volume 5 / number 5 / 2011 issn 1840-2291 health...

HealthMEDVolume 5 / Number 5 / 2011 ISSN 1840-2291

Journal of Society for development in new net environment in B&H

Thomson Reuters ISI web of Science,Science Citation Index-Expanded, Scopus

EBSCO Academic Search Premier, Index Copernicus, getCITED

HealthMED journal with impact factor indexed in:

HealthMED - Journal of Society for developm

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EDITORIAL BOARD

Editor-in-chief Mensura Kudumovic Execute Editor Mostafa Nejati Associate Editor Azra Kudumovic Editorial assistant Jasmin Musanovic Technical editor Eldin Huremovic Members Paul Andrew Bourne (Jamaica) Xiuxiang Liu (China) Nicolas Zdanowicz (Belgique) Farah Mustafa (Pakistan) Yann Meunier (USA) Forouzan Bayat Nejad (Iran) Suresh Vatsyayann (New Zealand) Maizirwan Mel (Malaysia) Budimka Novakovic (Serbia) Diaa Eldin Abdel Hameed Mohamad (Egypt) Zmago Turk (Slovenia) Bakir Mehic (Bosnia & Herzegovina) Farid Ljuca (Bosnia & Herzegovina) Sukrija Zvizdic (Bosnia & Herzegovina) Damir Marjanovic (Bosnia & Herzegovina) Emina Nakas-Icindic (Bosnia & Herzegovina) Aida Hasanovic(Bosnia & Herzegovina) Bozo Banjanin (Bosnia & Herzegovina)

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Published by DRUNPP, Sarajevo Volume 5 Number 5, 2011 ISSN 1840-2291

HealthMEDVolume 5 / Number 5 / 2011


Sadržaj / Table of Contents

HealthMED journal with impact factor indexed in: - Thomson Reuters ISI web of Science, - Science Citation Index-Expanded, - Scopus, - EBSCO Academic Search Premier, - Index Copernicus, - getCITED, and etc.

Free Oxygen Radicals Associated with Growth inCoeliacDisease ......................................................................... 1008Mustafa Ozcetin, Muzaffer Katar, Resul Yilmaz, Erhan Karaaslan, Fikret Ozugurlu

Consumer acceptance, knowledge and attitudes towards organic and genetically modified foods: a cross-sectional study among Turkish university students .................. 1014Aylin Ayaz, Saniye Bilici, Muhemmet Fatih Uyar, Betül Ay,Sema Börekci, Emel Kök

RNAi-mediated Suppression of Stromal cell derivedfactor-1 expression in Bone Marrow Stromal Cells:Effects on the Co-cultured Jurkat Cells .................... 1022Pei-Yan Kong, Wen-Bo Yang, Xue Liang, Dong-Feng Zeng, Zhan-Zhong Shi, Cheng Chang, Li Wei, Xian-Gui Peng,Hong Liu, Xing-Hua Chen, Qing-Yu Wang

Perceived Social Support Level and Related Factors in Turkish University Students’ ....................................... 1033Şükran Özkahraman, Belgin Yildirim, Özlem Şahin Altun

Improving the skills of interpreting posteroanterior chest X-ray in primary care .................................................. 1038T. Set, M. Isik, K. Tastan, S. Oztora

A Study on the Changes of Mucosal Immune Factorsin Male Soccer Players between the Two Half Timesof a Game of Official Time .......................................... 1043Babisan Askari, Ayob Mehdivand, Asra Askari,Zynalabedin Fallah, Moslem Sharifi

Urinary incontinence at the women living in anursing home and the quality of life of the womenwith urinary incontinence ............................................ 1050Şeyma Uslu, Yurdagül Uysal, Dilek Sari, Sevnaz Şahin, Nil Tekin, Fisun Şenuzun

Prevalence of urinary incontinence and affecting factors among Turkish women ................................................ 1058S. Oztora, C. Cetin, N. Dagdeviren, A. Caylan, T. SetHER-2/neu protein expression and gene amplification in breast cancer: immunohistochemistry and chromogenicin situ hybridization study using tissue microarray ... 1065Ammar Imad Hazim, Gurjeet Kaur

A Sudden Death in a Child with ALL and Myelodysplastic Syndrome during Splenectomy; A Case Report ....... 1072Levent Sahin, Mehrican Sahin , Omer Aktas, Eray Mandollu

Sadržaj / Table of ContentsEvaluation of the association of anxiety level, body mass index, waist-hip circumference and blood pressure level with fasting blood glucose level ...................................... 1076Dilek Aygin, Ayse Cevirme, Mustafa Yildiz, Gulgun Durat,Olcay Semiz, Ahmet Cagri Aykan, Sevin Altınkaynak

Familialy mediteran fever, juvenile idiopathic arthritis and antiphospholipid syndrome: a case report ......... 1082Idriz Berisha, Blerim Berisha, Xhevdet Krasniqi

Completed and Attempted Suicide in Antakya (Antioch), Turkey during 2007-2009 ............................................. 1085Ebru Turhan, Tacettin Inandi

Efficiency Of The Peer Tutoring Model In SkillsTraining ......................................................................... 1091Vesile Unver, Nalan Akbayrak, Nuran Tosun

The importance of prevention of onset and development of cardiovascular disease applied on students of theUniversity of Sarajevo .................................................. 1100Zana Pozderac

Chemical feature of inorganic compounds as anticancer agents .............................................................................. 1112Emira Kahrovic

Amperometric Determination of Glucose with FeOand Glucose Oxidase Bulk-Modified Screen-PrintedCarbon Ink Biosensor ................................................... 1117Turkusic E., Begic S., Kahrovic E., Kalcher K.

Relationship between Parental Smoking and Respiratory Illness in Infants ............................................................ 1123Ayşe Gürol, Cantürk Çapik, Serap Ejder Apay, Çiğdem Köçkar

Usage of vıtreous humour hypoxanthıne and potassıum values for the estımatıon of postmortem ınterval ..... 1129Ali Yıldırım, Birol Demirel, Taner Akar, Ender Şenol ,Hüsamettin Erdamar

BMI Differences According to Fitness and Cardiovascular Function in Korean Women ........................................ 1137Wi-Young So, Dong-il Seo, Dai-Hyuk Choi

Participating Farmers’ Equity of Hospitalizationbenefit under the New Rural Cooperative MedicalSystem: Evidence from Shaanxi Province ................. 1145Jianmin Gao, Xianjiao Zhang, Rui Chen, Zhongliang Zhou

Blount dısease: bowlegs may not always bephysıologıcal .................................................................. 1156A.E.Yilmaz, H.Atalar, T.Tas, N.Celik

Evaluation of Prescription Legibility Leading to Death due to Erroneous Interpretation: A Field Survey inPharmacies .................................................................... 1159Rıza Yılmaz, Ali Yıldırım, Veli Özdemir, İlhan Çetin, Murat Aksu, Abdülkadir G. Şahan

Depigmenting and anti erythematic effects of 3%green tea emulsion ........................................................ 1165Naveed Akhtar, Tariq Mahmood, Barkat Ali Khan,Haji M Shoaib Khan, Tariq Saeed

Assessing Core Competencies for Public HealthProfessionals in Turkey ................................................ 1170Şükran Özkahraman, Süheyla Altuğ Özsoy

The effect of levosimendan on functional capacity inpatients with heart failure and atrial fibrillation:a clinical cohort study .................................................. 1177Turan Set, Umit Avsar, Zeliha Cansever, Mutlu Buyuklu

Influential Determinants in Human ResourcesDevelopment: a study of the managers in the healthservices sector ................................................................ 1182Mohammadkarim Bahadori, Mostafa Nejati

The effect of past use of injectable contraceptive onbone mineral density in malaysian postmenopausalwomen ............................................................................ 1187Fatemeh Mohammadi, Hamid Tengku Aizan, Mohd Yazid Nazri, Zanariah Othman, Rozi Mahmud

Treatment of developmental hip dysplasia (DDH)using Pavlik method ..................................................... 1195Sefcet Hajrovic, Ibrahim Preljevic, Slobodan Milisavljevic

Athroscopic acetabular anatomy in fetuses ............... 1202Dusan M. Maric, Dusica L. Maric, Milan Stankovic,Dusanka Dobanovacki

Hebal drugs in the treatment of nervous andcardiovascular disorders .............................................. 1206Vanja Tadic, Sofija Djordjevic, Ivana Arsic

Methodology for 3D Femur approximate modelgeneration ...................................................................... 1211Zoran Milojevic, Slobodan Navalusic, Miroslav Milankov,Ratko Obradovic, Eleonora Desnica, Vladimir Harhai

Wound healing potential of liquid crystal structureemulsion with sea buckthorn oil ................................. 1218Snezana M Cupara, Milica B Ninkovic, Milan G Knezevic,Ivan M Vuckovic, Slobodan M Jankovic

Incidence and structure of preterm deliveries at thedepartment of obstetrics and gynecology, CCV(2000.-2009) ................................................................... 1224Novakov Mikic A, Bogavac M, Milatovic S, Ilincic M,Kopitovic V, Radeka G

Breast reconstruction with extended Latissimus dorsiflap and silicone implant .............................................. 1232Milan Visnjic, Predrag Kovacevic, Ljiljana Paunkovic,Goran Djordjevic, Aleksandar Visnjic, Dragan Petrovic,Sladjana Petrovic

Radiological features of the Left spermatic vein inadolescent Varicocele .................................................... 1240Dobanovacki Dusanka, Vujosevic Bozica, Jokic Radoica,Maric Dusan, Maric Dusica

Influence of stimulation protocols on IVF outcome .... 1248Vesna L Kopitovic, Stevan V Milatovic,Aleksandra M Trninic Pjevic, Djordje L Ilic,Aleksandra Novakov Mikic, Aleksandra Kapamadzija

Bacterial contamination of mobile phones usedin hospitals .................................................................... 1254Nikolic M, Arandjelovic M, Stankovic A, Krivokapic LJ

Medical student’s perceptions of the graduate(bachelor) nurses .......................................................... 1260Dragana Milutinovic, Spela Golubovic, Jelena Kacavendic,Boris Golubovic

Sadržaj / Table of ContentsThe connection between visual perception andhand laterality ............................................................... 1268Spela Golubovic, Dragana Milutinovic, Dragan Rapaic,Sanja Kalaba

Prevalence of risk factors in ischemic strokepatients .............................................................................. 1273Natasa Turanjanin, Mirjana Jovicevic, Silvija Brkic,Petar Slankamenac, Ivana Divjak, Ksenija Bozic

Epileptic sezure reapearance risk, afther antiepileptic drug withdrawal in children with cerebral palsy ..... 1281Marija Kneževic-Pogancev, Danka Filipovic, Vesna Ivetic,Aleksandra Mikov, Dusan Vukovic

Influence of exercise on blood lipids and immunesystem in female Serbian judokas ...................... 1287Tatjana Trivic, Izet Radjo, Sergey Tabakov, Amel Mekic,Patrik Drid

The effects of rehabilitation on athletes aftersurgical treatment of recurrent anterior shoulderjoint luxation ................................................................. 1293Ivana Kacanski, Branka Protic Gava, Milena Mikalacki, Damjan Jaksic, Patrik Drid, Izet Radjo

Computerised baropodometric analysis of functionalstatus of the foot after heel reconstruction ............... 1302Sanela Salihagic, Zoran Hadziahmetovic, Branko Despot

Prevention infection in orthopedic surgeryimplementation of the hemoprophylactic protocol ..... 1308Elvedin Osmanovic, Mensura Asceric, Esed Omerkic, Farid Ljuca

Quantification and modeling of the illness andsurvival risks in health insurance ............................... 1312Jasmina Selimovic, Vanja Kenjic

Clinical effectiveness of the TVT-O method incomparison to vaginoplastics in the treatmentof stress urinary incontinence ..................................... 1322Ljuca Dz., Dzanic H., Tulumovic A.

Influence of chronic application of met-enkephalinand alpha 1-13 adrenocorticotropin (ACTH 1-13)on rats biochemical parameters ..................................... 1328Becic F., Rakanovic-Todic M., Kusturica J., Mulabegovic N.

The inability to read the emotional state of othersassociated with past experiences of catastrophic trauma among patients with chronic high indicative PTSD ... 1335Azra Kurtic, Nurka Pranjic, Farid Ljuca

Pathogens of Pleural Empyema in patients treatedon the Clinic for thoracic surgery of UKCS .............. 1344Ilijaz Pilav, Safet Guska, Safet Musanovic, Kenan Kadic,Kemal Grbic

Detection of anti-Brucella species specific IgM andIgG antibodies using ELISA test ................................ 1349Sadeta Hamzic, Edina Beslagic, Sukrija Zvizdic

Assessment of complications in surgical treatment of stress urinary incontinence with the TVT-O methodand vaginoplasty ........................................................... 1354Dzanic H., Ljuca Dz., Blazevic O.

Bioavailability of microelements (Cu, Zn, Mn)in medicinal plants ........................................................ 1358Mirzeta Saletovic, Zorica Hodzic, Bozo Banjanin, Aldina Kesic

Impact of chronic use Met-Enkephalin and AlphaAdrenocorticotropine 1-13 (ACTH 1-13) on someclinical and metabolical parameters in rats ................ 1365Becic F, Kusturica J, Rakanovic-Todic M, Mulabegovic N.

Instructions for the authors ......................................... 1375

Uputstvo za autore ........................................................ 1376

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HealthMED - Volume 5 / Number 5 / 2011

Journal of Society for development in new net environment in B&H 1293

Abstract

By means of a surgical treatment of the recu-rrent anterior shoulder joint dislocation in active athletes, along with the use of an appropriate re-habilitation treatment, the chances to resume full sports activity considerably increase. The aim of the research was to determine the effects of reha-bilitation on resuming shoulder joint function in active athletes after the surgical treatment of the recurrent anterior dislocation. All of 29 male at-hletes, aged 17.55 on average, sustained the injury during sports activities. The rehabilitation process lasted for six months (2008-2010) and it included electrotherapy, cryotherapy, hydrotherapy, fitness, controlled kinesiotherapy, occupational and physi-cal therapy. None of the patients experienced re-currence of dislocation during the 24-month con-trolled monitoring. The rehabilitation process was conducted at the Department of Sports Medicine of Novi Sad, as recommended by Hayes and in accordance with the modified procedure of Hod-gins. The amplitude was measured by goniometer, while the results were expressed in degrees. The range of motion was measured after Desault ban-dage was removed (4-6 weeks), before the kinesio-therapeutic treatment and every two weeks during the treatment (until the end of the third month). The assessment of the functional results was carri-ed out through postoperative monitoring of the values of the Neer scale (37.93% of the patients had excellent post rehabilitation results, 51.72%

satisfactory, and 10.34% unsatisfactory results). The data were processed using the statistical pro-gram SPSS for Windows version 15.0. Univariate analysis of variance for repeated measures at the level of significance p < 0.05 was used to establish the differences in the range of movement. The re-search results indicate the evident statistically si-gnificant difference between the initial and final states (flexion: F=2502.04; p=0.00; abduction: F=1638.83; p=0.00; external rotation: F=471.67; p=0.00; inner rotation: F=2144.63; p=0.00). The results show a statistically significant difference in all the variables and all the repeated measuring when compared to the previous one.

Key words: rehabilitation, anterior dislocation, shoulder, open Bankart procedure, kinesiotherapy

Introduction

Glenohumeral (GH) instability is a common shoulder disorder, especially in male adolescents. Luxation is the hardest and the final outcome of the GH instability, which is directly related to sports trainings. The annual incidence of shoulder dislocation is 1.7 per 1000 people. The younger population is at a greater risk of dislocation [1.2].

During the examination of anterior (also the most frequent) dislocations, changes are evident in the external form of the shoulder girdle. The patient is not able to touch the opposite shoulder with his palm, as the very attempt to move causes

The effects of rehabilitation on athletes after surgical treatment of recurrent anterior shoulder joint luxationIvana Kacanski1, Branka Protic Gava2, Milena Mikalacki2, Damjan Jaksic2, Patrik Drid2, Izet Radjo3 1 Department of Sports Medicine, Health Center “Novi Sad”, Serbia, 2 The Faculty of Sport and Physical Education, University of Novi Sad, Serbia, 3 Faculty of Sport and Physical Education, University of Sarajevo, Bosnia and Herzegovina.

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pain. In the case of recurrent dislocations, the pa-tient is able to return the shoulder to its natural po-sition with no one’s help, but with lots of pain and discomfort. In that case, during the physical exa-mination, it is possible to clearly see the shoulder instability and its tendency towards dislocation in the specific tests.

Insufficiently long period of immobilization in younger patients (up to 30 years of age), leads to the recurrent luxation in up to 90% of the cases, while that percentage in patients of the same age and with the 5-week period of immobilization is considerably lower (17%) [2]. Treatment of these cases of luxation is entirely surgical, which was described in over 300 procedures in the literatu-re [3], where the most important one is the labral/Bankart repair.

The Future career of the injured athletes to a considerable extent depends on the success of sur-gical treatment, particularly if they aspire to high scores. Some authors remark the appearance of another dislocation over the same year in which the first one occurred. The reoccurrence of dislocation in athletes, who were treated non-operatively, by means of immobilization, happens in 60%-75% of the cases, while in 11%-20% of the cases among the patients surgically treated [4]. This is precise-ly the reason why certain orthopedists follow the principle according to which the first reoccurrence of luxation is an indicator for surgery [5]. In mo-dern orthopedics, there is a great interest in the early surgical treatment of the Bankart lesion in young male athletes, particularly if they are engaged in a very demanding physical activity. The indisputable tendency towards surgical treatment of the patients with recurrent luxation is implied by several studies encouraging an early surgical treatment of young athletes with shoulder instability [6-10]. Substantial damage to the joint capsule and to the bone struc-tures of the shoulder joint in patients with recurrent dislocation leads to poor tissue quality and difficul-ties during surgical reproduction of normal anato-mic relationships [11,12].

Besides, an early surgery is prevention against the development of further damage to the shoulder joint, loss of bone mass in the anterior edge of sca-pula, development of Hill-Sachs lesion in the poste-rior superior head of the humerus bone and further damage to cartilage. In the case of patients who su-

ffered a great number of shoulder joint dislocations, the result of the surgical treatment is less successful when compared to patients who were treated early, especially in the case of the restriction of shoulder external rotation [4]. The need for surgical procedu-re is determined individually, according to the type and amount of consequential damage to tissues in the shoulder joint and those around it, as well as to other factors: the sport the patient is engaged in, the age and the goal the patient sets for himself. The diagnosis of recurrent anterior dislocation of the shoulder joint is set based on anamnesis, clinical images, radiographic images analysis and nuclear magnetic resonance. The procedure of the modi-fied open Bankart reconstruction is applied due to destroyed tissue substrate, but also due to the low percentage of recurrence (3%) [13,14]. This type of treatment, along with suitable recovery and appli-cation of kinesiology treatment, increases the chan-ces for professional return of athletes to their full sports activities, which is proved by numerous stu-dies [15-19]. Rehabilitation exercises are normally prescribed after the anterior shoulder dislocation, usually after a period of immobilization. Some aut-hors [20] did not find exercises that would be useful in preventing recurrence. Similarly, rehabilitation exercise did not prove to be significantly useful [21]. However, regardless of the exercise program, there is a considerable recurrence rate of 92% [22] and 80% [6] in young active patients. Unlike these researches, which claim that post-reduction rehabi-litation is of no particular use, some authors highli-ght the recurrence rate of 25% in 20 young active patients after the strengthening program, with the average monitoring period of 35.8 months [23].

The studies observing the rehabilitation proce-dure after the operative treatment, which will de-termine the further sports career of an athlete, con-firm differences in successful return to full sports activities: 80 % of 49 patients resumed the same sport at the same level after rehabilitation trea-tment [24], while others state that only 65.5% of 180 patients resumed full sports activities [25]. The analysis of the level and frequency of engaging in the sport before and after the surgery of 56 pati-ents [26], irrespective of the sports specificities of shoulder strain, shows that all the patients, except one of them who experienced shoulder pain while doing “overhead” activities (98%), resumed their



preoperative levels. In the comparative study [27], in the case of 63 patients, 11% patients from the group with the arthroscopic procedure did not ma-nage to return to sport, while the whole group of patients after the open Bankart procedure managed to do so. Over 50% of the patients in every group had minor to serious restrictions while performing sports activities postoperatively. These authors do not report on continuation with the sports activities of the patients. 52 of 58 American football players who underwent open shoulder stabilization after re-current instability were able to resume full sports activity in less than a year [28]. However, only 50% of these patients continued with trainings after three or more years. The authors do not state reasons for the cessation of sport activity.

The results of different studies show that in the case of athletes who have undergone open Bankart procedure of the anterior shoulder dislocation and a shorter or longer rehabilitation program, 65.5% [25] up to 98% [26], resume full sports activities. The open Bankart procedure gave the most relia-ble results with respect to the recurrence rate and joint function. However, there can never be suffi-cient amount of data on the sports abilities reco-very after such an operation and a suitable kinesi-ology treatment.

The aim of this research was to determine the effects of rehabilitation after surgical treatment of the anterior recurrent luxations on resuming sho-ulder joint function in active athletes.

Materials and methods

The research included 29 male athletes, aged 17.55 on average (between 15 to 20 years of age) who underwent 6-month rehabilitation process in the period between 2008 and 2010 after surgical in-tervention of the recurrent shoulder joint luxation. The patients were operated at the Clinic for Trauma Surgery and Orthopedics in Novi Sad, at the Institu-te for Orthopedic Surgery “Banjica” Belgrade and at the Clinic for Trauma Surgery and Orthopedi-cs in Niš: 10 handball players, 5 basketball, 3 vo-lleyball, 3 tennis players, 2 swimmers, 2 martial arts athletes, 1 football player, 1 rugby player, 1 water polo player and 1 rower. All 29 athletes sustained injuries during sports activities as a result of a di-

rect impact or excessive movement in the case of throwing mechanism (13), fall onto an outstretched hand or arm (10), direct fall or impact to the shoul-der (4) or violent bending arms over one’s head (2). Before the surgery, recurrent luxation appeared up to five times in 8, up to 10 in 5 and over 20 times in 16 athletes. All the patients used their right hand as their dominant hand, but the right shoulder was treated in 27, and the left one in 2 cases. Recurrent luxation appeared in the case of several athletes who stopped their rehabilitation process because they had a good subjective feeling in their shoulder joint or because they didn’t wear the immobilizer long enough. This fact was determined by means of the patients’ anamnesis taken during the first exa-mination. Neurocircular results were normal in all the patients.

The patients excluded from the research were those who already underwent surgeries on the inju-red shoulder. All the patients voluntarily entered the program of physical therapy and rehabilitation (in accordance with their clinical results), which in-cluded controlled kinesiotherapy, occupational and physical therapy, according to the specific needs (electrotherapy, cryotherapy, hydrotherapy and fit-ness). After six months of rehabilitation, the pati-ents would come for a check-up in the interval of 12 to 24 months after surgery. None of the patients experienced recurrent luxation within the given pe-riod after the rehabilitation and kinesia treatment.

Rehabilitation and the kinesiotherapy program were conducted at the Department of Sports Medi-cine in Novi Sad, according to the Hayes’ recom-mendations [29] and Hodgins’ modified procedure [30]. Rehabilitation according to Hodgins implies that treatment should be started as early as possi-ble in order to avoid harmful effects of immobi-lization. It is emphasized that electrotherapy and hydrotherapy do not improve the recovery due to a limited proof of their efficacy with respect to the mobility in the shoulder joint. This approach was changed and athletes were still included in these procedures. Cryotherapy was used after the surgi-cal procedure according to the standard procedure [29,31]. Upon the cessation of ice exposure, after exercises, cooling main cream was applied con-taining: Mentholum 0.6, Sol. Ac. Borici 3% 9.0, Vaselinum album 80.0, manufactured at the phar-macy “Higija“ in Novi Sad. Before performing

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the exercises, antirheumatic aqueous solution was applied to the treated shoulder as a means of reli-eving pain and fatigue: Mentholi 5.0, Anaestesi-ni 2.0, Procaini chl 2.0, Spiriti diluti 200.0 [32]. The movement amplitude was measured using goniometer, while the results were expressed in degrees. The range of motion was measured after Desault bandage was removed (4-6 weeks), befo-re the kinesiotherapeutic treatment and every two weeks during the treatment (until the end of the third month). The program of kinesiotherapeutic exercises was carried out in four phases for the six months [33]. The first one, the protective one, extended until the end of the sixth postoperative week (stitch healing and tissue recovery). The ne-gative effects of immobilization were diminished by means of mild, monitored exercises aimed at improving a range of motion, protecting them from excessive abduction, as well as outer/inner rotation with the initial isometric exercises which include the movement of flexion and extension. The early phase of rehabilitation was of great im-portance for maintaining strength and movement in the adjacent joints not treated operatively, such as: elbow, wrist, hand and fingers. The second, middle phase, which extends from 6 to 12 weeks, was aimed at achieving full painless range of mo-tion. With that purpose in mind, actively assisted exercises were used for normalization of the joint mobility, strength increase and gaining neuromus-cular control. An important part of this phase was a joint program for the rhythmic stabilization of the glenohumeral joint and the protocol to stabi-lize the scapulothoracic joint, with rubber, isoto-nic and isometric exercises. The pattern of normal movement was set in the swimming pool with the aid of the water buoyancy, which helps the injured extremity float with the use of the floating equi-pment, rather than let the kinesiotherapist lead the extremity through the water as part of the actively assisted exercises in the gravity environment [34]. The third phase extended between the twelfth and twentieth week and it consisted of the progressive and dynamic protocol of exercises aimed at stren-gthening and stabilizing of the functional move-ments. The goals of this period include strength and force improvement, stamina and neuromus-cular control. The criteria for entering this phase were complete or nearly complete painless range

of motion, as well as achieving at least 70% of the power at the opposite side of the body. In this phase, specific exercises were added which were closely related to the sport the patient is engaged in, while in the case of hydrotherapy, resistance was increased by using hand paddles, oars, or ot-her equipment, as well as the workout speed [35]. The fourth phase extended between the fourth and eighth month, while the athletes applied the previous exercises to the training and competitive process, as well. Full and painless range of motion in all the planes was a precondition for resuming the activities. Exercises from the previous phases were also used, as well as simulation of situations closely related to the sports discipline; fitness exer-cises and balance on the board were also included. The final consent regarding patient’s return to the sports field was given by a sports medicine physi-cian and an orthopedist [36,37].

The assessment of functional results was done through postoperative monitoring of the values of the Neer scale [38]. The Neer scale helped obta-in the score used to monitor the results after the surgical treatment of the anterior shoulder insta-bility. The following was compared: pain degree, range of motion and muscular strength, daily life activities and anatomic changes before surgical in-tervention and after the kinesiotherapy treatment.

The data were processed using statistical pro-gram SPSS for Windows version 15.0. Univaria-te analysis of variance for repeated measures was used to establish the differences in the repeated measuring of the range of movement in the sho-ulder joint.

Results

Through postoperative and rehabilitation mo-nitoring of the patients, over the course of 2 years approximately, according to the Neer scale (Graph 1), the following results were obtained: 11 patients (37.93%) had excellent post-rehab results (grade A exceeding 89 points), 15 patients (51.72%) had satisfactory results (grade B from 80 to 88 points or more), while only three patients (10.34%) had unsatisfactory results (grade C from 79 to 70 po-ints). None of the patients belonged to a group of the unsuccessful (grade D below 70 points).



Graph 1. Post-rehabilitation values of the Neer scale for the shoulder joint

Three months after the surgical procedure and rehabilitation, patients are expected to attain full range of motion in all the plains and to continue with the program of kinesiotherapeutic exercises for shoulder stabilization. In 14 (48.27%) of 29 athletes, the rehabilitation effects were entirely as expected. In 9 (31.04%), external rotation deficit occurred in the final measuring ranging from 5° to 10°. Upon completed rehabilitation, approxima-tely after 6 months, these athletes reached a full range of motion of the external rotation in abduc-tion. Six patients (20.69%) showed much bigger deficit in the case of this type of range of motion during the final measuring, ranging from 10° up to 40°. The athlete who had the smallest range of motion (50°) did not attend the rehabilitation pro-gram regularly nor perform the assisted exercises

for reaching the full range of motion. Given the observations taken from the medical charts of the-se six patients, in the final measuring, these athle-tes had mobility difficulties, shoulder instability, shoulder muscle hypotrophy, and in the case of three of them pain. After two years, all 29 patients had good final results in the final control check-up.

The results referring to the shoulder joint mobi-lity are given in the Table 1. Measuring of range of motion (flexion, abduction, external and internal rotation) was done during the rehabilitation proce-ss. The results in all the variables show a trend of improvement after every check-up.

During the first phase of rehabilitation, the pa-tients did exercises to strengthen the abductor and external and internal rotators of the shoulder joint in an isometric regime, due to the reduction of mo-tion which is rather demanding on behalf of the or-thopedist. Given the insight into the results of the measuring, it is evident that the range of motion has considerably improved after the second me-asuring, since in this phase exercises with higher motion amplitude were allowed. Furthermore, in all other phases there has been considerable im-provement in the range of motion in all directions, i.e. statistically significant difference between the initial and final condition was evident (flexion: F = 2502.04; p = 0.00; abduction: F = 1638.83; p = 0.00; external rotation: F = 471.67; p = 0.00; inner rotation: F = 2144.63; p = 0.00).

Table 1. Descriptive statistics and differences in the range of motion before, during and after rehabilitationA variable and a number of measurements Mean SD Min Max Kurt Skew F p

Upper arm flexion

I 94.31 5.13 80 100 0.94 -0.99

2502.04 0.00II 130.00 12.75 100 145 -0.32 -1.08III 161.55 12.75 120 180 2.79 -1.59IV 169.31 10.15 135 180 3.24 -1.56

Upper arm abduction

I 83.79 6.64 70 95 0.57 -1.00

1638.83 0.00II 123.45 11.03 90 140 1.72 -1.31III 151.90 12.64 110 165 2.83 -1.54IV 163.10 12.28 125 180 1.835 -1.17

External rotation

I 17.41 5.11 10 25 -1.085 -0.49

471.67 0.00II 30.52 5.72 20 40 -0.51 -0.21III 69.48 11.75 40 95 0.99 -0.22IV 87.07 5.72 50 110 1.58 -0.68

Inner rotation

I 22.76 5.28 15 30 -1.08 -0.34

2144.63 0.00II 39.31 5.13 30 50 0.17 0.08III 73.10 6.87 55 80 0.55 -1.03IV 81.55 6.14 65 90 0.23 -0.52

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The results of the univariate analysis of varian-ce for repeated measures of the range of motion in the shoulder joint were given in the Table 2.

The results show statistically significant dif-ference in all the variables (flexion, abduction, external and inner rotation) and in all the repeated measures when compared to the previous (the se-cond with respect to the first one, the third compa-red to the second and the fourth compared to the third one).

This confirmed the thesis that a bigger range of motion is expected in the shoulder joint in all di-rections after every measuring and after the com-pletion of rehabilitation. This further implies the fact that the program of kinesiotherapeutic exerci-ses gave positive and expected results.

Discussion

In the case of all the patients included in this research, initial luxations occurred at the sports arenas, but all the recurrences happened during trainings and competitions. Given the anamnesis, which was determined during the first examinati-on, the information was obtained about the occu-rrence of repeated luxations which happened as a result of the hasty removal of immobilizer without the prior consultation of the orthopedist, as well as a result of returning to sports activities too early. Comparing these statements with the statements of other authors [39] we find certain similarities which point out that adolescents returned to their sports activities all too soon and that it was one of the reasons for the recurrence. In addition, they in-

dicate the fact that the patients who suffered initial dislocations during sports activities had a greater number of recurrences (82%) than the patients not engaged in sport (60%). As another option, they mention the initial trauma caused by the high le-vel of strain, which occurs in the case of contact sports, leading to more serious injuries, including the bone injuries, such as Hill-Sachs and Bankart lesions, which entirely coincides with the anamne-sis of the athletes engaged in our research.

After the surgery and the first half of the re-habilitation, the repeated instability in case of our patients was found to be largely connected to the preoperative episodes of dislocations, since in the case of five of six stated patients, they occurred 20 times or more. In this instance, unsatisfactory range of motion was pointed out in the case of ab-duction and external rotation in abduction. Howe-ver, after six months, these patients were said to have shown satisfactory mobility along with the muscular hypotrophy and terminal limitation of external rotation.

The applied rehabilitation protocol resembled postoperative protocol [41] in the case of 83 pa-tients after the open Bankart procedure. The ave-rage decrease in range of motion in these patients in the matter of external rotation of 90° in the ab-duction was 19°, while in the case of our patients, the whole sample considered, the average deficit of the range of motion was only 2.93°. This result can probably be accounted for by the fact that two patients reached full range of 110°, one patient that of 105° and two other patients the range of 100°, which reduced the bad result of six patients. Another possible reason is probably the fact that

Table 2. The results of the univariate analysis of variance for repeated measures

VariableI measuring II measuring II measuring III measuring III measuring IV measuring

vs vs vsf p f p f p

Upper armflexion 534.18 0.00 1335.74 0.00 101.98 0.00

Upper armabduction 1508.35 0.00 1621.91 0.00 266.44 0.00

Externalrotation 816.81 0.00 1054.67 0.00 582.62 0.00

Innerrotation 1084.23 0.00 1465.46 0.00 127.33 0.00



all the patients in our research are active athletes in different sports whose nature of the sport requi-res a much bigger range of motion in the shoulder joint and thus, looser shoulder connections (laxi-tas art. humeroscapularis) than in the patients in the abovementioned paper.

Our patients were observed over the two years after the operative treatment and during this period no recurrence was detected. Emphasizing the im-portance of a long-term monitoring of patients [40], a bigger recurrence was perceived in the second year after the surgery (4.8%, over the 18-month monitoring period). In a retrospective study [41], which lasted for 9 years approximately, the first po-stoperative dislocation occurred 11 years after the surgery and after the existing trauma.

The obtained recurrence rate is rather favora-ble when compared to the data [40] from a shor-ter rehabilitation protocol, which was essentially identical to the 16-week protocol [43], after whi-ch the patients resumed full activity. The authors point to the total recurrence rate of 7.7% of the cases. They believe that their well-established shorter rehabilitation program does not imply the outcome in terms of the final shoulder stability, but that in general it is more successful in the case of patients who have strong desire to return to the highest level of sports activities, both pro-fessional and amateur ones.

Comparing our rehabilitation protocol to that from the previously stated paper and recurrence rate, in our case complete physical therapy was conducted with kinesiotherapy along with hydro- and fitness therapies. Good results were obtained (89.66%) according to the Neer scale, but only 10.34% fell within the unsatisfactory group. Mo-reover, this type of rehabilitation proved as a good one considering the fact that none of the patients belonged to the group of the unsuccessful. Unlike the results of other studies [25, 26], the results of our work show that our patients entirely returned to their previous sports activities.

Conclusion

The results of our research show that the applied rehabilitation program, which included kinesiothe-rapy, occupational therapy, electrotherapy, cryothe-

rapy, hydrotherapy and fitness, produced expected and positive effects. In the postoperative shoulder rehabilitation the basic principles were applied, as follows: restoring glenohumeral stability, synchro-nization of scapulohumeral movement and propri-oceptive mechanisms. Most of the criteria for the “ideal” return of an athlete to the sports arenas af-ter the operative treatment are the same - painless condition, physiological range of motion and musc-le strength, good hand function and the ability to perform specific movements closely related to the sports discipline the athlete is engaged in. The time period within which the treated athlete was expec-ted to return to the game was 6 months.

According to the Neer scale in the final measu-ring after six months in the case of 24 patients there was no pain, while five patients experienced slight pain, but not during sports activities. All the trea-ted patients resumed their old sports activities in the positions they had before the operative procedure.

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Corresponding author Ivana Kacanski, Health Center "Novi Sad", Department of Sports Medicine, Serbia, E-mail: [email protected]

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