printer.

Fig (7): A Motor-Driven Treadmill.

1. b-Hand-Held Dynamometry: was used to assess the muscle strength of both upper and lower body.
The muscle test has been done through using Hand-held Dynamometry (manufactured by instrument company 3700 sagamore parkway north lafaytte, in 47904 U.S.A). Hand-Held Dynamometry system is a hand-held device used objectively quantifying muscle strength. It is small enough to held in one hand easily read.
          The device has six function buttons and LCD screen that control the menus and allow the selection of options and as following: Fig. (8)
·        On/Off switch: that used to activate the device when switch to the '' on ''position.
·        Reset button: the reset button is located on the top of the device; it is placed for easy access the thumb regardless of right or left operation. The reset button clears the display of all data and sets the zero point for the measurements.
·        Range button: the range button toggles between high and low measurement rang. An H or L is displayed on the main measurements screen to indicate the device range setting. Changing the range cause the device to automatically reset and clear all time and force values.
·        Scroll/LB/KG: the lb/Kg button has dual functionality depending on which screen is accessed. In the main measurement screen, the lb/Kg button toggles the force measurement scale between pounds and kilograms. An indicator on the main measurement screen shows which scale is selected. When a menu or data display screen is active, this button becomes a scroll button. The scroll button was used to select option by advancing a cursor from on option to the next. The scroll button was also used step through data.

Oval: 1                                           

Fig.(8 ): The hand-Held Dynamometry Used in this Study Showed the Function Buttons and Main Measurement Screen.
1- On/off switch.                         2- Reset button.
            3- Range button.                          4- Scroll LB/KG button.
5- Enter/Store button.                    6- Menu button.    
7- LCD screen.
·        Enter/store button: the enter/store button has dual functionality depending on which screen is accessed. In the main measurement screen, the button was used as store button. Pressing the store button stores the current test data in the device memory. Only the peak force and peak time were stored in memory. When the menu screen are accessed, the button is used as an enter button the enter button is used to activate setting and menu option. It was also used to clear some error and warning messages.
·        Menu button: the menu button was used to enter the main menu the main menu was used to select the device option and access the submenus.
·          The LCD screen on the front section of device used to display force and time.
   The main measurement screen showed all of the current measurement information. This screen was shown whenever a measurement was in progress. This screen was also the default start- up display.
¨     Peak force: the peak measurement force was displayed in large numbers on the upper left of the main measurement screen. This value was the peak pounds or kilograms applied during a test. Force values were displayed tenths of pound or kilogram.
¨     Peak time: the peak time value is displayed in the second on the button left of the screen under the peak force. This number is the time during the test when the peak force occurred. Time value was displayed to hundredths of second.
¨     Instaneous force: the instaneous force value was displayed on the upper right on the main measurement screen this value was the force applied to the device at any time.
¨     Running time: the running time value was displayed on the lower right of the main measurement screen .this value showed the total time that force has been applied after a test had ended; this showed the total length of the test in seconds.
¨     Range indicator (H or L): the range shows if the device is set in the high or low measurement setting. If in Kg's the high range would 0Kg-1361Kg, and the low rang would 0Kg-22.6Kg. If in lbs, the high rang would 0lbs-300lbs, and the low range would 0lbs-50lbs. the range indicator was the upper most indicators in the center of the main measurement screen.
¨     Scale 3 indicator (lb or KG): the scale indicator shows if the device is set in pound or kilograms. The scale indicator was the second indicator in the center of the main measurement screen.
¨     Low battery indicator: the low battery is present when a law battery condition exists. The low battery indicator was third indicator in the center of the main measurement screen.
¨     Time unit label: the time unit label indicate is the –S- on the button center of the main measurement screen. This label indicated that the time measurements were in seconds, this label did not change.
1. c- Iowa Fatigue Scale
It was used to measure the degree of fatigue in this children and QoL. It is a self report questionnaire developed by Department of Family Medicine, University of Iowa College of Medicine to measure the degree of fatigue and its progression. It is consisted of many questions about the quality of life and its affection by fatigue. The 11 item scale contains four subscales: cognitive, fatigue, energy and productivity. Patients with a higher fatigue score are much more likely to have lower health status, greater depression and more somatic symptoms, (Appendix I) (Hartz et al., 2003).     

Therapeutic Tools:
·        Strength training include exercise engaging the major muscle groups (bench press , shoulder press , leg extension , leg press , leg curl , abdominal crunch , low back extension ,arm curl ,elbow extension ).
·        Stretching exercise of the muscles involved in the previous exercise was stretched.
·        Aerobic exercise consisted of pedaling a cycle ergometer, running and walking on treadmill.

Procedures of the Study:
A verbal explanation about the important of the study procedure, main aim and conceptual approach was explained to every patient.
The procedure of this study was divided into two main procedures:
Measurement Procedures:
·        Before starting the study a consent form was taken from each parent of participant as an agreement to be included in the present study. Also before initiating the treatment program the following task was performed :
·        The children's hemoglobin level and plat let count was obtained from the medical record to observe changes in physical stability.
·        Each subject was examined medically in order to exclude any abnormal medical problem which previously mentioned.
·        Measurement was taken pre-test assessment and post test assessment and 12 week later after the intervention program as follow ;

(1)Procedures of Cardiopulmonary Exercise Test:
Prior to the study each subject was instructed:
·        Not to eat at least 2 hours before exercise testing.
·        Not to do unusual physical activities for at least 48 hours before testing.
·        To dress appropriately for exercise especially with regard to footwear.
·        Exercise testing was performed according to the recommendation and guidance of the American heart association ( AHA) (Fletcher et al .,2001)
On the testing day:
The cardiopulmonary exercise testing was electronically calibrated by click upon the icon of calibration at the computer monitor. Before starting Gas-calibration, the following steps were checked in advance:
·        Zan testing unit had been ON for a minimum warm up time of 20 min.
·        Gas bottle was opened
·        Gas-suction tube removed from flow sensor and connected to calibration nipple (Cal) on front panel of Zan Testing Unit (it is recommended that Gas-calibration must be carried out before every measurement).
·        Calibration was started with (Enter); the flow of Calibration-Gas was clearly audible. As Calibration was ok, the results wer saved with (Enter) (the recommended composition for calibration gas is: 5%Co2, 15.9%O2). At the end, Gas bottle was closed and Gas-Suction tube was removed to flow sensor.
·        The subjects were measured for height and weight, and then the computer unit was fed up the subjects' demographic parameters.
1.     Age           (date of birth)
2.     Sex           male or female
3.     Weight      in(Kg)
4.     Height       in (cm)
Exercise Test:
·        A clean and sterilized facemask was applied and fitted to the face of the participant and connected to the flow to the sensor. The expired air was obtained from a valve connected to a mouthpiece and then was analyzed for VO2 volume. Data was delivered to a computer and was integrated to calculate O2 consumption.(fig 9)
·        After a 3 min standing rest period, the participant was asked to walk for 5 min at 0% grad for warm up.
·        Maximum oxygen consumption (VO2max) determined for each participant by maximum exercise testing according to Bruce protocol.
·        Participants were verbally encouraged to continue the test until exhaustion.
·        A cool-down period of 5 min was allowed and then the test was terminated.

Fig (9): The Child was Asked to Run on Treadmill Until Exhaustion.

Bruce Protocol:
The starting speed of the Bruce protocol is 1.7 mph and 10% grade, and progressing to increased treadmill speed and grades every 3 minutes until exhaustion as shown in (table 1)      (Hillegas and Sadowsky,2001)
Table (1): Bruce Treadmill Protocol

Criteria for terminating exercise testing:

1-    Drop in systolic blood pressure (persist below baseline, despite an increasing in workload).
2-    Development of chest pain.
3-    Signs of poor perfusion (cyanosis or pallor).
4-    Subject's request to stop.
5-    Fatigue, shortness of breath, leg cramps or claudicating pain.
6-    General appearance.
7-    Hypertensive response (systolic pressure > 250 mm hg and /or diastolic blood pressure >115mmhg) (Fletcher et al., 2001).
Maximum oxygen consumption (VO2max) (ml/min/Kg) was obtained through breath-by breath gas exchange analysis. VO2max was considered to be attained if subject reported a feeling of fatigue and if one of the following criteria was reached:
a)     Failure of VO2 to increase despite of increased work rate.
b)    Respiratory exchange ratio( RER)> 1.1
c)     Maximal heart rate within 10 beats/min of age-predicted maximum (220-age).
 (2)Muscle Strength Assessment Procedures:
     a- Knee Extensor:
          The hand-held dynamometry was one instrument used to test knee extensor muscle performance. All subjects were tested by the same tester. Subjects were seated at the edge of a treatment table and positioned at about 90ohips flexion and 80o knee flexion; lower leg vertical to floor; foot not touching floor. The hand-held dynamometry was position two finger widths above the lateral malleolus on the anterior of tibia. Subjects' were asked to stabilize their pelvis by holding onto the edge of the treatment table. A make test was used , in which the tester matches the muscle force generated by the subject, as contrasted with a break test, in which the tester attempts to exceed the force generated by the subject.
Four warm-up contractions were performed, with subjects instructed to gradually increase their knee extension force over 3 seconds. Subjects were instructed to give approximately 50% effort in the first three warm-ups and a maximal contraction on the fourth worm-up. Four maxima trials were then performed, with the peak force of the fourth contraction recorded.

B-Elbow Flexor:
Subjects were seated at the edge of a treatment table. Subjects were asked to hold onto the edge of the treatment table by the other hand to stabilize the trunk. The examined elbow should be held against the patient's side to avoid shoulder movement and put the elbow in supination of the forearm with the elbow at a right angle. The hand-held dynamometry was positioned at the distal end of the forearm above the wrist (to avoid twisting the wrist). The subject was asked to flex his/her elbow while the pressure was in the direction of extension.    
A make test was used , in which the tester matches the muscle force generated by the subject, as contrasted with a break test, in which the tester attempts to exceed the force generated by the subject.
Four warm-up contractions were performed, with subjects instructed to gradually increase their elbow flexion force over 3 seconds. Subjects were instructed to give approximately 50% effort in the first three warm-ups and a maximal contraction on the fourth worm-up. Four maxima trials were then performed, with the peak force of the fourth contraction recorded. Fig (11)

Fig. (11): Procedure of Measuring Elbow Flexor Muscle Strength through Hand-Held Dynamometry.
3-The QoL and Fatigue assessment procedure:
          Each child was instructed to complete answer the list of question with an assistant from his/her parents. The evaluation was carried out before and at the end of rehabilitation. (Appendix I)

Therapeutic Procedures:
All the children in the exercise group followed a 12 weeks training program consisting of three weekly session with a duration ranging from 90 min (in the first few weeks of the program ) to 120 min ( by the end of the program ) each session started and end with a low- intensity 15 min warm up and cool –down period consisting of walking on treadmill at very light work load and stretching exercise involving all major muscle groups the core portion of the training session is divided into strength and aerobic exercises.
·        Strength training included 11exercise engaging the major muscle group (bench press ,shoulder press ,leg extension ,leg press, leg curl ,abdominal crunch ,low back extension ,arm curl elbow extension ,seated raw , and lateral pull-down).for each exercise the children perform one set of 8-15 repetition (total of approximately 20-s duration )
·        Rest period of 1-2 min separate the exercises.
·        Stretching exercises of the muscles involved in the previous exercises were performed during the rest period between exercises
·        The load was gradually increased as the strength of each child improved.
·        Aerobic exercise consisted of pedaling a cycle ergo meter, running, walking and aerobic games involving large muscle group (i.e. jumping exercise, ballgames group games, etc).
·        The duration and intensity of the aerobic training was gradually increased during the 12 week period so that the subject start with at least 10 min of aerobic exercises at 50% of age predicted maximum heart rate (HRMax), (calculated as 220 minus age minus rest heart rate) and progress to at least 30 min of contentious exercise at ≥ 7o% HRmax by the end of the 12 weeks program (San Juan et al., 2007).

Statistical Procedures:
- In this study, the obtained data were recorded on the evaluative sheet.
- These data were transferred into IBM card using IBM personal computer with statistical program.

The statistical procedures were focused to the following phases:-
1-Data Collection Phases: -
The data regarding to the patients’ age, sex, height, weight; collected before entry of the study. The data regarding to (IGA) had been collected before initiation of experiment (pre), and post-treatment.
The data collection was performed at the same sequences and procedures for all patients in the two groups of the study (exercise and control groups).

2-Data Analysis: -
          The collected data was analyzed statistically to obtain the following statistical tools:

(a)Descriptive Statistics:
·  In this study, the descriptive statistics in form of mean and standard deviation were calculated for all patients in both groups of the study to determine the homogeneity and central deviation. The mean is the sum of the observations on the number of the observations. The stander deviation is the squire root of the variance and it is expressed in the unit of the original measure. Variance is a measure of the variability around the mean within a data set.  
(b) Analytic Statistics:
The analysis and comparison of the data were made by these tools of statistics.
·        Paired T-test was used to compare the dependent variable
·        Cardiopulmonary endurance and physical fitness ,
● Muscle strength (elbow flexor and knee extensor),
·        Fatigue and Quality of life (QOL) , 
            In children receiving chemotherapy in ALL, within each group (i.e. pre-treatment and post-treatment to the individuals in both groups) to detect level of significant.
Unpaired T-test was used to compare the dependent variable (
§  Cardiopulmonary endurance and physical fitness ,
§  Muscle strength (elbow flexor and knee extensor),
§  Fatigue and Quality of life (QOL) , 
     and independent (age, sex, height, weight of children) Variables between both groups to detect level of significant.
Sign test was used to compare the data obtained, within each group (i.e. pre-treatment and post-treatment to the individuals in both study and control groups) to detect level of significant.
Sign test: - It is a non-parametric alternative to the one sample t-test; it is designed to test a hypothesis about the location of a population distribution. It is most often used to test the hypothesis about a population median, and often involves the use of matched pairs. It can be applied when the observations in a sample of data are ranks
·       Mann-Whitney test was used to compare the data obtained between the exercise and the control group.
     Mann-Whitney test: - It is a non-parametric alternative to the independent samples t-test. Like t-test Mann-Whitney tests the null-hypothesis that two independent samples come from the same population. Rather than being based on parameters of a normal distribution like mean and variance, the Mann-Whitney statistic are based on ranks. The Mann-Whitney statistic is obtained by counting the number of times an observation from the group with the smaller sample size precedes an observation from the larger group.
● Both descriptive and analytical statistics were used to examine, describes and analyses the collected data to detect if there was inter-group or intra-group difference before and after treatment.
● Each hypothesis was tested separately by the using the appropriate statistical tools. The data analysis and the level of significance were set at the level of 0.05....
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