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
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http://www.srji.info.ms
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Email
[email protected]
Contact
+91-9320699167, 9839973156
Copyright 2013 Scientific Research Journal of India
All rights reserved.

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 youll 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 subjects active effort. To
measure the JPS, passive CPM was used. Outcomes were measured before and immediately after
intervention and 5 min. after 2
nd
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 2
nd
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 2
nd
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 skin
1
. 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
receptors
2
.
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 input
3
.
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 pads
3
. Recent research has
identified ruffinilike ending in the glenohumeral
joint capsules, found pacinian corpuscles in
glenohumeral ligaments, and free nerve endings in
the glenoid labrum of human cadavers
3
. 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
stability
4
. 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 2
nd
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 2
nd
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 2
nd
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 2
nd
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 2
nd
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 2
nd

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 appreciation
5,20
.

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 2
nd
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)
8
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 & ADLs 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
ADLs 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 ADLs 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 services
16

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 men
1
.

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 lifestyle
3

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 poor
4

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 are
5
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 adults
7
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 lifetime
10

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 people
11

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 score
12

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 disability
13

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
association
14
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 patients
15

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 ADLs 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 subjects 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 ADLs
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
services
3
.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)**, Ganesh 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 structures
1
.

Temporomandibular dysfunctions are defined as
common non-dental cause of orofacial pain
4
.
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 system
6
.
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 movements
8
, head
and cervical posture alterations
9, 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 origin
7
, 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 dysfunction
16
.
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 cases
17
.
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 body
11
. 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
Questionnaire
12
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
questionnaire
12
. 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 patients 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 Index
13
, index of
cervical mobility (ICM)
14
and VAS score.
Other 15 volunteers that were primarily
presenting cervical spine Dysfunction according to
Neck disability Index
13
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 Index
13
. 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 patients 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.
Spearmans 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 patients 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, spearmans 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, spearmans 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
patients 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, spearmans 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, spearmans 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). Relaes entre postura corporal e sistema estomatogntico. 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. Amanta DV, Novaes AP, Campolongo GD and Barros TP(2004). A importncia da avaliao
postural no paciente com disfuno temporomandibular. Acta Ortop Brs; 12:1-8.
12. Kariny Nomura, Mathias Vitti, Anamaria Siriani de Oliveria, Thas Cristina Chaves, Marisa Semprini,
Selma Siessere, Jaime Eduardo Cecilio Hallak and Simone Cecilio Hallak Regalo (2007). Use of the
Fonsecas 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. Dbora Bevilaqua-Grossi, Thas 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 childs 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 DCDQ07 who also obtained total scores below the 15
th
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 Studentt 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
Questionaire07(DCDQ07), 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 childs
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 disorder
3
.
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 childrens 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 up
5
.
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 (DCDQ07) 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 DCDQ07 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
DCDQ07 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 childs 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 childrens 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 DCDQ07, Obtained total
scores on the TGMD-2 below the 15
th
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 DCDQ07 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
childs 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
childs 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
childs 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 childs motor performance on
the range of tasks then the kinaesthetic training
based on Laszlos 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 pairedt test. For 24 degrees of
freedom and at 5% level of significance, the
tablet value is 2.064 and the calculated t value
was 11.586 . As the calculatedt 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 pairedt test. For 25
degrees of freedom and at 5% level of
significance, the tablet value is 2.060 and the
calculated t value was 11.588. As the
calculatedt 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 independentt test. For 49 degrees
of freedom and 5% level of significance, the
tablet value 1.960 and the calculated t value is
0.207. As the calculatedt value was lesser than
the tablet 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 independentt test. For 49 degrees
of freedom and 5% level of significance, the
tablet value 1.960 and the calculated t value is
1.292. As the calculatedt value was lesser than
the tablet 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
COHENS 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 DCDQ07, 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 510 years
(13)
. As this study was done
only with DCDQ07 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 34: 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
Cohens 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 childrens 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 DCDQ07 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 15
th

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 Studentt
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 (DCDQ07) 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, 545561.
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: 122128
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)527548.
18. Margaret Cousins, Mary M. Smyth., Developmental Coordination Impairments in Adulthood.
Human Movement Science 22 (2003) 433459.
19. Barnhart RC, Davenport MJ, Epps SB, Nordquist VM. Developmental Coordination Disorder.
Phys Ther. 2003; 83: 722731.
20. Dale A Ulrich. Test Of Gross Motor Development. Examiners 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 neurologists 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 neurologists 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 inconclusive
15
, 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.com
18
,
BICBrainInjuryCentre.co.uk
19
, Peartrees.com
20
,
Mind360.com
21
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 Learning
22
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, 297301.
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):68591.
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):38197.
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):11927.
15. OBrien 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):7619.
16. Chooi, Weng-Tink; Thompson, Lee A. (2012). "Working memory training does not improve
intelligence in healthy young adults". Intelligence 40 (6): 53142.
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): 30726.
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: 18.
24. Camp CJ, Foss JW, OHanlon AM, et al. Memory interventions for persons with dementia. Appl Cog
Psychol 1996; 10: 193210.

* 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 scheduling
1
or queue
management
2
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
Queueing
6
and Choke
7
, 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 links 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 links available bandwidth (750 kbps).
On the second bottleneck link (R2-S4),
much of the traffic from flow B is discarded. Due
to the links 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 links remaining
bandwidth
9
.

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
fall
10
, 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 flows
11
.
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 control
10
. 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 successful
5
.
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
Renos 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 flows packets are leaving the network,
whereas rate control allows an ingress router to
police the rate at which each flows 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 flows 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 routers
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 headers flow label,
whereas in the case of IPv4, it is done by
examining the packets Source and destination
addresses and port numbers. Each flows 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 networks 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 flows 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 networks 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 packets 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 routers 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 routers rate controller, which uses
them to adjust the parameters of each flows 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 flows byte counter
exceeds a threshold, denoted TX, the ingress
router generates and transmits a forward feedback
packet to the flows 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. NBPs 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 flows packets
at each router hop. To do this, the algorithm first
computes the product of the flows ingress rate and
deltaRTT.
This value provides an estimate of the
amount of the flows 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 flows 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 flows 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 flows 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 flows
egress rate decremented by MRC. In other words,
an observation of congestion forces the ingress
router to send the flows 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 flows 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 NBPs 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. 299305.
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. 112.
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. 344357, 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.
118130.28
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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. 127137.
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. 362373, 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. 158181, 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 Abadi***

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
countrys 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
(Bykzkan, Feyzioglu, & Nebol, 2008; Chen &
Tsao, 2007; Kahraman, Bykzkan, & Ates, 2007;
Ont & 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 researchs
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 researchs 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)
n j m i
X X X
X X X
X X X
A
A
A
D
C C C
mn m m
n
n
m
n
,..., 2 , 1 , ,..., 2 , 1 ,
~ ~ ~
~ ~ ~
~ ~ ~
~
2 1
2 22 21
1 12 11
2
1
2 1
= =
(
(
(
(
(
=
L
M M M M
L
L
M
L

In which,
m
A A A ,...,
2
,
1
represent alternatives,
n
C C C ,...,
2
,
1
represent indices, and
ij
x
~

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) [ ] n j m i r R
n m
ij
,..., 2 , 1 , ,..., 2 , 1 ,
~
~
= = =

(3)
ij j
j
ij
j
ij
j
ij
ij
c c
c
c
c
b
c
a
r max , , ,
~
=
|
|
\
|
=
+
+ + +

(4)
ij j
ij
j
ij
j
ij
j
ij
a a
a
a
b
a
c
a
r min , , ,
~ _
_ _ _
=
|
|
\
|
=
Step 3: calculation and make harmonic normalize
matrix as relation (5) using relation (6).
(5) [ ] n j m i v V
n m
ij
,... 2 , 1 , ,..., 2 , 1 ,
~
~
= = =

(6)
j ij ij
w r v
~ ~ ~
=
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) ( ) } { m i J j
v v ij j
,...., 1 max
~ ~
= =
+

(8) ( ) } { m i J j
v v ij j
,...., 1 min
~ ~
= =

+
ij
v
~
And
ij
v
~
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
2
0 ,
~ c b a
A S
+ +
=
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) ( ) A e
~
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) m i
d d
d
cc
i i
i
i
,..., 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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* 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
63

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 Strength 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.

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