Rajiv Gandhi University of Health Sciences



Rajiv Gandhi University of Health Sciences,

Bangalore, Karnataka

ANNEXURE II

Proforma for registration of subjects for Dissertation

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| |Name of the Candidate and Address |MITHSU VYAS DITOSA D’SOUZA |

| | |SHREE DEVI COLLEGE OF PHYSIOTHERAPY, MANGALORE |

| |Name of the Institution |SHREE DEVI COLLEGE OF PHYSIOTHERAPY, BALLALBAGH, |

| | |MANGALORE, 5750003 |

| |Course of study and subject |MASTER OF PHYSIOTHERAPY(MPT) |

| | |2 YEARS DEGREE COURSE. |

| | |(CARDIOTHORACIC AND CHEST) |

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| |Date of Admission to Course |O7th APRIL 2010 |

| |Title of the Topic: |

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| |“An Analysis of Effect of Smoking on Chest Expansion, Breath Holding in Smokers as Compared to Non Smokers” |

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| |Brief resume of the intended work : |

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| |Need for the study |

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| |As we all know what smoking is doing to our health, it reduces the work capacity of the individual by reducing the capacities and volumes |

| |of the lung. As the atmospheric pollution was not enough the human has invented the new way to reduce his life span. |

| |Cigarette smoking has become a very common phenomenon, especially among the young as it is believed to be an instrument of fad & fashion. |

| |However, young smokers never realize the amount of damage being done with each cigarette they smoke. It is a major cause of COPD. The risk|

| |of developing COPD in smokers is 30 times higher than in non-smokers. |

| |Cigarette smoking leads to an overall decline in the rate of pulmonary function. of all the ingredients, NICOTINE is the most harmful & it|

| |is the drug of addiction it reaches the brain within 10 sec after intake and stimulates the brain & CNS. |

| |The other harmful chemicals & metals found in cigarette are. |

| |Carbon monoxide |

| |Formaldehyde Ammonia |

| |Carbon dioxide |

| |Aluminum |

| |Copper |

| |Lead |

| |Mercury |

| |Zinc |

| |Among these chemicals Carbon monoxide affects the oxygen transport in the body by converting normal hemoglobin into carboxy hemoglobin |

| |which has no value in oxygen transport. |

| |As well known, an individual’s ability to perform muscular work is dependent on his capacity to transport oxygen from the atmosphere to |

| |the cells in the exercising muscles. Thus smoking decrease the work capacity of the individual. |

| |It has been repeatedly stated by international agencies that tobacco is the main cause of death in most countries. The extent of diseases |

| |and disabilities related to tobacco has not been completely explored, since only some categories of disease (cancer, cardiovascular, |

| |respiratory) have been extensively and accurately investigated. If current smoking patterns continue, there will be more than one billion |

| |deaths attributable to tobacco smoking in the 21st Century compared with, 100 million deaths in the 20th Century. |

| |According to a recent systematic evaluation, ‘‘…tobacco is a potent multisite carcinogen with a worldwide impact, causing cancers of the |

| |lung, upper aero-digestive tract (oral cavity, nasal cavity, nasal sinuses, pharynx, larynx, oesophagus), pancreas, stomach, liver, lower |

| |urinary tract (renal pelvis and bladder), kidney, uterine cervix and myeloid leukemia’’1. |

| |Smoking causes even more deaths from vascular, respiratory and other diseases than from cancer; therefore, in total, tobacco smoking is |

| |estimated to account for approximately four to five million deaths a year worldwide. |

| |Cigarette smoking has extensive effects on respiratory function and is clearly implicated in the etiology of a number of respiratory |

| |diseases, particularly chronic bronchitis, emphysema, and bronchial carcinoma 2 |

| |In India smoking is a common habit prevalent in both urban and rural areas irrespective of mode of smoking i.e. cigarettes, bidis, pipes, |

| |cigar, hookah etc. The cigarette / bidi smoke is a heterogeneous aerosol produced by the incomplete combustion of the tobacco leaf. In |

| |India, tobacco is consumed mainly in the form of bidis (54%), followed by smokeless tobacco (27%) and cigarettes (9%) 3. |

| |Evaluation of respiratory function has for a long time consisted of inspection, palpation, tape measurements, auscultations, chest |

| |radiographs and lung volume measurements. Additional evaluation methods have emerged during the last decades for example methods to assess|

| |respiratory muscle strength and movements of the diaphragm 4,5. |

| |The rib cage, composed of several types of solid and soft tissues, is a biomechanical unit responsible for respiratory movements and |

| |protection of the underlying organs. The thoracic vertebrae, ribs and sternum comprise the solid part, but the soft part consists of the |

| |inter-vertebral discs, articular capsules, ligaments and the diaphragm, together with the intercostal and accessory respiratory muscles 6.|

| |For optimal respiratory movement to take place all structures must be intact and function normally 7. |

| |Smoking, once regarded as a ‘dirty smelly habit’, is now widely accepted as an addiction to nicotine. The smoking population spectrum |

| |encompasses those with little or no addiction, to those who are so severely addicted that they are unable to quit smoking despite serious |

| |smoking-related diseases. |

| |The need of the study is to see how smoking is limiting the physical function of the human body, as statistical analysis will help us to |

| |understand better the effect of smoking on humans so the study… |

| |Research Question |

| |To find the effect of smoking on smokers as compared to non smokers. |

| |To study the effect of smoking on chest expansion in asymptomatic smokers compared to asymptomatic non- smokers. |

| |To study the effect of smoking on breath holding in asymptomatic smokers compared to asymptomatic non- smokers |

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| |Null hypothesis |

| |There will be no difference in chest expansion and breath holding in asymptomatic smokers as compared to asymptomatic non smokers. |

| |Alternate hypothesis |

| |It is assumed that there will be significant difference in chest expansion and breath holding in asymptomatic smokers compared to |

| |asymptomatic non smokers. |

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| |6.2 Review of literature |

| |A study found that people who could hold their breath for longer had a greater rate of success at stopping smoking after a course of |

| |antismoking treatment. In another study, it was determined that breath holding ability correlated with grip-holding ability 8, a finding |

| |which gave validity to the measure and implied a more general trait of endurance for physical discomfort, of which both measures were |

| |markers. |

| |Breath-holding ability at age 21 was assessed by timing study members while they held their breath for as long as possible, as described |

| |in previous research 9. |

| |Smoking status was assessed by self-report in an interview at ages 21 and 32, and was coded as “current smoker”, “ex-smoker”, or |

| |“non-smoker” at each age. To be classified as smokers or ex-smokers, participants had to have smoked 20 packs of cigarettes, or at least |

| |one cigarette per day for as long as a year during their lives 10. Current smokers were those who reported currently smoking at interview.|

| |Length of breath holding has subsequently been used as a measure of tolerance of negative affect from physiological symptoms of smoking |

| |withdrawal. For example, breath holding ability was compared between groups of smokers who had previously abstained for long (seven days |

| |or more) or short (less than seven days); it did not differ 11. More extreme groupings of smokers: smokers who had previously relapsed |

| |within a day at best vs those who had previously sustained quitting for three months or longer prior to relapse, on the other hand, did |

| |show a difference in breath-holding ability whereby sustained quitters held their breaths for longer 12. |

| |As per the criteria of smoking index, it was observed that most smokers were light smokers (42.0%) followed by moderate smokers (32.0%) |

| |and heavy smokers (26.0%). Similarly, Burrows et al 13 reported that there is quantitative significant relationship between impaired |

| |ventilatory function and duration and frequency of smoking. |

| |Medical evidence of the harm done by smoking has been accumulating for 200 years, at first in relation to cancers of the lip and mouth, |

| |and then in relation to vascular disease and cancer of the lung. The evidence was generally ignored until five case-control studies |

| |relating smoking to the development of lung cancer were published in 1950. These stimulated much research, including the conduct of cohort|

| |studies, which, by the late 1950s, were beginning to show that smoking was associated with the development of many other diseases as well.|

| |A cross sectional study was conducted in Pravara Rural Hospital, PIMS, Loni from January 2007 to August 2008. The study population |

| |included 100 male subjects comprising of 50 smokers and 50 non smoker controls aged between 30-60 years. Individuals with history of |

| |smoking cigarettes / bidis daily for at least one year were considered as smokers. The smokers were selected voluntarily from amongst |

| |Pravara Medical Trust employees, patients coming to OPD of Pravara Rural Hospital for non-respiratory ailments, and from residents living |

| |in and around the Pravara Rural Hospital premises. Ex-smokers or past smokers were excluded from the study. Purposive sampling was done |

| |and results were analyzed by statistical methods. The mean values of all the pulmonary function tests are significantly reduced in smokers|

| |compared to non smokers.14 |

| |Changes in respiratory movements are evident in connection with deformities, skeletal disorders and cardiopulmonary diseases. Chronic |

| |obstructive pulmonary disease is a good example, where the respiratory movements are decreased judged by the decrease in tidal volume 15. |

| |The breathing becomes increasingly more thoracic as the disease progresses and can even become paradoxical.16 On the other hand, an |

| |example of abnormal respiratory movement pattern is the increase in Pump handle motion Bucket handle motion 17 upper thoracic movements |

| |occurring in chronic hyperventilation syndrome. In contrast, decreased frequency of breathing is associated with drug overdose 18 and |

| |diseases such as myasthenia gravis. |

| |Exhaled alveolar air contains carbon monoxide that has passed from the blood during a period of breath holding and so provides an accurate|

| |guide to carboxy haemoglobin concentration, itself affected by inhaling tobacco smoke. It has been claimed that breath hold duration makes|

| |no appreciable difference to the expired air carbon monoxide (ECO) concentration obtained. A study was conducted to determine the |

| |relationship between duration of breath holding prior to exhalation and EC) value. It was found that ECO concentration increased.19 |

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| |6.3 Objectives of the study |

| |To evaluate chest expansion in asymptomatic smokers and asymptomatic non smokers. |

| |To evaluate breath holding in asymptomatic smokers and asymptomatic non smokers. |

| |To compare and evaluate the effect of smoking amongst the two groups of people. |

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| |Materials and methods |

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| |7.1 Source of data |

| |Shree Devi Education trust college clinic. |

| |Wenlock Hospital |

| |7.2 Method of collection of data |

| |60 Subjects of age group between 30-40 years will be randomly assigned into two groups. |

| |Group A : Consists of 30 Subjects who will be smokers. |

| |Group B : Consists of 30 Subjects who will be non smokers. |

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| |Selection Criteria: |

| |Subjects age between 30 to 40 years. |

| |Males only – for convenience. |

| |Smokers who smoke 10 to 12 cigarettes per day for atleast four years. |

| |Non smokers who are healthy without any respiratory complications. |

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| |Exclusion criteria: |

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| |Subjects with acute symptoms. |

| |Subjects who have respiratory complain at the time of examination |

| |Study Design: |

| |Cohort Comparative Study. |

| |Sampling: |

| |Blocked Random Sampling. |

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| |Statistical Test: |

| |Comparison between two groups is done by Unpaired t-test. |

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| |Outcome measure: |

| |Two groups will be made, group A smokers & group B non-smokers, total 40 subjects will be included in the study, 20 in each group. |

| |Group A subjects will be included using selection criteria. |

| |Group B subjects will be included using selection criteria except point 3 of selection criteria.. |

| |Writing consent will be taken from the subject. |

| |Data will be collected by using following Performa – |

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| |Name |

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| |Age |

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| |Sex |

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| |Occupation |

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| |Personal History |

| |Smoker/Nonsmoker – If smoker no. of cigarette per day |

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| |Measurements of chest expansion |

| |( measurements is after maximum expiration & inspiration difference between two give us the reading) |

| |Upper Lobe – at axilla |

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| |Middle Lobe – at xyphoid process |

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| |Lower Lobe – subcostal angle |

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| |Measurement of Breath Holding Time |

| |Subject will be told to take deep breath and hold it as long as they can & the time will be noted. |

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| |Both above measurement will be taken three times for each subject to avoid any error & their means will be noted as final measurement. |

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| |METHODOLOGY: |

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| |All the subjects will be assessed and evaluated using the table chart. A minimum of 60 subjects who were willing and interested in |

| |participating in the following study were selected using the selection criteria. |

| |The selected subjects were divided into two groups depending on the selection criteria. |

| |Group A are smokers and group B are non smokers. Both the groups consist of males in the age group of 30-40 years. |

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| |For chest expansion subjects from both the groups will be asked to relax and take 2-3 normal breaths. The subject will first explained and|

| |demonstrated how to take a normal breath. After which the subjects will be asked to expire all the air from the lungs. Now the subject has|

| |to take a deep inspiration and the difference between the expired and inspired chest will be noted using a measuring tape. Three different|

| |readings will be taken and the mean reading will be considered as the final reading. |

| |The readings will be taken at three different levels ie |

| |1 .at axilla |

| |2. at xiphoid process and |

| |3. at subcostal angle. |

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| |For assessing breath holding time the subjects from both the groups will be asked to sit in a relaxed comfortable position. |

| |The therapist will keep a stopwatch ready to note the time. The subject is asked to take a deep inspiration and hold upto his tolerance |

| |level. The time duration he holds his breath is noted in secs on the stopwatch. Three different readings will be taken and the mean |

| |reading will be considered as the final reading. |

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| |For both the tests the subject is asked to sit in a straight upright position on a chair which has a straight back rest. During both the |

| |tests the subjects back is always supported. The subject is allowed to rehearse the procedure for atleast twice before the final reading |

| |is taken. |

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| |TOOLS |

| |Measuring tape. (inch tape) |

| |Stop watch. |

| |Chair with straight back rest. |

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| |7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please |

| |describe briefly. |

| |Yes. |

| |Assessment of chest expansion and breath holding conducted on patients. No physical interventions. |

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| |7.4 Has ethical clearance been obtained from your institution in case of 7.3? |

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| |Yes. |

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| |List of References: |

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| |World Health Organization, International Agency for Research on Cancer. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans.|

| |Tobacco Smoking and Involuntary Smoking. Vol. 83. Lyon, IARC, 2004. |

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| |WHO; World tobacco epidemic; 1993; 2nd Edition; p-47. |

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| |Anonymous. IUALTD: The world tobacco situation. IUALTD News Bull Tobacco Health 1998; 11: 19-21. |

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| |Ayoub J, Cohendy R, Dauzat M, De La Coussaye J, Bourgeois J, Ramonatxo M, Prefaut C, Pourcelot L.. Non-invasive quantifivation of |

| |diaphragm kinetiks using m-mode sonography. Can J Anaesth 44 (7): 739-744, 1997 |

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| |Chu W, Li A, Ng B, Chan D, Lam T, Lam W, Cheng J. Dynamic magneting resonance imaging in assessing lung volumes, chest wall, and diaphragm|

| |64 motions in adolescent idiopathic scoliosis versus normal controls. Spine 31 (19): 2243-2249, 2006. |

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| |Gray´s. Anatomy. Edinburgh: Churshill Livingstone, 1995. |

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| |Celli B, Grassino A. Respiratory Muscles: Functional Evaluation. Seminars in resp crit care med19 (4): 367-381, 1998. |

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| |Hajek P. Breath holding and success in stopping smoking: what does breath holding measure? Int J Addict 1989; 24(7): 633-9. |

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| |Hajek P, Belcher M, Stapleton J. Breath-holding endurance as a predictor of success in smoking cessation. Addict Behav 1987; 12:285-8 |

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| |Ferris BG. Epidemiology standardization project. Am Rev Respir Dis 1978; 118: 1-120. |

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| |Zvolensky MJ, Feldner MT, Eifert GH, et al. Affective style among smokers - Understanding anxiety, sensitivity, emotional reactivity, and |

| |distress tolerance using biological challenge. Addict Behav 2001; 26(6): 901-15. |

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| |Brown RA, Lejuez CW, Kahler CW, et al. Distress tolerance and duration of past smoking cessation attempts. J Abnorm Psychol 2002; 111(1):|

| |180-5. |

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| |Burrows B, Khudson R.J, Martha Jeline, Lebowitz M.D. Quantitative relationship between cigarette smoking and ventilatory function. Amer. |

| |Review. Resp. Dis. 1977; Vol. 115, 195-205. |

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| |Rubeena Bano, Mahagaonkar AM, Kulkarni NB, Nadeem Ahmad, Nighute .Study of pulmonary function tests among smokers and non smokers in rural|

| |area Pravara Med Rev 2009; 4(1) |

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| |Tobin M, Chadha T, Jenouri G, Birch S, Gazeroglu H, Sackner M. Breathing patterns. 2. Diseased subjects. Chest 84 (3): 286-94, 1983. |

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| |Cahalin L, Ragnarsdottir M. Reliability, validity and clinical utility of a novel respiratory movement measuring instrument. Chest 122 |

| |(4): 207S, 2002 |

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| |Chu W, Li A, Ng B, Chan D, Lam T, Lam W, Cheng J. Dynamic magneting resonance imaging in assessing lung volumes, chest wall, and diaphragm|

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| |Hillegass E. Assessment Procedures. In: Hillegass E, Sadowsky H, eds. Essentials of Cardiopulmonary Physical Therapy. Second Edition. |

| |Philadelphia: W.B. Saunders Company, pp. 622, 2001. |

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| |West. (1984): Addictive Behaviors, 1984; 9: 307-309 |

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| |Signature of the Candidate | |

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| |Remark of the Guide | |

| |Name and Designation of | DR. LITTY KURIAKOSE Chandy |

| |(In Block Letters) |ASSISTANT PROFESSOR |

| | |SHREE DEVI COLLEGE OF PHYSIOTHERAPY |

| |Guide |MANGALORE 03. |

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| |Signature | |

| | | DR. HARIPRIYA .S |

| |Co-guide (if any) | |

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| |Signature | |

| | | DR. VIJAY .P |

| |11.5 Head of Departmant |PRINCIPAL, |

| | |SHREE DEVI COLLEGE OF |

| |11.6 Signature |PHYSIOTHERAPY, MANGALORE-03. |

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| |12.1 Remark of the Chairman And Principal | |

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| |12.2 Signature | |

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